Some relevant nursing diagnosis:
- Acute pain related to amputation
- Risk for disturbed sensory perception: phantom limb pain related to amputation
- Impaired skin integrity related to surgical amputation
- Disturbed body image related to amputation of body part
- Ineffective coping, related to failure to accept loss of body part
- Risk for anticipatory and/or dysfunctional grieving related to loss of body part
- Self-care deficit: feeding, bathing/hygiene, dressing/grooming, or toileting, related to loss of extremity
- Impaired physical mobility related to loss of extremity
Some of the most important goals:
- relief of pain
- absence of altered sensory perceptions
- wound healing
- acceptance of altered body image
- resolution of the grieving process
- independence in self-care
- restoration of physical mobility
- absence of complications
Interventions:
- Relieving pain
- Many different options for this
- Minimizing altered sensory perceptions
- Promote wound healing if recent amputation
- Enhancing body image
- Helping the patient achieve physical mobility
Expected outcomes:
- Experiences absence of pain
- appears relaxed
- verbalizes comfort
- uses measures to increase comfort
- Experiences absence of phantom limb pain
- reports diminished phantom sensations
- uses distraction techniques
- performs stump desensitization massage
- Achieves wound healing
- controls residual limb edema
- achieves healed, non-tender, non-adherent scar
- demonstrates residual limb care
- Demonstrates improved body image and effective coping
- acknowledges change in body image
- participates in self-care activities
- demonstrates increasing independence
- Exhibits resolution of grieving
- expresses grief
- works through feelings with family and friends
- focuses on future functioning
- participates in support group
Resource:
http://www.nursing-help.com/2011/03/amputation-and-nursing-care-plan.html