Answer

NURSING DIAGNOSIS

Diagnosis 1: safety or protection class 1. Risk of infection related to indwelling Foley catheter, the feeding tube, IV catheter, and the bowel incontinence

(Doenges, and Moorhouse, 2012)

Diagnosis 2: safety or protection class 2. Physical injury

risk of impaired skin integrity concerning physical immobilization, moisture, mechanical factors, and impaired circulation.

(Doenges, and Moorhouse, 2012)

Diagnosis 3: Activity/ Reset

Class 2. Activity and exercise

Impaired physical mobility concerning cognitive impairment, activity, intolerance, and prescribed restrictions on movement.

(Doenges, and Moorhouse, 2012)

SMART GOALS

Specific: The main objective is to lower the risk of getting infected while at the hospital. In regards to the current condition of the patient, she’s exposed to various risks related to infection. Failure to protect the patient from infection can lead to sepsis and also death if not treated on time. The healthcare provider and the patient should coordinate to achieve this goal.

Measurability: The infection prevention should be monitored by inspecting and assessing through a lab routine and blood work performed during the patient’s admission period. The goal is considered as achieved after the infection is prevented within the entire stay of the patients at the hospital.

Achievable: The goal is achievable if the healthcare providers follow the protocol for handling infections, using PPE, and maintain hand hygiene. Also, the use of clean equipment should be routine when caring for patients. Resources are available in the hospital.

Relevance: The objective is necessary for infection and sepsis prevention. Several procedures have been performed and the bowel incontinent. The open wounds can be infected if not properly cleaned. The skin integrity gets compromised if the bowel movement is not cleaned appropriately and can enter the vagina or urethra which can bring infection. Thus the goal matches the patient condition.

Timely: the goal timeline is within the patient’s stay at the hospital. The achievement of this goal will be after the infection has disappeared.

(Chulay, Suzanne, Chulay, and Suzanne, 2020)

Specific: The primary objective is to lower the risk for impaired skin integrity. The condition can lead to more complications in the future such as infections, necrosis, and even death. The healthcare specialist and the patient should work together towards achieving this goal. The resources required are medical equipment such as prevalent boots, assistive lift, and calazime cream among others.

Measurability: The patient’s progress should be tracked by inspections, monitoring, and documenting every skin assessment, capillary refill on the fingers, and toes, and pulses on lower extremities. The goal is achieved after the patient’s skin remains intact during their stay in the hospital.

Achievable: the goal is achievable if the healthcare providers follow the protocol for skin integrity maintenance. The repositioning of patients is mandatory since the patient is unconscious. The wrinkle-free sheet is to be maintained and sheering of skin should be prevented. The skin is to be kept dry. The required resources are available in the hospital.

Relevance: The objective is necessary for infection and necrosis of skin prevention, and skin integrity maintenance. The skin is in the front line to defend the body from pathogens entry in the body and therefore must remain intact for successful performance. Open wounds offer a loophole for pathogens entry and infections. The goal is in line with the patient’s needs

Timely: The timeline of this goal last as long as the patient is at the hospital. The goal is achieved after the impairment of skin integrity has disappeared.

(Chulay, Suzanne, Chulay, and Suzanne, 2020)

Specific: The primary objective is to offer assistance in the range of motion and tolerated mobility for easy circulation and mass muscle maintenance for the patient. However, the patient has cognitive impairment but physical movement maintenance and motion range are crucial in reducing stiffness around the joints and muscles, and circulation throughout the body. Both the specialist and the patients should corporate in this plan to achieve the goal.

Measurability: The patient’s progress is tracked through documentation of every session and completion of movement types. The exercise intervals are authorized by the physician and followed by the nurse or therapist. The objective is achieved after the patient’s consciousness and conduct mobility independently.

Achieve: the goal is achievable. Although the assessment and the therapy sessions require monitoring of mobility progress after the bed rest, the patient will be in a safer state than having no therapy.

Relevance: The goal is necessary for stiffness and weakness reductions around the joints and muscles while the patient is unconscious. It also promotes easy circulation of the body and lower extremities. The patient is too young to have immobility issues after gaining consciousness. The goal matches the patient’s conditions.

Timely: the goal timeline matches the patient’s stay at the hospital. The goal is achieved after the patients gain back her consciousness with minimal impaired mobility.