Question

Two Nursing Diagnosis and Interventions

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 vascular damage from an 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 piggy back 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. Revised 9/18

Answer 1

Answer:

• Impaired physical mobility related to loss of right leg secondary to tissue and vascular damage.

Intervention:

*Assist the patient with transfer techniques and mobility aids such as Walker

*Provide residual limb care as a routine basis as advised by the doctor

*Provide trochanter roll as per doctor's advice

*Measure the circumference of the limb periodically and assess the site for any signs of infection and inflammation.

•Impaired skin integrity related to the surgical procedure (amputation)

Intervention:

*Assess the surgical site of the patient for any signs of infection and bleeding

*Rewrap the residual limb tightly with elastic bandages

*Administer antibiotics as per doctor's advice to prevent infection

*Keep the surgical site free from contamination and provide dressing according to the order.