NUR2356_Module 06 Assignment-2
Module 06 Assignment – Designing a Care Map
Purpose of Assignment
Assist students todevelop a care plan that includes safe discharge information for a clientwith musculoskeletal trauma.
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NUR2356_Module 06 Assignment-2
Module 06 Assignment – Designing a Care Map
Purpose of Assignment
Assist students todevelop a care plan that includes safe discharge information for a clientwith 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 discharge after a fracture of his right tibia and fibula. He has a long leg cast that he will need to wear for the next 8 weeks. The nurses have observed him using a hanger to scratch the skin under the cast. The nurse 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.
Develop a care map for Mr. Roost using the template directly after these instructions. Include information important for his discharge home. For this assignment, you will need to include three nursing diagnoses, outcomes, and nursing interventions with rationale.
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.
Subjective Subjective Subjective
Objective Objective Objective
Diagnostic Diagnostic Diagnostic
Subjective: patient states he can walk on his own and refuses help from nursing staff
Objective: Patient has a long leg cast which limits his range of motion
Diagnostic: Xray to confirm fracture Subjective: Patient refuses need for assistive devices and nursing staff while ambulating
Objective: Fracture of right tibia & fibula and long leg cast
Diagnostic: Assessment of mores fall risk Subjective: Patient started scratching for relief and reports feeling itchy
Objective: Ecchymoses
Diagnostic: Full lab work up to rule out infection
Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis
Impaired physical mobility related to pain and discomfort as evidenced by Reports of pain/discomfort on movement
(Ackley &Ladwig 2008) and (Gulanick & Myers, 2014) Risk for falls related to getting up without assistance as evidence by patient hopping to bathroom
(Ackley &Ladwig 2008) and (Gulanick & Myers, 2014) Impaired skin integrity related to physical immobilization as evidenced by reports of itching and disruption of skin surface
(Ackley &Ladwig 2008) and (Gulanick & Myers, 2014)
SMART Goal SMART Goal SMART Goal
Client will maintain a position of function, as evidenced by the absence of contracture by end of hospital stay.
Client will display increased strength and function of affected joint and limb. Participate in ADLs/rehabilitation program by end of week. Client will maintain stabilization and alignment of fracture(s) by end of hospital stay
Client will demonstrate body mechanics that promote stability at the fracture site by end of the day.
Client will verbalize relief of discomfort throughout the day.
Client will demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing as indicated by end of week.
Nursing Interventions Nursing Interventions Nursing Interventions
1.Medicate before procedures and activities. Muscle relaxants, narcotics, analgesics decrease pain.
2. Demonstrate and assist with transfer techniques and use of mobility aids, e.g., trapeze, walker. Facilitates self-care and patient’s independence.
3. Inspect skin, observe for reddened areas. Prevents skin breakdown and eases irritation.
4.Maintain affected joint in prescribed position and body in alignment when in bed. Provides for stabilization of prosthesis and reduces the risk of injury during recovery from effects of anesthesia
5. Turn on the unoperated side using an adequate number of personnel and maintaining operated extremity in prescribed alignment. Prevents dislocation of hip prosthesis and prolonged skin or tissue pressure, reducing the risk of tissue ischemia and/or breakdown.
6. Determine upper body strength as appropriate. Involve in the exercise program. Replacement of lower extremity joint requires increased use of upper extremities for transfer activities and use of ambulation devices.
7.Perform and assist with the range of motion exercises to unaffected joints. Patient with degenerative joint disease can quickly lose joint function during periods of restricted activity.
8.Total knee: Quadriceps setting, gluteal contraction, flexion/extension exercises, isometrics.Strengthens muscle groups, increasing muscle tone and mass; stimulates circulation; prevents decubitus
(Ackley &Ladwig 2008) and (Gulanick & Myers, 2014) 1. Maintain bed rest or limb rest as indicated. Provide support of joints above and below fracture site, especially when moving and turning. Provides stability, reducing the possibility of disturbing alignment and muscle spasms, which enhances healing
2. Secure a bed board under the mattress or place patient on the orthopedic bed. A soft or sagging mattress may deform a wet (green) plaster cast, crack a dry cast, or interfere with the pull of traction.
3. Support fracture site with pillows or folded blankets. Maintain a neutral position of affected part with sandbags, splints, trochanter roll, footboard. Prevents unnecessary movement and disruption of alignment. Proper placement of pillows also can prevent pressure deformities in the drying cast.
4. Use sufficient personnel for turning. Avoid using abduction bar for turning patient with a spica cast. Hip, body or multiple casts can be extremely heavy and cumbersome. Failure to properly support limbs in casts may cause the cast to break
5. Observe and evaluate splinted extremity for resolution of edema. Coaptation splint (Jones-Sugar tong) may be used to provide immobilization of fracture while excessive tissue swelling is present
6. Maintain position or integrity of traction. Traction permits pull on the long axis of the fractured bone and overcome muscle tension or shortening to facilitate alignment and union
7. Ascertain that all clamps are functional. Lubricate pulleys and check ropes for fraying. Secure and wrap knots with adhesive tape. Ensures that traction setup is functioning properly to avoid interruption of fracture approximation
8. Keep ropes unobstructed with weights hanging free; avoid lifting or releasing weights. An optimal amount of traction weight is maintained
(Ackley &Ladwig 2008) and (Gulanick & Myers, 2014) 1. Examine the skin for open wounds, foreign bodies, rashes, bleeding, discoloration, duskiness, blanching. Provides information regarding skin circulation and problems that may be caused by application or restriction of cast, splint or traction apparatus, or edema formation that may require further medical intervention
2. Assess the position of splint ring of traction device. Improper positioning may cause skin injury or breakdown.
3. Massage skin and bony prominences. Keep the bed linens dry and free of wrinkles. Reduces pressure on susceptible areas and risk of abrasions and skin breakdown
4. Reposition frequently. Encourage use of trapeze if possible. Lessens constant pressure on the same areas and minimizes the risk of skin breakdown
5. Cleanse skin with soap and water. Provides a dry, clean area for cast application
6. Rub gently with alcohol or dust with small amount of a zinc or stearate powder. Useful for padding bony prominences, finishing cast edges, and protecting the skin
7. Cut a length of stockinette to cover the area and extend several inches beyond the cast. Prevents indentations or flattening over bony prominences and weight-bearing areas (back of heels), which would cause abrasion or tissue trauma
8. Use the palm of hand to apply, hold, or move cast and support on pillows after application. Uneven plaster is irritating to the skin and may result in abrasions
(Ackley &Ladwig 2008) and (Gulanick & Myers, 2014)
References:
Ackley, B. J., &Ladwig, G. B. (2008). Nursing diagnosis handbook: an evidence-based guide to planning care. St. Louis, MO: Mosby Elsevier.
Gulanick, M., & Myers, J. L. (2014). Nursing care plans: 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, and common labs, diagnostic tests, and history. Briefly identifies the four factors including the disease process, common labs, diagnostic tests, and history. Clearly identifies four factors including the disease process, common labs, and other diagnostic tests, and history. Identifies all factors including the disease process, common labs, other diagnostic tests, and health history and demonstrated deep understanding of the assessment
Points - 0-7 Points - 8 Points - 9 Points - 10
Nursing Hypothesis / Diagnosis (should fit the data)
(10 Pts) Nursing hypothesis/diagnosis is insufficient and/or does not fit the data. Writes nursing hypothesis/ diagnosis in the correct format with adequate connection to identified data. Writes nursing hypothesis/diagnosis in the correct format with a clear connection to identified data. Writes nursing hypothesis/diagnosis in the correct format with a strong connection to identified data.
Points – 0-7 Points – 8 Points - 9 Points - 10
SMART Goal (should reflect the diagnosis and follow guidelines)
(15 Pts) The goal meets few SMART goal guidelines and/or is not related to the nursing diagnosis. The goal meets some of the SMART goal guidelines and is related to the nursing diagnosis. The goal meets most of the SMART goal guidelines and is related to the nursing diagnosis. The goal meets all of the SMART goal guidelines and is related to the nursing diagnosis.
Points – 0-11 Points - 12 Points - 13 Points – 14-15
Interventions and Rationale
(20 Pts) Lacks appropriate interventions to assist the client in resolving the issues leading to the problem. Write 3 interventions to assist the client in resolving the issues leading to the problem with appropriate references. Write 5 interventions to assist the client in resolving the issues leading to the problem with appropriate references. Writes more than 5 interventions to assist the client in resolving the issues leading to the problem with appropriate references.
Points – 0-15 Points - 16 Points – 17-18 Points –19- 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- 0-2 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- 0-2 Points- 3 Points- 4 Points- 5
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