Primary Nursing Diagnosis

Impaired mobility related to loss of lower extremity

OUTCOMES. Balance; Body positioning; Ambulation; Bone healing; Comfort level; Joint movement; Mobility level; Muscle function; Pain level; Wound healing; Safety behavior: Fall prevention

INTERVENTIONS. Positioning; Body image enhancement; Fall prevention; Exercise promotion; Exercise therapy: Ambulation and balance; Pain management; Positioning; Prosthesis care; Skin surveillance; Wound care


MANAGEMENT OF TRAUMATIC AMPUTATION. If complete amputation of a body part occurs, flush the wound with sterile normal saline, apply a sterile pressure dressing, and elevate the limb. Do not apply a tourniquet to the extremity. Wrap the amputated body part in a wet sterile dressing that has been soaked with sterile normal saline solution. Place the body part in a clean, dry plastic bag, label the bag, and seal it. Place the bag in ice, and transport it with the trauma patient. Do not store the amputated part on dry ice or in normal saline. Following reimplantation surgery, assess the color, temperature, peripheral pulses, and capillary refill of the reimplanted body part every 15 minutes. If the skin temperature declines below the recommended temperature or if perfusion decreases, notify the surgeon immediately.

POSTOPERATIVE MANAGEMENT. Many interventions can help improve the patient's mobility—for example, care of the surgical wound, control of pain, and prevention of further injury. If any excessive bleeding occurs, notify the surgeon immediately and place direct pressure on the area of hemorrhage. Occasionally, a patient returns from surgery with either a Jobst air splint or an immediate postsurgical fitted prosthesis already in place. Explain that the device is intended to aid ambulation and prevent the complications of immobility.

A particular danger to mobility for the patient with a lower limb amputation is contracture of the nearest joint. Elevate the stump on a pillow for the first 24 hours following surgery to control edema. However, after 24 hours do not elevate the stump any longer, or the patient may develop contractures. To prevent contractures, turn the patient prone for 15 to 30 minutes twice a day with the limb extended if the patient can tolerate it. If not, keep the joints extended rather than flexed.



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