2) Pain

History of peripheral artery disease

R leg PAD with necrotic tissue and
cellulitis to right foot
incisions to R thigh, R tibia, and R groin
6 days post-op R fem pop bypass, R
femoral endarterectormy w/ patch, R iliac
angioplasty
Patient c/o aching 8/10 pain to R lower
extremity which indicates for needed
nursing intervention
Aspirin
PRN 5-10 mg Oxycodone Q4H
Elevation of R lower extremity

4) Infection
WBC 12.45
R foot cellulitis c erythema and edema present
Necrotic tissue to 1st, 3rd and 4th toe to R foot
Piperracillin/Tazobactam (Zosyn)
Vancomycin
Cefepime

Chief Medical Diagnosis

Diabetes Mellitus Type 2

1) Oxygenation/Decreased Perfusion
RBC 3.4, Hgb 10, Hct 30
cap refill to all extremities < 3 seconds
History of hypertension
History of aortic stenosis
History of peripheral artery disease (PAD)
Aspirin
Warfarin
Enoxaparin (prophylactic Tx)
Incentive spirometer (10 breaths hourly)
CMS intact for bilateral lower extremities
bilateral dorsalis pedis and posterior tibialis
pulses heard upon auscultation by Doppler
ultrasound
ACE wrap to R lower extremity
Elevation of R lower extremity

Impaired Skin Integrity

~ 3 cm incision present to R side of groin, ~ 4 cm incisions
to R thigh and R tibia
no redness, swelling, purulent drainage, or warmth present to
incisions
dry dressing to groin incision with Telfa and paper tape
dry drsg to R thigh & R tibia with Telfa & ACE wrap
redness, swelling & necrotic tissue to R foot

Priority Assessments include:

Alona K Valmoja
N360 Clinical 4/18/2016
5) Impaired Physical
Mobility
Pain to R lower extremity with
activity and movement
R lower extremity weakness
Fatigue
Use of walker
Fall precautions
Bed at lowest position/bed alarm
Use of bedside commode as
indicated
active and passive ROM exercises
Call light within reach of patient

Oxygenation/Decreased Perfusion, Pain,

Unstable Blood Glucose Levels, Infection,
Impaired Mobility, Impaired Skin Integrity
& Activity Intolerance

3) Unstable Blood Glucose Levels

BG 159mg/dL(before breakfast)
BG 257mg/dL(before lunch)
50% of breakfast eaten, 50% of lunch eaten
accu checks TID w/ meals
Insulin Aspart (Novolog Flexpen)
Insulin Glargine (at bedtime)
Pioglitazone Actos, Glimerpiride
Sitagliptin (Januvia)

6) Activity Intolerance
Patient states I feel very tired after
position change from supine to sitting
on side of bed
Weakness/limited mobility to R lower
extremity
Pain to R lower extremity
Patient able to tolerate transfer from
bed to bedside commode, and transfer
from bed to chair
use of walker, assist with ambulation