chap 45 EAQ med surg

Which patient is at the highest risk for an upper extremity amputation?

A young adult man working with explosives. A traumatic event, such as working with explosives and firearms can lead to an upper extremity amputation. Because these accidents are typically occupational hazards, the victims are usually young men.

The nurse is assessing a patient 24 hours after an above-the-knee amputation and finds bright red blood on the bed, under the patient's thigh. Place the immediate nursing interventions for this patient in order of priority.

Apply pressure to the site. Elevate the residual limb. Assess the patient's vital signs. Notify the health care provider.

The patient tells the LPN that he feels nauseated after being injected with contrast medium for arteriography. Which is the priority nursing action?

Continue to monitor the patient; this response to the contrast is expected. The patient may experience a flushed feeling or nausea in response to the contrast medium. Nausea is an expected response to the contrast medium, not evidence that the patient has received too much contrast medium or of an anaphylactic reaction.

While monitoring a patient who has undergone an amputation, the nurse finds a blood pressure of 96/64 mmHg and bluish discoloration of the skin. Which complication does the nurse suspect?

Hemorrhage A blood pressure of 96/64 mmHg and bluish discoloration of the skin indicates hypotension and cyanosis, which are late signs of hemorrhage in a patient who has undergone amputation.

Which signs and symptoms are observed in a patient with phantom limb sensation? Select all that apply.

Patients with phantom limb sensation experience itching, tingling, and numbness due to stimulation along a nerve pathway whose sensory endings were in the amputated body part.

How does massaging the residual limb help a patient who underwent amputation?

Promotes circulation Massaging the residual limb helps to improve blood circulation.

Which finding helped the nurse to conclude that a patient has a diminished blood supply to the extremities?

The patient's capillary refill time is 5 seconds.

The nurse is teaching a patient with a recent below-the-knee amputation. What should the nurse include in the teaching plan?

The prosthesis socket should be cleaned with soap and water and dried thoroughly before use. The patient should wash and dry the residual limb with soap and water every day.

While caring for a patient who has undergone an amputation, the nurse observes that the patient has skin disintegration. Which intervention will be beneficial for the patient?

Using "shrinker socks" at the site

A patient has had a bilateral below-the-knee amputation as a result of a work-related explosion. The patient has been discharged to an inpatient rehabilitation center to learn how to function without his legs. In order for the patient to transfer safely, what exercises should the physical therapist include in the patient's care?

Arm presses After lower extremity amputation, safe mobility is a priority. The patient should be encouraged to do exercises that strengthen his upper extremities. In order for a patient with a double amputation to transfer safely, he/she must possess upper body strength. This is accomplished by having the patient complete arm presses while seated. The other options do not promote increased arm strength.

Which diagnostic test is used to palpate the peripheral pulses?

Doppler ultrasound uses sound waves to determine the presence of pulses in the extremities. Arteriography helps to detect arterial occlusion.

Which complication can be prevented by applying a heavy cast on the residual limb after an amputation?

Edema Edema of the residual limb is common during the first 24 hours after amputation. Therefore, applying a heavy cast exerts pressure on the limb and helps to decrease swelling.

A patient returns to the medical/surgical unit following a replantation of the left arm. Which nursing intervention(s) would be appropriate for this patient? Select all that apply.

Keep the patient's room temperature at 80º F. Ensure patient's pajamas and/or gown is nonconstrictive. Elevate limb but not above the level of the heart Measures to promote circulation to the replanted limb include elevation of the limb; however do not elevate above the level of the heart as this may impair arterial flow. Elevate the limb on a single pillow to promote venous return and lymphatic drainage. The patient should not smoke or consume products with caffeine as these are vasoconstriction agents. Loosen all tight clothing to prevent circulatory problems. The nurse should prevent the patient from becoming chilled, as shivering causes metabolic acidosis and vasoconstriction.

While caring for a patient who has undergone amputation of the left leg, the nurse observes that the patient has developed contracture of the hip. Which actions of the nurse might have caused this complication?

Placing pillows below the knee of the amputated limb for a prolonged period Placing pillows below the knee of the amputated leg would cause an inability to straighten the leg and lead to contracture. Therefore, the prolonged use of pillows below the knee of the amputated leg should be avoided. Shrinker socks help to maintain compression and thereby enhance healing and shrinking, which is essential to fit the prosthetic well. A high Fowler position may cause flexion contraction at the hip in a patient who has undergone amputation. Therefore, a low Fowler position or semi-Fowler position is preferred. Elevating the left leg by raising the foot of the bed helps to reduce edema in the residual limb.

The nurse is teaching a patient to apply a compression dressing to the residual limb. If the patient asks about the purpose of the compression dressing, what would be the best response by the nurse?

The compression dressing is used to promote healing and to help shrink and taper the residual limb." the residual limb is bandaged to promote healing and to shrink and shape the residual limb to a tapered, round, smooth end that will fit the prosthesis.

The nurse is caring for a patient with a right below-the-knee amputation. The nurse knows that this patient most likely also suffered from which disorder?

Vascular disease Vascular diseases account for the majority of the estimated 30,000 lower extremity amputations performed in the United States each year. Trauma tends to be the most common reason for upper extremity amputations.

The nurse is caring for a patient who has had an above-the-knee amputation on the left side and is preparing the patient for discharge. The nurse educates the patient that which is the best type of diet to promote healing and to maintain or build strength after an amputation?

high protein, high calorie emphasizing high-calorie and high-protein intake is essential to promote healing and to build and maintain strength. The extra energy is essential for healing and building strength.

The nurse is caring for a patient with a left above the knee amputation. The patient is complaining of severe pain in the left leg and wants something for pain. What should the nurse do first?

tell the patient that this is phantom limb pain and sometimes follows amputation. The nurse should first explain to the patient that this is phantom limb pain and sometimes follows amputation. The patient should be given pain medication afterwards. The surgeon should be notified if this is continuous. The patient should also be advised that there are several therapies available for the treatment of this problem.

Why does the nurse perform plethysmography in a patient who has undergone an amputation?

to measure the volume of blood flow Plethysmography is a noninvasive procedure that records the pulse volume and helps to determine the volume of blood flow.

A patient who has undergone amputation of the right leg has a body temperature of 39°C, and the residual limb is red, warm, and edematous. Which laboratory test does the nurse expect to be ordered?

White blood cell count

The nurse is assessing a patient with an above-the-knee amputation during the early postoperative period for complications. The nurse should understand that the patient is at risk for what complications? Select all that apply.

1. Pain 2. Edema 4. Infection 6. Hemorrhage The most common problems in the early postoperative period for patients with amputations are hemorrhage, edema, infection, and pain. If infection were present, the patient would have an elevated WBC (leukocytosis), not a decreased WBC (leukopenia). Dysuria would not be associated with amputations.

The LPN is caring for a postoperative patient who had a surgical amputation. Which aspect of care is considered the priority in the early postoperative period?

Monitor vital signs for changes Monitoring vital signs is a priority because of the risk for hemorrhage and decreased cardiac output. Although verifying that the wound is healing and confirming that no evidence of infection is present are both important, monitoring vital signs that might prevent complications that could develop is the more immediate concern.

Which complication of amputation requires surgical debridement?

Necrosis Necrosis is tissue destruction and death. It requires surgical debridement of the necrotized tissue. Inadequate blood supply and bacterial destruction of tissue cause the death of healthy tissue and gangrene formation.

After amputation surgery, the interdisciplinary team works to increase the patient's functional ability and mobility. Which discipline is usually charged with initiating an exercise program?

Physical therapist

A patient is scheduled for a diagnostic test that uses a noninvasive device that gives general information about the volume of blood flow to an extremity. The nurse knows to prepare the patient for which diagnostic procedure?

Pulse-volume recording Pulse-volume recording uses a noninvasive device that gives general information about the volume of blood flow to an extremity. Doppler ultrasound uses sound waves to determine the presence of pulses in the extremities. Thermography involves the use of a device that detects and records heat in various parts of the body. Angiography is a procedure that involves the injection of a radiopaque dye into the blood vessels, which are then viewed radiographically to determine their patency.

The nurse finds that a patient who has undergone amputation of an arm has an elevated body temperature, redness, warmth, and exudate formation at the site of the wound. Further examination reveals necrosis at the amputated area. Which intervention does the nurse suspect to be beneficial in this patient for safe and effective care?

Reamputation An elevated body temperature, redness, warmth, and exudate formation indicates infection. Necrosis resulting from bacterial destruction is called gangrene, which requires reamputation to prevent the spread of infection. Sympathectomy is a treatment approach used to reduce pain. Surgical debridement is indicated for necrosis. Reclosure of the wound is indicated if the patient has wound dehiscence.

Radiographic examination of a patient who has undergone an amputation indicates that lesions are present at the site of surgery. The primary health care provider has instructed the nurse to obtain signed consent for further examination and treatment. What could be the reason for this action?

The patient is scheduled for a biopsy A biopsy is a procedure in which a bone sample is taken surgically and examined for the presence of lesions. Biopsy is an invasive procedure, so the patient is asked to sign the consent form. The patient has lesions at the site of surgery, which are a sign of cancer. A blood test will help to assess the white blood cell count and the presence of infection. However, a consent form is not required to perform a blood test. Plethysmography is a device that helps to assess the pulse volume reading and arterial blood flow and does not require a consent form. Doppler ultrasound examination is helpful to assess the patency of the blood vessels after amputation, but it does not require a consent form.

Which conditions/situations may lead to an amputation? Select all that apply

Tumors Trauma Disease Congenital anomalies Bone tumors may result in amputation of a limb. Patients may be born with a deformed limb, or a limb may be absent altogether. Serious accidents may sever a limb completely or may damage a limb to the extent that amputation is needed. Vascular disease accounts for the majority of lower-limb amputations in the United States.

While caring for a patient who has undergone an amputation, the nurse observes that the patient has skin disintegration. Which intervention will be beneficial for the patient?

Using "shrinker socks" at the site Shrinker socks will help to bind the residual limb moderately and reduce the risk of edema, which will maintain skin integrity appropriately. The bandage should not be too tight or like a tourniquet because it may cause injury to the residual limb and reduce blood flow. Elevating the extremity above heart level increases the risk of backflow of blood to the heart. Placing the patient in a high Fowler position may result in contracture of the hip.

A patient presents to the emergency department by ambulance after severing the left ring finger. The paramedics transport the severed finger with the patient. What is the most effective way to care for an amputated digit (finger) pending replantation?

Wrap it in a normal saline-saturated clean cloth, seal it in a plastic bag, place it in ice water, and transport it with the patient. A severed body part that can be replanted should never be placed directly on ice due to the fragility of the blood vessels. The severed digit should be wrapped with a normal saline or a lactated Ringer's-saturated clean cloth, sealed in a plastic bag, placed in ice water, and transported with the patient.