About
Removal of a body part, typically the lower extremities either above the knee ( AKA) or below the knee ( BKA) because of gangrenous or necrotic conditions.
Assess
Assess stump of extremity amputated; assess for capillary refill, sensation, color, warmth; assess for pain or "phantom pain" effecting the limb; Assess psychosocial coping; Assess mobility, compliance with rehabilitation.
Complications
Infection- monitor site for drainage, odor, redness, etc. Notify physician if increased temperature.
Tissue ischemia- monitor for circulation to flap.
Ineffective coping
Diagnosis
- Impaired physical mobility related to loss of limb
- Acute pain related to actual tissue damage from surgical procedure and phantom limb pain.
- Grieving related to loss of body part
- Disturbed body image related to loss of limb
Goals
- The client will be able to state care for the affected body limb after surgery.
- The client will have adequate tissue perfusion after surgery.
The client will state pain level acceptable after intervention.
Interventions
- Assess the limb for pinkness, warmth, and positive arterial pulses at area proximal to the amputated limb.
- Assess the clients pain frequently on a scale of 0 to 10, zero being no pain and 10 being the worst pain imaginable.
- Assess the client's coping abilities, encourage positive coping measures and opportunities to grieve.
- Monitor for signs and symptoms of an infection ( site, temp, etc).
- Administer pain medications, as prescribed by a physician, as needed for pain levels at or above four.
- Encourage active participation in a rehabilitative program both inpatient and in the community.
- Monitor for signs/ symptoms of complications.
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