| 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 |