The nurse in the intensive care unit is caring for a 78 year old male who has experienced weight loss of 15 pounds, decreased mobility, and has had loss of appetite. A complete skin assessment reveals stage 1 pressure injury over the coccyx. The client is receiving parenteral nutrition, was placed on a pressure reducing mattress, had barrier cream placed to his stage 1 pressure injury, is repositioned hourly ,and mobilized once a shift. Physical Therapy has assessed the client and is working on his strength and mobility. The client is alert and oriented to person, place, time, and situation. Muscle strength is normal in upper and lower extremities equal bilaterally.
Highlight the assessment findings in the table below that demonstrate that the interventions have been effective:
| Body System | Assessment Findings |
| Neurological | Client is alert and oriented to person, place, time, and situation. Muscle strength normal in upper and lower extremities equal bilaterally. |
| Integumentary | Client’s skin has no evidence of deterioration or additional injuries that were not present on admission |
| Cardiovascular | S1 and S2 auscultated, S3 appreciated; radial and pedal pulses palpable, +2 bilaterally; capillary refill less than 3 seconds in upper and lower extremities; +1 non-pitting edema found in bilateral lower extremities. |
| Gastrointestinal | Abdomen flat, nondistended. Bowel sounds present in all four quadrants. No pain on palpation. |
| Musculoskeletal | Increased muscle strength and balance. |