Care of the Adult Population

NURS 3101P

Nursing Care Plan

February 8, 2023

Soria Choc

Submitted to: Ms. Shantel Neal

Patient Information:

Name: L.M

Age: 72 years

Dx: Above Knee Amputation to right foot secondary to infected amputation below the knee, DM type 2 and HTN.

Assessment Diagnosis Planning Intervention Rationale Evaluation

 Actual Throughout 1. Maintain aseptic 1. To avoid Goal met:
the 8 hours technique for wound
1.Infection introducing
shift the care. Throughout the 8 hours shift the
related to the microorganism into
patient will pt. condition improved and
Subjective: disease process 2. Monitor vital
show reduced the wound. 
as evidenced by signs especially temperature remained within
Pt. states this is my sign of
pt. having fever temperature
infection. 2. To obtain baseline normal limits of 96.9 F
fourth day after my and swelling to
3. Administer data which will be
the wound site.
foot was cut off antibiotics as per compared to indicate
drug chart. if patients’ condition
because it got infected
has improved.
after they cut it off
3. To reduce the
first below my knee. growth of bacteria.
.

Objective: .
Flushed appearance, Goal met:
2. Low self- At the end of 6 1.Assist patient to 1. By allowing him
swelling to wound
site, esteem r/t loss of days of cope with his altered to express his feelings At the end of 6 days, Pt. was able
right foot and hospital stay
Febrile and skin warm body image. about the reality of to identify resources that assist
alteration Pt. will be
to touch. life without a limb. him to integrate changes to build
functional able to identify
2. Assess degree of
V/S taken as follows: abilities as resources that self-esteem.
support available to 2. Relatives/ friends
evidenced by will assist him
T- 100.5F
patient to integrate pt. can facilitate
verbalizing changes to
P- 88 bpm feeling about the build self- 3. Refer patient to rehabilitation process.
foot amputation, esteem.
R- 18 bpm Psychiatric Nurse
and being unable 3. Psychiatric Nurse
B/P- 170/70 Practioner
to move around Practioner can assist
SPO2 -98% as he wants.
pt. with positive ways

Glucose- 190 mg/dl to cope with loss of

limb.

1. To promote

At the end of independence.

Potential
eight-hour 1.Demonstate and
Risk for injury 2. To prevent patient
shift, the assist patient with
from falling.
related to the use of crutches.
patient will 3. Prevent accidental
amputated limb. Goal met:
remain free 2. Assist patient falls that can cause
from injuries. further injury to
with ambulation At the end of eight hour, the
patient.

3. Ensure that patient remained free from injury.

bedrails are up.