Student Nurses’ Community

NURSING CARE PLAN ─ Amputation

ASSESSMEN DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATION
T N

SUBJECTIVE: Impaired Amputation After 4 hours Independent:  Provides After 4 hours

physical is the total or of nursing opportunity to of nursing
“I am having a mobility may partial interventions,  Provide evaluate interventions,
hard time be related to surgical the patient residual limb healing and the patient
moving some loss of limb removal of an will verbalize: care on a note was able to
certain parts particularly a extremity or routine basis. complications verbalize:
of my body lower digit. It is  Understandi  Measure unless covered
unlike before” extremity; done in cases ng of circumference y immediate  Understandi
as verbalized pain or of inadequate individual periodically prosthesis. ng of
by the discomfort; tissue situation,  Rewrap  Measurement is individual
patient. perceptual perfusion not treatment residual limb done to situation,
impairment. responsive to regimen immediately estimate treatment
OBJECTIVE: other and safety with an elastic shrinkage to regimen and
treatments, measures bandage ensure proper safety
 Reluctance such as with  Maintain  Assist with fit of sock and measures
to attempt diabetes position of prosthesis.  Maintain
specified
movement mellitus or function as  Edema will position of
range of
 Impaired other evidenced occur rapidly, function as
motion
coordination peripheral by absence thus delaying evidenced
exercises for
 Decreased vascular of rehabilitation. by absence
both the
muscle diseases. contracture of
affected and  Prevents
strength s unaffected contracture contractures
 Demonstrat limbs deformities,  Demonstrat
 V/S taken as e  Provide which can e
follows: techniques trochanter develop rapidly techniques
and rolls, as and could delay and
T: 37.2 °C behaviors indicated. prosthesis behaviors
P: 80 that enable  Instruct usage. that enable
R: 17 resumption patient to lie  Prevents resumption
BP: 100/80 of activities; prone position external of activities;
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and as tolerated, rotation of and
 Display at least twice lower-limb  Display
willingness a day with residual limb. willingness
to pillow under  Strengthens to
participate abdomen and extensor participate
in activities. lower- muscle and in activities.
extremity prevents
residual limb flexion
 Demonstrate contracture of
or assist with the hip, which
transfer can begin to
techniques develop within
and use of 24 hours of
mobility aids sustained
such as malpositioning.
trapeze or a  Facilitates self-
walker. care and
patient’s
Collaborative: independence.
Proper transfer
 Refer to techniques
rehabilitation prevent
team such as shearing
physical and abrasion/derma
occupational l injury related
therapy and to “scooting”
prosthetic  Provides for
specialists. creation of
 Provide foam exercise and
or flotation activity
mattress. program to
meet individual
needs and
strengths and
identifies
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mobility
functional aid
to promote
independence.
 Reduces
pressure on
skin and tissues
than can impair
circulation,
potentiating
risk of tissue
ischemia and
breakdown.