Nursing 213

N213: Health Differences Across the Lifespan 3 Study Guide Nursing diagnosis for traumatic amputations: • Altered peripheral tissue perfusion related to traumatic amputation • Impaired skin integrity related to traumatic amputation • Pain related to traumatic injury • Body image disturbance related to the loss of a body part • Risk for infection related to a break in skin integrity and contamination of exposed tissue Nursing interventions for traumatic amputations: • Monitor vital signs frequently for signs of hypovolemic shock • Take measures to control bleeding prior to surgery • Give increased IV fluids • Prepare to give blood transfusions if needed • Give pain medications per MD order • Give antibiotics per MD order before and after surgery • Tetanus injection if needed; if patient cannot remember last vaccination or cannot speak give TD booster • Wrap body part and amputation site in moist gauze to preserve tissue • Thoroughly irrigate wound with normal saline to removecontamination • Fill complete amputations, place moist bulky dressing over stump; for partial amputations, re- align body part and wrap in moist rolled gauze • In post-op monitor stump for signs of infection: redness, swelling, drainage, andwarmth • Apply a pressure bandage to stump with elastic wrap over gauze • Continually assess pain levels and inquire about “phantom” pain (where patients will continue to feel pain in the lost extremity even if it isn’t thereanymore) • Teach patient stump care: clean with normal saline, wrap in rolled gauze, andwrap with elastic wrap • Refer to physical therapy for rehabilitationprogram • Refer to community support groups Expected outcomes for traumatic amputations: • Patient remains free from infection • Verbalizes increased comfort • Circulation remains stable with no signs of hypovolemia • Vital signs remain stable • Dressings are clean, dry, and intact • Verbalizes knowledge of stump wound care, wrapping, and rehabilitation plan

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