Question

PN 105 Fundamentals of Nursing I Concept Map - Amputation Mark Ryan, a 14-year-old male, was admitted to your unit from the operating room. He has had an amputation of his right leg resulting from tissue and alligator attack. His vital signs are T. 101, P 104, R 24, B/P 112/72, 02 sats 98. He has an IV running of Ringers Lactate Solution at 100 mL/Hour and a piggyback of Rocephin 1g which he is to receive every 12 hours. He has a massive pressure dressing to his right stump which has a scant amount of dark red drainage. There is a number 18 Insyte catheter in his left antecubital space with 1000 mL of Ringers Lactate running at 125 m/L per hour. He is restless and wakes up intermittently crying. Please complete your concept map. Reviewed 9/19

Answer 1

Amputation

Nursing Diagnosis Risk for infection related to incision as evidenced by dressing ,raise in body temperature	Nursing diagnosis Anxiety/ impaired sleep pattern related to surgery as evidenced by age ,restless, waking up crying
Intervention Assess the pain level ,to plan for care Monitor vital signs to get baseline data about patient status Administer antibiotics as per order to prevent infection Meticulous hand hygiene to prevent cross infection Follow infection control practice and aseptic procedures to prevent contamination	Intervention Provide a calm and quite environment Explain the procedure to the child in simple language without inducing fear to gain cooperation Encourage parents to be with the child to feel secured
Positive outcomes The patient will have an normal temperature and reduced infection	Positive outcomes The child will be anxious free
Negative outcomes Risk for impaired mobility	Negative outcomes May increase the chance for being non cooperative to the treatment
Evaluation The patient will have reduced infection	Evaluation The child s6ill have an uninterrupted sleep