Nursing Diagnosis for Musculoskeletal disorder PDF

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Summary

Purpose of Assignment:
Purpose of Assignment:
Familiarity of musculoskeletal disorder is to the nurse. Identification of the different diagnoses are often routine functions of the care delivery team...

Description

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, 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. Check out the following link for information about writing SMART goals and to see examples: http://rasmussen.libanswers.com/faq/212524 You can find useful reference materials for this assignment in the School of Nursing guide: https://guides.rasmussen.edu/nursing/referenceebooks Have questions about APA? Visit the online APA guide: https://guides.rasmussen.edu/apa

Nursing Diagnosis

Nursing Diagnosis

Safety/protection Risk for impaired skin integrity. Related to physical immobilization, moisture, mechanical factor (e.g., friction, shearing forces), & impaired circulation (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014)

Activity /rest Activity Exercise Impaired physical mobility Related to cognitive impairment, activity intolerance, & prescribed movement restriction (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014)

SMART Goal

SMART Goal

Specific; The goal is to reduce the risk for impaired skin integrity, Measurable: Skin progress tracked by inspecting, monitoring and documentation of the skin assessment. Achievable: yes, It is an achievable goal as long as protocol for maintaining skin integrity is followed by the healthcare provider: like keep skin dry, repositioning the patient because patient is on bedrest. Relevant: This goal is important to maintain skin integrity: to prevent infection and damage the skin. Timely; This goal will be in place until patient is discharged from the hospital Ackley & Ladwig, 2008), (Gulanick & Myers, 2014

Specific; The goal is to provide passive ROM and tolerated mobility for circulation to maintain muscle mass for the patient. Measurable: This is tracked by documenting every session completed. Achievable: This is achievable. physical therapy session may be required to monitor progress. Relevant: This goal is important to reduce stiffness and weakness of the joints and muscle. It also helps with circulation. Timely: This goal will remain in place until patient discharged from the hospital. Ackley & Ladwig, 2008), (Gulanick & Myers, 2014

Reference

Nursing Diagnosis Safety/Protection Infection-Risk for Infection related to indwelling foley catheter, tube feeding, IV catheter, & bowel incontinence (Ackley & Ladwig, 2008), (Gulanick & Myers, 2014)

SMART Goal Specific: The goal is to reduce the risk for infection while in the hospital. Measurable: prevention of infection is monitored by inspecting and assessing routine lab and blood work done on the patient in the hospital. Achievable: This is achievable as far as the infection prevention protocol is followed. Relevant: This goal is important to prevent infection. Timely: This goal will be in place until patient is discharged from the hospital. Ackley & Ladwig, 2008), (Gulanick & Myers, 2014

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: an evidence- based guide to planning care. St Louis, MO: Mosby Elsevier. Gulanick, M., & Myers, J. L. (2014). Nursing care plan: diagnosis, interventions, and outcomes. Philadelphia, PA: Elsevier/Mosby.

Module 04 Written Assignment – Nursing Diagnosis Rubric Total Assessment Points - 35

Levels of Achievement Competence

Proficiency

Mastery

Nursing diagnoses are insufficient Nursing Diagnosis and/or do not fit the data. (should fit the Failure to submit data) Nursing Diagnosis will result in zero (10 Pts) points for this criterion. Points – 7

Writes ONE NANDA-I approved nursing diagnosis in the correct format (including related to/as evidenced by) with a strong connection to identified data. Points – 8

Writes TWO NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data. Points - 9

Writes THREE NANDA-I approved nursing diagnoses in the correct format (including related to/as evidenced by) with a strong connection to identified data. Points - 10

The goals meet few SMART goal SMART Goal guidelines and/or are (should reflect the not related to the nursing diagnoses. diagnosis and follow guidelines) Failure to submit SMART goals will result in zero points (15 Pts) for this criterion. Points – 11

Writes ONE goal for ONE nursing diagnosis and the goal meets all the SMART goal guidelines and are related to the nursing diagnosis.

Writes ONE goal for TWO nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses.

Writes ONE goal for THREE nursing diagnoses and the goals meet all the SMART goal guidelines and are related to the nursing diagnoses.

Points - 12

Points - 13

Points – 15

Some spelling and grammar errors, which detract from the audience's ability to comprehend material.

Few spelling and grammar errors.

Minimal to no spelling and grammar errors.

Criteria

Spelling and Grammar (5 Pts)

Emerging

Numerous spelling and grammar errors, which detract from the audience's ability to comprehend material.

APA Citation (5 Pts)

Points: 2

Points: 3

Points: 4

Points: 5

APA in-text citations and references are missing.

Attempted to use APA in-text citations and references.

APA in-text citations and references are used with few errors.

APA in-text citations and references are used correctly.

Points: 2

Points: 3

Points: 4

Points: 5...