Designing a Care Map with Safe Discharge Information for a Client with Musculoskeletal Trauma

 

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Assessment

and

Data Collection

 Three NANDA-I Approved                    Nursing Diagnosis One Smart Goal for EACH Nursing Diagnosis Two Nursing Interventions with Rationale for EACH Nursing Diagnosis

Disease Process: Musculoskeletal trauma

 

 

 

 

 

 

 

 

Common Lab work/Diagnostics:

X-rays to visualize the fractures.

Blood tests to reveal any systemic problem contributing to the patient’s presentation.

 

 

Assessment Data (consider subjective, objective, and heath history):

Subjective: Patient’s age, comorbidity, family history of musculoskeletal disorders, tobacco, and alcohol use.

 

Objective: Patient’s gait, ability to ambulate and participate in activities of daily living, and BMI.

 

History: History of fractures, motor vehicle accidents, and musculoskeletal disorders.

 

Nursing Diagnosis:

Impaired skin integrity-related abrasions and lacerations evidenced by pressure due to cast application and the patient’s scratching of the skin.

 

 

 

 

 

 

 

 

 

 

Nursing Diagnosis:

Risk for peripheral neurovascular dysfunction due to the possibility of vascular and nerve compression related to the applied cast.

 

 

 

 

 

 

 

 

 

 

Nursing Diagnosis

Deficient knowledge related to unfamiliarity with the treatment process, evidenced by the patient scratching the skin beneath the cast

 

SMART Goal:

The patient will demonstrate behaviors to prevent skin breakdown by the time of discharge.

 

 

 

 

 

 

 

 

 

 

 

SMART Goal:

The patient will maintain perfusion to the areas to which the cast is applied during the entire time of cast application.

 

 

 

 

 

 

 

 

 

 

 

SMART Goal:

The patient will demonstrate knowledge by verbalization of why the cast was applied to his limb and the necessary measures to prevent injury by the time of discharge.

1.    Protect the applied cast and the skin beneath by massaging the skin around the cast with alcohol. Alcohol has a drying effect and may help in toughening the skin.

2.    Educate the patient and their other caregiver on the need to avoid inserting objects inside the cast. Inserting an object may increase skin and tissue injury (Parisien & McAlpine, 2019).

 

1.    Apply ice around the cast intermittently for short durations. This may reduce hematoma and edema that impede circulation (Parisien & McAlpine, 2019).

2.    Educate the patient on the need for routine mild exercise and ambulation. Exercise and ambulatory movem

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