Module 04 Written Assignment – Nursing Diagnosis
Purpose of the Assignment
1. Assist students in clustering assessment data when developing a nursing diagnosis.
2. 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 the instructions, write 3 nursing diagnoses in proper format based
on the client case provided below. Write one SMART client-centered outcome for each
m
diagnosis. Consider the client’s medical history and medications.
er as
Kacie Benson, a 19 year-old woman, is a client on your unit as a result of a skiing accident.
co
eH w
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
o.
ROM. She responds to painful stimuli with slight non-purposeful withdrawal. No
rs e
spontaneous movements are noted. The recent lower extremity ultrasound showed no
ou urc
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
o
heels are reddened, but otherwise her skin is intact.
aC s
vi y re
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.
Check out the following links for information about writing SMART goals and to see
examples:
ed d
http://rasmussen.libanswers.com/faq/212524
ar stu
You can find useful reference materials for this assignment in the School of Nursing guide:
https://guides.rasmussen.edu/nursing/referenceebooks
is
Have questions about APA? Visit the online APA guide:
Th
https://guides.rasmussen.edu/apa
sh
, Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis
Domain 11: Domain 11: Domain 4:
Safety/Protection Safety/Protection Activity/Rest
Class 1. Infection- Class 2. Physical Injury- Class 2.
Risk for infection Risk for impaired skin Activity/Exercise
Related to indwelling integrity Impaired physical
foley catheter, tube Related to physical mobility
immobilization, moisture,
feeding, IV catheter, & Related to cognitive
mechanical factors (e.g.,
bowel incontinence impairment, activity
friction, shearing forces,
(Ackley & Ladwig, 2008), intolerance, & prescribed
pressure), & impaired
(Gulanick & Myers, 2014) movement restrictions
circulation
m
(Ackley & Ladwig, 2008),
er as
(Ackley & Ladwig, 2008),
(Gulanick & Myers, 2014)
co
(Gulanick & Myers, 2014)
eH w
SMART Goal SMART Goal SMART Goal
o.
Specific: The goal is to Specific: The goal is to Specific: The goal is to
reduce the risk for
rs e reduce the risk for provide assisted range of
ou urc
infection while in the impaired skin integrity. motion and tolerated
hospital. Based on the Impaired skin integrity mobility for circulation
patient’s current leads to further, more and maintain muscle
o
condition, there are many severe problems, such as mass for the patient.
risks for infection. infection, necrosis, or Although the patient has
aC s
Infection can lead to even death. Patient and cognitive impairment
vi y re
sepsis and possible death healthcare provider are (unconscious), it is
if not treated in time. both involved in important to maintain
Both the patient and achieving this goal. physical movement and
healthcare providers are Resources used are range of motion to
ed d
involved in achieving this medical equipment such reduce stiffness and
ar stu
goal. as prevalon boots and weakness of the joints
Measurable: Prevention sequential compression and muscles. This also
of infection is monitored devices, pillows, assistive helps with circulation
by inspection and lift devices, & calazime throughout the entire
is
assessment and routine cream. body including lower
Th
lab and bloodwork done Measurable: Progress is extremities. Both the
on the patient during tracked by inspecting, patient and healthcare
their admission in the monitoring, and providers are involved
hospital. Goal is achieved documenting skin with this plan of care in
sh
when infection is assessment every shift; achieving this goal.
prevented during the capillary refill on fingers Measurable: Progress is
patient’s entire stay and toes, blanching skin, tracked by documenting
within the hospital. and pulses on lower every session and the
Achievable: Yes, this is a extremities. Goal is types of movement
realistic achievable goal achieved when patient’s completed. How often
as long as healthcare skin integrity remains these exercises are
T
Purpose of the Assignment
1. Assist students in clustering assessment data when developing a nursing diagnosis.
2. 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 the instructions, write 3 nursing diagnoses in proper format based
on the client case provided below. Write one SMART client-centered outcome for each
m
diagnosis. Consider the client’s medical history and medications.
er as
Kacie Benson, a 19 year-old woman, is a client on your unit as a result of a skiing accident.
co
eH w
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
o.
ROM. She responds to painful stimuli with slight non-purposeful withdrawal. No
rs e
spontaneous movements are noted. The recent lower extremity ultrasound showed no
ou urc
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
o
heels are reddened, but otherwise her skin is intact.
aC s
vi y re
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.
Check out the following links for information about writing SMART goals and to see
examples:
ed d
http://rasmussen.libanswers.com/faq/212524
ar stu
You can find useful reference materials for this assignment in the School of Nursing guide:
https://guides.rasmussen.edu/nursing/referenceebooks
is
Have questions about APA? Visit the online APA guide:
Th
https://guides.rasmussen.edu/apa
sh
, Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis
Domain 11: Domain 11: Domain 4:
Safety/Protection Safety/Protection Activity/Rest
Class 1. Infection- Class 2. Physical Injury- Class 2.
Risk for infection Risk for impaired skin Activity/Exercise
Related to indwelling integrity Impaired physical
foley catheter, tube Related to physical mobility
immobilization, moisture,
feeding, IV catheter, & Related to cognitive
mechanical factors (e.g.,
bowel incontinence impairment, activity
friction, shearing forces,
(Ackley & Ladwig, 2008), intolerance, & prescribed
pressure), & impaired
(Gulanick & Myers, 2014) movement restrictions
circulation
m
(Ackley & Ladwig, 2008),
er as
(Ackley & Ladwig, 2008),
(Gulanick & Myers, 2014)
co
(Gulanick & Myers, 2014)
eH w
SMART Goal SMART Goal SMART Goal
o.
Specific: The goal is to Specific: The goal is to Specific: The goal is to
reduce the risk for
rs e reduce the risk for provide assisted range of
ou urc
infection while in the impaired skin integrity. motion and tolerated
hospital. Based on the Impaired skin integrity mobility for circulation
patient’s current leads to further, more and maintain muscle
o
condition, there are many severe problems, such as mass for the patient.
risks for infection. infection, necrosis, or Although the patient has
aC s
Infection can lead to even death. Patient and cognitive impairment
vi y re
sepsis and possible death healthcare provider are (unconscious), it is
if not treated in time. both involved in important to maintain
Both the patient and achieving this goal. physical movement and
healthcare providers are Resources used are range of motion to
ed d
involved in achieving this medical equipment such reduce stiffness and
ar stu
goal. as prevalon boots and weakness of the joints
Measurable: Prevention sequential compression and muscles. This also
of infection is monitored devices, pillows, assistive helps with circulation
by inspection and lift devices, & calazime throughout the entire
is
assessment and routine cream. body including lower
Th
lab and bloodwork done Measurable: Progress is extremities. Both the
on the patient during tracked by inspecting, patient and healthcare
their admission in the monitoring, and providers are involved
hospital. Goal is achieved documenting skin with this plan of care in
sh
when infection is assessment every shift; achieving this goal.
prevented during the capillary refill on fingers Measurable: Progress is
patient’s entire stay and toes, blanching skin, tracked by documenting
within the hospital. and pulses on lower every session and the
Achievable: Yes, this is a extremities. Goal is types of movement
realistic achievable goal achieved when patient’s completed. How often
as long as healthcare skin integrity remains these exercises are
T
