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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

Module 06 Assignment – Designing a Care Map

Purpose of Assignment

Assist students to develop 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 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 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.

Module 06 Assignment – Designing a Care Map

Assessment

and

Data Collection

Three NANDA-I Approved                    Nursing Diagnosis

 

*Risk: Nursing diagnosis____Related to_____

*Problem: 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):

 

 

 

 

 

 

 

 

Common Labwork/Diagnostics:

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

Nursing Diagnosis:

 

 

 

 

 

 

 

 

Nursing Diagnosis:

 

 

 

 

 

 

 

 

Nursing Diagnosis

SMART Goal:

 

 

 

 

 

 

 

 

 SMART Goal:

 

 

 

 

 

 

 

 

SMART Goal:

 

1.

2.

 

 

 

 

 

 

 

1.

 

2.

 

 

 

 

 

 

1.

 

2.

 

 

 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, common labs, diagnostic tests, and subjective, objective, and health history data. Clearly 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, common 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 diagnosis are insufficient and/or 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 strong connection to identified data. Writes TWO NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data. Writes THREE NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong 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 are 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

(20 Pts)

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

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

 

Writes 3 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references. Writes 5 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references. Writes more than 2 interventions with rationale to assist the client in resolving the 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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