Module 04 Written Assignment Nursing Diagnosis Purpose Of Th

Module 04 Written Assignment Nursing Diagnosispurpose Of The Assignm

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 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.

Paper For Above instruction

The scenario presented involves a young woman, Kacie Benson, who is critically injured and unconscious following a skiing accident. Her condition necessitates comprehensive nursing assessment and interventions focused on preventing complications associated with immobility, maintaining physiological stability, and ensuring appropriate care for her skin integrity and comfort. Based on her clinical presentation, three appropriate nursing diagnoses are identified using the North American Nursing Diagnosis Association-International (NANDA-I) guidelines. These diagnoses are complemented by SMART (Specific, Measurable, Achievable, Relevant, Time-bound) goals aimed at fostering optimal patient outcomes.

Nursing Diagnosis 1: Risk for Pressure Ulcers related to immobility and impaired skin integrity as evidenced by reddened heels and prolonged bedrest

The first nursing diagnosis addresses the patient's increased susceptibility to pressure ulcers due to immobility, a common complication in critically ill, bedbound patients. Immobility significantly elevates the risk for skin breakdown because of sustained pressure, especially over bony prominences like the heels. The reddened heels observed indicate initial skin changes that can progress to full-thickness pressure ulcers if preventive measures are not instituted promptly. According to Lyder et al. (2011), pressure injuries are associated with significant morbidity, prolonged hospitalization, and increased healthcare costs. Preventive interventions are the cornerstone of management, including regular repositioning, skin assessments, and the use of pressure-redistributing surfaces (Dealer et al., 2014).

SMART Goal for Risk for Pressure Ulcers:

Within 48 hours, the patient will be repositioned every two hours, and heel protectors will be applied, resulting in no further development of skin breakdown on her heels, as evidenced by skin assessments showing intact skin without redness or open areas.

Nursing Diagnosis 2: Imbalanced Nutrition: Less than Body Requirements related to impaired swallowing reflex and reliance on tube feeding at 60 mL/hr as evidenced by the absence of oral intake and reliance on enteral nutrition

The second diagnosis pertains to the risk of malnutrition stemming from her unconscious state and potential swallowing dysfunction. Adequate nutrition is vital for tissue repair, immune function, and overall recovery. Her tube feeding at a continuous rate indicates an effort to meet her nutritional needs; however, ongoing monitoring is essential to prevent deficiencies or overfeeding. Parenteral nutrition may be necessary if gut function deteriorates or if caloric needs are unmet. Nutritive status can influence wound healing, immune responses, and muscle strength, underscoring the importance of careful nutritional management (Krause et al., 2018).

SMART Goal for Imbalanced Nutrition:

Within 24 hours, the patient's nutritional intake will be maintained at 60 mL per hour via tube feeding, with daily monitoring of serum albumin and prealbumin levels to ensure nutritional adequacy, and no weight loss will be observed over the next 72 hours.

Nursing Diagnosis 3: Risk for Infection related to indwelling urinary catheter and immobility as evidenced by urinary incontinence, Skin reddening, and prolonged bedrest

The third diagnosis emphasizes the elevated risk of infection, particularly urinary tract infection (UTI), due to the indwelling Foley catheter and compromised immune defenses associated with immobility and critical illness. Catheter-associated urinary tract infections are among the most common healthcare-associated infections, often leading to systemic implications if unmanaged. Proper catheter care, aseptic technique during insertion, and routine assessment are critical strategies to mitigate infection risk (Jansen et al., 2014).

SMART Goal for Risk for Infection:

By the end of her hospitalization, the patient's indwelling catheter will be maintained using aseptic technique, with daily assessment for signs of infection, and no evidence of urinary tract infection will be observed during her stay.

References

• Dealer, M., et al. (2014). Pressure ulcer prevention: The use of pressure-redistributing surfaces. Nursing Times, 110(6), 20-23.
• Jansen, N., et al. (2014). Catheter-associated urinary tract infections: Pathogenesis, prevention, and management. Infectious Disease Clinics of North America, 28(4), 823-837.
• Krause, M. M., et al. (2018). Nutrition therapy and metabolic support in critically ill patients. Springer Publishing.
• Lyder, C. H., et al. (2011). Pressure ulcers: A review of recent developments. Journal of Clinical Nursing, 20(3-4), 441-445.
• Roberts, S., et al. (2013). Prevention of pressure ulcers in adults. Cochrane Database of Systematic Reviews, (12), CD009618.
• Stephen, J. F., et al. (2017). Preventing pressure ulcers in critically ill patients. Critical Care Nursing Clinics of North America, 29(2), 151-164.
• Thomas, D. R. (2014). Prevention and management of pressure ulcers. Journal of Wound Care, 23(Sup2), S10-S16.
• Wong, S., et al. (2016). Nutritional assessment and support strategies in critical care. Nutrition in Clinical Practice, 31(2), 181-192.
• Yang, Y., et al. (2015). Management of nutrition in critically ill patients. Intensive & Critical Care Nursing, 31(3), 150-157.
• Zerwekh, J., & Claborn, J. (2016). Pathophysiology and care of the critically ill patient. Elsevier.