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Module 06 Assignment – Designing a Care Map

Purpose of Assignment

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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.

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

Total Assessment Points – 65

Levels of Achievement
CriteriaEmergingCompetenceProficiencyMastery
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 – 7Points – 8Points – 9Points – 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 – 7Points – 8Points – 9Points – 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 – 11Points – 12Points – 13Points – 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 5 interventions with rationale to assist the client in resolving the issues leading to the problem with appropriate references.
Points – 15Points – 16Points – 18Points –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- 2Points- 3Points- 4Points- 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- 2Points- 3Points- 4Points- 5

Module 05 Assignment – Designing a Care Map

Dr. Christina Cyrus

Rasmussen College

COURSE#: NUR2356

Dr. Cyrus

November 8th , 2020

Assessment/Data Collection

I have chosen to write about Diabetes Mellitus Type 1. In Type 1 Diabetes the langerhan cells that produce insulin are destroyed by an autoimmune process. This means that the pancreas produce little to no insulin. Insulin is required to move glucose into the cells for energy. Without insulin, glucose builds up in the blood and causes adverse effects such as impaired circlation.(Author last name, year). Common labs to diagnosis Type 1 Diabetes are a HGB AIC. This lab tests the average amount of glucose in the blood over the past 2-3 months and can give insight into the function of the pancreas. A client with Type 1 Diabetes may have a genetic disposition or a history of a viral illness. On assessment of a client with Type 1 Diabetes the client may report subjective findings of polyuria, polydipsia, and polyphagia. Objective findings may be decreased sensation, slow healing wounds, and changes in vision. Comment by Christina Cyrus: Clearly identify the Musculoskeletal disorder from Chapter 5 that you are writing about Comment by Christina Cyrus: Explain the disease process clearly so I know that you know what is happening in the body. Comment by Christina Cyrus: Describe applicable lab and diagnostic tests and explain why they are significant for the disorder you are writing about. Comment by Christina Cyrus: Explain risk factors or a health history that would contribute to the disorder. Comment by Christina Cyrus: Describe potential objective and subjective findings on assessment for a client with the disorder.

Nursing Diagnosis/ Goal/ Intervention Comment by Christina Cyrus: You must have THREE correctly done for full credit.

Imbalanced Nutrition: less than body requirements related to inability to not use glucose as evidence by HGB A1C greater than 7% Comment by Christina Cyrus: Nursing Diagnosis with all required parts. Relates to disease and potential problem

Client will maintain pre-prandial glucose levels between 60 and 100 mg/dl for 3 consecutive days within 2 weeks. Comment by Christina Cyrus: Comment by Christina Cyrus: SMART goal that addresses problem identified in nursing diagnosis.

Nurse will teach client how to obtain pre-prandial glucose levels with glucometer and strips. Rationale: The client will need to be able to monitor their glucose levels to make sure it is being utilized for energy and not building up in the vessels (Author last name, year).

Nurse will teach client how to count carbohydrates for insulin administration. Rationale: The client will have to administer the proper amount of insulin to move the glucose into the cells for energy (Author last name, year). Comment by Christina Cyrus: TWO interventions and rationale that will help the client meet the SMART Goal

References Comment by Christina Cyrus:

Author’s Last Name, First initial. Middle initial. (Year). Title of article. Journal Title, Volume Number(Issue number), Page numbers.

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