Designing a Care Map

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 7 th Edition Guide

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