NURSING PROCESS: THE PATIENT UNDERGOING AN AMPUTATION
Before surgery, the nurse must evaluate the neurovascular and func-tional status of the extremity through history and physical assess-ment. If the patient has experienced a traumatic amputation, the nurse assesses the function and condition of the residual limb. The nurse also assesses the circulatory status and function of the unaf-fected extremity. If infection or gangrene develops, the patient may have associated enlarged lymph nodes, fever, and purulent drainage. A culture is taken to determine the appropriate antibiotic therapy.
The nurse evaluates the patient’s nutritional status and creates a plan for nutritional care, if indicated. For wound healing, a bal-anced diet with adequate protein and vitamins is essential.
Any concurrent health problems (eg, dehydration, anemia, car-diac insufficiency, chronic respiratory problems, diabetes mellitus) need to be identified and treated so that the patient is in the best possible condition to withstand the trauma of surgery. The use of corticosteroids, anticoagulants, vasoconstrictors, or vasodilators may influence management and wound healing.
The nurse assesses the patient’s psychological status. Deter-mination of the patient’s emotional reaction to amputation is es-sential for nursing care. Grief response to a permanent alteration in body image is normal. An adequate support system and pro-fessional counseling can help the patient cope in the aftermath of amputation surgery.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Acute pain related to amputation
· Risk for disturbed sensory perception: phantom limb pain related to amputation
· Impaired skin integrity related to surgical amputation
· Disturbed body image related to amputation of body part
· Ineffective coping, related to failure to accept loss of body part
· Risk for anticipatory and/or dysfunctional grieving related to loss of body part
· Self-care deficit: feeding, bathing/hygiene, dressing/grooming, or toileting, related to loss of extremity
· Impaired physical mobility related to loss of extremity
Based on the assessment data, potential complications that may develop include the following:
· Postoperative hemorrhage
· Skin breakdown
The major goals of the patient may include relief of pain, absence of altered sensory perceptions, wound healing, acceptance of al-tered body image, resolution of the grieving process, indepen-dence in self-care, restoration of physical mobility, and absence of complications.
Surgical pain can be effectively controlled with opioid analgesics, nonpharmaceutical interventions, or evacuation of the hematoma or accumulated fluid. Pain may be incisional or may be caused by inflammation, infection, pressure on a bony prominence, or hematoma. Muscle spasms may add to the patient’s discomfort. Changing the patient’s position or placing a light sandbag on the residual limb to counteract the muscle spasm may improve the pa-tient’s level of comfort. Evaluation of the patient’s pain and re-sponses to interventions is an important part of the nurse’s role in pain management. The pain may be an expression of grief and alteration of body image.
Amputees may experience phantom limb pain soon after surgery or 2 to 3 months after amputation. It occurs more frequently may in above-knee amputations. The patient describes pain or un-usual sensations, such as numbness, tingling, or muscle cramps, as well as a feeling that the extremity is present, crushed, cramped, or twisted in an abnormal position. When a patient describes phantom pains or sensations, the nurse acknowledges these feel-ings and helps the patient modify these perceptions.
Phantom sensations diminish over time. The pathogenesis of the phantom limb phenomenon is unknown. Keeping the patient active helps decrease the occurrence of phantom limb pain. Early intensive rehabilitation and stump desensitization with kneading massage brings relief. Distraction techniques and activity are help-ful. Transcutaneous electrical nerve stimulation (TENS), ultra-sound, or local anesthetics may provide relief for some patients. In addition, beta-blockers may relieve dull, burning discomfort; anti-seizure medications control stabbing and cramping pain; and tri-cyclic antidepressants are used to improve mood and coping ability.
The residual limb must be handled gently. Whenever the dress-ing is changed, aseptic technique is required to prevent wound infection and possible osteomyelitis.
Residual limb shaping is important for prosthesis fitting. The nurse instructs the patient and family in wrapping the residual limb with elastic dressings (Figs. 69-18 and 69-19). After the in-cision is healed, the nurse teaches the patient to care for the resid-ual limb.
Amputation is a reconstructive procedure that alters the patient’s body image. The nurse who has established a trusting relationship with the patient is better able to communicate acceptance of the patient who has experienced an amputation. The nurse encour-ages the patient to look at, feel, and then care for the residual limb. It is important to identify the patient’s strength and resources to facilitate rehabilitation. The nurse assists the patient to regain the previous level of independent functioning. The patient who is ac-cepted as a whole person is more readily able to resume responsi-bility for self-care; self-concept improves, and body-image changes are accepted. Even with highly motivated patients, this process may take months.
The loss of an extremity (or part of one) may come as a shock even if the patient was prepared preoperatively. The patient’s behavior (eg, crying, withdrawal, apathy, anger) and expressed feelings (eg, depression, fear, helplessness) will reveal how the patient is cop-ing with the loss and working through the grieving process. The nurse acknowledges the loss by listening and providing support.
The nurse creates an accepting and supportive atmosphere in which the patient and family are encouraged to express and share their feelings and work through the grief process. The support from family and friends promotes the patient’s acceptance of the loss. The nurse helps the patient deal with immediate needs and become oriented to realistic rehabilitation goals and future inde-pendent functioning. Mental health and support group referrals may be appropriate.
Amputation of an extremity affects the patient’s ability to pro-vide adequate self-care. The patient is encouraged to be an active participant in self-care. The patient needs time to accomplish these tasks and must not be rushed. Practicing an activity with consistent, supportive supervision in a relaxed environment en-ables the patient to learn self-care skills. The patient and the nurse need to maintain positive attitudes and to minimize fatigue and frustration during the learning process.
Independence in dressing, toileting, and bathing (shower or tub) depends on balance, transfer abilities, and physiologic toler-ance of the activities. The nurse works with the physical therapist and occupational therapist to teach and supervise the patient in these self-care activities.
The patient with an upper extremity amputation has self-care deficits in feeding, bathing, and dressing. Assistance is provided only as needed; the nurse encourages the patient to learn to do these tasks, using feeding and dressing aids when needed. The nurse, therapists, and prosthetist work with the patient to achieve maximum independence.
Positioning assists in preventing the development of hip or knee joint contracture in the patient with a lower extremity amputa-tion. Abduction, external rotation, and flexion of the lower ex-tremity are avoided. Depending on the surgeon’s preference, the residual limb may be placed in an extended position or elevated for a brief period after surgery. The foot of the bed is raised to elevate the residual limb.
The nurse encourages the patient to turn from side to side and to assume a prone position, if possible, to stretch the flexor mus-cles and to prevent flexion contracture of the hip. The nurse discourages sitting for prolonged periods, to prevent flexion con-tracture. The legs should remain close together to prevent an abduction deformity.
Postoperative ROM exercises are started early, because contrac-ture deformities develop rapidly. ROM exercises include hip and knee exercises for below-knee amputations and hip exercises for above-knee amputations. It is important that the patient under-stand the importance of exercising the residual limb.
The upper extremities, trunk, and abdominal muscles are ex-ercised and strengthened. The extensor muscles in the arm and the depressor muscles in the shoulder play an important part in crutch walking. The patient uses an overhead trapeze to change position and strengthen the biceps. The patient may flex and extend the arms while holding weights. Doing push-ups while seated strengthens the triceps muscles. Exercises, such as hyper-extension of the residual limb, conducted under the supervision of the physical therapist or occupational therapist, also aid in strengthening muscles as well as increasing circulation, reducing edema, and preventing atrophy.
Because an upper extremity amputee uses both shoulders to operate the prosthesis, the muscles of both shoulders are exercised. A patient with an above-the-elbow amputation or shoulder dis-articulation is likely to develop a postural abnormality caused by loss of the weight of the amputated extremity. Postural exercises are helpful.
Strength and endurance are assessed, and activities are in-creased gradually to prevent fatigue. As the patient progresses to independent use of the wheelchair, use of ambulatory aids, or ambulation with a prosthesis, the nurse emphasizes safety con-siderations. Environmental barriers (eg, steps, inclines, doors, wet surfaces) are identified, and methods of managing them are prac-ticed. It is important to anticipate, identify and manage problems associated with the use of the mobility aids (eg, pressure on the axillae from crutches, skin irritation of the hands from wheelchair use, residual limb irritation from a prosthesis).
Amputation of the leg changes the center of gravity; therefore, the patient may need to practice position changes (eg, standing from sitting, standing on one foot). The patient is taught transfer techniques early and is reminded to maintain good posture when getting out of bed. A well-fitting shoe with a nonskid sole should be worn. During position changes, the patient should be guarded and stabilized with a transfer belt at the waist to prevent falling.
As soon as possible, the patient with a lower extremity am-putation is assisted to stand between parallel bars to allow ex-tension of the temporary prosthesis to the floor with minimal weight bearing. How soon after surgery the patient is allowed to touch down the artificial foot depends on the patient’s physical status and wound healing. As endurance increases and balance is achieved, ambulation is started with the use of parallel bars or crutches. The patient learns to use a normal gait, with the resid-ual limb moving back and forth while the patient is walking with the crutches. To prevent a permanent flexion deformity from occurring, the residual limb should not be held up in a flexed position.
The patient with an upper extremity amputation is taught how to carry out the ADLs with one arm. The patient is started on one-handed self-care activities as soon as possible. The use of a temporary prosthesis is encouraged. The patient who learns to use the prosthesis soon after the amputation is less dependent on one-handed self-care activities.
A patient with an upper extremity amputation may wear a cotton T-shirt to prevent contact between the skin and shoulder harness and to promote absorption of perspiration. The pros-thetist advises about cleaning the washable portions of the harness. Periodically, the prosthesis is inspected for potential problems.
The residual limb must be conditioned and shaped into a con-ical form to permit accurate fit, maximum comfort, and function of the prosthetic device. Elastic bandages, an elastic residual limb shrinker, or an air splint is used to condition and shape the resid-ual limb. The nurse teaches the patient or a member of the family the correct method of bandaging.
Bandaging supports the soft tissue and minimizes the forma-tion of edema while the residual limb is in a dependent position. The bandage is applied in such a manner that the remaining muscles required to operate the prosthesis are as firm as possible, whereas those muscles that are no longer useful atrophy. An improperly applied elastic bandage contributes to circulatory prob-lems and a poorly shaped residual limb.
Effective preprosthetic care is important to ensure proper fitting of the prosthesis. The major problems that can delay prosthetic fit-ting during this period are (1) flexion deformities, (2) nonshrink-age of the residual limb, and (3) abduction deformities of the hip.
The physician usually prescribes activities to condition or “toughen” the residual limb in preparation for a prosthesis. The patient begins by pushing the residual limb into a soft pillow, then into a firmer pillow, and finally against a hard surface. The patient is taught to massage the residual limb to mobilize the sur-gical incision site, decrease tenderness, and improve vascularity. Massage is usually started once healing has occurred and is first done by the physical therapist. Skin inspection and preventive care are taught.
The prosthesis socket is custom molded to the residual limb by the prosthetist. Prostheses are designed for specific activity lev-els and patient abilities. Types of prostheses include hydraulic, pneumatic, biofeedback-controlled, myoelectrically controlled, and synchronized prostheses.
Adjustments of the prosthetic socket are made by the prosthetist to accommodate the residual limb changes that occur during the first 6 months to 1 year after surgery. A light plaster cast, an elastic bandage, or a shrinking sock is used to limit edema during periods when the patient is not wearing the permanent prosthesis.
Some patients are not candidates for a prosthesis and are thus nonambulatory amputees. If use of a prosthesis is not possible, thepatient is instructed in the use of a wheelchair to achieve indepen-dence. A special wheelchair designed for patients who have had am-putations is recommended. Because of the decreased weight in the front, a regular wheelchair may tip backward when the patient sits in it. In an amputee wheelchair, the rear axle is set back about 5 cm (2 inches) to compensate for the change in weight distribution.
After any surgery, efforts are made to reestablish homeostasis and to prevent problems related to surgery, anesthesia, and immobil-ity. The nurse assesses body systems (eg, respiratory, gastrointes-tinal, genitourinary) for problems associated with immobility (eg, pneumonia, anorexia, constipation, urinary stasis) and institutes corrective management. Avoiding problems associated with im-mobility and restoring physical activity are necessary for mainte-nance of health.
Massive hemorrhage due to a loosened suture is the most threat-ening problem. The nurse monitors the patient for any signs or symptoms of bleeding. It is also important to monitor the patient’s vital signs and to observe the suction drainage.
Infection is a frequent complication of amputation. Patientswho have undergone traumatic amputation have a contaminated wound. The nurse administers antibiotics as prescribed. It is im-portant to monitor the incision, dressing, and drainage for indi-cations of infection (eg, change in color, odor, or consistency of drainage; increasing discomfort). The nurse also monitors for systemic indicators of infection (eg, elevated temperature) and promptly reports indications of infection to the surgeon.
Skin breakdown may result from immobilization or from pres-sure from various sources. The prosthesis may cause pressure areas to develop. The nurse and the patient assess for breaks in the skin. Careful skin hygiene is essential to prevent skin irritation, infec-tion, and breakdown. The healed residual limb is washed and dried (gently) at least twice daily. The skin is inspected for pres-sure areas, dermatitis, and blisters. If they are present, they must be treated before further skin breakdown occurs. Usually, a resid-ual limb sock is worn to absorb perspiration and to prevent direct contact between the skin and the prosthetic socket. The sock is changed daily and must fit smoothly to prevent irritation caused by wrinkles. The socket of the prosthesis is washed with a mild detergent, rinsed, and dried thoroughly with a clean cloth. The nurse advises the patient that the socket must be thoroughly dry before the prosthesis is applied.
Before discharge to the home or to a rehabilitation facility, the nurse encourages the patient and family to become active parti-cipants in care. They participate, as appropriate, in skin care and residual limb care and in the management of the prosthesis. The patient receives ongoing instructions and practice sessions in learning how to transfer and how to use mobility aids and other assistive devices safely. The nurse explains the signs and symp-toms of complications that must be reported to the physician (Chart 69-5).
After the patient has achieved physiologic homeostasis and has demonstrated achievement of major health care goals, rehabili-tation continues either in a rehabilitation facility or at home. Continued support and supervision by the home care nurse are essential.
Before the patient’s discharge to the home, the nurse should as-sess the home environment. Modifications are made to ensure the patient’s continuing care, safety, and mobility. An overnight or weekend experience at home may be tried to identify problems that were not identified on the assessment visit. Physical therapy and occupational therapy may continue in the home or on an out-patient basis. Transportation to continuing health care appoint-ments must be arranged. The social service department of the hospital or the community agency managing continued health care may be of great assistance in securing personal assistance and transportation services.
During follow-up health visits, the nurse evaluates the patient’s physical and psychosocial adjustment. Periodic preventive health assessments are necessary. Frequently, an elderly spouse is unable to provide the assistance required, and additional help at home is needed. Modifications in the plan of care are made on the basis of such findings. Often, the patient and family find involvement in an amputee support group to be of value; here, they are able to share problems, solutions, and resources. Talking with those who have successfully dealt with a similar problem may help the patient develop a satisfactory solution.
Because patients and their family members and health care providers tend to focus on the most obvious needs and issues, the nurse reminds the patient and family about the importance of continuing health promotion and screening practices, such as reg-ular physical examinations and diagnostic screening tests. Those patients who have not been involved in these practices in the past are instructed in their importance and are referred to appropriate health care providers.
Expected patient outcomes may include:
1) Experiences absence of pain
a) Appears relaxed
b) Verbalizes comfort
c) Uses measures to increase comfort
d) Participates in self-care and rehabilitative activities
2) Experiences absence of phantom limb pain
a) Reports diminished phantom sensations
b) Uses distraction techniques
c) Performs stump desensitization massage
3) Achieves wound healing
a) Controls residual limb edema
b) Achieves healed, nontender, nonadherent scar
c) Demonstrates residual limb care
4) Demonstrates improved body image and effective coping
a) Acknowledges change in body image
b) Participates in self-care activities
c) Demonstrates increasing independence
d) Projects self as a whole person
e) Resumes role-related responsibilities
f) Reestablishes social contacts
g) Demonstrates confidence in abilities
5) Exhibits resolution of grieving
a) Expresses grief
b) Works through feelings with family and friends
c) Focuses on future functioning
d) Participates in support group
6) Achieves independent self-care
a) Asks for assistance when needed
b) Uses aids and assistive devices to facilitate self-care
c) Verbalizes satisfaction with abilities to perform ADLs
7) Achieves maximum independent mobility
a) Avoids positions contributing to contracture development
b) Demonstrates full active ROM
c) Maintains balance when sitting and transferring
d) Increases strength and endurance
e) Demonstrates safe transferring technique
f) Achieves functional use of prosthesis
g) Overcomes environmental barriers to mobility
h) Uses community services and resources as needed
8) Exhibits absence of complications of hemorrhage, infection, skin breakdown
a) Does not experience excessive bleeding
b) Maintains normal blood values
c) Is free of local or systemic signs of infection
d) Repositions self frequently
e) Is free of pressure-related problems
f) Reports any skin discomfort and irritations promptly