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

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Data Collection

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.

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

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.

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 movements enhance blood flow and reduce venous pooling (Parisien & McAlpine, 2019).

1.    Educate the patient on his suffering and why he should maintain the cast for the recommended time. This will enhance his accountability in self-care (Amarilla-Donoso et al., 2020).

2.    Assess the patient’s knowledge of precautionary measures against tissue and skin injury. Knowing protective measures against skin injury will prevent the patient from engaging in behaviors that predispose him to injury (Amarilla-Donoso et al., 2020).