Review the case study for the following patient and then answer questions that follow.

Richard Wilson is a 72-year-old African American male with a history of diabetes, hypertension, and prostate cancer in remission. He was admitted to the hospital after a fall at home while trying to reach for a box on top of his refrigerator. Mr. Wilson has lived alone since his wife, Mary, passed away last year. His daughters, Anita and Sandra, visit once a month as they have full-time jobs and raise young children. Mr. Wilson lost consciousness because of the fall, and his Medical Alert System alerted 911. When paramedics arrived, he was still on the floor and could not recall what had happened. When asked, Mr. Wilson could not remember his own name or his daughters' contact information. He seemed confused and had weakness in his arms and legs.

Nurse Jackie evaluated Mr. Wilson at the hospital. Her assessment indicates that Mr. Wilson was not oriented to person, place, time, or situation. Dr. Fowler, the attending physician, ordered a CT scan of the head and requested the help of the social worker in contacting Mr. Wilson's family members.

The social worker was able to contact daughter Anita with the help of Mr. Wilson's Medical Alert System. Anita arrived at the hospital with her sister Sandra a few hours later. They both reported that Mr. Wilson had trouble following a conversation during their last visit, seemingly struggling to find the right words. Though Mr. Wilson appeared confused, they didn't think much of it, putting it down to old age. They also recalled that the home didn't appear as clean as usual and that their father was letting the mail and bills pile up without addressing them. Anita made a joke of it at the time, but their father didn't notice. Sandra commented that she thought her father was depressed, as he still missed his wife and has not gotten over her passing. Both daughters expressed a desire to visit more often but explained that they don't have the time.

The next day, Mr. Wilson was feeling better, and his vitals were stable, but he was still confused and did not know what had caused him to be admitted to the hospital. The CT ruled out a stroke but did indicate degeneration of the brain's cortex and loss of brain mass. A Mini-Mental State Examination conducted by the social worker showed a decline in cognitive function associated with early stages of dementia.

The interdisciplinary team of Dr. Fowler, nurse Jackie, and the social worker met to discuss Mr. Wilson's case. The social worker presented her assessment findings to Dr. Fowler and nurse Jackie. They all agreed that it would not be safe to discharge Mr. Wilson back to the community without some form of support.

With Mr. Wilson's daughters, the social worker broached the topic of living arrangements upon discharge, including the possibility of him living with one of them. Sandra communicated that her home was too small, so she wouldn't be able to accommodate him, but that Anita would be able to. Anita seemed reluctant and asked about long-term options, perhaps in a dementia-care facility. Sandra responded, "We are not putting Dad in a home. Nana and Grandad, and Great Gran and Grandad didn't go in homes. Our family sticks together."

Sandra brought up the idea of asking their pastor for advice. Mr. Wilson is an active member of the local Baptist church, where up until that fall, he had served as an elder. Through the years, he has held leadership positions at church and developed close relationships with congregation members. He is widely respected by all for his wisdom and soft-spoken but firm leadership style. Making Hard Decisions

Later in the day, the social worker walked in on a conversation between Sandra and Anita regarding discharge plans. The two sisters seemed overwhelmed and were arguing about how to move forward. Sandra was firm about not placing Mr. Wilson in a nursing home, but Anita had gone behind her back and talked to their father about it. Mr. Wilson was left very upset, and he was reluctant to any type of long-term placement, saying, "I am not going anywhere, and I don't need your help. You and your sister can leave me alone. I've been alone for a year now, and I haven't needed you."

Questions:

Describe one problem and propose at least one patient goal (in SMART format) for the patient case.

Why is this goal appropriate for the problem and for the individual patient?

what psychological or social factors might present barriers to goal achievement?