A man was involved in a motor vehicle accident yesterday. He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator
Which of the following would be an appropriate nursing diagnosis for him at this time?
a. Risk for Infection related to subcutaneous injuries
b. Risk for Impaired Skin Integrity related to immobility
c. Impaired Tissue Integrity related to ventilator dependency
d. Impaired Skin Integrity related to ventilator dependency
B
This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state. Thus, he is unable to turn himself to relieve pressure. There is no mention of subcutaneous injuries, ruling out Risk for Infection related to subcutaneous injuries. Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.
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