Designing a Care Map
| Assessment and Data Collection | Three NANDA-I Approved Nursing Diagnosis | One Smart Goal for EACH Nursing Diagnosis | Two Nursing Interventions with Rationale for EACH Nursing Diagnosis |
| Disease Process: A fracture is a complete or partial discontinuity of bone structure. Tibiofibular fractures occur due to low-energy or high-energy impact (Wu et al., 2021). Following injury, inflammation occurs, and the process of bone healing begins. Cellular proliferation occurs, followed by callus formation and ossification. Mature bone remodeling is the final step. Common Labwork/Diagnostics: Physical examination CBC Electrolyte and creatinine levels Blood glucose levels Coagulation profile Blood group and cross-matching Toxicology screen X-ray of the affected limb Assessment Data (consider subjective, objective, and health history): Subjective Site of the fracture The severity of pain. Relieving and exacerbating factors of pain. Symptoms associated with pain. Itchiness under the cast. Objective 78-year-old male, Right tibiofibular fracture, Right long leg cast, It uses a hanger to scratch the skin under the cast, Sits for long periods with the leg in a dependent position, He gets up without help, Hops on one leg without crutches. | Nursing Diagnosis: Risk for falls related to right tibia and fibula as evidenced by hopping to the bathroom and walking without crutches (Canuto et al., 2020) Nursing Diagnosis: Deficient knowledge related to lack of information, as evidenced by sitting on the sides of the bed for long periods with the affected limb in a dependent position. (Assis et al., 2018) Nursing Diagnosis Impaired skin integrity about a long leg cast, as evidenced by the patient using a hanger to scratch the skin under the cast. | SMART Goal: The patient will keep the fracture fixed and aligned. SMART Goal: The patient will express the comprehension of their illness, outlook, and potential consequences. SMART Goal: Physical examination of the skin for the integrity of circulation. | 1. Intervention: Maintain limb rest as indicated. Proper positioning of the fractured limb (Ferreira et al., 2022). Rationale: Prevents irrational movement and alignment disturbance. 2. Intervention: Follow-up right lower limb x-rays. Rationale: Monitors commencement of callus formation and healing process. Furthermore, assess the need for therapy adjustment. 1. Intervention: Review disease process and expected outcomes. Rationale: It gives the patient the ability to make an informed decision. 2. Intervention: Reiterate the recommended ambulation and mobility techniques. Rationale: Inadequate usage of ambulatory equipment could result in further injury and a delay in healing. 1. Intervention: Massaging skin and placing soft padding on bony prominences. Rationale: Reduces pressure on vulnerable areas and decreases the chance of skin abrasions and disintegration. 2. Intervention: Frequent repositioning of the fractured limb. Rationale: Reduces persistent pressure on the same regions and lowers the chance of skin disintegration. |