Background Information and Demographics
Assessment Findings
Review of Systems
Laboratory Results
Diagnostic Tests & Procedures Performed
Medications
Nursing Diagnosis
- Nursing Dx #1: Risk for Aspiration r/t presence of endotracheal tube
- Nursing Dx #2: Risk for Impaired Skin Integrity r/t immobility
- Nursing Dx #3: Risk for Impaired Oral Mucous Membrane r/t mouth breathing
Interventions, Routine Nursing Management
Interdisciplinary Care: Collaborative Management
Therapeutic Modalities
Nursing Role Reflection