July 5, 2012 Patient Name: L.P.

/ #105-1 Age: 58 Date of Birth: 7/30/1953 Allergies: NKA Code Statue: Full Code Diet: NCS & NAS Diet Recommended refused by patient Patient Information Patient Current Complaint: Patient is recovering from amputation of first digit on right foot. Patient is non compliant with the Drs orders regarding staying off of his foot. Past Medical History: Patient has a history of diabetes mellitus type II; HTN; obesity; gangrenous 1st digit on right foot that resulted in amputation; chronic noncompliance; alcohol withdrawal; Peripheral Artery Disease. Family History: Patient has a daughter who lives locally. Daughter verbalizes understanding of fathers medical needs but is unable to care for him at home. Surgical History: The patient had the right first digit of his foot amputated related to complications of neuropathy associated with diabetes mellitus. Subjective Information: Patient is alert to his surroundings and knows why he is in the facility. The patient denied any pain during the dressing change of the post amputation wound. Patient also denied any pain during the dressing change of the stage 1 diabetic ulcer on his left first digit. Objective Information: Vital Signs: BP 130/50; T 97.3; P 84; R 20; SPO2 96 RA. Foul odor or purulent drainage was not noted during dressing change. The patient has a non blanchable stage 1 diabetic ulcer on the left lateral side of his left first digit. There was 4+ pitting below the knee bilaterally. Patients noncompliance was observed by wound care nurse and student nurse (self). Assessment: Neurological: Patient seemed restless during assessment but agreed when I told him he could leave afterward. Patient is alert and oriented to person, location, and date, and situation. Patient verbalized why he was in the facility but also stated that it was unnecessary for him to be there. PERRLA was observed in but both eyes were sluggish

with accommodation. Pupils are approximately 4 mm bilaterally. Conjunctiva pink and sclera was cloudy. No drainage was noted from eyes, ears, or nose. Respiratory: Patients lung sounds were clear throughout all fields both anterior and posterior. Patient shows no signs or symptoms of respiratory distress. Cardiac: Apical pulse 86; S1/S2, regular rate and rhythm noted. Circulatory: Neck veins flat upon palpation. Radial pulses +2 bilaterally. Capillary refill was <2 bilaterally in hands. No peripheral edema noted bilaterally in hands. Capillary refill could not be assessed on feet due to thick hard toe nails and dry peeling skin around the nails. Pedal pulses located bilaterally and noted at bounding +3. Edema in lower extremities was noted at 4+ bilaterally. Skin on both feet was cool to touch when the dressing was removed. GI/GU: Patient has active bowel sound in all four quadrants. Abdomen is soft and nondistended upon palpation. Patient denied any pain or discomfort upon palpation. Patient is continent of urine and bowel movement. When I asked patient when he last used the bathroom he stated sometime today. Musculoskeletal: Patient requires assistance to transfer between bed and wheelchair due to the recent amputation. Patient ambulates himself throughout the facility throughout in a wheelchair. Integumentary: Patients skin is warm and dry to touch on upper extremities. Patients skin is very dry and peeling on his feet. Patient has an open wound bed on the right great digit of his foot related to a recent amputation. Patient has a stage 1 diabetic ulcer on the first digit of his left foot. Labs: Basic Metabolic Panel: Consists of several tests which I will break down individually. This test gives the physician a general picture of a patients health. Sodium 138 WNL (137-147) may be ordered to determine if a disease or condition involving the brain, lungs, liver, heart, kidney, thyroid, or adrenal glands is causing or being made worse by a sodium deficiency or excess; it may be ordered with other electrolytes Calcium 8.94 WNL (8.7-10.7) - A calcium test is ordered to screen for, diagnose, and monitor a range of conditions relating to the bones, heart, nerves, kidneys, and teeth. Blood calcium levels do not tell how much calcium is in the bones but how much calcium is circulating in the blood. Potassium 3.8 WNL (3.4-5.3) may be ordered to monitor effects of drugs that can cause the kidneys to lose potassium, particularly diuretics; may also be done if someone has a condition or disease, such as acute or chronic kidney failure

Chloride 108 WNL (99-108) - Chloride may be ordered when acidosis or alkalosis is suspected or someone has an acute condition with symptoms that may include the following prolonged vomiting and/or diarrhea, weakness, fatigue or respiratory distress. This test may be ordered regularly when a person is taking medication that can cause an electrolyte imbalance. Blood Glucose 118 >normal limit (60-99) blood glucose is a measurement of the level of sugar in the blood. This test is used to check for diabetes or hypoglycemia. Bicarbonate 22 WNL (22-29) high or low bicarbonate levels suggest the body is having trouble maintaining its acid-base balance or electrolyte balance, perhaps by losing or retaining fluid. Both of these imbalances may be due to a wide range of dysfunctions. BUN 7 WNL (5-20) - BUN test is used, along with the creatinine test, to evaluate kidney function, to help diagnose kidney disease, and to monitor patients with acute or chronic kidney dysfunction or failure Creatinine - .54 <normal limits (.75-1.20) BUN test is used, along with the creatinine test, to evaluate kidney function, to help diagnose kidney disease, and to monitor patients with acute or chronic kidney dysfunction or failure Bun/Creat Ratio 12.96 WNL (8-21) - BUN test is used, along with the creatinine test, to evaluate kidney function, to help diagnose kidney disease, and to monitor patients with acute or chronic kidney dysfunction or failure Nursing Diagnosis #1 Knowledge deficit r/t understanding disease process AEB patients statements to medical staff I keep walking on my foot because it doesnt hurt & refusal of diabetic diet. Short Term Goal #1 Patient will identify an alternative to transfer from bed to wheelchair and back without putting weigh on foot Interventions with Rationales Nurse will talk to PT and ask what the criterion is for a patient to use a slide board. ***If the patient is a candidate for the slide board then the nurse could ask the Dr for a PT consult. A slide board would allow the patient to feel less restricted but protect his foot. Nurse will inquire with patient why he will not use the call light and let an aide assist him with transferring. ***If patient refuses to weight for assistance because of a delay is having is call light answered, that can be addressed with staff. Nurse will consult with PT and ask if patient could use a walker to assist with transfer between bed and chair. ***This would give patient another method to get from bed to chair without assistance. If the PT thinks he would be a candidate, then the nurse will contact the Dr and request a consult for PT.

Evaluation: Goal was partially met. Physical therapy did not think the patient was a candidate for the slide board or walker. PT did say that when his would was more stable it might be an option and they would contact the Dr. The patient did say that his call light took too long so the issue was addressed with staff. In the last 5 days, patient has pushed his light when he wanted up. There are times he would get up on his own before the aide could get to him so the intervention is continued. Short Term Goal #2 Patient will express understanding that he may cause damage to his feet even without feeling pain by end of shift 07/10/12 1700hrs. Interventions with Rationales Nurse will ask the patient if he would watch a video on diabetes education. ***This may prove to be more interesting for the patient than verbally being told to do it. Nurse will offer patient printed diabetes education material (printed in large print) for the patient to read. ***The patient may feel less pressure if he can read the material at his pace. The nurse should offer to assist with reading when initially issuing the material. Nurse will offer to meet with patient and answer any questions that the patient may have. ***This can make the patient feel like he is an important part of his own care. Evaluation: Goal was not met. Patient did agree to and did watch a diabetes education video. Patient stated the video was informative but he wasnt ready to be bed bound when he felt fine. Since there was some progress made with the video the next step will be to try to find other education videos review the goal in another week 7/15/12. Long Term Goal #1 Patient will identify one meal that follows the NCS diet plan that he would follow and implement the plan by 7/23/12 1500hrs. Interventions with Rationales Nurse will provide patient with printed material of what items are included on the NCS diet plan. ***The patient will be able to see how many foods are available instead of what is not available. Nurse will explain to patient the importance that a healthy blood sugar plays in the healing process. ***The patient may relate this to following the diet means he will heal sooner and go home sooner. Nurse will educate patients family about what items are included on the NCS diet plan. ***This allows the family to be involved and still be able to provide food or treats for the patient but in a healthy manner.

Evaluation: Goal met. Patient has identified and implemented one meal a day. It is usually lunch that the patient chooses. The next step is to try to implement a second meal from the NCS diet plan by the next review date of 8/23/12 1500 hrs. Nursing Diagnosis #2 Risk for infection r/t open wound Short Term Goal #1 Patient will identify at least one risk factor for development of infection by end of shift 7/05/12 1500 hrs. Interventions and Rationales Nurse will explain to patient that the open wound on his foot is a source for infection to enter his body. ***Patient needs to be aware that infections that enter the blood stream can be fatal. Nurse will explain to patient the steps he can take to help prevent developing infection. Some things he can do are to not touch the wound; take medication as ordered by his Dr; report any pain or feelings of fever. ***If the patient is aware of some of signs and symptoms then he can report if he feels ill. Nurse will take patients vitals every shift and notify Dr of any temperature over 100. ***A change in vital signs could indicate an infection. If an infection is detected, then treatment can begin immediately. Any positive findings should be reported to Dr. Evaluation: Goal met. Patient identified that if he felt sick he would let the nurse know. The patient verbalized understanding of not touching the wounds. Patient has been compliant with medication as order by Dr. Continue with monitoring vitals and reinforcing positive behavior until next review date. Short Term Goal #2 Patient will verbalize understanding that if his foot does become infected that it will extensively delay his recovery and healing process by the end of the shift 7/05/12 1500 hrs. Interventions and Rationales Nurse will educate patient on the decreased circulation in his lower extremities because of his diabetes and how that effects his bodies healing process. ***The patient needs to be educated that his poor circulation means that his body will not fight an infection quickly. Nurse will educate patients family on the risk of infection and how an infection would impact him because of his poor circulation. ***The patients family may be able to communicate to the patient in a way that we cant. Nurse will provide patient with a printed material regarding how to prevent infection. ***This will give the patient something to refer back to at a later time if he has any questions.

Evaluation: Goal not met. Patient verbalized that he didnt want to stay there any longer so he didnt want to get an infection. The patient then stated that he didnt think he had an infection now because his foot didnt hurt. Nurse will continue to educate the patient on the disease process and review at next review session. Long Term Goal #1 Patients wound will remain without any signs or symptoms of infection by next doctor appointment 7/25/12 0900 hrs. Interventions with Rationales Nurse will administer antibiotics as ordered by Dr. ***Antibiotics decrease the risk of infection developing. Nurse will ensure that wound dressing remains dry and intact throughout shift. ***The dressing staying dry decreases the risk of infection developing. Nurse will assess wound every shift, as ordered per Dr, for signs and symptoms of infection. ***If an infection is detected, then treatment can begin immediately. Any positive finding should be reported do Dr. Evaluation: Goal met. Patient showed no signs or symptoms of infection at wound site at follow up doctor appointment on 7/25/12. Wound is still continuing to heal so continue with above interventions until next review date. Nursing Diagnosis #3 Ineffective coping r/t disease process AEB patients continued noncompliance with doctor and nurse orders Short Term Goal #1 Patient will verbalize one statement of understanding regarding the general diagnosis of diabetes by the end of the week 7/10/12 1700. Interventions with Rationales Nurse will provide patient with literature that would be given to a patient that was just diagnosed with diabetes for the first time. ***Because the patient has been non-compliant for so long it may be of most benefit to start over with him. Nurse will provide patient with a complete copy of the NCS Diet plan. ***All of the material is being provided to the patient as a new diabetic to possibly help him reach a point of acceptance. Nurse will provide patient with the educational information on how diabetes can be managed and how to prevent complications. ***If the patient sees that it is possible to live with diabetes then he may reach a point of acceptance. Evaluation: Goal met. Patient accepted the literature although he did state he had already gotten it before. When later asked if he had any questions, the patient asked do people really live happy with crap. Nurse will continue with the education as there seems to be progress on the part of the patient.

Short Term Goal #2 Patient will consent to regular blood glucose checks as ordered by doctor by the end of the week 7/10/12 1700. Interventions with Rationales Nurse will educate patient regarding the importance of blood sugar checks and balanced sugar. ***This will be the first time that regular blood sugar and healing have been discussed since the reset. Nurse will educate patient that once his blood sugar is regulated that the doctor may not require the checks as often. ***The patient has been so focused on the negative for so long that this in another opportunity to try and redirect him. Nurse will educate patient on the current monitors being used. They require very little blood which means you feel very little if any discomfort. ***Monitors used to be very bulky and painful and many older diabetic remember those. Evaluation: Goal partially met. Patient would not allow the nurse to take his blood sugar early in the morning before breakfast. He said he didnt like being woken up. But the patient was compliant on allowing the nurse to check his sugar at all other time throughout the day. There has been a request sent to the doctor to change the time of the morning check so that it could be done just before he eats instead of waking him up. Long Term Goal #1 Patient will verbalize understanding that walking on his foot is delaying the healing process by follow up doctor visit 7/25/12 0900. Interventions with Rationales Nurse will go talk to physical therapist to learn ways to assist patient with transfer. ***Patient has become more compliant and seems willing to learn. Nurse will consult with wound nurse to find out status of patients healing process. Is the patient at a point that the doctor would approve him bearing just enough weight to pivot or is it too soon. ***Since the patient has made steps in compliance, his wound may have healed some. Nurse will explain to the patient what she is doing but that until they have an answer (or if the answer is no) he needs to remain off his foot so as to not reverse the progress he has made. ***This allows the patient to feel like hes making some progress. Evaluation: Goal met. Patient verbalized understanding that walking on his foot was delaying the healing and has in fact been compliant. The doctor progressed him to have a consult with physical therapy so the interventions will be reviewed after the physical therapy consult.