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					                      Student Nurses’ Community

                                                                                                                    NURSING CARE PLAN – Amputation
ASSESSMENT             DIAGNOSIS           INFERENCE               PLANNING              INTERVENTION                RATIONALE             EVALUATION
SUBJECTIVE:           Impaired           Amputation is the      After 4 hours of     Independent                                          After 4 hours of
                      physical           total or partial       nursing               Provide residual            Provides              nursing
“Hindi ko             mobility may be    surgical removal       interventions, the      limb care on a              opportunity to        interventions, the
maigalaw ang          related to loss    of an extremity or     patient will            routine basis.              evaluate healing      patient was able
ibang parte ng        of limb            digit. It is done in   verbalize                                           and note              to verbalize
katawan ko, di        particularly a     cases of               understanding of                                    complications         understanding of
tulad dati” (I'm      lower extremity;   inadequate tissue      individual                                          unless covered        individual
having a hard time    pain or            perfusion not          situation,                                          by immediate          situation,
moving some certain   discomfort;        responsive to          treatment                                                                 treatment
parts of my body
                                                                                                                    prosthesis.
unlike before) as
                      perceptual         other treatments,      regimen, and            Measure                   Measurement is        regimen, and
                      impairment.        such as with           safety measures;         circumference              done to estimate      safety measures;
verbalized by the
                                         diabetes mellitus      Maintain position        periodically.              shrinkage to          Maintain position
patient.
                                         or other               of function as                                      ensure proper fit     of function as
                                         peripheral             evidenced by                                        of sock and           evidenced by
                                         vascular               absence of                                          prosthesis.           absence of
OBJECTIVE:
                                         diseases.              contractures;           Rewrap residual           Edema will occur      contractures;
                                                                demonstrate              limb immediately           rapidly, thus         demonstrate
                                                                techniques and           with an elastic            delaying              techniques and
   Reluctance
                                                                behaviors that           bandage.                   rehabilitation.       behaviors that
    to attempt
    movement
                                                                enable                  Assist with               Prevents              enable
                                                                resumption of            specified range of         contracture           resumption of
   Impaired                                                    activities; and                                                           activities; and
    coordination                                                                         motion exercises           deformities, which
                                                                display                  for both the               can develop           display
   Decreased                                                   willingness to                                                            willingness to
    muscle                                                                               affected and               rapidly and could
                                                                participate in           unaffected limbs.          delay prosthesis      participate in
    strength                                                    activities.                                                               activities.
                                                                                                                    usage.
   V/S taken as
    follows                                                                             Provide trochanter        Prevents external
                                                                                         rolls, as indicated.       rotation of lower-
    T: 37.2˚C                                                                                                       limb residual limb.
    P: 80                                                                               Instruct patient to       Strengthens
    R: 17                                                                                lie prone position         extensor muscle
    BP: 110/ 80                                                                          as tolerated, at           and prevents
                                                                                         least twice a day          flexion
                                                                                         with pillow under          contracture of the
                                                                                         abdomen and                hip, which can
                                                                                         lower-extremity            begin to develop
Student Nurses’ Community

                                residual limb.            within 24 hours of
                                                          sustained mal-
                                                          positioning.
                               Demonstrate or          Facilitates self-
                                assist with transfer      care and patient’s
                                techniques and use        independence.
                                of mobility aids          Proper transfer
                                such as trapeze,          techniques
                                crutches or a             prevent shearing
                                walker.                   abrasion/dermal
                                                          injury related to
                                                          “scooting”.

                            Collaborative
                             Refer to                  Provides for
                                rehabilitation team      creation of
                                such as physical         exercise and
                                and occupational         activity program
                                therapy and              to meet individual
                                prosthetic               needs and
                                specialists.             strengths and
                                                         identifies mobility
                                                         functional aid to
                                                         promote
                                                         independence.
                               Provide foam or         Reduces pressure
                                flotation mattress.      on skin and
                                                         tissues that can
                                                         impair circulation,
                                                         potentiating risk
                                                         of tissue ischemia
                                                         and breakdown.

				
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posted:10/3/2011
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