Risk for Ineffective Tissue Perfusion — Amputation

In general, amputation of limbs is the result of trauma, peripheral vascular disease, tumors, and congenital disorders. This is an amputation nursing care plan for a patient with a risk for ineffective tissue perfusion.

Nursing Diagnosis:

• Tissue Perfusion, risk for ineffective: peripheral

Risk factors: 

• Reduced arterial/venous blood flow; tissue edema, hematoma formation
• Hypovolemia

Desired Outcomes: 

• Patient will Maintain adequate tissue perfusion as evidenced by palpable peripheral pulses, warm/dry skin, and timely wound healing.

Nursing Interventions & Rationale

Nursing Interventions	Rationale
Monitor vital signs. Palpate peripheral pulses, noting strength and equality.	General indicators of circulatory status and adequacy of perfusion.
Perform periodic neurovascular assessments (sensation, movement, pulse, skin color, and temperature).	Postoperative tissue edema, hematoma formation, or restrictive dressings may impair circulation to stump, resulting in tissue necrosis.
Inspect dressings/drainage device, noting amount and characteristics of drainage.	Continued blood loss may indicate need for additional fluid replacement and evaluation for coagulation defect or surgical intervention to ligate bleeder.
Apply direct pressure to bleeding site if hemorrhage occurs. Contact physician immediately.	Direct pressure to bleeding site may be followed by application of a bulk dressing secured with an elastic wrap once bleeding is controlled.
Investigate reports of persistent/unusual pain in operative site.	Hematoma can form in muscle pocket under the flap, compromising circulation and intensifying pain
Evaluate nonoperated lower limb for inflammation, positive Homans’ sign.	Increased incidence of thrombus formation in patients with preexisting peripheral vascular disease/diabetic changes.
Encourage/assist with early ambulation.	Enhances circulation, helps prevent stasis and associated complications. Promotes sense of general well-being.
Administer IV fluids/blood products as indicated.	Maintains circulating volume to maximize tissue perfusion.
Apply antiembolic/sequential compression hose to non-operated leg, as indicated.	Enhances venous return, reducing venous pooling and risk of thrombophlebitis.
Administer low-dose anticoagulant as indicated.	May be useful in preventing thrombus formation without increasing risk of postoperative bleeding/hematoma formation.
Monitor laboratory studies, e.g.: Hb/Hct;	Indicators of hypovolemia/dehydration that can impair tissue perfusion.
PT/activated partial thromboplastin time (aPTT).	Evaluates need for/effectiveness of anticoagulant therapy and identifies developing complication, e.g., posttraumatic disseminated intravascular coagulation (DIC)