Care Map for Mr. Roost

Relevant Data:

• Disease Process: Fracture of right tibia and fibula (closed or open depending on additional information)
• Lab Work and Diagnostics: X-rays likely performed to diagnose the fracture. Possible additional labs for blood work to assess overall health and rule out infection (CBC, CMP).
• Subjective Data: Mr. Roost might express pain in his leg, frustration with mobility limitations, and anxiety about returning home.
• Objective Data: Deformity or swelling in the right leg, cast present on the right leg, limited weight-bearing on the right leg as observed by the nurse, possible use of crutches or other mobility aids.
• Health History: Consider factors such as age (78 years old), previous surgeries, medications, and any underlying health conditions (e.g., osteoporosis) that could affect healing.

Nursing Diagnoses:

1. Risk for Impaired Skin Integrity related to cast application and immobility
2. Acute Pain related to fracture
3. Deficient Knowledge: Self-care Management of Cast and Home Safety after Cast Removal related to new information

SMART Goals:

1. Skin Integrity: To maintain Mr. Roost’s skin integrity under the cast, as evidenced by no signs of redness, irritation, or breakdown within 7 days.
2. Pain Management: To reduce Mr. Roost’s pain score to a level of 4 or less on a 0-10 scale using medication and non-pharmacological methods within 24 hours.
3. Knowledge Acquisition: To educate Mr. Roost on proper cast care and home safety measures after cast removal by discharge, as evidenced by his ability to demonstrate these skills and answer related questions correctly.

Nursing Interventions:

Diagnosis 1: Risk for Impaired Skin Integrity

• Intervention 1: Daily skin assessment under the cast edges, monitoring for signs of redness, irritation, or breakdown.

• Rationale: Early detection of skin problems under the cast allows for prompt intervention to prevent further complications.

• Intervention 2: Educate Mr. Roost on proper cast care, including avoiding scratching under the cast and keeping the cast dry.

• Rationale: Empowering Mr. Roost with knowledge about cast care promotes self-management and reduces the risk of skin irritation.

Diagnosis 2: Acute Pain

• Intervention 1: Administer pain medication as prescribed by the physician and monitor for effectiveness.

• Rationale: Medications can effectively manage pain and improve Mr. Roost’s comfort level.

• Intervention 2: Implement non-pharmacological pain management techniques such as elevation of the affected leg and application of cold therapy (as appropriate).

• Rationale: Non-pharmacological methods can provide additional pain relief and potentially reduce reliance on medication.

Diagnosis 3: Deficient Knowledge: Self-care Management of Cast and Home Safety after Cast Removal

• Intervention 1: Provide education on proper cast care techniques, including signs of infection to monitor for and proper cleaning methods for the cast itself (if applicable).

• Rationale: Knowledge of proper cast care empowers Mr. Roost to manage his cast effectively at home and prevent complications.

• Intervention 2: Educate Mr. Roost on home safety measures after cast removal, such as fall prevention strategies and proper use of assistive devices (if needed).

• Rationale: Understanding home safety measures helps Mr. Roost prevent falls and injuries during recovery.

Discharge Instructions:

• Specific instructions on cast care and signs of infection to monitor for.
• Pain management strategies, including any medications prescribed for home use.
• Weight-bearing instructions as directed by the physician.
• Proper use of assistive devices (if needed).
• Schedule for follow-up appointments.
• Referral to physical therapy or home health services (if needed).