Nursing Care Plan For Amputation 3e655g

Student Nurses’ Community

NURSING CARE PLAN ─ Amputation ASSESSMEN T SUBJECTIVE: “I am having a hard time moving some certain parts of my body unlike before” as verbalized by the patient. OBJECTIVE:  Reluctance to attempt movement  Impaired coordination  Decreased muscle strength  V/S taken as follows: T: 37.2 °C P: 80 R: 17 BP: 100/80

DIAGNOSIS

INFERENCE

PLANNING

Impaired physical mobility may be related to loss of limb particularly a lower extremity; pain or discomfort; perceptual impairment.

Amputation is the total or partial surgical removal of an extremity or digit. It is done in cases of inadequate tissue perfusion not responsive to other treatments, such as with diabetes mellitus or other peripheral vascular diseases.

After 4 hours of nursing interventions, the patient will verbalize:  Understandi ng of individual situation, treatment regimen and safety measures  Maintain position of function as evidenced by absence of contracture s  Demonstrat e techniques and behaviors that enable resumption of activities;

INTERVENTIO N Independent:  Provide residual limb care on a routine basis.  Measure circumference periodically  Rewrap residual limb immediately with an elastic bandage  Assist with specified range of motion exercises for both the affected and unaffected limbs  Provide trochanter rolls, as indicated.  Instruct patient to lie prone position

RATIONALE

EVALUATION

 Provides opportunity to evaluate healing and note complications unless covered y immediate prosthesis.  Measurement is done to estimate shrinkage to ensure proper fit of sock and prosthesis.  Edema will occur rapidly, thus delaying rehabilitation.  Prevents contracture deformities, which can develop rapidly and could delay prosthesis usage.  Prevents external

After 4 hours of nursing interventions, the patient was able to verbalize:  Understandi ng of individual situation, treatment regimen and safety measures  Maintain position of function as evidenced by absence of contractures  Demonstrat e techniques and behaviors that enable resumption of activities;

Student Nurses’ Community and  Display willingness to participate in activities.

as tolerated, at least twice a day with pillow under abdomen and lowerextremity residual limb  Demonstrate or assist with transfer techniques and use of mobility aids such as trapeze or a walker. Collaborative:  Refer to rehabilitation team such as physical and occupational therapy and prosthetic specialists.  Provide foam or flotation mattress.

rotation of lower-limb residual limb.  Strengthens extensor muscle and prevents flexion contracture of the hip, which can begin to develop within 24 hours of sustained malpositioning.  Facilitates selfcare and patient’s independence. Proper transfer techniques prevent shearing abrasion/derma l injury related to “scooting”  Provides for creation of exercise and activity program to meet individual needs and strengths and identifies

and  Display willingness to participate in activities.

Student Nurses’ Community mobility functional aid to promote independence.  Reduces pressure on skin and tissues than can impair circulation, potentiating risk of tissue ischemia and breakdown.