Amputation

AMPUTATION AMPUTATION

I believe these were notes done prior to class

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Surgical removal of all or part of extremity Lower Extremity at Risk For Progressive: o Peripheral Vascular Disease  Diabetes o Fulminating Gas Gangrene o Chronic Infection  Pressure ulcers o Tumors o Trauma  Crushing injuries, burns, frostbite, electrical burns o Congenital deformities  Fit prosthesis o Chronic Osteomyelitis  Chronic Infection o Malignant Tumor

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Amputations are a last resort treatment used to relieve symptoms, improve function, save or improve quality of life Performed at most distal part will heal successfully Site is determines by two factors: o Circulation in the part (Doppler, physical exam) o Functional usefulness – change requirement prosthesis (leave joint) Preservation of knee and elbow joint are desired

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COMPLICATIONS • • • •

Hemorrhage Infection Skin Breakdown Phantom limb pain o Treat as real pain o Talk with patient that it is a normal occurrence and to keep active because that will decrease the pain o Takes about 2 weeks for suture to heal

TYPES OF AMPUTATIONS •

Open o Infection remove part most infected and leave open 3-7 day with aggressive treatment. Drain with soft dressing

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Closed or Flap o Use bottom portion for flap with no evidence of infection with no drain if small

PROMOTING WOUND HEALING • • •

Handle residual limb gently Dressing changes with aseptic techniques – Soft dressing – Open kelix with ace wrap monitor any changes Residual limb shaping is important for prosthesis formation – wrap with elastic dressing to decrease edema

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Rigid or cast maybe plaster dressing o Looks and feels like cast with closed to ensure shrinking and shaping prosthesis  May return from surgery with prosthesis gives person feeling of something there compared to nothing  Rehab ASAP  May change done 3-4 times before prosthesis  Monitor bleeding and drainage  Compression of area thus decreasing edema and prevents contrctures  Strict weight bearing – crutch walking / transfer – position prone, position stretch gluteal thigh

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Pre Operative o Teaching what will happen after surgery (dsg chgs, exercises)

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Age Consideration o Young Age: o Young children have to deal with trauma (sudden or quick) or tumors as reason for amputation o Is a traumatic situation o Make sure they have interaction with others who have gone through before o Young age is better due to fact they are healthier and heal faster o Difficulty with loss of limb o A lot of rehab involved and lifestyle changes o o o o o o

Elderly: More time to adjust Other health problems along with amputation May not be candidate for prosthesis Relieved to have procedure (eg. PVD, relieve pain) Must work through adjustment

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Neurovascular Assessment – Any S/S infection o ROM as often as possible (mobilize area to prevent contractors) o Elderly: Hydrated, anemia, respiratory, nutrition

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Physchological Assessment o Important to discuss with client give time to express feeling / fears o Report extreme depression and fears

o Address family feelings o Patient response to social workers and rehab •

Post Operative o Increased R/F Hemorrhage – most serious /threatening problem  Frequent VS – Q30-1o – chk dressing, assess drain, monitor, stability with pressure  Turn at bedside  Notify MD if potential for hemorrhage o Neurovascualr assessment: monitor stump, pulses o Contractors: reinforce exercise – has been taught preop o Pain: Expected outcome (PCA) – Client may find ways to deal with phantom pain  Hematoma may develop with C/O increased pain with no relief o Infection: Increased R/F, Monitor VS, S/S o Grieving: Dealing emotionally with therapeutic communication o Body Image: o General Post Op Complication: Resp, F/E. Nutrition, Emboli o General Self Care: Limited to what do after surgery with time encourage independence o Home Management: A lot of teaching with correct information  Stump Care: washing, dressing • Wash area with gently massage dry thorough (avoid lotions and skin creams) • DO not soak stump • Dressing or ACE wrap • Stump Sock – Clean and dry – increased risk for breakdown • Teach assessment for infection • Wear prosthesis amount of time told to build up to all day  Prosthesis Care: taught by company reinforce  Pt work with transfer, crutch walking or need  Wt bearing 2 weeks post op to toughen skin  Never adjust or mechanically alter – exercise all extremities  Include family in all of teaching

AMPUTATION

These must have been from class; they seemed a little more organized than the others.

COMPLICATIONS • • • •

Hemorrhage: Major BV Severed – Massive bleeding may occur Infection: Risk because of surgical procedure Skin Breakdown: Skin irritation R/T prosthesis Phantom Limb Pain: Severing Peripheral Nerves

MEDICAL MANAGEMENT •

Objective: To achieve healing of amputation wound, resulting in nontender residual limb (stump) with healthy skin for prosthesis o Enhanced by gentle handling of residual limb o Controlling residual limb edema through rigid or soft compression dressing o Use aseptic technique in wound care to avoid infection

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Closed Rigid Cast Dressing: o 10-14 days o Elevated temp, severe pain, or loose fitting cast may require replacement o Provides uniform compression support soft tissue to control pain and prevent contractures

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Soft Dressing: o With or without compression may be used when frequent inspection of residual limb (stump) is desired o Immobilizing splint incorporated in dressing o Stump (wound) hematomas controlled with wound drainage devices to minimize infection

REHABILITATION THERAPY •

Severe Trauma o Generally, NOT always, young and healthy, heal rapidly and participate vigorous rehab program o Psychological support in accepting sudden change in body image and dealing with stresses of hospitalization and long-tem rehab, and modification of lifestyle o Need time to work through feelings about permanent loss and change in body image o Unpredictable and can include anger, bitterness, hostility

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Multidisciplinary rehab team helps client achieve highest possible level of function and participation in life activities Prosthetic clinics and amputee support groups facilitate rehab process Vocational counseling and job retraining may be necessary to help client return to work NOT fully rehabbed until prosthesis fitted and client learned how to use it o Best accomplished in specialized rehab unit or center

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PREOPERATIVE • • • • •

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Assess neurovascular and functional status of extremity o History and Physical Exam Assess Circulatory status and function of unaffected extremity With Infection or gangrene have enlarged lymph nodes, fever, purulent drainage; culture taken to determine appropriate antibiotic therapy Evaluate clients nutritional status and create plan o Wound healing balanced diet with adequate protein and essential vitamins Concurrent problems (dehydration, anemia, cardiac insufficiency, chronic respiratory problems, DM) be identified and treated so client best condition to withstand trauma of surgery o Use Of:  Corticosteriods  Anticoagulants  Vasoconstrictors  Vasodilators o These may influence management of wound healing Assess clients psychological status o Determination of clients emotional reaction to amputation essential for nursing care o Grief response to alteration of body image is normal

POST OPERATIVE • •

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Efforts made to reestablish homeostasis and prevent problems related to surgery anesthesia, and immobility Problems Associated with Immobility Assess body Systems: Pneumonia  Respiratory Constipation  GI Anorexia Urinary Stasis  GU Massive Hemorrhage due to loosened suture most threatening problem o Monitor for S/S of bleeding and also Monitor VS o Observe suction drainage o Large tourniquet at bedside so if severe bleeding occurs can be applied to residual limb Infection o Administer antibiotic as ordered o Monitor incision, dressing, drainage for S/S of infection o Promptly report to surgeon Skin breakdown R/T immobilization and pressure form various sources o Prosthesis may cause pressure areas to develop o Careful skin hygiene essential to prevent skin irritation, infection, and breakdown  Residual limb washed and dried Gently at least twice daily  Residual limb sock worn to absorb perspiration and prevent direct contact between skin and prosthetic socket • Sock changed daily and must fit smoothly to prevent irritation caused by wrinkles

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Socket prosthesis washed with mild detergent, rinsed, and dried thoroughly with clean cloth Must be thoroughly dried before prosthesis is applied

PROMOTING HOME AND COMMUNITY BASED CARE • • • • •

Encourages client and family to become active participants in care o Skin care and residual limb care and management of prosthesis Receives ongoing instruction and practice sessions in learning how to transfer and how to use mobility and ADL aids safely Explains S/S of complications MUST be reported to MD Continued support and supervision by home care nurse essential to assess home environment PT and OT are continued at home