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Amputations - Ch 54 Amputations(page 1199-1204 y removal of...

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Unformatted text preview: Ch. 54 Amputations (page 1199-1204) y removal of a part of the body y reduced number of amputations r/t advances in microvascular surgical procedures, better use of antibiotic therapy, improved surgical techniques for traumatic injury and bone cancer y psychosoial aspects are more devastating then than physical impairments y complete and permanent loss - change in body image and often in self esteem y collaborate with other health care team members when providing care (prosthetists, rehab therapists, psychologists, case managers, physiatrists [rehab physicians]) I. Patho A. Types of Amputation 1. electiveor surgical y most are r/t complications of PVD and arteriosclerosis, DM underlying cause a. these result in ischemia in distal areas of LE b. considered only after other interventions to restore circulation failed y limb salvage procedures - i.e. percutaneous transluminal angioplasty (PTA) 2. traumatic y most often result from accidents and are the a. primary cause of UE amputation y i.e. snow blower/lawn mover, motor vehicle or industrial machine accident etc. y increase during war bc of mines and bombs (affect legs most often) - veterans b. injury that causes severe crushing of tissues or significant blood vessel damage y usually results in amputation to function of the residual limb c. ability to salvage limbs injured r/t trauma is increasing y some body parts can be reattached or replanted B. Levels of Amputation y LE much more common than UE amputation 1. 5 types of LE amputations a. above knee (AKA) y when cause for amputation extends beyond the knee y more common in younger patients than in older ones who cannot handle the prostheses required for amputation y higher level of amputation, the more energy is required for mobility y these higher level procedures are typically done for cancer of the bone, osteomyelitis, cancer y greater in black and hispanic populations because diabetes and arteriosclerosis is greater in these populations (limited access to health care, language barriers) (1) hip disarticulation y (2) removal of the hip joint hemipelvectomy y removal of half of the pelvis with the leg b. below knee (BKA) y try to preserve the knee joint y common for PVD y most of the foot is removed by the ankle remains - weight bearing can occur c. syme without use of prosthesis and with reduced pain d. mid-foot y i.e. Lisfran&Chopart y common for PVD e. toe (1) loss of any or all of small toes = minor disability (2) loss of great toe/big toe = significant disability y affects balance, gait & "push off" ability while walking 2. UE amputations y less than 10% of all amputations y more incapacitating, trouble performing ADLs y as much length as possible is saved to maintain function y early replacement with a prosthetic device is vital C. Complications of Amputation 1. Common complications a. hemorrhage y major blood vessels are severed y if uncontrolled, patient is at risk for hypovolemic shock and possibly death b. infection y with any surgical procedure or trauma y can occur in wound or bone (osteomyelitis) y older adult who is malnourished and confused is at greatest risk - incontinence, soiled wounds; may remove dressing and pick at incision y prevention! in some cases Medicare will not reimburse for acquired infections c. phantom limb pain (PLP) y frequent complication y sensation is felt in the amputated part immediately after surgery, usually diminishes over time, when it persists it is PLP y more often in patients who had limb pain before surgery y rare in those who have traumatic amputations y patient reports pain in removed body part shortly after surgery (usually AKA) y pain is intense burning , crushing sensation or cramping, sometimes reported as in a distorted or uncomfortable position y experience numbness and tingling (phantom limb sensation) as well as pain y most distal area of the removed part feels as if its retracted into the residual limb end y triggered by: (1) touching the residual limb (2) temp or barometric pressure changes (3) concurrent illness (4) fatigue (5) anxiety (6) stress (7) routine activities (urination) (8) any stimulus y if pain is long-standing, esp if it existed before amputation, any stimulus can cause it (including touching any part of the body) d. neuroma y a sensitive tumor consisting of damaged nerve cells y forms mostly in amputations of the UE but can be anywhere y may or may not have pain y diagnosed by sonography y treated surgically or nonsurgically y surgery - removal of neuroma but it often regrows and is more painful than before y nonsurgical - nerve blocks (i.e. with phenol), steroid injections, cognitive therapies (hypnosis) e. flexion contractures (of the hip or knee) y seen with LE amputations y must be avoided so patient can ambulate with prostheses y proper positioning, active ROM are preventative 2. Health Promotion and Maintenance a. typically an elective amputee patient is a middle aged or older man with a hx of smoking or diabetes, most likely has not cared for his feet properly resulting in an infected foot ulcer and possibly gangrene therefore adherence with the dzmgmt plan may prevent a need for a later (1) amputation lifestyle habits like maintaining a healthy weight, regular exercise and avoiding (2) smoking can help prevent chronic diseases like diabetes b. second largest group, young men with motorcycle or other vehicle crashes or who are injured by industrial equipment or by combat or accidents in war y teach on importance of taking safety precautions to prevent injury at work and to avoid speeding or driving while drinking (1) traumatic amputation OR (2) undergo a surgical amputation because of a severe crushing injury and massive soft-tissue damage D. PATIENT CENTERED COLLABORATIVE CARE 1. Assessment a. Physical Assessment/Clinical Manifestations y assessneuro status in the affected extremity that will be amputated y when patient has PVD, assess circulation in other parts of the body y assess skin color, temp, sensation, and pulses in both affected and unaffected extremities y if can't assess capillary refill (i.e. in older adults) then assess the skin near the nail bed y capillary refill may not be as reliable as other things y observe and document and discoloration of the skin, edema, ulcerations, necrosis, and hair distribution of affected extremity before surgery b. Psychosocial Assessment (1) amputation of portion of one finger, especially thumb is traumatic (needed for hand activities) (2) patients face a complete, permanent loss (3) evaluate preparation for a planned amputation, expect grieving (4) traumatic, unexpected amputation is more difficult (5) younger patient may be bitter, hostile, depressed (6) loss of body part, may lose a job, recreational activity involvement ability loss, loss of social relationship if others cannot accept change (7) altered self concept y y may think intimate relationship is no longer possible y (8) affects body image and self esteem older adult - less independence assess the patient's feelings about themselves and ID areas in need of emotional support y y (9) referpt to chaplain, spiritual leader or social worker counseling resources available attempt to determine patient's willingness and motivation y to withstand prolonged rehab after amputation y ask questions about how they have previously dealt with life crises y adjustment is less difficult if the patient is willing to make needed changes (10) assess family's reaction to to the surgery or tauma y their response is usually goes along with the patient's recovery and rehab y expect family to grieve y give them time to adjust to the change (11) assess patient's and family's coping abilities y help them ID personal strengths and weaknesses y assess religious, spiritual, cultural beliefs y certain groups require amputated part be stored for later burial with the rest of the body or not buried immediately c. Diganostic Assessment y surgeon determines tests y assess for viability of the limb (based on blood flow) - lg # of noninvasive techniques y (1) for accuracy, doesn't rely on single test measurement of segmental limb blood pressures y ankle brachial index (ABI) is calculated by dividing ankle systolic pressure by brachial systolic pressure (normal ABI is 1 or higher) (2) Doppler ultrasonograpy, laser Doppler flowmetry, transcutaneous oxygen pressure (TcPO2) y noninvasive ways to assess blood flow in extremity y ultrasonograpy and laser Doppler measure speed of blood flow in limb y TcPO2 measures oxygen presssure, indicating blood flow in the limb is adequate for healing 2. Interventions a. Emergency Care: Traumatic Amputation y fingers most likely to be amputated and replanted (1) Call 911. (2) Assess airway or breathing problems. (3) Examine amputation site and apply direct pressure with layers of dry gauze or other cloth, using clean gloves if applicable. finger: y wrap the completely severed finger in dry sterile gauze or clean cloth y put finger in a water tight sealed plastic bag y put bag in ice water (not directly on ice, 1 part ice: 3 parts water) y avoid contact between the finger and the water to prevent tissue damage y don't remove any semi-attached parts of the digit y be sure the part goes with patient to hospital (4) Elevate extremity above head to decrease the bleeding. (5) Do not remove the dressing to prevent disloding the clot. (6) Not confined to a wheelchair r/t prosthetics y promotes independence in ambulation and ADLs y complications from extended bedrest are not common, even for older adults b. Assessment of Tissue Perfusion y primary focus: monitor for signs indicating tissue perfusion but not hemorrhage y skin flap at end of residual limb should be pink (light skinned person) and not discolored (too light or too dark) in a dark skinned patient y warm but not hot y assess closest proximal pulse for strength, compare with other extremity (if pt have bilateral vascular disease than this is not accurate) c. Management of Pain y PLP must be distinguished from residual limb pain (RLP) because they are managed different y sometimes both are at the same time y ifpt has PLP, recognize this is REAL pain and should be managed promptly and completely! ± interferes with activities and daily living y not therapeutic to say limb cannot be hurting because it is missing y to prevent increased pain, handle what is left of the limb carefully when assessing site or changing the dressing (1) opioid analgesics y (2) not as effective for PLP as they are for RLP IV infusion calcitonin (Miacalcin/ Calcimar) y y (3) week after amputation reduces PLP other drugs basis of type of PLP the patient has (a) beta blockers (proppranolol/Inderal) y constant, dull, burning pain (b) antieleptic drugs/anticonulsants (carbamazepine/Tegretol& gabapentin/Neurontin) y knifelike or sharp burning pain (c) antispasmodics (baclofen/Lioresal) y muscle spasms or cramping d. Complementary & Alternative Therapies y assess willingness y incorporate into plan of care if pt agrees (1) ultrasound (2) massage (3) exercises (4) biofeedback (5) distraction therapy (6) hypnosis (7) psychotherapy e. Prevention of Infection (1) broad-spectrum prophylatic antibiotics y prescribed before elective surgery or immediately before surgery y may be continued in (1) pt with traumatic amputations (2) pts with open wounds on residual limb (2) pressure dressing and drains y usually removed by surgeon 48-72 hours after surgery y inspect the wound site for inflammation (redness, swelling) y monitor for wound healing y record appearance, amount, and odor of drainage (if present) y change the soft dressing every day until the sutures or staples are removed y dressings are usually an elastic bandage wrapped firmly around the limb over a sterile gauze dressing on the incision f. Promotion of Mobility y collaborate with PT to begin exercises ASAP y therapist may work with pt before surgery to start muscle strengthening and evaluate need for crutches (practice with ambulatory aids before surgery makes ambulation after easier) y AKAs & BKAs - teach ROM for prevention of flexion contractures (hip and knee esp) y trapeze and overhead sling aid in strengthening of arms & allow the pt to move independently in bed y legs - firm mattress prevents contractures y assistpt to a prone position q 3-4 hours for 20-30 minute periods if tolerated (may be uncomfortable but necessary to prevent hip flexion contractures) y havept pull the limb close to the other leg and contract the gluteal muscls of butt y for BKAs - teach pt how to push the residual limb down toward the bed while supporting it on a pillow y after sutures are removed - resistive exercises "sling and spring" apparatus y elevation of lower leg residual limb on a pillow while pt is supine is controversial (promotes hip or knee flexion contracture, but elevation during first 24-48 hours reduces swelling and discomfort) y inspect residual limb daily to ensure it lies completely flat on bed g. Preparation of Prostheses y before elective, often see a certified prosthetis-orthotist (CPO) so that planning can begin for post-op pt y arm replacement esp important so pt can be independent y sometimes fitted with temporary prosthesis at time of surgery y others (usually older pts) are fitted after the residual limb has healed y leg prosthesis fitting - bring sturdy pair of shoes, prostheses adjusted to that heel height (1) devices used to shape and shrink residual limb to prepare for prosthesis (a) rigid, removable dressings y decrease edema, protect and shape the limb and allow easy access to the wound for inspection i) Jobst air splint y plastic inflatable device inflated to 20 mmHg for 22/24 hours y disadvantage: air leakage & loss of compression y used for same reason as listed in (a) ii) elastic bandages y reduces edema, shrink limb and hold the wound dressing in place y to be effective they must be reapplied q 4-6 hours or more often if they become loose y figure-8 wrapping prevents restriction of blood flow y distal to proximal wrapping (decreased tightness) y after wrapping, anchor to highest joint (above knee for BKAs) (b) improved design and materials for prosthesis y computer assisted design and manufacturing (CAD-CAM) makes a custom fit y most important dev in LE prosthetics - ankle-foot prosthesis (Flex-Foot for more active amputees) h. Promotion of Body Image and Lifestyle Adaptation (1) feelings of inadequacy y (esp older adult) - arrange a meeting with a rehabilitated amputee ab the same age (2) the word "stump" y using the word referring to the remaining portion of the limb remains controversial y pts feeling "as if they were part of a tree" y some rehab specialists feel it is appropriate bc it forces pt to realize and adjust to the amputation y (3) assesspt to determine if it appropriate to use assess verbal and nonverbal references to the affected area y some extremely happy and accept loss y DO NOT JUMP TO CONCLUSION THAT ACCEPTANCE HAS OCCURRED y (i.e. may verbalize acceptance but refuse to look at the area during dressing change - document and share with other members of health care team) y (4) askpt to describe feelings about changes in body image & self esteem coping with loss after discharge y may be difficult to cope with loss after discharge even if pt adjusted to amputation during hospitalization y teachab available resources and support from organizations (a) Amputee Coalition of America (ACA) (b) National Amputation Foundation (NAF) y (5) originally for veterans but now for everyone prosthetic advancements and advances in surgical techniques y pt can usually return to jobs and activities (if job or career change is necessary collaborate with social worker to evaluate skills) y (6) can participate in physically demanding activities intimate relationship y may think it is no longer possible because of physical changes y discuss issues with pt and partner as needed y prof assistance (sex therapist, intimacy coach or psychologist) may be needed (7) realistic goals y one day at a time y recognize personal strengths y unrealistic outcomes result in frustration and disappointment and may decrease rehab motivation E. Community Based Care y discharged directly home or to a skilled facility or rehab facility (depends on extent of amputation) y if rehab isn't possible (i.e. in demented or debilitated older adult) may be discharged to long term care facility y coordinate transfer with case manager for continuity of care 1. knee amputee at home y needs to have enough room to use WC if prosthesis is not available yet y must be able to use toileting facilities y access to areas needed for self-mgmt (i.e. kitchen) y may require structural home modifications 2. after sutures or staples are removed y residual limb care begins y home care nurse may be needed to teach the patient and/or family how to care for the limb and prosthesis y limb should be rewrapped 3x day with an elastic bandage in a figure-8 manner y for some pts, a shrinker stocking or sock is easier to apply y after healing, cleansed daily with the rest of the body during bathing (soap & water) y teachpt to inspect daily for signs of inflammation or skin breakdown 3. collaborate with prosthetist about prosthesis care y ensure reliability and proper function y custom-made devices y take into account patient's level of amputation, lifestyle andoccupation y prosthesis requires special care: teach regarding correct cleansing of socket & inserts, wearing correct liners, assessing shoe wear and a schedule of follow up car is essential BEFORE discharge (may be needed by home care nurse) ...
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