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.
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.
