Nursing Diagnosis for Kacie Benson, a 19-year-old woman Kacie Benson, a 19-year-old woman, is a client on your unit due to a skiing accident. She is unconscious and may or may not regain consciousness. She is on complete bed rest. She requires frequent repositioning to maintain correct body alignment and attention to her ROM.
She responds to painful stimuli with slight non-purposeful withdrawal. No spontaneous movements are noted. The recent lower extremity ultrasound showed no evidence of venous thrombosis, and she continues on low molecular weight heparin injections. Her fluid and electrolyte balance is continuously maintained by tube feeding at 60 mL per hour. She is incontinent of stool and has an indwelling Foley catheter. Her heels are reddened, but otherwise, her skin is intact.
| Nursing Diagnosis | Nursing Diagnosis | Nursing Diagnosis |
| 4th Domain: Rest or Exercise
Class Two: Exercise or Activity (Ackley et al., 2019). -Restricted movement due to cognitive dysfunction, activity resistance, and decreased body movement
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11th Domain: Protection and Safety
Class One: High infection risk (Ackley et al., 2019). -Threat of infection associated with tube feeding, an IV catheter, a Foley catheter in situ, unconsciousness, aspiration, bowel dysfunction, and bedridden. |
11th Domain: Protection and Safety
Class Two: Threat of loss of the skin turgor (Ackley et al., 2019). -Risk of poor skin turgor associated with physical immobility, dampness, mechanical variables (such as friction, mechanical stress, and pressure), skin breakages, electrolyte disturbances, poor circulation, dehydration, poor nutrition, and pressure sores |
| SMART Goal | SMART Goal | SMART Goal |
| Specific: The objective is to retain the patient’s muscular mass while allowing for an aided range of motion (ROM) and tolerable movement for blood flow. Despite the client’s cognitive problems (unconsciousness), keeping ROM and physical activity is essential to lessen muscle and joint stiffness and weakening. Additionally, this promotes blood circulation throughout the body, especially the lower limbs. The treatment plan involves the client and the medical staff to accomplish this goal.
Measurable: Every meeting is recorded, along with the movements performed, to monitor progress. The doctor will specify how frequently these exercises should be done (twice daily), and the nurse or physiotherapist will carry them out. The goal is accomplished when the client becomes conscious and is no longer utterly motionless from hospitalization. The patient will be allowed to move around a little on their own. Achievable: This is an aim that is doable and attainable. Even though evaluation and physiotherapy appointments may be necessary to track the client’s movement after extended hospitalization, this is preferable to the client receiving no therapy while asleep. Relevant: This objective is crucial to lessen muscle and joint stiffness and atrophy when unconscious. It also encourages circulation in the torso and the lower limbs to prevent inadequate perfusion. The client is too young to experience immobilization problems after regaining consciousness. This objective aligns with the patient’s unique requirements and present state. Timely: Until the client leaves the facility, this objective will remain. When the client becomes conscious, achieving this objective would mean their movement is hampered (Wüller et al., 2019). |
Specific: Infection risk during hospitalization needs should be minimized. There are numerous hazards for infection depending on the patient’s state. If an infection is not controlled on time, it might cause sepsis and even death. To accomplish this, both the healthcare professionals and the client must participate.
Measurable: Inspection, examination, and frequent laboratory investigations performed on the patient when admitted to the hospital are used to evaluate infection control practices. The aim is met once the infection is avoided throughout the patient’s overall hospital admission. Achievable: As medical practitioners adhere to the proper routine for infection control, using hand-washing and PPEs is an attainable and reachable goal. When providing routine medical care, sterile, clean devices are always required. Through the facility, services are accessible. Relevant: This objective is crucial for avoiding infection and septic shock. The patient has lost bowel control and Order a similar paper |