Items

Assessment categories

Information included in the case

Information not included in the case

Conclusions and reasons

Nutrition

Low TP

Height/weight

Low ALB

Skin

Low Hb

Intravenous drip

Eating half of a meal

Patient’s perception of nutrition

Calorie intake is half

Saying “I might not be hungry because I do not walk”

Activity level

Usually in a dorsal position on the bed

Scar pain

Patient can walk around the ward freely

Constipation

No stool for 3 days

Liquid intake

Problems and factors of the issues

Loss of appetite

Low activity level

Constipation

Imbalanced nutrition: less than body requirements

Bedsores

Pressure on the same parts of the body for a long time

Bedsores skin around sacrum

He can walk by himself

Low nutrition

Low risk of impaired tissue integrity/progress surveillance

Infections

High CRP

Infection

He was treated with lung lobectomy 5 days ago

Low nutrition

Vital signs

Red/flushed

Normal reaction for surgery

Scar pain

Scar intention

Score

13

13

8