ATI Med Surg Chapter 61 Amputations

A nurse is presenting information to a group of clients at a health fair about measures to reduce the risk of amputation. Which of the following information should the nurse provide? (select all that apply.) A. Clients who smoke should consider smoking cessation programs. B. Clients who have diabetes mellitus should maintain blood glucose within the expected reference range. C. Unplug electrical equipment when preforming repairs. D. Clients who have vascular disease should maintain good foot care. E. Wait 2 hr after taking pain medication before driving.

Answer: A, B, C, D

A nurse is caring for a client following a below-the-elbow amputation. Which of the following actions should the nurse take? (select all that apply.) A. Encourage dependent positioning of residual limb. B. Inspect the presence and amount of drainage on the dressing. C. Implement shrinkage intervention of the residual limb. D. Wrap the residual limb in circular manner using gauze. E. Observe for body image changes.

Answer: A, B, C, E

A nurse is collecting data from an older adult client who has arteriosclerosis and is scheduled for a right lower extremity amputation. Which of the following are expected findings n the affected extremity? (select all that apply.) A. Skin cool to touch from mid-calf to the toes. B. Lower leg appearing dusky when client is sitting. C. Palpable pounding pedal pulse. D. Lack of hair on lower leg. E. Blackened areas on several toes.

Answer: A, B, D, E

A nurse is assisting with preparing a plan of care to prevent a client from developing flexion contractions following a below‑the‑knee amputation 24 hr ago. Which of the following actions should the nurse include in the plan of care? A. Limit any type of exercise to the residual limb for the first 48 hr after surgery. B. Position the client prone several times each day. C. Wrap the residual limb in a figure‑eight pattern. D. Encourage sitting in a chair during the day.

Answer: B

A nurse is caring for a client who had an above‑the‑knee amputation. The client reports a sharp, stabbing type of phantom pain. Which of the following actions should the nurse take? A. Remove the initial pressure dressing. B. Encourage use of cold therapy. C. Question whether the pain is real. D. Administer an antiepileptic medication

Answer: D

Complications

Flexion contractures Flexion contractures are more likely with the hip or knee joint following amputation due to improper positioning. NURSING ACTIONS ●Prevention includes range-of-motion (ROM) exercises and proper positioning immediately after surgery. ●To prevent hip or knee flexion contracture, some providers do not advocate elevating the stump on a pillow. Other providers allow elevation for the first 24 to 48 hr to reduce swelling and discomfort. ●Have the client lie prone for 20 to 30 min several times a day to help prevent hip flexion contractions. ●Have a physical therapist teach the client some exercises that will prevent contractions. CLIENT EDUCATION: Stand using good posture with the residual limb in extension. This also will aid in balance.

Patient-Centered Care Conti...

Management of traumatic imputation ●Implement a medical emergency system (EMS). ●Apply direct pressure using gauze (if available) or clean cloth to prevent life-threatening hemorrhage. ●Elevate the extremity above the heart to decrease blood loss. ●Wrap the severed extremity in dry sterile gauze (if available) or in a clean cloth, and place in a sealed plastic bag in ice water (one part ice and three parts), and send with the client. Pain ●Monitor and treat pain. ●Differentiate between phantom limb and incisional pain. Incisional pain is treated with analgesics or PCA pump. Phantom limb pain ●The sensation of pain in the location of the extremity following the amputation ●Related to severed nerve pathways and is a frequent complication in clients who experienced chronic limb pain before the amputation ●Can be expected immediately after surgery, for up to several weeks, or indefinitely. ●Occurs less frequently following traumatic amputation. ●Often described as deep and burning, tingling, cramping, shooting, or aching. ●Treated much differently from incisional pain ●IV fusion of ketamine can reduce or eliminate phantom pain. ◯Administration of calcitonin during the first week after having an amputation can decrease phantom limb pain. ◯Administering beta-blocker, such as propranolol, can relieve the continual dull, burning sensation associated with phantom pain. ◯Administering antiepileptics (gabapentin or pregabalin) can relieve sharp, stabbing, and burning phantom limb pain. ◯Some clients have relief from antispasmodics, such as baclofen, and antidepressant medications. ◯Recognize the pain is real and manage it accordingly. ◯Alternative treatment for phantom limb pain can include nonpharmacological methods (massage, heat, transcutaneous electrical nerve stimulation [TENS], ultrasound therapy, biofeedback, acupuncture, relaxation therapy). ◯A stump stocking with an electromagnetic shield blocks external electromagnetic impulses from outside sources, which are thought to cause phantom pain. ◯Virtual reality goggles help visualize the limb as a whole. ◯Reinforce with the client how to push the residual limb down toward the bed while supported on a soft pillow. This helps reduce phantom limb pain and prepare the limb for a prosthesis. Client perception and feelings regarding amputation ●Allow for the client and family to grieve for the loss of the body part and change in body image. ●Feelings can include depression, anger, withdrawal, and grief. ●Monitor the psychosocial well-being of the client. Check for feelings of altered self-concept and self-esteem, and willingness and motivation for rehabilitation. ●Facilitate a supportive environment for the client and family so grief can be processed. Refer the client to religious/spiritual adviser, social worker, or counselor. ●Rehabilitation should include adaptation to a new body image and integration of prosthetic and adaptive devices into self-image. Residual limb preparation and prosthesis fitting Residual limb must be shaped and shrunk in preparation for prosthetic training. SHRINKAGE INTERVENTIONS ●Wrap the residual limb up to three times daily, using elastic bandages (figure-eight wrap) to prevent restriction of blood flow and decrease edema. ●Use a residual limb shrinker sock (easier for the client to apply). ●Use an air splint (plastic inflatable device) inflated to protect and shape the residual limb and for easy access to inspect the wound. CLIENT EDUCATION ●Amputation can alter sense of balance due to a disruption in the body's center of gravity. ●Use a mirror to monitor the stump daily for redness, or abrasions. ●Wash the stump daily with bacterial soap and completely rinse and dry it. ●Replace the stump sock daily. ●Apply the prosthesis immediately when getting out of bed to reduce swelling. ●Perform exercises to increase strength. ●Replace shoes frequently to prevent falls, ●Clean the prosthesis socket daily with a damp cloth. Dry the prosthesis socket thoroughly. ●Consult with prosthetic orthosis for prosthetic adjustments and yearly checks THERAPEUTIC PROCEDURES Closed amputation: This is the most common technique used. A skin flap is sutured over the end of the residual limb, closing the site. A compression dressing is applied after surgery to decrease swelling and prevent infection. Open amputation: This technique is used when an active infection is present. A skin flap is not sutured over the end of the residual limb, allowing for drainage of infection. The skin flap is closed at a later date. INTRAPROFESSIONAL CARE Intensive efforts by the interprofessional team are necessary to facilitate successful rehabilitation. ●A certified prosthetic orthotist will fit client with prosthesis after the wound is healed and the residual limb has shrunk. ●A physical therapist will train the client in the application and care of the prosthesis and mobility aids. ●An occupational therapist can assist the client with performing ADLs. ●A psychologist can be needed to help with adjustment to loss of the extremity. ●A social worker will assist the client who has financial issues and can refer the client to resources and a support group or organization for people who have had amputations

Patient-Centered Care

NURSING CARE Preoperative ●Involve the client in decision to amputate, and explain what to expect postoperatively. ●Expect clients to experience stages of denial and anger. ●Reinforce teaching about phantom limb pain. ●Reinforce teaching about muscle strengthening exercises. Postoperative ●Prevent postoperative complications (hypovolemia, pain, edema, infection). ●Elevate for the first 24 to 48 hr (lower extremities are usually not elevated for longer than 24 hr due to the risk of hip contractures). ●Monitor dressings and surgical site for bleeding. Monitor vital signs frequently. ●Monitor tissue perfusion of end of residual limb. ◯Palpate residual limb for warmth. Heat can indicate infection. ◯Compare pulse most proximal to incision with pulse in other extremity. ●Monitor for manifestations of infection and non-healing of incision. Infection can lead to osteomyelitis. ◯Elevate the stump, if ordered, to increase circulation and decrease pain and swelling. ◯Administer antibiotics and change dressings as prescribed if open amputation was performed. ◯Record characteristics of drainage (amount, color, and odor). ◯Keep a surgical tourniquet at the beside. ◯Change positions frequently.

Data Collection

RISK FACTORS ●Traumatic injury: motor vehicle crashes, industrial equipment, war-related injuries ●Thermal injury: frostbite, electrocution, burns ●Malignancy CHRONIC DISEASE PROCESSES ●Older adult clients have a higher risk of peripheral vascular disease and diabetes mellitus resulting in decreased tissue perfusion and peripheral neuropathy. Both conditions place older adult clients at risk for lower extremity amputation ●Peripheral vascular disease resulting in ischemia/gangrene ●Diabetes mellitus resulting in peripheral neuropathy and peripheral vascular disease ●Infection (osteomyelitis) ●Congenital defects EXPECTED FINDINGS Decreased tissue perfusion ●Clients might report pain ●History of injury or disease process precipitating amputation ●Altered peripheral pulses compared to the client's expected skin tone (can use a Doppler if needed) ●Differences in temperature of extremities (note the level of leg at which temperature becomes cool) ●Altered color of extremities (pallor, cyanosis, or gangrenous skin) ●Presence of infection and open wounds ●Lack of sensation in the affected extremity NURSING ACTIONS Neurological checks ●Monitor capillary refill by comparing the extremities. In older adult clients, capillary refill can be difficult to monitor due to thickened and opaque nails. ●Observe for edema, necrosis, and lack of hair distribution of the extremity due to inadequate peripheral circulation. ●Monitor peripheral pulses bilateral DIAGNOSTIC PROCEDURES To determine blood flow at various levels of an extremity Angiography: Allows visualization of peripheral vasculature and areas of impaired circulation. Doppler laser and ultrasonography studies: Measures speed of blood flow in an extremity. Transcutaneous oxygen pressure (TcPO2): Measures oxygen pressures in an extremity to indicate blood flow in the extremity, which is reliable indicator for healing. Ankle-brachial index: Measures difference between ankle and branchial systolic pressures.

Upper and Lower

UPPER EXTREMITY AMPUTATIONS ●Upper extremity amputations include above- and below-the-elbow amputations, wrist, and shoulder disarticulations, and finger amputations. ●Traumatic amputation caused by accidents, war, or injury is the primary cause of upper extremity amputations. ●Other causes include vasospastic disease, malignancy, and infection of extremity. LOWER EXTREMITY AMPUTATIONS ●Lower extremity amputations include above-and below-the-knee amputations, hip and knee disarticulations, Syme's amputation (removal of foot with ankle saved), and mid-foot and toe amputations. ●Peripheral vascular disease is the cause of most lower extremity amputations. ●Every effort is made to save as much of the extremity as possible. Even loss of the big toe can significantly affect balance, gait, and push-off ability during ambulation. Salvage of the knee with a below-the-knee amputation also improves function vs. an above-the-knee amputation.

Health Promotion and Disease Preventions

●Clients who have diabetes mellitus should monitor blood glucose and maintain it within the expected reference range. ●Use safety measures when working with heavy machinery or in areas where there is a risk of electrocution or burns. ●Encourage clients to quit or not start smoking, maintain a healthy weight, and exercise regularly. ●Tell clients to maintain good foot care and to seek early medical attention for non-healing wounds