Module 04 Written Assignment- Nursing Diagnosis

Module 04 Written Assignment- Nursing Diagnosis

Nursing Diagnosis	Nursing Diagnosis	Nursing Diagnosis
Risk of impairment of skin integrity resulting in pressure sores related to lack of mobility as evidenced by reddening of the heels. The patient also falls into the at-risk population’ since she is in the intensive care unit and is immobile (Herdman & Kamitsuru, 2021). Impaired skin integrity in this patient is caused by stool incontinence, poor circulation status, impaired mobility, cognitive impairment, and poor nutritional status.	Electrolyte imbalance is related to lack of feeding, as evidenced by tube feeding. Main imbalances include sodium, potassium, magnesium, phosphorus, copper, zinc, water, and trace elements (Berlana, 2022).	Risk of nosocomial infections related to stool incontinence, indwelling foley catheter, impaired mobility, and tube feeding as evidenced by reduced immune defenses (Story, 2020). The primary nosocomial infection is pneumonia due to aspiration or associated with the ventilator.
SMART Goal	SMART Goal	SMART Goal
The patient will be free of pressure sores throughout the admission period. This goal will be achieved by repositioning the patient every 3 hours, using additional pillows on the heels and sacrum, changing diapers immediately after a bowel movement, and using wrinkle-free sheets every day until the patient is no longer unconscious to reduce the risk of pressure sores.	The patient will achieve electrolyte balance until she is discharged. The nurse will maintain adequate tube feeding until the patient regains consciousness. The goal is achieved by fluid management and evaluated by observing for the clinical feature of imbalance and checking UECs.	The patient will not have any infection throughout her stay in the hospital. It is achieved by using PPE and applying aseptic techniques when handling the patient to prevent sepsis. Regular inspection and monitoring are used to evaluate the goal. Additionally, blood work can be done to check on the levels of white blood cells.

 References

Berlana, D. (2022). Parenteral nutrition overview. Nutrients, 14(21), 4480.

Herdman, T. H., & Kamitsuru, S. (2021). Nursing diagnoses.

Story, L. (2020). Pathophysiology: A Practical Approach: A Practical Approach. Jones & Bartlett Learning.

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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.

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 maintained by continuously feeding her tube 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.