Amputation is the surgical or traumatic removal of a body part, most commonly involving the lower or upper extremities. This nursing diagnosis focuses on providing comprehensive care for patients undergoing or recovering from amputation, addressing both physical and psychological aspects of care.
Causes (Related to)
Amputation can occur due to various conditions and circumstances, with several factors influencing the necessity for surgical intervention:
- Medical conditions such as:
- Peripheral vascular disease
- Diabetes mellitus complications
- Severe infections
- Gangrene
- Cancer
- Traumatic causes including:
- Motor vehicle accidents
- Industrial accidents
- Combat injuries
- Severe burns
- Congenital conditions affecting:
- Limb development
- Bone growth
- Vascular formation
Signs and Symptoms (As evidenced by)
The presentation of amputation patients varies depending on the stage of care and type of amputation.
Subjective: (Patient reports)
- Phantom limb sensation
- Phantom limb pain
- Residual limb pain
- Anxiety about body image
- Depression
- Fear of functional loss
- Concerns about independence
Objective: (Nurse assesses)
- Surgical wound presence
- Residual limb edema
- Changes in skin integrity
- Altered mobility
- Modified balance
- Psychological distress signs
- Vital sign changes
Expected Outcomes
The following outcomes indicate successful management post-amputation:
- The patient will demonstrate proper residual limb care
- The patient will show progressive mobility improvement
- The patient will effectively manage phantom limb pain
- The patient will display positive adaptation to body image changes
- The patient will achieve maximum independence in ADLs
- The patient will avoid complications
- The patient will participate actively in rehabilitation
Nursing Assessment
1. Physical Assessment
- Monitor wound healing
- Assess residual limb condition
- Check circulation status
- Evaluate pain levels
- Monitor vital signs
2. Functional Assessment
- Evaluate mobility status
- Assess balance and coordination
- Check transfer abilities
- Monitor ADL performance
- Document assistance needs
3. Psychological Assessment
- Assess coping mechanisms
- Monitor mood changes
- Evaluate support systems
- Check body image perception
- Document adaptation progress
4. Complication Assessment
- Monitor for infection signs
- Check for pressure areas
- Assess for contractures
- Watch for circulation problems
- Evaluate pain management effectiveness
Nursing Care Plans
Nursing Care Plan 1: Acute Pain
Nursing Diagnosis Statement:
Acute Pain related to surgical amputation and phantom limb sensation as evidenced by verbal reports of pain, grimacing, and protective behavior.
Related Factors:
- Surgical trauma
- Nerve damage
- Phantom limb phenomenon
- Psychological stress
Nursing Interventions and Rationales:
- Assess pain characteristics and intensity
Rationale: Enables appropriate pain management strategies - Administer prescribed analgesics
Rationale: Provides pain relief and comfort - Implement non-pharmacological pain management
Rationale: Supports comprehensive pain control
Desired Outcomes:
- The patient will report decreased pain levels
- The patient will demonstrate effective pain management techniques
- The patient will maintain comfort during activities
Nursing Care Plan 2: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to loss of limb as evidenced by difficulty with movement and required assistance with transfers.
Related Factors:
- Loss of body part
- Decreased muscle strength
- Balance impairment
- Pain
- Fear of falling
Nursing Interventions and Rationales:
- Assist with prescribed exercises
Rationale: Maintains strength and prevents complications - Teach safe transfer techniques
Rationale: Promotes independence and prevents injury - Provide appropriate mobility aids
Rationale: Facilitates safe movement
Desired Outcomes:
- The patient will demonstrate safe transfer techniques
- The patient will show increased independence in mobility
- The patient will use mobility aids correctly
Nursing Care Plan 3: Risk for Impaired Skin Integrity
Nursing Diagnosis Statement:
Risk for Impaired Skin Integrity related to pressure on the residual limb and decreased mobility as evidenced by vulnerability to skin breakdown.
Related Factors:
- Pressure from prosthetic devices
- Decreased circulation
- Limited mobility
- Moisture accumulation
Nursing Interventions and Rationales:
- Perform regular skin assessments
Rationale: Early detection of skin problems - Implement pressure relief measures
Rationale: Prevents skin breakdown - Teach proper skin care techniques
Rationale: Promotes skin integrity
Desired Outcomes:
- The patient will maintain intact skin
- The patient will demonstrate proper skincare
- The patient will identify early signs of skin breakdown
Nursing Care Plan 4: Disturbed Body Image
Nursing Diagnosis Statement:
Disturbed Body Image related to loss of body part as evidenced by verbalized negative feelings about the body and social withdrawal.
Related Factors:
- Physical loss of body part
- Changed physical appearance
- Altered functional abilities
- Social stigma
Nursing Interventions and Rationales:
- Provide emotional support
Rationale: Helps patient cope with changes - Facilitate peer support connections
Rationale: Provides real-life role models - Encourage the expression of feelings
Rationale: Promotes emotional healing
Desired Outcomes:
- The patient will express acceptance of body changes
- The patient will participate in social activities
- The patient will demonstrate positive coping strategies
Nursing Care Plan 5: Self-Care Deficit
Nursing Diagnosis Statement:
Self-care deficit related to functional limitations following amputation as evidenced by inability to perform ADLs independently.
Related Factors:
- Physical limitations
- Weakness
- Pain
- Psychological adjustment
Nursing Interventions and Rationales:
- Assess self-care abilities
Rationale: Identifies areas needing assistance - Teach adaptive techniques
Rationale: Promotes independence - Provide assistive devices
Rationale: Facilitates self-care activities
Desired Outcomes:
- The patient will demonstrate increased independence in ADLs
- The patient will use adaptive equipment effectively
- The patient will maintain an optimal level of self-care
References
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