Basic Nursing Care Plan
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You should also list your day 2 labs 21 In order of priority may change for day 2 Priority W TH Nursing Diagnosis 1 1 Impaired Skin Integrity r/t immobility, pressure 2 2 Risk for Infection r/t open wounds 3 3 Risk for Ineffective Tissue Perfusion, peripheral r/t interrupted venous flow secondary to prolonged immobility 4 4 Powerlessness r/t loss of function 5 5 Chronic Sorrow r/t permanent disability 6 6 Chronic Pain r/t disease process 7 7 Disturbed Body Image r/t trauma (quadriplegia) 8 9 10 11 8 9 10 11 Ineffective Protection r/t abnormal blood profile (see labs) Impaired Bed Mobility r/t neuro‐ muscular impairment (classification level 4: does not participate in activity) Imbalanced Nutrition, less than body requirements r/t loss of appetite (wgt: 125 lbs BMI: 20.2) Self‐care Deficit, Include specifics bathing/hygiene, dressing/grooming, toileting r/t neuromuscular impairment Objective Test Data Test Norms Results Dates Interpretation Sodium 135‐145 2‐13: 131 2‐14: 135 Chloride 96‐107 2‐13: 96 2‐14: 102 Slightly decreased due to sweating (febrile x3 days), deficient dietary intake Slightly decreased with sodium loss Potassium 3.5‐5 2‐14: 3.2 Glucose 70‐110 2‐13: 121 BUN 8‐21 2‐13: 5 2‐14: 5 Slightly decreased to sweating, draining wounds, inadequate dietary intake Slightly elevated may be r/t meds Decreased may be due to low protein intake, malnutrition Decreased due to low protein, decreased muscle mass, malnutrition Creatinine 0.5‐1.2 2‐13: 0.4 2‐14: 0.3 Prealbumin 18‐36 2‐13: 17.7 Protein (CSF) 15‐45 2‐13: 45.8 WBC 3‐11 2‐13: 15.4 2‐14: 7.3 Acute infection (cellulitis) MCV 82‐96 2‐13: 80.2 2‐14: 81.7 RBC’s are slightly microcytic Neutrophils 42‐83 2‐13: 88 Acute, localized infection, inflammation Lymphocytes 2‐13: 5 13‐47 2‐14: 6.9 Decreased due to low protein, malnutrition Not significant.. Tablet must be swallowed whole and not crushed, split, or chewed 3.Give with or without food 1.Teach patient about maintaining adequate fluid and fiber intake Side eff
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