Nursing Care Plan A Client with a Below-the-Knee Amputation

John Rocke is a 45-year-old divorcee with no children.He has a history of type one diabetes mellitus and poor control of blood glucose levels. Mr. Rocke is unemployed and currently receives unemployment compensation. He lives alone in a second-floor apartment. Mr. Rocke had developed gangrene in the toe and failed to seek prompt medical attention; as a result, a left belowthe-knee amputation was necessary. Mr. Rocke is in his second postoperative day and his vital signs are stable. The stump is splinted and has a soft dressing. The wound is approximating well without signs of infection. He has not performed ROM exercises or turning since his surgery, complaining of severe pain. When the nurse goes into the room, he yells,Get out! I dont want anyone to see me like this.No one has visited him since his hospitalization. He is tolerating an 1800-kcal American Diabetes Association diet and is using a urinal independently. He has an order for meperidine (Demerol), 100 mg IM every 4 hours prn for pain, and cefazolin (Ancef ), 1 g IV every 8 hours. He is on blood glucose coverage with regular insulin subcutaneously. Be allowed to control his pain with a PCA pump. Verbalize a decrease in pain. Verbalize the importance of turning. Turn every 2 hours.

PLANNING AND IMPLEMENTATION

Encourage verbalization of feelings. Actively listen to the client. Offer to arrange a visit with a fellow amputee. Ask the physician if the client can be placed on a PCA pump. Teach the client the importance of turning every 2 hours to prevent contractures. Encourage turning and lying prone. Teach the importance of antibiotics in preventing and treating infection.

EVALUATION
One week after his surgery, Mr. Rocke is actively participating in his care. He has apologized for his behavior and has explained to Ms. Simmons that he was angry about the loss of his leg. He states, I thought I knew what to expect, but I didnt.

ASSESSMENT
Jane Simmons, RN, has just come on duty. She notes that the client is upset and angry. Mr. Rocke will not let anyone enter the room to give him medication or assess his vital signs.

Critical Thinking in the Nursing Process

1. Once Mr. Rocke is ready to assist with his stump care, how would you proceed? Would you give him full responsibility for care and dressings, or would you gradually increase his participation? Why? 2. What factors in Mr. Rockes home environment and medical history may make self-care more difficult? Do you expect Mr. Rocke to follow up on care after his discharge? Why or why not? 3. Mr. Rocke states, Why should I exercise this legit was already cut off! How would you respond? What is the purpose of exercising the stump? See Critical Thinking in the Nursing Process in Appendix C.

DIAGNOSIS
Disturbed body image, related to amputation of a left lower leg Dysfunctional grieving, related to anger and loss of left lower leg Situational low self-esteem, related to appearance Risk for injury from infection and contractures, related to refusal of care Pain, related to surgery

EXPECTED OUTCOMES
Verbalize his feelings about the amputation. Allow the staff to monitor his vital signs and administer medications.