amoody_module4writtenassignment_10.24.19.

Purpose of the Assignment 1. Assist students in clustering assessment data when developing a nursing diagnosis. 2. Develop students’ ability to write client based outcomes when planning care. Course Competencies  Explain components of multidimensional nursing care for clients with musculoskeletal disorders. Instructions Using the template below the instructions, write 3 nursing diagnoses in proper format based on the client case provided below. Write one SMART client-centered outcome for each diagnosis. Consider the client’s medical history and medications. Kacie Benson, a 19 year-old woman, is a client on your unit as a result of a skiing accident. She is unconscious and may or may not regain consciousness. She is on complete bedrest. 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 being maintained by a tube feeding at 60 mL per hour continuously. She is incontinent of stool and has an indwelling Foley catheter. Her heels are reddened, but otherwise her skin is intact. Use at least two scholarly sources to support your nursing diagnoses. Be sure to cite your sources in-text and on a reference page using APA format. Check out the following links for information about writing SMART goals and to see examples: You can find useful reference materials for this assignment in the School of Nursing guide: Have questions about APA? Visit the online APA guide: This study source was downloaded by from CourseH on :51:37 GMT -05:00 Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis Domain 11: Safety/Protection Class 1. InfectionRisk for infection Related to indwelling foley catheter, tube feeding, IV catheter, & bowel incontinence (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) Domain 11: Safety/Protection Class 2. Physical InjuryRisk for impaired skin integrity Related to physical immobilization, moisture, mechanical factors (e.g., friction, shearing forces, pressure), & impaired circulation (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) Domain 4: Activity/Rest Class 2. Activity/Exercise Impaired physical mobility Related to cognitive impairment, activity intolerance, & prescribed movement restrictions (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) SMART Goal SMART Goal SMART Goal Specific: The goal is to reduce the risk for infection while in the hospital. Based on the patient’s current condition, there are many risks for infection. Infection can lead to sepsis and possible death if not treated in time. Both the patient and healthcare providers are involved in achieving this goal. Measurable: Prevention of infection is monitored by inspection and assessment and routine lab and bloodwork done on the patient during their admission in the hospital. Goal is achieved when infection is prevented during the patient’s entire stay within the hospital. Achievable: Yes, this is a realistic achievable goal as long as healthcare Specific: The goal is to reduce the risk for impaired skin integrity. Impaired skin integrity leads to further, more severe problems, such as infection, necrosis, or even death. Patient and healthcare provider are both involved in achieving this goal. Resources used are medical equipment such as prevalon boots and sequential compression devices, pillows, assistive lift devices, & calazime cream. Measurable: Progress is tracked by inspecting, monitoring, and documenting skin assessment every shift; capillary refill on fingers and toes, blanching skin, and pulses on lower extremities. Goal is achieved when patient’s skin integrity remains Specific: The goal is to provide assisted range of motion and tolerated mobility for circulation and maintain muscle mass for the patient. Although the patient has cognitive impairment (unconscious), it is important to maintain physical movement and range of motion to reduce stiffness and weakness of the joints and muscles. This also helps with circulation throughout the entire body including lower extremities. Both the patient and healthcare providers are involved with this plan of care in achieving this goal. Measurable: Progress is tracked by documenting every session and the types of movement completed. How often these exercises are This study source was downloaded by from CourseH on :51:37 GMT -05:00 providers follow the correct protocol for infection prevention, use of PPE, and hand hygiene. Use of clean/sterile equipment should always be used when performing routine care for the patient. Resources are available through the hospital. Relevant: This goal is important in order to prevent infection and sepsis. The patient has had many invasive procedures performed and is also bowel incontinent. Open wounds from procedures can get infected easily if not properly cleaned. Skin integrity becomes compromised if bowel movement is not cleaned in an appropriate amount of time and could also enter vagina or urethra leading to infection. This goal matches the specific needs of the patient and her current condition. Timely: This goal will remain until patient is discharged from the hospital. Achieving the goal would mean that no infection occurred during the entire stay in the hospital. (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) intact during the entire stay within the hospital. Achievable: Yes, this is a realistic achievable goal as long as healthcare providers follow the correct protocol for maintaining skin integrity. Patient repositioning is mandatory because patient is on bedrest. Maintain wrinkle-free sheets and prevent shearing of skin. Keep skin dry. Resources are available through the hospital. Relevant: This goal is important in order to prevent infection and necrosis of the skin and maintain skin integrity. The skin is the body’s first line of defense to protect from pathogens entering the body and must remain intact in order to successfully do its job. Open wounds provide risk for pathogens to enter as well as infection. This goal matches the specific needs of the patient and her current condition. Timely: This goal will remain until patient is discharged from the hospital. Achieving the goal would mean no impaired skin integrity during entire stay in the hospital. (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014) performed is ordered by the physician (at least twice a day) and completed by the nurse and/or physical therapist. Goal is achieved when the patient regains consciousness and is not fully immobile due to bedrest. Patient will be able to conduct some mobility independently. Achievable: Yes, this is a realistic achievable goal. Although assessment and physical therapy sessions may be required to monitor progress of mobility after prolonged bedrest, patient will be in a better state than having no therapy provided during unconsciousness. Relevant: This goal is important in order to reduce stiffness and weakness of the joints and muscles while unconscious. It also promotes circulation of the body and lower extremities to prevent poor perfusion. The patient’s age is too young to have immobility issues once consciousness is regained. This goal matches the specific needs of the patient and her current condition. Timely: This goal will remain until the patient is discharged from the hospital. Achieving this goal would mean minimal impaired mobility once the patient regains consciousness. (Ackley & Ladwig, 2008), This study source was downloaded by from CourseH on :51:37 GMT -05:00 (Gulanick & Myers, 2014) Reference Ackley, B. J., & Ladwig, G. B. (2008). Nursing diagnosis handbook: an evidencebased guide to planning care. St. Louis, MO: Mosby Elsevier. Gulanick, M., & Myers, J. L. (2014). Nursing care plans: diagnoses, interventions, and outcomes. Philadelphia, PA: Elsevier/Mosby. Module 04 Written Assignment – Nursing Diagnosis Rubric