Sample Care Plan Template Page 27
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51A low BUN could indicate malnutrition or
liver disease/damage. The patient is diagnosed
with malnutrition and upon admission patient
BUN stands for blood, urea, and nitrogen.
7-20
was diagnosed with transaminitis and hepatitis
BUN
The test measures the amount of each in
6 (L)
6 (L)
11
mg/dL
affecting the liver. Also, the CT abdomen
blood serum (Chabner, 2011, p. 990).
showed a fatty liver from the patient’s alcohol
dependency.
0.66-
The test measures the amount of
Patient’s values are within normal limits.
Creatinine
1.25
0.83
0.82
0.81
creatinine in the blood serum.
mg/dL
The test measures the amount of glucose
The patient is on enteral nutrition, which often
74-106
Glucose
present in the blood serum (Chabner,
146 (H)
139 (H)
136 (H)
can cause high blood glucose because of the
mg/dL
2011, p. 991).
high calorie liquid feedings.
The test measures the amount of calcium
8.4-10.2
Patient’s values are within normal limits.
Ca
present in the blood serum (Chabner,
8.4
8.4
8.6
mg/dL
2011, p. 991).
The test measures the amount of MG
1.6 - 2.4
Patient’s values are within normal limits.
Mg
present in blood serum (Chabner, 2011, p.
1.8
1.7
1.7
mEq/L
991).
Result/
Result/
Result/
Pathophysiology: explanation of abnormal
Lab Data
Normal
Description of Lab Test
Date
Date
Date
lab value, including trends and correlation
(per Level)
Value
2/17/13
2/18/13
2/19/13
with disease process
Measures the troponin levels in the blood.
Troponin is released when damage to
0 - 0.1
Patient’s values within normal limits.
Troponin 1
2/13/13: 0.030
heart muscle occurs and is part of cardiac
ng/m
markers tested for MI (Chabner, 2011).
High CK can indicated that there was some
Maker for muscle damage and is used as a
<150
2/12/13: 202 (H); 2/13/13: 180
muscle damage; possibly to the heart. The
CK
cardiac markers tested for MI (Chabner,
U/L
(H)
doctors thought patient might have alcoholic
2011).
cardiomyopathy.
Page 27
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012
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