multidimensional care 1
Module 06 Assignment – Designing a Care Map Purpose of Assignment Assist students in developing 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. Scenario Mr. Harry Roost is a 78-year-old male being discharged 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 observed him using a hanger to scratch the skin under the cast and reminded him each time that he should not put anything down his cast. He also sits on the side of the bed for extended periods with his leg in a dependent position and gets up to go to the bathroom without calling for help, often hopping to the bathroom without using his crutches. Upon assessment, the nurse notes warmth and redness above the cast and +2 edema to the right foot. The client states he has 5 out of 10 pain on a numeric scale and severe itching under the cast. Vital signs are temperature 98.7 °F/ 37.1 °C, blood pressure 138/88 mmHg, heart rate 88 beats per minute, respirations 18 breaths per minute, and oxygen saturation 94% on room air. The client has a history of falls at home and is being monitored for pre-hypertension. White blood cell count on admission was 12,000/MM³, and current white blood cell count is 10,000/MM³. The client will continue taking prescribed antibiotics at home. Instructions Develop a care map for Mr. Roost using this template, including information relevant for discharge instructions. In this table, include this information: • • • • Relevant data: Disease process, common lab work and diagnostics, and subjective, objective, and health history data Three NANDA-I approved nursing diagnoses One SMART goal for each nursing diagnosis Two nursing interventions provided with a supporting rationale for each SMART goal • Two scholarly sources to support information in the care map. • Cite sources in-text and on a reference page using APA format. Resources What is the SMART method? How do I set realistic goals? Nurse Reference eBooks APA 7th Edition Guide Relevant Data Three NANDA-I Approved Nursing Diagnosis One Smart Goal for EACH Nursing Diagnosis Two Nursing Interventions with Rationale for EACH SMART Goal Disease Process: Nursing Diagnosis: SMART Goal: 1. 2. Common Lab work/Diagnostics: Nursing Diagnosis: SMART Goal: 1. 2. Nursing Diagnosis Assessment Data (consider subjective, objective, and health history): SMART Goal: 1. 2. Module 06 Assignment – Designing a Care Map Rubric Total Assessment Points – 65 Levels of Achievement Criteria Relevant Data 15 Points Nursing Diagnoses Mastery Proficiency Competence Emerging Advanced/exceeds achievement Clear/effective achievement Adequate/basic achievement Limited/growing achievement 15 Points Thoroughly identified relevant data, including disease process, common lab work and diagnostics, and subjective, objective, and health history data. 13 Points Sufficiently identified relevant data, including disease process, common lab work and diagnostics, and subjective, objective, and health history data. 11 Points Reasonable identification of relevant data, including disease process, common lab work and diagnostics, and subjective, objective, and health history data. 9 Points Partial identification of relevant data, including disease process, common lab work and diagnostics, and subjective, objective, and health history data. 0 Points Did not submit. 0 Points Three NANDA-I diagnoses not provided. 0 Points Did not submit. 0 Points One SMART goal for each nursing diagnosis not provided. 0 Points Did not submit. 5 Points Three NANDA-I diagnoses provided. 5 Points SMART Goals 5 Points 5 Points One SMART goal for each nursing diagnosis provided. The achievement of this criteria is assessed at either the Emerging or Mastery levels. Demonstration of this action or skill is either achieved or not achieved. The achievement of this criteria is assessed at either the Emerging or Mastery levels. Demonstration of this The achievement of this criteria is assessed at either the Emerging or Mastery levels. Demonstration of this action or skill is either achieved or not achieved. The achievement of this criteria is assessed at either the Emerging or Mastery levels. Demonstration of this Not Submitted SMART Goals 10 Points Superior SMART goals. action or skill is either achieved or not achieved. action or skill is either achieved or not achieved. 9 Points Satisfactory SMART goals. 8 Points Reasonable SMART goals. The achievement of this criteria is assessed at either the Emerging or Mastery levels. Demonstration of this action or skill is either achieved or not achieved. 9 Points The achievement of this criteria is assessed at either the Emerging or Mastery levels. Demonstration of this action or skill is either achieved or not achieved. 8 Points Satisfactory nursing interventions provided with sufficient rationales. Reasonable interventions provided with occasional rationales. 7 Points Inappropriate SMART goals. 0 Points Did not submit. 0 Points Two interventions were not provided for each SMART goal. 0 Points Did not submit. 7 Points 0 Points Inappropriate nursing interventions provided with minimal rationales. Did not submit. 0 Points Two scholarly sources not provided. 0 Points Did not submit. 10 Points Nursing Interventions 5 Points Two interventions provided for each SMART goal. 5 Points 10 Points Superior nursing Nursing Interventions with interventions provided with well-developed rationales. Rationale 10 Points Scholarly Sources 5 Points 5 Points Two scholarly sources provided. The achievement of this criteria is assessed at either the Emerging or Mastery levels. Demonstration of this The achievement of this criteria is assessed at either the Emerging or Mastery levels. Demonstration of this 10 Points Spelling, Grammar, Exemplary format and style APA Format and throughout with no Style spelling, grammar, or APA errors present. 10 Points action or skill is either achieved or not achieved. action or skill is either achieved or not achieved. 9 Points 8 Points 7 Points 0 Points Satisfactory format and style throughout, with minor spelling, grammar, or APA errors present. Reasonable format and style throughout, with some spelling, grammar, or APA errors present that occasionally detract from reading. Format and style throughout need development, with several spelling, grammar, or APA errors present that often detract from reading. Did not submit.
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