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
patients
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.