AMPUTATION

AMPUTATION I believe these were

notes done prior to class
• 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

• 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

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

• 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

• 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

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

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

• Neurovascular Assessment – Any S/S infection

o ROM as often as possible (mobilize area to prevent contractors)
o Elderly: Hydrated, anemia, respiratory, nutrition

• 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

• 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

• 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

• 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
PREOPERATIVE
• 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
• Efforts made to reestablish homeostasis and prevent problems related to surgery
anesthesia, and immobility
• Assess body Systems: Problems Associated with Immobility
Pneumonia
 Respiratory Constipation
 GI Anorexia
 GU Urinary Stasis

• 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
 • 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