Multidimensional Care for Musculoskeletal Disorders: Case of Rotator Cuff Injury

This care map outlines a multidimensional approach for a client with a rotator cuff injury, focusing on nursing interventions and goals.

Relevant Data:

• Disease Process: Rotator cuff injury refers to damage to the tendons or muscles that stabilize the shoulder joint. It can cause pain, weakness, and limited mobility in the arm.
• Common Lab Work and Diagnostics: X-rays may be used to rule out fractures, while an MRI scan can confirm a rotator cuff tear.
• Subjective Data: Patient reports pain in the shoulder, difficulty raising their arm, and weakness when performing daily activities.
• Objective Data: Limited range of motion in the shoulder joint, tenderness to palpation in the rotator cuff area, positive impingement test findings.
• Health History: Previous injuries, repetitive overhead activities, age (older adults are more prone).

NANDA-I Diagnoses:

1. Pain, Acute: Related to inflammatory response secondary to rotator cuff tear evidenced by verbal reports of pain and point tenderness.
2. Risk for Impaired Physical Mobility: Related to pain and weakness in the affected shoulder evidenced by limitations in range of motion.
3. Deficient Knowledge: Related to lack of information about rotator cuff injury and self-care strategies evidenced by verbalization of misconceptions about the condition.

SMART Goals:

Diagnosis 1: Pain, Acute

• SMART Goal: Within 2 days of intervention initiation, the patient will report a decrease in pain intensity from a score of 8 on a 0-10 pain scale to a score of 5, using non-pharmacological pain management techniques (e.g., ice application, heat therapy).

Diagnosis 2: Risk for Impaired Physical Mobility

• SMART Goal: The patient will achieve a passive range of motion of 120 degrees of abduction and 180 degrees of forward flexion in the affected shoulder within 3 days of starting physical therapy.

Diagnosis 3: Deficient Knowledge

• SMART Goal: The patient will demonstrate a basic understanding of rotator cuff injury, treatment options, and preventative measures by correctly answering 80% of questions about the condition after receiving patient education.

Nursing Interventions:

Pain Management:

• Implement pain management strategies like ice application, heat therapy, and over-the-counter pain medication as prescribed by the physician.
• Educate the patient on proper positioning and techniques for pain management at home.

Improving Mobility:

• Assist the patient with passive range of motion exercises to maintain joint flexibility and prevent stiffness.
• Collaborate with a physical therapist to develop a safe and effective exercise program for regaining strength and mobility in the shoulder.
• Instruct the patient on proper body mechanics and lifting techniques to prevent further injury.

Patient Education:

• Explain the anatomy of the rotator cuff, the cause and symptoms of the injury, and the treatment plan in a clear and concise manner.
• Provide educational materials about rotator cuff injuries, including self-care strategies and preventative measures.
• Encourage the patient to ask questions and address any concerns they might have.

Additional Considerations:

• Monitor for signs of infection, such as increased pain, redness, or swelling at the injury site.
• Assess the patient’s emotional well-being and provide support as needed, as pain and limitations in mobility can cause frustration and anxiety.
• Collaborate with other healthcare professionals involved in the patient’s care, such as physicians and physical therapists, to ensure a coordinated approach to treatment.

By implementing these nursing interventions and focusing on achieving the SMART goals, nurses can provide a multidimensional approach to care for clients experiencing a rotator cuff injury. This approach aims to manage pain, improve mobility, promote patient education, and ultimately enhance the patient’s recovery and quality of life.