A.L. is a 68 year-old female who came to the hospital via ambulance because her caregiver noted new onset confusion. A.L

[answerhappygod]

A.L. is a 68 year-old female who came to the hospital via
ambulance because her caregiver noted new onset confusion. A.L. is
paraplegic and spends most of her time in her wheelchair or bed.
Her only past medical history is paraplegia from a skiing accident
in 2012. She has a caregiver 24/7 who assists her with all her
ADL’s. Her baseline orientation is alert and oriented x4 but now in
ED she is only oriented to self.
A.L. is Oriented x1 to self. Lethargic. BP 104/66. Pulse 101. Temp
99F. IV in Left Forearm 20g. Lung sounds are clear. NPO.
Incontinent. A Stage 3 pressure ulcer was noted on her coccyx as
well as MASD (Moisture Associated Skin Damage) in her perineal
area. Labs showed a WBC of 14,000 and a positive UA. She received
1L NS bolus and 1 gram of Rocephin. She will be admitted to the
floor for treatment of her UTI and Pressure Ulcers.
Develop 5 Nursing Diagnosis, no at risk, all must be
actual. Next develop 4 nursing interventions per NANDA, and one
goal per NANDA.