Amputation and 4 Amputation Nursing Care Plans and Nursing Diagnosis

Amputation and 4 Amputation Nursing Care Plans and Nursing Diagnosis

This guide is about Amputation and 4 Amputation Nursing Care Plans and Nursing Diagnosis. It can be employed in the creation of amputation nursing care plans for educational purposes.

Amputation

What is an Amputation?

Amputation and 4 Amputation Nursing Care Plans and Nursing Diagnosis
Amputation

In general, the amputation of limbs is the result of trauma, peripheral vascular disease, tumors, and congenital disorders. For the purpose of this plan of care, amputation refers to the surgical/traumatic removal of a limb. Upper extremity amputations are generally due to trauma from industrial accidents. Reattachment surgery may be possible for fingers, hands, and arms. Lower-extremity amputations are performed much more frequently than upper-extremity amputations.

Five levels are currently used in lower-extremity amputation: foot and ankle, below the knee (BKA), knee disarticulation and above (thigh), knee-hip disarticulation; and hemipelvectomy and translumbar amputation. There are two types of amputations: (1) open (provisional), which requires strict aseptic techniques and later revisions, and (2) closed, or “flap.”

4 Amputation Nursing Care Plans and Nursing Diagnosis

Amputation and 4 Amputation Nursing Care Plans and Nursing Diagnosis
4 Amputation Nursing Care Plans and Nursing Diagnosis

How do you diagnose and care for an amputation?

Nursing care planning for patients who had an amputation includes: support psychological and physiological adjustment, alleviate pain, prevent complications, promote mobility and functional abilities, provide information about surgical procedure/prognosis and treatment needs.

Here are four (4) nursing care plans and nursing diagnosis for amputation:

  1. Impaired Physical Mobility
  2. Risk for Infection
  3. Risk for Ineffective Tissue Perfusion
  4. Situational Low Self-Esteem

1. Impaired Physical Mobility

Nursing Diagnosis

  • Impaired Physical Mobility

Related to: 

  • Loss of a limb (particularly a lower extremity); pain/discomfort; perceptual impairment (altered sense of
  • balance)

Possibly evidenced by

  • Reluctance to attempt movement
  • Impaired coordination; decreased muscle strength, control, and mass

Desired Outcomes: 

  • Client will verbalize understanding of the individual situation, treatment regimen, and safety measures.
  • Client will maintain a position of function as evidenced by the absence of contractures.
  • Client will demonstrate techniques/behaviors that enable resumption of activities.
  • Client will display willingness to participate in activities.
Types of Lower Extremity Amputations
Impaired Physical Mobility
Nursing Interventions Rationale
Encourage patient to perform prescribes exercises. To prevent stump trauma.
Provide stump care on a routine basis: inspect the area, cleanse and dry thoroughly, and rewrap stump with an elastic bandage or air splint, or apply a stump shrinker (heavy stockinette sock), for “delayed” prosthesis. Provides an opportunity to evaluate healing and note complications (unless covered by immediate prosthesis). Wrapping stump controls edema and helps form stump into a conical shape to facilitate the fitting of the prosthesis.
Measure circumference periodically Measurement is done to estimate shrinkage to ensure proper fit of sock and prosthesis.
Rewrap stump immediately with an elastic bandage, elevate if “immediate or early” cast is accidentally dislodged. Prepare for reapplication of the cast. Edema will occur rapidly, and rehabilitation can be delayed
Assist with specified ROM exercises for both the affected and unaffected limbs beginning early in the postoperative stage. Prevents contracture deformities, which can develop rapidly and could delay prosthesis usage.
Encourage active and isometric exercises for the upper torso and unaffected limbs. Increases muscle strength to facilitate transfers and ambulation and promote mobility and more normal lifestyle.
Maintain knee extension. To prevent hamstring muscle contractures.
Provide trochanter rolls as indicated. Prevents external rotation of lower-limb stump
Instruct patient to lie in the prone position as tolerated at least twice a day with a pillow under the abdomen and lower-extremity stump. Strengthens extensor muscles and prevents flexion contracture of the hip, which can begin to develop within 24 hr of sustained malpositioning.
Caution against keeping the pillow under a lower-extremity stump or allowing BKA limb to hang dependently over the side of bed or chair. Use of pillows can cause permanent flexion contracture of the hip; a dependent position of stump impairs venous return and may increase edema formation.
Demonstrate and assist with transfer techniques and use of mobility aids like trapeze, crutches, or walker. Facilitates self-care and patient’s independence. Proper transfer techniques prevent shearing abrasions and dermal injury related to “scooting.”
Assist with ambulation. Reduces the potential for injury. Ambulation after lower-limb amputation depends on the timing of prosthesis placement.
Instruct patient in stump-conditioning exercises. Hardens the stump by toughening the skin and altering feedback of resected nerves to facilitate the use of the prosthesis.
Refer to the rehabilitation team. Provides for the creation of exercise and activity program to meet individual needs and strengths, and identifies mobility functional aids to promote independence. Early use of a temporary prosthesis promotes activity and enhances general well-being and positive outlook.
Provide foam or flotation mattress. Reduces pressure on skin and tissues that can impair circulation, potentiating the risk of tissue ischemia and breakdown.

2. Risk for Infection

Nursing Diagnosis

  • Risk for Infection

Risk factors may include

  • Inadequate primary defenses (broken skin, traumatized tissue)
  • Invasive procedures; environmental exposure
  • Chronic disease, altered nutritional status

Desired Outcomes

  • Achieve timely wound healing; be free of purulent drainage or erythema, and be afebrile.
Nursing Interventions Rationale
During emergency treatment, monitor vital signs (especially in hypovolemic shock), clean the wound, and give tetanus prophylaxis, and antibiotics as ordered. To prevent skin infection.
After a complete amputation, wrap the amputated part in wet dressing soaked in normal saline solution. Label the part, seal it in a plastic bag, and float the bag in ice water. So that it is not inadvertently discarded.
Flush the wound with sterile saline solution, apply a sterile pressure dressing. Prevent introduction to bacteria.
Maintain aseptic technique when changing
dressings and caring for the wound.
Minimizes opportunity for the introduction of bacteria.
Inspect dressings and wound; note characteristics of drainage. Early detection of developing infection provides an opportunity for timely intervention and prevention of
more serious complications.
Maintain patency and routinely empty drainage device. Hemovac, Jackson-Pratt drains facilitate removal of drainage, promoting wound healing and reducing the risk of
infection.
Cover the dressing with plastic when using the bedpan or if incontinent. Prevents contamination in lower-limb amputation.
Expose stump to air; wash with mild soap and water after dressings are discontinued. Maintains cleanliness, minimizes skin contaminants, and promotes healing of tender and fragile skin.
Monitor vital signs. Temperature elevation and tachycardia may reflect developing sepsis.
Obtain wound and drainage cultures and sensitivities as appropriate. Identifies the presence of infection and specific organisms and appropriate therapy.
Administer antibiotics as indicated. Wide-spectrum antibiotics may be used prophylactically, or antibiotic therapy may be geared toward specific organisms.

3. Risk for Ineffective Tissue Perfusion

Nursing Diagnosis

  • Risk for Ineffective Tissue Perfusion

Risk factors: 

  • Reduced arterial/venous blood flow; tissue edema, hematoma formation
  • Hypovolemia

Desired Outcomes: 

  • Client will maintain adequate tissue perfusion as evidenced by palpable peripheral pulses, warm/dry skin, and timely wound healing.
Nursing Interventions Rationale
Monitor vital signs. Palpate peripheral pulses, noting strength and equality. General indicators of circulatory status and adequacy of perfusion.
Perform periodic neurovascular assessments (sensation, movement, pulse, skin color, and temperature). Postoperative tissue edema, hematoma formation, or restrictive dressings may impair circulation to stump, resulting in tissue necrosis.
Inspect dressings and drainage device, noting amount and characteristics of drainage. Continued blood loss may indicate the need for additional fluid replacement and evaluation for coagulation defect or surgical intervention to ligate bleeder.
Apply direct pressure to the bleeding site if hemorrhage occurs. Contact the physician immediately. Direct pressure to the bleeding site may be followed by application of a bulk dressing secured with an elastic wrap once bleeding is controlled.
If the patient experiences throbbing after the stump is wrapped, the bandage may be too tight. Remove the bandage and reapply. Throbbing indicates impaired circulation.
Check the bandage regularly. To prevent further complication.
Investigate reports of persistent or unusual pain in the operative site. A hematoma can form in muscle pocket under the flap, compromising circulation and intensifying pain
Evaluate non-operated lower limb for inflammation, positive Homans’ sign. Increased incidence of thrombus formation in patients with preexisting peripheral vascular disease and diabetic changes.
Monitor laboratory studies: Hb and Hct. Indicators of hypovolemia and dehydration that can impair tissue perfusion.
Monitor PT and activated partial thromboplastin time (aPTT). Evaluates need and effectiveness of anticoagulant therapy and identifies developing complication such as posttraumatic disseminated intravascular coagulation (DIC)
Encourage and assist with early ambulation. Enhances circulation, helps prevent stasis and associated complications. Promotes a sense of general well-being.
Administer IV fluids and blood products as indicated. Maintains circulating volume to maximize tissue perfusion.
Apply antiembolic and sequential compression hose to the non-operated leg, as indicated. Enhances venous return, reducing venous pooling and risk of thrombophlebitis.
Administer low-dose anticoagulant as indicated. May be useful in preventing thrombus formation without increasing the risk of postoperative bleeding and hematoma formation.

4. Situational Low Self-Esteem

Nursing Diagnosis

  • Situational Low Self-Esteem

May be related to

  • Loss of body part/change in functional abilities

Possibly evidenced by

  • Anticipated changes in lifestyle; fear of rejection/reaction by others
  • Negative feelings about the body, focus on past strength, function, or appearance
  • Feelings of helplessness, powerlessness
  • Preoccupation with a missing body part, not looking at or touching the stump
  • Perceived change in usual patterns of responsibility/physical capacity to resume the role

Desired Outcomes

  • Client will begin to show adaptation and verbalize acceptance of self in the situation (amputee).
  • Client will recognize and incorporate changes into self-concept in an accurate manner without negating self-esteem.
  • Client will develop realistic plans for adapting to new role/role modifications.
Nursing Interventions Rationale
Assess and consider patient’s preparation for and view of amputation. Research shows that amputation poses serious threats to the patient’s psychological and psychosocial adjustment. Patient who views amputation as life-saving or reconstructive may be able to accept the new self more quickly. Patient with sudden traumatic amputation or who considers amputation to be the result of a failure in other treatments is at greater risk for self-concept disturbances.
Help the amputee cope with his altered body image. To accept the new self more quickly.
Encourage expression of fears, negative feelings, and grief over the loss of body part. Venting emotions help the patient begin to deal with the fact and reality of life without a limb.
Reinforce preoperative information including type and location of amputation, type of prosthetic fitting if appropriate (immediate, delayed), expected postoperative course, including pain control and rehabilitation. Provides an opportunity for the patient to question and assimilate information and begin to deal with changes in body image and function, which can facilitate postoperative recovery.
Assess degree of support available to patient. Sufficient support by SO and friends can facilitate the rehabilitation process.
Ascertain individual strengths and identify previous positive coping behaviors. Helpful to build on strengths that are already available for the patient to use in coping with the current situation.
Encourage participation in ADLs. Provide opportunities to view and care for the stump, using the moment to point out positive signs of healing. Promotes independence and enhances feelings of self-worth. Although integration of stump into body image can take months or even years, looking at the stump and hearing positive comments (made in a normal, matter-of-fact manner) can help the patient with this acceptance.
Encourage and provide for a visit by another amputee, especially one who is successfully rehabilitating. A peer who has been through a similar experience serves as a role model and can provide validity to comments and hope for recovery and a normal future.
Note withdrawn behavior, negative self-talk, use of denial, or over-concern with actual and perceived changes. Identifies the stage of grief and the need for interventions.
Provide an open environment for the patient to discuss concerns about sexuality. Promotes sharing of beliefs and values about the sensitive subject, and identifies misconceptions and myths that may interfere with adjustment to the situation.
Discuss the availability of various resources: psychiatric and sexual counseling, occupational therapist. May need assistance for these concerns to facilitate optimal adaptation and rehabilitation.

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