Designing a Care Map – Osteoporosis, Distal Radius Fracture

Common Labwork/Diagnostics:

Complete Blood Count (CBC)

Comprehensive Metabolic Panel (CMP):

Vitamin D Levels:

Thyroid Function Tests

Bone Turnover Markers:

Dual-Energy X-ray Absorptiometry (DXA) Scan:

X-rays

Bone Scintigraphy

Magnetic Resonance Imaging (MRI)

Assessment Data (consider subjective, objective, and heath history):

Subjective Data

Wrist pain (7/10)

low appetite

Difficulty with meal preparation.

Objective Data

Low body weight (85 pounds)

Medical history

Health History

Type 1 diabetes

Bipolar disorder

Depression

Hysterectomy

Smoking

Risk for falls related to osteoporosis, impaired balance, and history of fractures.

Nursing Diagnosis:

Ineffective self-health management related to poor nutrition and meal skipping.

Nursing Diagnosis

Risk for impaired skin integrity related to osteoporosis, low body weight, and limited mobility.

The patient’s balance and fall risk will be positively impacted through regular physical therapy exercises, as indicated by a 20% decrease in fall risk within six weeks.

SMART Goal:

The patient’s nutritional status will be enhanced through strict adherence to a diabetic diet and consistent administration of prescribed insulin, aiming to attain and sustain a healthy weight within three months.

SMART Goal:

The patient will demonstrate a high level of cognitive ability, as evidenced by the absence of pressure ulcers, within four weeks.

Reasoning: Mitigating environmental hazards is crucial for preventing falls (Campani et al., 2020).

2. Work with a physical therapist to create a customized exercise program that emphasizes improving balance and building strength.

Reasoning: Regular physical activity enhances balance and decreases the likelihood of falling in individuals with osteoporosis.

1. Work with a registered dietitian to develop a customized meal plan, focusing on foods rich in nutrients and maintaining consistent meal schedules.

Reasoning: Proper nutrition plays a vital role in effectively managing diabetes and attaining a balanced weight (Gray & Threlkeld, 2019).

2. Offer knowledge regarding the significance of insulin management, highlighting the necessity of regular insulin pump usage and monitoring blood glucose levels.

Reasoning: Maintaining a regular insulin regimen is essential for managing blood sugar levels and promoting overall well-being in individuals with diabetes.

1. Perform routine skin evaluations.

Reasoning: Conducting regular skin assessments can aid in the early detection of skin breakdown, enabling prompt intervention and the prevention of pressure ulcers (National Library of Medicine, 2018).

2. Offer guidance on skin protection and repositioning techniques:

Reasoning: By providing education on effective skin care and repositioning techniques, the patient can be empowered to actively prevent pressure ulcers, considering their limited mobility and risk factors.