Notes

1) risk for impaired skin integrity related to limited bed mobility and possible bowel incontinence
Subjective data : patient verbalization of feeling fatigued and weak
Objective data : patient is weak and cannot re-position himself , patient has bowel incontinence
Goal : to maintain patient's skin intact
Expected Outcome : patient will not experience pressure sores as evidenced by absence of signs indicating skin irritation, redness, maceration
Nursing Intervention : change position q hr
Patient Action :

2) risk for Imbalanced nutrition: less than body requirements related to anorexia
Subjective data : patient states that he does not feel hungry
Objective data : patient eats very small amount and refuse to eat more
Goal : to prevent nutritional imbalance
Expected Outcome : patient will demonstrate increased appetite by eating an adequate amount of food
Nursing Intervention : encourage exercises to stimulate appetite , provide quiet environment
Patient Action : patient shows increase appetite