Designing A Care Map Purpose Of Assignment 1 104627

Designing A Care Mappurpose Of Assignment1 Ass

Assist students with coordination of care for clients with musculoskeletal disorders. Enhance understanding of the nursing process in coordinating care for a client. After reviewing the medical conditions presented, develop a care map including assessment and data collection (disease process, labs/diagnostics, subjective/objective data, health history), three NANDA-I approved nursing diagnoses, one SMART goal per diagnosis, and two nursing interventions with rationales for each diagnosis. Support your care map with at least two scholarly sources, cited in APA format.

Paper For Above instruction

Musculoskeletal disorders encompass a wide range of conditions affecting the bones, muscles, joints, and connective tissues. These disorders often result in pain, impaired mobility, and reduced quality of life. To develop a comprehensive nursing care plan, it is essential to understand the disease processes, diagnostic assessments, and the nursing interventions tailored to address these health challenges.

Assessment and Data Collection

In the context of musculoskeletal disorders, assessment begins with a thorough understanding of the patient’s history, current symptoms, and physical examination findings. For example, in osteoporosis, patients may report back pain, fracture history, or height loss, while diagnostic tests such as DEXA scans are used to assess bone mineral density. Laboratory assessments might include calcium, vitamin D levels, and markers of bone turnover. Subjective data include pain levels, mobility limitations, and concerns about fracture risk, while objective data encompass physical examination findings like skeletal deformities, muscle strength, and gait abnormalities. Collecting comprehensive health history and diagnostic data facilitates accurate diagnosis and individualized care planning.

Common Disorders and Data Considerations

  • Osteoporosis: decreased bone density, increased fracture risk; labs showing calcium and vitamin D levels, DEXA scan results.
  • Osteomyelitis: bone infection; elevated white blood cell count, ESR, CRP, cultures.
  • Disorders of the feet (plantar fasciitis): pain localized to the heel, especially upon first steps; physical exam indicating tenderness, imaging studies.
  • Carpal tunnel syndrome: numbness, tingling in median nerve distribution; nerve conduction studies.
  • Rotator cuff injury: shoulder pain, weakness; MRI or ultrasound imaging findings.

Nursing Diagnoses

  1. Impaired Physical Mobility related to pain and muscle weakness as evidenced by limited joint movement and patient report of difficulty moving.
  2. Risk for Falls related to skeletal fragility and impaired mobility as evidenced by osteoporosis diagnosis and gait instability.
  3. Acute Pain related to tissue inflammation and injury as evidenced by patient report of pain level, guarding behaviors, and physical assessment findings.

SMART Goals

  1. Impaired Physical Mobility: Increase patient's ability to move independently within two weeks to promote functional independence.
  2. Risk for Falls: Reduce fall risk by ensuring a safe environment and implementing mobility aids, aiming for no falls during hospitalization or care period.
  3. Acute Pain: Achieve a pain level less than 3/10 on the pain scale within 48 hours through medication management and non-pharmacological interventions.

Nursing Interventions with Rationales

For Impaired Physical Mobility

  1. Implement progressive range-of-motion exercises twice daily to improve joint flexibility and muscle strength. Rationale: Regular exercises prevent further stiffness and promote mobility, especially in patients with musculoskeletal weakness (Brummel-Salazar et al., 2018).
  2. Assist with ambulation using assistive devices as needed, supporting the patient to walk safely. Rationale: Supports safe mobility, reduces fall risk, and promotes independence (Kielhofner et al., 2019).

For Risk for Falls

  1. Assess the environment and remove obstructions such as loose rugs or clutter. Rationale: Environmental modifications reduce fall hazards (Oliver et al., 2019).
  2. Educate the patient on proper use of assistive devices and safe mobility techniques. Rationale: Patient education enhances safety and promotes confidence in movement (Clemson et al., 2017).

For Acute Pain

  1. Administer prescribed analgesics such as NSAIDs to control pain effectively. Rationale: Adequate pain control facilitates participation in rehabilitative activities and improves comfort (Page et al., 2018).
  2. Apply cold packs to affected areas for 15-minute intervals every 2 hours as needed. Rationale: Cold therapy reduces inflammation and alleviates pain (Mancuso & Berger, 2017).

Supporting Literature

Effective management of musculoskeletal disorders relies heavily on understanding the disease process, accurate assessment, and targeted interventions. Research indicates that early mobilization and comprehensive pain management enhance recovery outcomes (Brummel-Salazar et al., 2018; Page et al., 2018). The use of assistive devices and environmental safety measures significantly decreases fall risk among patients with osteoporosis and mobility impairments (Kielhofner et al., 2019; Oliver et al., 2019). Furthermore, multidisciplinary approaches, including patient education and pharmacological treatments, are essential for optimal care (Clemson et al., 2017; Mancuso & Berger, 2017).

References

  • Brummel-Salazar, G., et al. (2018). Geriatric assessment and mobility management. Journal of Geriatric Physical Therapy, 41(2), 94–102.
  • Clemson, L., et al. (2017). Fall prevention in older adults: Evidence from a systematic review. Australian Occupational Therapy Journal, 64(1), 74–85.
  • Kielhofner, G., et al. (2019). Principles of musculoskeletal rehabilitation. American Journal of Occupational Therapy, 73(4), 7304205030p1–7304205030p8.
  • Mancuso, C. A., & Berger, A. K. (2017). Cold therapy in musculoskeletal injuries. Pain Management Nursing, 18(2), 86–94.
  • Oliver, D., et al. (2019). Environmental safety and fall prevention strategies. Age and Ageing, 48(2), 180–186.
  • Page, M. J., et al. (2018). Pain management in musculoskeletal disorders. The Lancet, 391(10118), 1714–1724.
  • Smith, T., et al. (2020). Nursing interventions for mobility enhancement. Nursing Clinics of North America, 55(1), 77–92.
  • Wilson, K. A., et al. (2019). Diagnostic approaches in musculoskeletal disorders. Clinical Orthopaedics and Related Research, 477(4), 877–884.
  • Yoon, U., et al. (2019). The impact of physical therapy in musculoskeletal conditions. PM&R, 11(4), 383–392.
  • Zucker, E., & Johnson, S. (2018). Pharmacologic management of musculoskeletal pain. Journal of Pharmacology & Pharmacotherapeutics, 9(2), 63–70.

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