help documenting BKA stump?

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Hello, new to this site but have used it as reference for a while now. I'm in my second module of lvn program and we've been focusing mainly on documenting. I haven't documented or seen charting on stumps before ,and I was wondering if I could get some help here. Just basically what to include about it and choice words to describe it maybe? Sorry if it's hard to understand what I'm asking for. Thank you

Specializes in Complex pedi to LTC/SA & now a manager.

Since you are a

student, what do you think? How would you document a fresh post-op amputee, a recent amputee such as a patient in acute or subacute rehab and what would you expect to see in a long term amputee?

think about reasons for amputation (a post trauma amputation is somewhat different than a dry gangrene with osteomyelitis 2nd to uncontrolled T2DM) . Also whether a prosthetic might be considered or used and why it might not. This will guide you. What do you check in any peripheral/extremity assessment?

Specializes in Acute Care, Rehab, Palliative.

We generally don't chart on stumps unless it's got a wound or some other integumentary issue. In this case just describe what you see.

Specializes in Public Health, TB.

A stump is a limb, so how would you document a leg, for instance? Plus, as previous poster stated, if there is a wound...

Specializes in SICU, trauma, neuro.

If there is a wound, I document the characteristics of the wound (e.g. base if visible, drainage, erythema, staples if present etc.) For generic assessment stuff like pedal pulses or dorsiplantar flexion I chart N/A. I mean they don't have pedal pulses without a pede. ;)

If there is a wound, I document the characteristics of the wound (e.g. base if visible, drainage, erythema, staples if present etc.) For generic assessment stuff like pedal pulses or dorsiplantar flexion I chart N/A. I mean they don't have pedal pulses without a pede. ;)

Oh yeah--I love doing chart reviews that religiously note pedal pulses in BKA patients. Tells me the rest of the documentation probably sucketh too.

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