Impaired Physical Mobility — Amputation

In general, amputation of limbs is the result of trauma, peripheral vascular disease, tumors, and congenital disorders. This is an amputation nursing care plan for a patient with 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: 

§     Verbalize understanding of individual situation, treatment regimen, and safety measures.

§     Maintain position of function as evidenced by absence of contractures.

§     Demonstrate techniques/behaviors that enable resumption of activities.

§     Display willingness to participate in activities.

Nursing Interventions

Nursing Interventions	Rationale
Provide stump care on a routine basis, e.g., inspect area, cleanse and dry thoroughly, and rewrap stump with elastic bandage or air splint, or apply a stump shrinker (heavy stockinette sock), for “delayed” prosthesis.	Provides opportunity to evaluate healing and note complications (unless covered by immediate prosthesis). Wrapping stump controls edema and helps form stump into conical shape to facilitate fitting of prosthesis. Note: Air splint may be preferred, because it permits visual inspection of the wound
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/early” cast is accidentally dislodged. Prepare for reapplication of 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 postoperative stage.	Prevents contracture deformities, which can develop rapidly and could delay prosthesis usage.
Encourage active/isometric exercises for upper torso and unaffected limbs.	Increases muscle strength to facilitate transfers/ambulation and promote mobility and more normal lifestyle.
Provide trochanter rolls as indicated.	Prevents external rotation of lower-limb stump
Instruct patient to lie in prone position as tolerated at least twice a day with pillow under 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 pillow under lower-extremity stump or allowing BKA limb to hang dependently over side of bed or chair.	Use of pillows can cause permanent flexion contracture of hip; a dependent position of stump impairs venous return and may increase edema formation.
Demonstrate/assist with transfer techniques and use of mobility aids, e.g., trapeze, crutches, or walker.	Facilitates self-care and patient’s independence. Proper transfer techniques prevent shearing abrasions/dermal injury related to “scooting.”
Assist with ambulation.	Reduces potential for injury. Ambulation after lower-limb amputation depends on 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 use of prosthesis.
Refer to rehabilitation team	Provides for creation of exercise/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/positive outlook. Note: Vocational counseling/retraining also may be indicated.
Provide foam/flotation mattress.	Reduces pressure on skin/tissues that can impair circulation, potentiating risk of tissueischemia/breakdown

Risk for Infection — Amputation

In general, amputation of limbs is the result of trauma, peripheral vascular disease, tumors, and congenital disorders. This is an amputation nursing care plan for a patient with a 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

Nursing Interventions	Rationale
Maintain aseptic technique when changing dressings/caring for wound.	Minimizes opportunity for introduction of bacteria.
Inspect dressings and wound; note characteristics of drainage.	Early detection of developing infection provides 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 risk of infection.
Cover 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/fragile skin.
Monitor vital signs.	Temperature elevation/tachycardia may reflect developing sepsis.
Obtain wound/drainage cultures and sensitivities as appropriate.	Identifies presence of infection/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.

Risk for Ineffective Tissue Perfusion — Amputation

In general, amputation of limbs is the result of trauma, peripheral vascular disease, tumors, and congenital disorders. This is an amputation nursing care plan for a patient with a risk for ineffective tissue perfusion.

Nursing Diagnosis:

§     Tissue Perfusion, risk for ineffective: peripheral

Risk factors: 

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

§     Hypovolemia

Desired Outcomes: 

§     Patient will Maintain adequate tissue perfusion as evidenced by palpable peripheral pulses, warm/dry skin, and timely wound healing.

Nursing Interventions & Rationale

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/drainage device, noting amount and characteristics of drainage.	Continued blood loss may indicate need for additional fluid replacement and evaluation for coagulation defect or surgical intervention to ligate bleeder.
Apply direct pressure to bleeding site if hemorrhage occurs. Contact physician immediately.	Direct pressure to bleeding site may be followed by application of a bulk dressing secured with an elastic wrap once bleeding is controlled.
Investigate reports of persistent/unusual pain in operative site.	Hematoma can form in muscle pocket under the flap, compromising circulation and intensifying pain
Evaluate nonoperated lower limb for inflammation, positive Homans’ sign.	Increased incidence of thrombus formation in patients with preexisting peripheral vascular disease/diabetic changes.
Encourage/assist with early ambulation.	Enhances circulation, helps prevent stasis and associated complications. Promotes sense of general well-being.
Administer IV fluids/blood products as indicated.	Maintains circulating volume to maximize tissue perfusion.
Apply antiembolic/sequential compression hose to 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 risk of postoperative bleeding/hematoma formation.
Monitor laboratory studies, e.g.: Hb/Hct;	Indicators of hypovolemia/dehydration that can impair tissue perfusion.
PT/activated partial thromboplastin time (aPTT).	Evaluates need for/effectiveness of anticoagulant therapy and identifies developing complication, e.g., posttraumatic disseminated intravascular coagulation (DIC)

Situational Low Self-Esteem — Amputation

Nursing Diagnosis

§     Self-Esteem, situational low

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 body, focus on past strength, function, or appearance

§     Feelings of helplessness, powerlessness

§     Preoccupation with missing body part, not looking at or touching stump

§     Perceived change in usual patterns of responsibility/physical capacity to resume role

Desired Outcomes

§     Begin to show adaptation and verbalize acceptance of self in situation (amputee).

§     Recognize and incorporate changes into self-concept in accurate manner without negating self-esteem.

§     Develop realistic plans for adapting to new role/role modifications.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Assess/consider patient’s preparation for and view of amputation.	Research shows that amputation poses serious threats to 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 failure in other treatments is at greater risk for self-concept disturbances.
Encourage expression of fears, negative feelings, and grief over loss of body part.	Venting emotions helps patient begin to deal with the fact and reality of life without a limb.
Reinforce preoperative information including type/location of amputation, type of prosthetic fitting if appropriate (i.e., immediate, delayed), expected postoperative course, including pain control and rehabilitation.	Provides opportunity for 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 rehabilitation process.
Ascertain individual strengths and identify previous positive coping behaviors.	Helpful to build on strengths that are already available for patient to use in coping with current situation.
Encourage participation in ADLs. Provide opportunities to view/care for stump, using the moment to point out positive signs of healing.	Promotes independence and enhances feelings of selfworth. 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-offact manner) can help patient with this acceptance.
Encourage/provide for 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 overconcern with actual/perceived changes.	Identifies stage of grief/need for interventions.
Provide open environment for patient to discuss concerns about sexuality.	Promotes sharing of beliefs/values about sensitive subject, and identifies misconceptions/myths that may interfere with adjustment to situation.
Discuss availability of various resources, e.g., psychiatric/ sexual counseling, occupational therapist.	May need assistance for these concerns to facilitate optimal adaptation and rehabilitation.

Posted in: Fundamental of Nursing,Medical-surgical Nursing