Nursing Diagnosis
| Nursing Diagnosis | Nursing Diagnosis | Nursing Diagnosis |
| Risk for infection.
This is because of continuous enteral feeding and the presence of an indwelling Foley Catheter. According to Lai et al. (2021), feeding nasogastric tubes and indwelling urinary catheters are potential sources of infections. |
Risk for Disuse syndrome.
Kacie is unconscious and on complete bed rest. She only responds to painful stimuli and has no unprompted movements. Essentially, prolonged physical inactivity reduces muscle bulk and strength (Miyata, 2019). Furthermore, it limits the joint range of movement. Reduced bone density is also an effect of prolonged physical inactivity. |
Impaired Swallowing and Imbalanced Nutrition: Less Than Body Requirements.
Kacie is unconscious; therefore, she cannot swallow food on her own. She has to be fed through a tube. This introduces the risk of aspiration (Biderman, 2018). It also can lead to imbalanced nutrition due to inadequate administration of enteral feeds. |
| SMART Goal | SMART Goal | SMART Goal |
| Specific: Infection prevention and control in the hospital.
Measurable: Infection control can be assessed by doing a complete blood count with differential. An elevated number of white blood cells indicates the presence of infection (Gupta et al., 2019). Achievable: Sterile techniques can be used while handling the feeding tube and the Foley catheter. A complete blood count can be done in the hospital laboratory. Relevant: The patient is predisposed to infection, which may worsen her current status. It is, therefore, necessary to monitor and prevent the occurrence of infection. Timely: Infection prevention and control will be done throughout the patient’s stay in the hospital.
|
Specific: Perform passive movement for the patient.
Measurable: Current muscle mass and range of motion of joints can be evaluated and used as a baseline for future comparison. A schedule can be created to monitor times for changing her position. Achievable: A physical therapist can be introduced to help care for Kacie. Kacie can be maintained in a comfortable position using pillows, towels, or foam heal positioners. Additionally, her position can be changed every two hours. Relevant: Performing passive movements for Kacie will help maintain her range of motion, muscle bulk, and strength. Timely: Passive movements will be performed until Kacie regains the ability to move on her own. |
Specific: Provision of balanced nutrition and prevention of aspiration.
Measurable: Intake and output can be measured through calorie counts, checking residuals before feeding, and daily weighing. Achievable: Elevating the head of the bed and maintaining this position a few minutes after feeding will prevent aspiration. Administering total parenteral nutrition solution as prescribed will prevent imbalanced nutrition. Relevant: Kacie is feeding through a tube and is at risk of aspiration and imbalanced nutrition: less than body requirements. Timing: Proper feeding through the tube and prevention of aspiration will be done until Kacie can properly feed herself. |
References
Biderman, P., van Heerden, P. V., Avitzur, Y., Iakobishvili, Z., & Singer, P. (2018). The efficacy of a novel peristaltic feeding tube (PFT) in reducing reflux and aspiration of gastric contents in mechanically ventilated patients. Clinical Nutrition Experimental, 21, 1-8. https://doi.org/10.1016/j.yclnex.2018.07.002
Gupta, D., Arora, J., Agrawal, U., Khanna, A., & de Albuquerque, V. H. C. (2019). Optimized Binary Bat algorithm for classification of white blood cells. Measurement, 143, 180-190. https://doi.org/10.1016/j.measurement.2019.01.002
Lai, C. K., Audrey, P., Leung, Y., Lee, R. L., Kwong, E. W., Kwan, R. Y., & Liu, J. Y. (2021). Infection prevention and control practices in long-term residential care settings: a multiple methods approach. Asian Journal of Gerontology and Geriatrics, 16(1), 5-12. https://doi.org/10.12809/ajgg-2020-416-oa
Miyata, K. (2019). Developing a nursing intervention for patients who suffer from disuse syndrome following prolonged bedrest to enable them to sit without trunk support. Impact, 2019(4), 76-78. https://doi.org/10.21820/23987073.2019.4.76
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Question 
Purpose of the Assignment
Assist students in clustering assessment data when developing a nursing diagnosis.
Develop students’ ability to write client-based outcomes when planning care.
Nursing Diagnosis
Course Competencies
Explain components of multidimensional nursing care for clients with musculoskeletal disorders.
Instructions
Using the template below, write 3 NANDA-I approved nursing diagnoses in a proper format based on the client case provided below. Write one SMART client-centered goal for each nursing diagnosis. Consider the client’s medical history and medications.
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 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.
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