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NURSING CARE PLAN Amputation ASSESSMENT SUBJECTIVE: Hindi ko maigalaw ang ibang parte ng katawan ko, di tulad dati (I'm
having a hard time moving some certain parts of my body unlike before) as

DIAGNOSIS Impaired physical mobility may be related to loss of limb particularly a lower extremity; pain or discomfort; perceptual impairment.

INFERENCE 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.

PLANNING After 4 hours of nursing interventions, the patient will verbalize understanding of individual situation, treatment regimen, and safety measures; Maintain position of function as evidenced by absence of contractures; demonstrate techniques and behaviors that enable resumption of activities; and display willingness to participate in activities.

INTERVENTION Independent Provide residual limb care on a routine basis.

RATIONALE

EVALUATION After 4 hours of nursing interventions, the patient was able to verbalize understanding of individual situation, treatment regimen, and safety measures; Maintain position of function as evidenced by absence of contractures; demonstrate techniques and behaviors that enable resumption of activities; and display willingness to participate in activities.

verbalized by the patient.

Measure circumference periodically.

OBJECTIVE: Reluctance to attempt movement Impaired coordination Decreased muscle strength V/S taken as follows T: 37.2C P: 80 R: 17 BP: 110/ 80

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 as tolerated, at least twice a day with pillow under abdomen and lower-extremity

Provides opportunity to evaluate healing and note complications unless covered by 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 rotation of lowerlimb residual limb. Strengthens extensor muscle and prevents flexion contracture of the hip, which can begin to develop

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residual limb. Demonstrate or assist with transfer techniques and use of mobility aids such as trapeze, crutches or a walker. within 24 hours of sustained malpositioning. Facilitates selfcare and patients independence. Proper transfer techniques prevent shearing abrasion/dermal injury related to scooting. Provides for creation of exercise and activity program to meet individual needs and strengths and identifies mobility functional aid to promote independence. Reduces pressure on skin and tissues that can impair circulation, potentiating risk of tissue ischemia and breakdown.

Collaborative Refer to rehabilitation team such as physical and occupational therapy and prosthetic specialists.

Provide foam or flotation mattress.