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Sonia Best 56 years old woman who will undergo a below the knee amputation as a result of a complicated diabetic foot ulcer, She is divorced. Patient check in : Her foot got a massive wound in it and she has to get a below-the-knee amputation. Patient is comfortable. She takes insulin, glargine and Aspart and Dapagliflozin, for her diabetes. Her heart medication is Aspirin and Rosuvastatin for her cholesterol. Patient is physically fine, except for the obvious. She has never been more depressed, though. She is worried about what might happen during the operation and sad she is going to lose her leg Past medical history: She has diabetes, coronary artery disease, and PVD. She also has this ulcer on her foot, which is why she is scheduled for amputation today. She is feeling as comfortable as she can given the circumstances, she will like some water when i get a changes. Personal Health: She doesn’t have any problem with elimination. She requested for assistance to the bathroom before I go. The pain is like a deep painful ache, it is at a 3 right now on a scale of 10. As long as she does not mess with her foot, she is ok. She has really taken much for the pain, she just handle it. She doesn’t know if she is coping. She has spoken to her counsellor about it, but she’s not necessarily an expert in helping people cope with the loss of a limb. She’s recommended maybe I should see a psychiatrist. She doesn’t know about that. She doesn’t have any religious preferences. Past Medical History: She doesn’t have any allergies.She has foot ulcer because of her diabetes. She has coronary artery disease and she has peripheral vascular disease. She has type 2 diabetes. She takes diabetes medication, takes her glucose and eats healthy. Social History: She is close with family and the members of her church community. She has a couple gardening friends, and she is close with people in the local Bajan community as well. She lives alone. She smoked cigarettes for a long time. She stopped 6 months ago, It is deadly habit, she figured out that she’s getting more serious about managing her health. That was a logical step. She doesnt take illicit drugs. She drinks alcohol occasionally. She takes one or maybe two glasses of wine a couple times a week. She haven’t smoked marijuana in a long time. She did start taking edibles recently. She smoked marijuana for about 36 years, and she quit 6 months ago. She started using marijuana edibles a few months ago. She does not remember the dose of the edibles but she know it’s not very much… she said she is a lightweight. Home Medications: She takes insulin, glargine and Aspart and Dapagliflozin, for her diabetes. Her heart medication is Aspirin and Rosuvastatin for her cholesterol. Patient didn’t really feel like going through the medication dosage list. She said she takes her medicine as approved Review of Systems: Her temperature has been fine. She haven’t had night sweats, chills or anything like that. She doesn’t feel all that tired even with the wound on her feet getting worse. She said her health is bad. She’s here for amputation. She thought she was doing what she had to do to prevent this, but apparently it wasn’t enough. The stress over my health has kept me up a lot of nights in the past couple of weeks. She has peripheral vascular disease and coronary artery disease. She has no chest pain and palpitations. She is breathing fine. No nausea, no vomiting, no constipation, and no abdominal pain noted. Auscultated Breath Sounds: Clear in all areas with no adventitious sounds Auscultated Heart sounds: S1 and S2 audible with regular rate and rhythm and no extra sounds. Palpated Bowel sounds: Normoacfive bowel sounds in all the quadrants Inspected surgical site: Initials and site markings are on the correct site according to the patient’s report and EHR. Inspected Ulcer: Wound is open, erythematous and necrotic. Dressing is clean, dry and intact with no drainage. Wound size is measured at 5cm x 5cm. No tunneling is present. As a nurse after a comprehensive assessment. Give a comprehensive subjective and objective data

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