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Nursing Diagnosis 3: Risk for Cardiovascular Disease Evidence: -High blood pressure on assessment -History of hypertension -History of diabetes -History of stroke -History of smoking -Daughter of the pt reports pt is not taking medications at home. -Current medication is not decreasing blood pressure to a safe range.

Nursing Diagnosis 1: Ineffective Pain Management Evidence: -Pt stating pain is 9/10 to leg and is 6-7/10 after giving PRN medications. -Pt taking narcotic pain medication 3-5x a day. -Pt becoming sedated after receiving pain medication but stating pain has not decreased.

Home Care Support Home care assists people in completing activities of daily living such as bathing and dressing and also help patients with thing such as dressing changes. The patient will benefit from home care support to change her stump dressings, assess her foot and stump for wounds and healing of her incision, and help her with ADLs such as bathing.

Glenrose Amputation Rehabilitation Referral The Amputation rehabilitation program provides rehab services for adults who have had an amputation (1). These services include physical, emotional, psychosocial, and spiritual needs of the person who has had an amputation (1). this program referral would be helpful to the patient because adjusting to life with an amputation can be hard and having a program to guide the patient along the way to recovery and adaptation to the loss of her leg would be beneficial to her physical and mental health.

Physiotherapy Physio is an important part of the rehabilitation process after a person has an amputation. Physiotherapists can work with the patient to help them achieve safe and proper physical mobility (6). Furthermore, physio can teach amputees range of motion exercises to maintain their muscle strength and prevent any abnormal rotation, flexion, or contracture of the extremity amputation (6). For this patient, physio's work can help the patient to adjust to the new way she will have to mobilize and do so safely. At present, physio has identified that this patient is weak and unsteady while mobilizing and will need further work to gain stability and strength while using her one leg.

Priority 1: Ineffective Health Management r/t hypertension and diabetes aeb increased blood glucose levels, progression of diabetes to affecting other organs, family reports of patient forgetting medications, and consistently high blood pressure. (Wittmann-Price, 2017). Evidence: -Had amputation due to diabetic foot ulcer -Pt has slightly high blood glucose levels -Pt lab values signify diabetes have been causing damage to kidneys -Vital signs show high BP -Daughter concerned that pt has not been taking home medications or caring for herself well at home alone. -Presence of confusion and forgetfulness

Nursing Diagnosis 7: Impaired Gas Exchange (Siela, 2017). Evidence: -Pt is on 2L nasal prongs and is not on oxygen at home. -Pt underwent surgery and had general anesthetic. -At present, patient's O2 sats drop to mid 80's when on room air. -Pt taking narcotics which suppress respiratory system

Nursing Diagnosis 4: Confusion Evidence: -Daughter stating patient has been confused at home and forgetting medication. -Assessment of pt seeing "exes" in room when no one was present.

Nursing Diagnosis 5: Risk for Impaired Skin Integrity (Zulkowski, 2017). Evidence: -Patient is currently spending more time in bed and her wheel chair because she has a hard time mobilizing after her amputation. -Diabetes impedes wound healing. -Pt already had a diabetes related ulcer that led to her amputation.

Priority 2: Impaired Physical Mobility r/t recent below the knee amputation aeb presence of one leg, unsteady mobility, lack of motivation to mobilize without nursing prompts, decreased strength while mobilizing, need for assistance by 2 nurses while transferring to chair. (Pomeroy, 2017). Evidence: -Has an amputated leg. -Pt is unsteady while transferring. -Pt needs assistance to mobilize. -Pt is not moving much without being prompted.

Nursing Diagnosis 6: Risk for Falls (Greenberg, 2017). Evidence: -Pt only has one leg. -Pt's amputation is new and she is not used to it. -Pt poorly transferring with help from 2 nurses. -Pt appears unsteady when transferring.

Nursing Diagnosis 2: Activity Intolerance (Duggan, 2017). Evidence: -Fatigue -Sedation from pain medications. -Pt has to be assisted by 2 nurses when transferring. -Pt appears tired after pivot transferring from bed to wheel chair -Physiotherapy

Socioeconomic Factors - Lives in an apartment alone - Has 4 children. 2 of which are in Grande Prairie. - Children are not willing to help her with care. - Family concerns regarding whether the pt is safe and can care for herself if she is discharged home. - Pt refusing long term care placement. - Not known if pt has a significant other - Not known if patient is employed.

Health History -Stroke in 2014 -Hypertension -History of smoking -Type 2 diabetes -History of stomach ulcers -Hypothyroidism

Medications Scheduled: *Gabapentin 300mg PO BID: This anitconvulsant medication can be used to decrease seizures and may also be used to decrease neuropathic pain (7). For this patient, she is using the medication to control her pain related to diabetic peripheral neuropathy (7). Sennosides 8.6mg PO QHS: This medication is a stimulant laxative that helps promote regular bowel movements by increasing the amount of water in the large intestine and increasing peristalsis (7). This patient has been taking this medication to ensure she is having regular bowel movements. Having the patient regularly take a laxative helps to prevent constipating effects of other medications that the patient is taking (7). PEG PO daily: This osmotic laxative works to promote regular bowel movements by drawing water into the GI tract (7). The patient is taking this medication to prevent constipation related to side effects of her other medications, such as hydromorphone (7). Tinzaparin 4500U SC Daily x14 days: This anticoagulant is given post-operatively to prevent the patient from developing any blood clots (3). This patient is taking the medication for the same reason; she has had an operative and the doctor wants to prevent blood clots from forming. Ancef 2g IV Q8h x2 doses: Also called cefazolin, this antibiotic is used post-operatively to prevent any infections from occurring (7). This patient is taking an antibiotic to prevent her amputation incision from becoming infected with bacteria. *Levothyroxine 125mcg PO daily: This hormone medication is commonly used in people with hypothyroidism to supplement lost thyroid hormones (7). The patient has been diagnosed with hypothyroidism and therefore takes this medication to ensure adequate hormone balance (7). *Metformin 1000mg PO BID: An antidiabetic medication used commonly as first line treatment for people with type 2 diabetes (7). It can also be used in conjunction with insulin, healthy diet, and other oral hypoglycemic medications to adequately control glucose levels within the body (7). This patient has type 2 diabetes that she has been controlling with the use of this oral medication. *Telmisartan 40mg PO daily: This angiotensin II receptor antagonist medication is used to decrease high blood pressure (7). It can also be used to prevent heart attack, stroke, and cardiovascular problems in people >55yrs old (7). This patient has hypertension as well as a history of stroke and therefore this medication is being used to control her hypertension and prevent future strokes from occurring (7). PRN: Hydromorphone 1-2mg IV/IM/SC Q3h: This medication is an opioid analgesic that relieves moderate to severe pain by binding to opioid receptors in the central nervous system (7). The patient is experiencing pain associated with the surgery she recently received and is therefore ordered this medication to alleviate her pain. The patient typically has been using this medication 3-5x per day during her time at the hospital so far. Tylenol #3 PO Q4h: This analgesic medication is used to relieve mild to moderate pain (7). This is another option the patient can use for pain relief. The patient is on this medication for pain relief associated with her recent surgery however should not be ordered/given this medication because she has said that she is allergic to codeine. Zofran 4-8mg IV Q6h: This antiemetic medication prevents nausea and vomiting (7). The patient may take this medication should she experience nausea from her surgery (7). Maxeran 10-20mg IV/IM/PO Q4h: Another type of antiemetic medication used in hospital for nausea and vomiting (7). The patient may ask for this medication should she experience any post operative nausea/vomiting.

Admitting Diagnosis Patient M.B has been admitted to the hospital for a right below the knee amputation. This surgery was performed because the patient had a diabetes related wound on her foot that was not healing and was instead causing further damage to her leg.

Assessment Vitals: 0800 vitals: 1200 vitals: BP 175/82 BP 175/90 HR 83 HR 86 Temp 37.2 Temp 36.6 SpO 94% on 2L NP SpO 94% on 2L NP Resps 16 Resps 16 Neuro: Patient is oriented x3 during morning assessment. However later in the day it was noted by dayshift nurse that pt was confused at times, stating that she sees her "two exes" standing in the room when there were no visitors present in the room. Patient rouses to verbal stimulation but appeared drowsy, noted by nurse to fall asleep during assessment. In conversation with the patient's daughter, she stated that the pt has been confused for a while and believes the patient is forgetting to take her home medications. During the day it was noted that the patient would become increasingly fatigued after receiving pain medications. Respiratory: Breath sounds are free and easy. Lung sounds are clear with decreased air entry to bases. The patient denies having a cough and nurse did not observe same during assessment. No shortness of breath noted. Noted by nurse that pt's SpO2 would drop between 85-89% when the patient was off of her O2. Cardiovascular: Radial pulse palpable x2 and is regular and strong. Pedal pulse palpable and strong on left foot and not applicable on the right. Right popliteal pulse palpable and strong. Cap refill is less than 3 seconds on hands bilaterally and in left foot. Gastrointestinal: Abdomen is soft and non-tender. Bowel sounds heard in all 4 quadrants. Patient states last bowel movement was "a few days ago". Pt is voiding in the bathroom with no concerns. Patient states she is passing gas and burping and denies any nausea/vomiting. Pt is diet as tolerated. Skin: Skin is dry, warm, and natural in colour. +1 non-pitting edema noted to the right leg stump. Musculoskeletal: Pt upper extremities have good range of motion and no lesions or bruises notes. Pt has a right below the knee amputation and adequate ROM of her right knee. Left leg has decreased ROM. Patient denies any numbness or tingling in her extremities. Pt states "I feel like my right leg is still there, it feels painful sometimes". Pt is full weight bearing and uses a two wheel walker and a wheel chair to mobilize. Pt is unsteady and weak when mobilizing and cannot tolerate being on her feet for very long. Patient is pivot transferring from her bed to wheelchair with assistance from 2 nurses. Pain: Pain is rated in the morning as a 9/10 to her right stump. The pain is only in her stump and is described by the patient as being constant pain. Patient also describes that she can feel as though her pain is extending into her right leg and foot although that limb has been amputated. After receiving narcotic medication for pain, the patient says her pain has not decreased much, rating it a 6-7/10. Patient appears sedated and fatigued after narcotics are given. IV: Patient's IV is located on her right arm and is saline locked between IV antibiotics. Her IV site appears healthy with no redness, pain, or swelling. Dressing: Dressing to her right stump is dry and intact. No blood is shadowing through the dressing. Glucometer: The patient's blood sugar over 2 days was: Sept 15 Sept 16 0730: 9.0mmol 0730: 8.8mmol 1130: 9.7mmol 1130: 11.3mmol 1630: 9.4mmol 1630: 10.4mmol 2200: 10.4mmol

Lab Values Creatinine: 115 Creatinine is a a lab test that measures the amount of creatinine in the blood to diagnose impaired renal function (5). Creatinine is a waste product that comes from skeletal muscle contractions (5). Creatinine is excreted by the kidneys, therefore, this measurement can tell us how well the kidneys are filtering (5). A normal creatinine level for a female is between 44-97mcmol/L (5). The patient has an above average creatinine, meaning that her kidney function is impaired. An abnormal elevation in creatinine is caused by renal disorders such as pyelonephritis, urinary obstruction, or diabetic nephropathy (5). This lab value relates to the patient because she has chronic diabetes which has started to damage her kidneys (5). Measuring this lab value is important for this patient because it tells health care providers (HCPs) of the progression of the patient's diabetes and how the illness has been affecting other organ systems. GFR: 43 The glomerular filtration rate is a lab test that measures the level of kidney function within a person's body and determines stages of kidney disease (4). The GFR measures how fast the kidneys are filtering the blood (5). A normal GFR for a 66yr old female is 85 (5). The patient's GFR level is below normal range and signifies a moderate loss of kidney function (4). In relation to the patient, this lab value is important because a decrease in GFR is a sign of diabetic nephropathy, a complication of unmanaged diabetes (2).

Concept Map for M.B - 66yr old aboriginal female - Admitted on 13/9/19 - full code status - allergies to codeine and morphine