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A 6-year-old male with cerebral palsy is hospitalized for respiratory distress secondary to aspiration pneumonia. During the patient’s third day in ICU, he remains ventilated and sedated. During a skin assessment, the nurse notes an open area on the patient’s occiput with the skull visible. During handoff, it was reported that the skin was intact. Upon review of the original assessment, there is no documentation of any open areas.
One applicable nursing diagnosis related to tissue trauma
A measurable, time-specific and realistic outcome for the identified nursing diagnosis
One nursing intervention (something the nurse does, interventions cannot be to assess)
Make sure to include a well-developed question that fosters additional thought and conversation
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