Question

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. I need 3 Nursing diagnosis for the above scenario. Thanks

Answer 1

Answer:

shock risk

risk of bleeding

high risk of falls

Explanation:

risk of shock: the polytraumatized patient is at risk of presenting severe pain that can lead to neurogenic shock

bleeding risk: patient using anticoagulation

High risk of falls due to Norton scale, patient with very bad clinical condition, stuporous, immobile, bedridden with urinary and fecal incontinence gives a score of 5