A patient has a pressure injury on the sacrum with visible subcutaneous fat and a deep depression below the skin level. What stage of pressure injury would you document?

A. Set a goal to maintain blood glucose levels within normal range: In the planning phase, establishing measurable and achievable goals is the priority. Setting a target for blood glucose guides the development of interventions and provides a benchmark for evaluating the effectiveness of care.

B. Document the patient's blood glucose readings: Documentation is part of the implementation and evaluation phases. While important for tracking trends, it does not establish the direction of care or plan interventions.

C. Teach the patient about carbohydrate counting: Patient education is an intervention that supports achieving the goal, but it cannot be implemented effectively without first defining the desired outcome.

D. Administer insulin as prescribed: Administering insulin is an implementation action. While critical for management, it is guided by the plan and goals set during the planning phase, rather than being the initial planning step.

A. To perform a nutritional assessment only: Nutrition is one component of a comprehensive pediatric assessment, but focusing solely on it does not capture the full scope of health evaluation. Comprehensive assessment addresses multiple body systems and psychosocial factors.

B. To establish a rapport with the child and family: Building rapport is an important part of the assessment process and supports cooperation, but it is a means to an end rather than the primary purpose.

C. To differentiate between expected and unexpected findings to guide diagnostic and management decisions: The primary goal of a comprehensive health assessment is to identify normal versus abnormal physical, developmental, and psychosocial findings. This differentiation directs appropriate diagnostic testing, interventions, and individualized care planning.

D. To evaluate the child's growth and development over time: Monitoring growth and development is a key element of pediatric assessment, but it represents only one aspect of the overall comprehensive evaluation. The primary purpose is broader, encompassing all health dimensions.