Nursing Diagnosis for Kacie Benson, a 19-year-old woman

Class Two: Exercise or Activity (Ackley et al., 2019).

-Restricted movement due to cognitive dysfunction, activity resistance, and decreased body movement

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.

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

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).

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 has undergone numerous invasive operations. Procedure-related open sores can quickly become infected if they are not adequately cleansed. If stool movements are appropriately washed on time, the integrity of the skin may be protected. Infection may also result if bowel movements penetrate the vagina or urinary tract (Wüller et al., 2019). This objective aligns with the patient’s unique requirements and present health.

Timely: This objective will be kept up until the patient leaves the facility. The aim would be met if there were no infections throughout the hospitalization.

Measurable: Each shift and skin examination, including capillary refill time, ski blanching, and lower limb pulses, are examined, monitored, and documented to determine progress. The aim has been accomplished if a client’s skin turgor is maintained throughout their hospitalization.

Achievable: If the healthcare professionals adhere to the standard guidelines for ensuring skin turgor, this is a feasible and reachable aim. Due to the client’s bed rest, patient rotation is necessary. Keep your linens straight and guard against skin tearing. Maintain dry skin (Wüller et al., 2019). Through the facility, services are accessible.

Relevant: The aim helps to keep the skin’s integrity intact and avoid infection and necrosis. The skin serves as the body’s protection against viruses that penetrate the body and should stay healthy to fulfill its function. Open wounds increase the danger of infection and pathogen entry. This objective aligns with the patient’s unique requirements and present state.

Timely: This objective will be kept up until the patient leaves the facility. Achieving this goal would require maintaining skin turgor throughout the entire hospitalization.