MUSCULOSKELETAL CARE PLAN TEMPLATE: assessment( objective/ subjective) nursing diagnosis, planning /outcome, interventions, rational for intervention, evaluation/ replanning.

Abigail Cantonelli, age 80, injured her left knee and wrist when she fell on an icy
sidewalk. She has been on your orthopedic and neurologic unit for several days.
She has an extended history of cardiomyopathy, for which she receives
furosemide (Lasix). Her vital signs are stable and she rates her pain as a 2 on a
scale of 1 to 10 (10 = worst pain). Because Mrs. Cantonelli has an increased risk of
falling, her primary care provider has ordered physical therapy and canewalking
instructions before discharge. Although the physical therapy staff has already
initiated the cane-walking instructions, you will need to ambulate Mrs. Cantonelli
with her cane during your shift. While you are ambulating down the hall, she says,
“Oh, dear! I feel dizzy.” She begins to lose her balance and falls toward you.

Medical orders
Physical therapy for cane-walking instruction
Ambulate every shift with cane assistance
Lasix 20 mg PO every morning
Potassium chloride 10 mEq PO every day
Lortab 5 one tab PO q 4-6 hours prn pain

ANSWER

Assessment

Objective:
Mrs. Cantonelli, age 80, injured her left knee and wrist from a recent fall on an icy sidewalk.
She has an extended history of cardiomyopathy and is currently on furosemide (Lasix) for management.
Vital signs are stable.
Pain rating is 2 on a scale of 1 to 10.
Mrs. Cantonelli has been receiving physical therapy for cane-walking instruction.

Subjective:
Mrs. Cantonelli rates her pain as a 2 on a scale of 1 to 10.
During ambulation with the cane, she expresses feeling dizzy and loses her balance, resulting in a fall.

Nursing Diagnosis:
Risk for falls related to dizziness and instability during ambulation with a cane.

Planning/Outcome:
By the end of the shift, Mrs. Cantonelli will be able to ambulate safely with the assistance of a cane without experiencing dizziness or falling.

Interventions

Ensure Mrs. Cantonelli’s vital signs are stable before ambulation.
Assess Mrs. Cantonelli’s readiness for ambulation and cane use.
Review proper cane-walking technique with Mrs. Cantonelli.
Encourage Mrs. Cantonelli to stand up slowly and take her time while walking with the cane.
Stay close to Mrs. Cantonelli during ambulation to provide support and prevent falls.
Monitor for signs of dizziness or imbalance during ambulation.
Instruct Mrs. Cantonelli to call for assistance if she feels dizzy or unsteady.

Rationale for Interventions

Stable vital signs ensure that Mrs. Cantonelli is medically stable for ambulation.
Assessing readiness ensures that she is physically capable of using the cane safely.
Reviewing proper technique reinforces correct cane-walking to reduce the risk of falling.
Encouraging slow movements minimizes the risk of dizziness or imbalance.
Providing close support reduces the risk of falls during ambulation.
Monitoring for signs of dizziness allows for early intervention if needed.
Instructing Mrs. Cantonelli to call for help promotes safety and timely assistance if any issues arise during ambulation.

Evaluation/Replanning

After ambulating with Mrs. Cantonelli, it was observed that she experienced dizziness and fell. The initial plan needs to be modified to ensure her safety during ambulation. Further assessment is required to identify the cause of dizziness, and physical therapy may need to reevaluate her cane-walking technique. The primary care provider should be informed of the fall incident and any changes in Mrs. Cantonelli’s condition to determine the appropriate course of action for her musculoskeletal care plan. Additional interventions may be implemented to address her risk for falls and to promote a safe and successful discharge.