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REDO -Module 06 Assignment – Designing A Care Map 8/25/2021 Please use this same format in doing the Assignment Do not use the same information IN THIS SA

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REDO -Module 06 Assignment – Designing A Care Map 8/25/2021 Please use this same format in doing the Assignment

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Module 06 Assignment – Designing a Care Map

Purpose of Assignment

Assist students in developing a care plan that includes safe discharge information for a client with musculoskeletal trauma.

Course Competency

 Explain components of multidimensional nursing care for clients with musculoskeletal disorders.

Instructions

Mr. Harry Roost is a 78-year old male being discharged after a fracture of his right tibia and fibula. He has a long leg cast that he will need to wear for the next eight weeks. The nurses have observed him using a hanger to scratch the skin under the cast. The nurses have reminded him each time that he is not to put anything down his cast. He also sits on the side of the bed for long periods with his leg in a dependent position. He also gets up to go to the bathroom without calling for help. The staff have observed him hopping to the bathroom without using his crutches. He currently rates his pain 5/10.

Develop a care map for Mr. Roost using the template directly after these instructions. Include information important for his discharge home. For this assignment, include the following: assessment and data collection (including disease process, common labwork/diagnostics, subjective, objective, and health history data), three NANDA-I approved nursing diagnosis, one SMART goal for each nursing diagnosis, and two nursing interventions with rationale for each SMART goal for a client with a musculoskeletal disorder.

Use at least two scholarly sources to support your care map. Be sure to cite your sources in-text and on a reference page using APA format.

Check out the following link for information about writing SMART goals and to see examples:

http://rasmussen.libanswers.com/faq/212524

You can find useful reference materials for this assignment in the School of Nursing guide:

https://guides.rasmussen.edu/nursing/referenceebooks

Have questions about APA? Visit the online APA guide:

https://guides.rasmussen.edu/apa

Assessment and

Data Collection

Three NANDA-I Approved Nursing Diagnosis

*Risk: Nursing diagnosis____Related to_____

*Actual: Nursing diagnosis____Related to____ as evidenced by

ONE SENTENCE

One Smart Goal for EACH Nursing Diagnosis

*Specific and measurable with a timeline. Find from the nursing diagnosis book (under client or expected outcomes section) and individualize to your patient-ONE

SENTENCE

Two Nursing Interventions with

Rationale for EACH Nursing Diagnosis

*From nursing diagnosis book under interventions section.

Choose 3 and individualize to patient. Cite these interventions.

Disease Process: (short description of patho of disorder- cite this):

gulanick, M., & Myers, j. L. (2014). Nursing care plans: diagnoses, interventions to, and outcomes (8th ed.). Philadelphia, PA: Elsevier/Mosby.

Ackley, B. J., & Ladwig, G. B.

(2008). the nursing diagnosis handbook: an evidence-based guide to planning care. St. Louis, MO: Mosby Elsevier.

Common Labwork/Diagnostics:

X-ray, bone scan, CT scan, MRI.

Doenges, M., Moorhouse, M. F., &

Murr, A. (2019)

Nursing Diagnosis:

Impaired physical mobility by related to pain and the discomfort as evidenced by Reports of pain/discomfort on movement (Ackley & Ladwig 2008) and of

(Gulanick & Myers, 2014)

Nursing Diagnosis:

The Risk for falls related to getting up without assistance as evidence by patient hoping to the bathroom (Ackley & Ladwig 2008) and (Gulanick & Myers, 2014)

SMART Goal:

The Client will maintain a function position, as evidenced by the absence of contracture by the end of the hospital stay.

SMART Goal:

The Client may maintain stabilization and alignment of Fracture (s) by the end of the hospital stay.

1. Medicate before procedures and activities. Muscle relaxants, narcotics, analgesics decrease pain (Ackley & Ladwig 2008) and

(Gulanick & Myers, 2014)

2. Demonstrate and assist with transfer of techniques and use of mobility aids, e.g., trapeze, walker. Facilitates self-care and patient’s independence (11th ed.).

Rationale: Inspect skin, observe for reddened areas. It prevents skin breakdown and eases irritation.

1. To maintain bed rest or limb rest as indicated. Providing support of joints above and below the fracture site, especially when moving and turning. (Ackley &

Assessment Data (consider subjective,

Pain at the Fracture the site and having difficulty in mobility, Acute pain on his right tibia and fibula; Client denied the need of assistance during transfer, Fatigue, Body ache, Stiffness of the right lower extremities, Swelling of the right leg,

Movement limitation, Muscle cramp itching under the cast.

Doenges, M., Moorhouse, M. F., & Murr, A. (2019)

Medications: Ibuprofen and Ice

Park no allergies objective, and heath

Ladwig 2008) and

(Gulanick & Myers, 2014)

2. Have Secure a bed board under the mattress or place the patient on the orthopedic bed to rest. Maybe, soft or sagging mattress may deform a wet (green) plaster cast, crack a dry cast, or interfere with the pull of traction. e, M. F., & Murr,

A. (2019)

Rationale: Secure a bed board under the mattress or place the patient on orthopedic bed rest. A soft or sagging mattress may deform and protect a wet and (green) crack a dry cast, plaster cast, or interfere with the pull of

Pain, infection edema tenderness, loss of function, Orientation to place, person, time, Fracture on right tibia and fibula, decrease in muscle function noted, Unstable balance, Presence of externe noted.

Nursing Diagnosis:

The Impaired skin integrity related to physical immobilization as evidenced by reports of itching and disruption of the skin surface

(Ackley & Ladwig 2008) and

(Gulanick & Myers, 2014)

SMART Goal:

The Client will verbalize relief of discomfort throughout the day.

traction.

1. Examine the skin for open wounds, foreign bodies, rashes, bleeding, discoloration, duskiness, blanching. (Ackley &

Ladwig 2008) and

(Gulanick & Myers, 2014)

2. Provides information regarding skin circulation and problems that may by application or restriction of cast, splint or traction apparatus, or edema formation that may require further medical intervention

Rationale: Assess the position of the splint ring of the traction device.

Improper positioning may cause skin injury or breakdown (Ackley & Ladwig 2008) and

(Gulanick & Myers, 2014)

Makic, M.B.F., Ladwig, G.B., & Ackley, B.J. (M.2017). Nursing diagnosis handbook: An evidences based guide to planning care (11th ed.). St Louis, MO: Elsevier. Retrieve from https://eds.b.ebscohost.com/eds/ebookviewer/ebook?sid=06fc04fe-0c2b-4485-9da5- f37f744d3f25%40sessionmgr103&ppid=pp_cover&vid=0&format=EB

Gulanick, M., & Myers, J. L. (2014). Nursing care plans care diagnoses, interventions, and outcomes (8th ed.). Philadelphia, PA: Elsevier/Mosby

Module 06 Assignment – Designing a Care Map Rubric

Total Assessment Points – 65

Levels of Achievement

Criteria

Emerging

Competence

Proficiency

Mastery

Assessment / Data Collection

(10 Pts)

Lacks basic factors of the disease process, common labs, diagnostic tests, and subjective, objective, and health history data.

Failure to submit

Assessment/Data Collection will result in zero points for this criterion.

Briefly identifies the factors including the disease process, standard labs, diagnostic tests, and subjective, objective, and health history data.

Identifies the factors, including the disease process, common labs, and diagnostic tests, and subjective, objective, and health history data.

Thoroughly identifies all factors, including the disease process, standard labs, diagnostic tests, and subjective, objective, and health history data with a deep understanding.

Points – 7

Points – 8

Points – 9

Points – 10

Nursing Diagnosis

(should fit the data)

(10 Pts)

Nursing diagnoses are insufficient and do not fit the data.

Failure to submit Nursing Diagnosis will result in zero points for this criterion.

Writes ONE NANDA-I approved nursing diagnosis in the correct format (including related to/as evidenced by) with a solid connection to identified data.

Writes TWO NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a solid connection to identified data.

Writes THREE NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a solid connection to identified data.

Points – 7

Points – 8

Points – 9

Points – 10

SMART Goal (should reflect the diagnosis

and follow guidelines)

(15 Pts)

The goals meet few SMART goal guidelines and/or are not related to the nursing diagnoses.

Failure to submit SMART goals will result in zero points for this criterion.

Writes ONE goal for ONE nursing diagnosis, and the goal meets all the SMART goal guidelines and is related to the nursing diagnosis.

Writes ONE goal for TWO nursing diagnoses, and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses.

Writes ONE goal for THREE nursing diagnoses, and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses.

Points – 11

Points – 12

Points – 13

Points – 15

Interventions and

Rationale

Lacks appropriate interventions and rationale to assist the Client in resolving the issues leading to the problem.

Writes 3 interventions with rationale to assist the Client in resolving the issues leading to the problem with appropriate

Writes 5 interventions with rationale to assist the Client in resolving the issues leading to the

Writes more than 2 interventions with rationale to assist the Client in resolving the

(20 Pts)

Failure to submit Interventions and Rationale will result in zero points for this criterion.

references.

problem with appropriate references.

issues leading to the problem with appropriate references.

Points – 15

Points – 16

Points – 18

Points –20

APA Citation

(5 Pts)

APA in-text citations and references are missing.

Attempted to use APA in-text citations and references.

APA in-text citations and references are used with few errors.

APA in-text citations and references are used correctly.

Points- 2

Points- 3

Points- 4

Points- 5

Spelling and Grammar

(5 Pts)

Numerous spelling and grammar errors, which detract from the audience’s ability to comprehend material.

Some spelling and grammar errors, which detract from the audience’s ability to comprehend material.

Few spelling and grammar errors.

Minimal to no spelling and grammar errors.

Points- 2

Points- 3

Points- 4

Points- 5

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