Nursing Care Plans
Studies depend on underlying condition necessitating amputation and are used to determine the appropriate level for amputation.
- X-rays: Identify skeletal abnormalities.
- CT scan: Identifies soft-tissue and bone destruction, neoplastic lesions, osteomyelitis, hematoma formation.
- Angiography and blood flow studies: Evaluate circulation/tissue perfusion problems and help predict potential for tissue healing after amputation.
- Doppler ultrasound, laser Doppler flowmetry: Performed to assess and measure blood flow.
- Transcutaneous oxygen pressure: Maps out areas of greater and lesser perfusion in the involved extremity.
- Thermography: Measures temperature differences in an ischemic limb at two sites: at the skin and center of the bone. The lower the difference between the two readings, the greater the chance for healing.
- Plethysmography: Segmental systolic BP measurements evaluate arterial blood flow.
- ESR: Elevation indicates inflammatory response.
- Wound cultures: Identify presence of infection and causative organism.
- WBC count/differential: Elevation and “shift to left” suggest infectious process.
- Biopsy: Confirms diagnosis of benign/malignant mass.
- Support psychological and physiological adjustment.
- Alleviate pain.
- Prevent complications.
- Promote mobility/functional abilities.
- Provide information about surgical procedure/prognosis and treatment needs.
- Dealing with current situation realistically.
- Pain relieved/controlled.
- Complications prevented/minimized.
- Mobility/function regained or compensated for.
- Surgical procedure, prognosis, and therapeutic regimen understood.
- Plan in place to meet needs after discharge.
1. Impaired Physical Mobility
- Impaired Physical Mobility
- Loss of a limb (particularly a lower extremity); pain/discomfort; perceptual impairment (altered sense of
Possibly evidenced by
- Reluctance to attempt movement
- Impaired coordination; decreased muscle strength, control, and mass
- Verbalize understanding of individual situation, treatment regimen, and safety measures.
- Maintain position of function as evidenced by absence of contractures.
- Demonstrate techniques/behaviors that enable resumption of activities.
- Display willingness to participate in activities.
|Encourage him to perform prescribes exercises.||To prevent stump trauma.|
|Provide stump care on a routine basis: inspect area, cleanse and dry thoroughly, and rewrap stump with elastic bandage or air splint, or apply a stump shrinker (heavy stockinette sock), for “delayed” prosthesis.||Provides opportunity to evaluate healing and note complications (unless covered by immediate prosthesis). Wrapping stump controls edema and helps form stump into conical shape to facilitate fitting of prosthesis. Note: Air splint may be preferred, because it permits visual inspection of the wound|
|Measure circumference periodically||Measurement is done to estimate shrinkage to ensure proper fit of sock and prosthesis.|
|Rewrap stump immediately with an elastic bandage, elevate if “immediate or early” cast is accidentally dislodged. Prepare for reapplication of cast.||Edema will occur rapidly, and rehabilitation can be delayed|
|Assist with specified ROM exercises for both the affected and unaffected limbs beginning early in postoperative stage.||Prevents contracture deformities, which can develop rapidly and could delay prosthesis usage.|
|Encourage active and isometric exercises for upper torso and unaffected limbs.||Increases muscle strength to facilitate transfers and ambulation and promote mobility and more
|Maintain knee extension.||To prevent hamstring muscle contractures.|
|Provide trochanter rolls as indicated.||Prevents external rotation of lower-limb stump|
|Instruct patient to lie in prone position as tolerated at least twice a day with pillow under abdomen and lower-extremity stump.||Strengthens extensor muscles and prevents flexion contracture of the hip, which can begin to develop within 24 hr of sustained malpositioning.|
|Caution against keeping pillow under lower-extremity stump or allowing BKA limb to hang dependently over side of bed or chair.||Use of pillows can cause permanent flexion contracture of hip; a dependent position of stump impairs venous return and may increase edema formation.|
|Demonstrate and assist with transfer techniques and use of mobility aids like trapeze, crutches, or walker.||Facilitates self-care and patient’s independence. Proper transfer techniques prevent shearing abrasions and dermal injury related to “scooting.”|
|Assist with ambulation.||Reduces potential for injury. Ambulation after lower-limb amputation depends on timing of prosthesis placement.|
|Instruct patient in stump-conditioning exercises||Hardens the stump by toughening the skin and altering feedback of resected nerves to facilitate use of prosthesis.|
|Refer to rehabilitation team||Provides for creation of exercise and activity program to meet individual needs and strengths, and identifies mobility functional aids to promote independence. Early use of a temporary prosthesis promotes activity and enhances general well-being and positive outlook. Note: Vocational counseling and retraining also may be indicated.|
|Provide foam or flotation mattress.||Reduces pressure on skin and tissues that can impair circulation, potentiating risk of tissue ischemia and breakdown.|
2. Risk for Infection
- Risk for Infection
Risk factors may include
- Inadequate primary defenses (broken skin, traumatized tissue)
- Invasive procedures; environmental exposure
- Chronic disease, altered nutritional status
- Achieve timely wound healing; be free of purulent drainage or erythema; and be afebrile.
|During emergency treatment, monitor vital signs (especially in hypovolemic shock), clean the wound and give tetanus prophylaxis, and antibiotics as ordered.||To prevent skin infection.|
|After a complete amputation, wrap the amputated part in wet dressing soaked in normal saline solution. Label the part, seal it in a plastic bag, and float the bag in ice water.||SO that it is not inadvertently discarded.|
|Flush the wound with sterile saline solution, apply a sterile pressure dressing.||Prevent introduction to bacteria.|
|Maintain aseptic technique when changing
dressings and caring for wound.
|Minimizes opportunity for introduction of bacteria.|
|Inspect dressings and wound; note characteristics of
|Early detection of developing infection provides
opportunity for timely intervention and prevention of
more serious complications.
|Maintain patency and routinely empty drainage device.||Hemovac, Jackson-Pratt drains facilitate removal of
drainage, promoting wound healing and reducing risk of
|Cover dressing with plastic when using the bedpan or if
|Prevents contamination in lower-limb amputation.|
|Expose stump to air; wash with mild soap and water after
dressings are discontinued.
|Maintains cleanliness, minimizes skin contaminants, and
promotes healing of tender and fragile skin.
|Monitor vital signs.||Temperature elevation and tachycardia may reflect
|Obtain wound and drainage cultures and sensitivities as
|Identifies presence of infection and specific organisms and
|Administer antibiotics as indicated.||Wide-spectrum antibiotics may be used prophylactically,
or antibiotic therapy may be geared toward specific
3. Risk for Ineffective Tissue Perfusion
- Risk for Ineffective Tissue Perfusion
- Reduced arterial/venous blood flow; tissue edema, hematoma formation
- Patient will Maintain adequate tissue perfusion as evidenced by palpable peripheral pulses, warm/dry skin, and timely wound healing.
|Monitor vital signs. Palpate peripheral pulses, noting strength and equality.||General indicators of circulatory status and adequacy of perfusion.|
|Perform periodic neurovascular assessments (sensation, movement, pulse, skin color, and temperature).||Postoperative tissue edema, hematoma formation, or restrictive dressings may impair circulation to stump, resulting in tissue necrosis.|
|Inspect dressings and drainage device, noting amount and characteristics of drainage.||Continued blood loss may indicate need for additional fluid replacement and evaluation for coagulation defect or surgical intervention to ligate bleeder.|
|Apply direct pressure to bleeding site if hemorrhage occurs. Contact physician immediately.||Direct pressure to bleeding site may be followed by application of a bulk dressing secured with an elastic wrap once bleeding is controlled.|
|If the patient experiences throbbing after the stump is wrapped, the bandage may be too tight. Remove the bandage and reapply.||Throbbing indicates impaired circulation.|
|Check the bandage regularly.||To prevent further complication.|
|Investigate reports of persistent or unusual pain in operative site.||Hematoma can form in muscle pocket under the flap, compromising circulation and intensifying pain|
|Evaluate nonoperated lower limb for inflammation, positive Homans’ sign.||Increased incidence of thrombus formation in patients with preexisting peripheral vascular disease and diabetic changes.|
|Encourage and assist with early ambulation.||Enhances circulation, helps prevent stasis and associated complications. Promotes sense of general well-being.|
|Administer IV fluids and blood products as indicated.||Maintains circulating volume to maximize tissue perfusion.|
|Apply antiembolic and sequential compression hose to non-operated leg, as indicated.||Enhances venous return, reducing venous pooling and risk of thrombophlebitis.|
|Administer low-dose anticoagulant as indicated.||May be useful in preventing thrombus formation without increasing risk of postoperative bleeding and hematoma formation.|
|Monitor laboratory studies: Hb and Hct;||Indicators of hypovolemia and dehydration that can impair tissue perfusion.|
|PT and activated partial thromboplastin time (aPTT).||Evaluates need and effectiveness of anticoagulant therapy and identifies developing complication such as posttraumatic disseminated intravascular coagulation (DIC)|
4. Situational Low Self-Esteem
- Situational Low-Self Esteem
May be related to
- Loss of body part/change in functional abilities
Possibly evidenced by
- Anticipated changes in lifestyle; fear of rejection/reaction by others
- Negative feelings about body, focus on past strength, function, or appearance
- Feelings of helplessness, powerlessness
- Preoccupation with missing body part, not looking at or touching stump
- Perceived change in usual patterns of responsibility/physical capacity to resume role
- Begin to show adaptation and verbalize acceptance of self in situation (amputee).
- Recognize and incorporate changes into self-concept in accurate manner without negating self-esteem.
- Develop realistic plans for adapting to new role/role modifications.
|Assess and consider patient’s preparation for and view of amputation.||Research shows that amputation poses serious threats to patient’s psychological and psychosocial adjustment. Patient who views amputation as life-saving or reconstructive may be able to accept the new self more quickly. Patient with sudden traumatic amputation or who considers amputation to be the result of failure in other treatments is at greater risk for self-concept disturbances.|
|Help the amputee cope with his altered body image.||To accept the new self more quickly.|
|Encourage expression of fears, negative feelings, and grief over loss of body part.||Venting emotions helps patient begin to deal with the fact and reality of life without a limb.|
|Reinforce preoperative information including type and location of amputation, type of prosthetic fitting if appropriate (immediate, delayed), expected postoperative course, including pain control and rehabilitation.||Provides opportunity for patient to question and assimilate information and begin to deal with changes in body image and function, which can facilitate postoperative recovery.|
|Assess degree of support available to patient.||Sufficient support by SO and friends can facilitate rehabilitation process.|
|Ascertain individual strengths and identify previous positive coping behaviors.||Helpful to build on strengths that are already available for patient to use in coping with current situation.|
|Encourage participation in ADLs. Provide opportunities to view and care for stump, using the moment to point out positive signs of healing.||Promotes independence and enhances feelings of self worth. Although integration of stump into body image can take months or even years, looking at the stump and hearing positive comments (made in a normal, matter-of-fact manner) can help patient with this acceptance.|
|Encourage and provide for visit by another amputee, especially one who is successfully rehabilitating.||A peer who has been through a similar experience serves as a role model and can provide validity to comments and hope for recovery and a normal future.|
|Note withdrawn behavior, negative self-talk, use of denial, or over concern with actual and perceived changes.||Identifies stage of grief and need for interventions.|
|Provide open environment for patient to discuss concerns about sexuality.||Promotes sharing of beliefs and values about sensitive subject, and identifies misconceptions and myths that may interfere with adjustment to situation.|
|Discuss availability of various resources: psychiatric and sexual counseling, occupational therapist.||May need assistance for these concerns to facilitate optimal adaptation and rehabilitation.|