Chapter 43

1. Chapter 43 Amputations

2. Learning Objectives • Identify the clinical indications for amputations. • Describe the different types of amputations. • Discuss the medical and surgical management of the amputation patient. • Identify appropriate nursing interventions during the preoperative and postoperative phases of care. • Assist in developing a nursing care plan for the amputation patient.

3. Amputation Can occur through a joint (between the bones) or through a bone itself Disarticulation: term used for an amputation through the joint The general site of the amputation is described by the joint nearest to it

4. Figure 43-1

5. Indications and Incidence Trauma Common types of accidents and injuries leading to amputation include those involving motorcycles and automobiles, farm machinery, firearms and explosives, electrical equipment, power tools, and frostbite Disease Peripheral vascular disease, diabetes mellitus, arteriosclerosis, and chronic osteomyelitis

6. Indications and Incidence Tumors Bone tumors that are very large and invasive Congenital defects Convert a deformed limb into a more functional one that can be fitted with a prosthetic device

7. Diagnostic Tests and Procedures Vascular studies Pulse volume recording Thermography Doppler ultrasound Biopsy

8. Medical Treatment Must include appropriate treatment and control of underlying diseases or injuries Diet, medication, and exercise help patients with diabetes and poor peripheral circulation If peripheral vascular disease, encourage to stop smoking; nicotine causes vasoconstriction Trauma patient may have to be stabilized to maintain normal heart rate and blood pressure

9. Surgical Treatment Amputation at the lowest level that will preserve healthy tissue and favor wound healing Surgeon chooses one of two procedures, depending on condition of the extremity and the reason for the surgery Closed amputations Create a weight-bearing residual limb, important for lower extremity amputations Open amputations The severed bone or joint is left uncovered by a skin flap Required when an actual or potential infection exists, as may occur with gangrene or trauma

10. Prostheses Artificial substitutes for missing body parts Prosthetist creates and supervises use of prosthesis A limb prosthesis may be placed while the patient is still in the operating room With lower extremity amputations, older or debilitated patients, and infection, prosthesis fitting delayed until residual limb heals Can usually bear full weight on permanent prosthesis about 3 months after amputation

11. Figure 43-2

12. Figure 43-3

13. Complications Hemorrhage and hematoma Necrosis Wound dehiscence Gangrene Edema Contracture Pain Infection Phantom limb sensation Phantom limb pain

14. Assessment Record conditions that resulted in need for amputation Preexisting cardiovascular problems Family history of diabetes, hypertension, and vascular diseases Signs and symptoms that relate to the vascular condition or other chronic and acute problems Diet and fluid intake, intake of salt and alcohol, and use of tobacco Exercise and rest and sleep habits as well as the effects of the current symptoms on the patient’s usual activities Patient’s psychosocial background may offer insight into how the patient will tolerate treatments and procedures

15. Physical Examination Height, weight, and vital signs Assess neurovascular status Skin color, texture, temperature, and turgor Palpate peripheral pulses for quality, symmetry Assess capillary refill Sensation; ask patient to identify touch on extremities Mental and emotional status and general cognitive abilities; determines patient’s understanding of the illness and its implications

16. Interventions Anxiety Anticipatory grieving

17. Postoperative Nursing Care Assessment Monitor vital signs frequently in the first 48 hours Inspect the dressing frequently for bleeding If drain receptacle, note color and amount of drainage Monitor patient’s temperature for elevations that may indicate infection Note any foul odor from the dressing After the dressing is removed, inspect the residual limb for edema Document patient’s pain, including type, location, severity, and response to treatment

18. Postoperative Nursing Care Interventions Decreased Cardiac Output Pain Risk for Infection Impaired Skin Integrity and Risk for Impaired Skin Integrity Disturbed Sensory Perception Risk for Injury Impaired Physical Mobility Activity Intolerance Self-Care Deficit Anxiety, Fear, and Ineffective Coping Disturbed Body Image

19. Figure 43-4

20. The Older Adult Amputee May have needs that should be taken into consideration when planning and providing care Completely capable of learning but often requires smaller units of information, more repetition, more time During teaching process patients with glasses or hearing aids should have them in place Remind that phantom sensations are not uncommon or bizarre; this can reduce fear or anxiety of these sensations Many have one or more chronic health problems The loss of a limb can be especially difficult; it is important to provide psychological support

21. Replantation Involves the use of a microscope and highly specialized instruments to reanastomose (reconnect) blood vessels and nerve fibers in a severed limb Limb sutured into its correct anatomic position Advances in microsurgical techniques and preservation of severed limbs have made this technique increasingly successful

22. Indications For amputations through the hand or wrist Amputated thumbs are reattached whenever possible because of their importance in hand function In severely injured hand in which two or more fingers are detached, surgeon restores as many fingers as possible Amputations above the wrist do not lend themselves as readily to replantation because of the extensive tissue, muscle, and bone damage accompanying the injury In general, the greater the muscle mass injury, the less likely replantation is possible

23. Emergency Care Wrap amputated parts in a clean cloth saturated with normal saline or Ringer’s lactate Put in a sealed plastic bag that is placed in ice water Direct contact between the amputated part and the ice can lead to further tissue damage and cell death Partially amputated parts should remain attached to the patient and be kept cool if possible Extra care to avoid detaching any parts since even small connections increase the chances for successful repair Patient may require treatment for shock due to blood loss Tourniquets should not be used unless absolutely necessary

24. Assessment Assess circulatory status Closely monitor vital signs Inspect the residual limb (or dressing) for bleeding Assess pain at the site of the injury and at other locations Measure and record fluid intake and output Note patient’s emotional status, and assess understanding of the preoperative activities and postoperative routines Identify sources of support

25. Preoperative Nursing Care Interventions Administer intravenous fluids and blood as ordered If the dressing becomes saturated with blood, reinforce the dressing Report continued or excessive bleeding to the physician Even though preparations for replantation are hurried, be sensitive to the patient’s fear and anxiety Accept the patient’s feelings Provide brief, simple explanations Administer analgesics as ordered for pain

26. Postoperative Nursing Care: Assessment Monitor vital signs, intake and output, and level of consciousness Hourly neurovascular assessment of limb Doppler device or pulse oximeter to evaluate circulation Note and record the limb’s color, capillary refill, turgor, temperature, and sensation Assess limb for edema because massive edema often accompanies replantation

27. Postoperative Nursing Care: Interventions Elevate the limb Abstain from nicotine- and caffeine-containing products for 7 to 10 days postoperatively Enforce a strict ban on cigarette smoking Room at 80° F to prevent compensatory vasoconstriction of peripheral tissues Loosen tight or restrictive gowns or pajamas Administer ordered drugs; monitor effects Discuss thoughts and feelings about the replantation, disfigurement, and loss of function