Altered Urinary Elimination Ineffective Airway Clearance
Incontinence RT q4h prn Ineffective Coping
Accurate I & O ordered Ineffective cough Alprazolam 0.5 mg
BUN CREAT 10L Crackles LLL Wellbutrin 300 mg
Citalopram 20 mg
Inability to meet role expectations
Chronic worry
Altered Nutrition Activity Intolerance
Ht 5'4" Wt 315 Up as tolerated
Low cholesterol/NAS-AHA1 NAS Weakness
Ca+ 7.9L Assistance with ADLs
Impaired activity patterns
Fatigue
Chief Medical Diagnosis: Verbalization of lack of energy
LLL pneumonia, fever, depression, Fever
anxiety, borderline diabetic, htn Depression
Risk for Impaired Skin Integrity Priority assessment: Anxiety
Immobility respiratory status, oxygenation,
Pull-ups for incontinence immobility, BP, pain, mental status
3+ bilateral ankle edema
Risk for Falls Self Care Deficit
Valsartan Unable to bathe without assistance
Pain Assist to chair and commode Unable to transfer to toilet without assistance
3 on a scale of 0-10 Fall precautions
BSC with assist
Uses walker
PMH right hip replacement
BL knee replacement
Risk for Infection
WBC 19.4 H
Lymph 19.6 L