Question

Aa Ada x x Aalbcd Ascend Athenate ANGEL L Altcode ANGEL Body ANGEL ANGEL Prad Moral 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.

3 nursing diagnoses and 3 smart goals

Answer 1

Ans:1)1. Ineffective airway clearance related to upper airway obstruction, by tongue and soft tissues, inability to clear respiratory secretions as evidenced by unclear lung sounds, unequal lung expansion.

2)Risk for complications – pressure sore, contractures, DVT, hypostatic pneumonia, constipation – related to immobility.

3)Imbalanced nutrition – less than body temperature, related to inability to eat and swallow as evidenced by weight and other nutritional parameters less than normal.

4). Self-care deficit-bathing, feeding, grooming, toileting related to unconscious state as evidenced by unkempt and poorly nourished look, bed soiling.

Goals:1)patient will gain consciousness in short time and will do her daily life activity .

2) patient will get out of bed and will done physical activity

3)patient will eat self without tube fee