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01.10 Amputation

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Overview

  1. Amputation
    1. Loss of limb
    2. Patient centered care

Nursing Points

General

  1. Reasons for amputation
    1. Disease
      1. Diabetes–>poor circulation, wounds
      2. PVD or arterial disorders–>lack of blood/oxygen to tissues, wounds
    2. Injury
    3. Tumor
    4. Severe infection–>osteomyelitis
  2. Amputation locations
    1. Leg
      1. Above knee
      2. Below knee
    2. Foot
    3. Toes
    4. Arm
      1. Above elbow
      2. Below elbow
    5. Hand
    6. Fingers
  3. Partial vs full
  4. Single vs bilateral
  5. Urgent vs planned surgery
    1. Stabilize patient
    2. Attempt antibiotic treatment first
    3. Address nutritional status–>need protein to heal
    4. MRI
      1. View infection and fluid buildup
      2. Help determine amputation location
    5. Time out
      1. Right limb
      2. Right patient
      3. Right surgery

Assessment

  1. Location of amputation
  2. Positioning
  3. Skin integrity
    1. If post-op, exam at least q24h
      1. Bleeding
      2. Necrosis
    2. If drains present, monitor output
  4. Pain level
    1. Stump pain after surgery
    2. Phantom pain –> in body part that was removed
      1. Medications
      2. Spinal cord stimulation

Therapeutic Management

  1. Wound care–>prevent infection
  2. Stump shrinker–>decreases swelling
  3. Check skin on stump
  4. Pain management
  5. Psychological support–>lost part of body
  6. Rehabilitation–>new ways of carrying out ADLs

Nursing Concepts

  1. Grief
    1. Loss of body part
  2. Tissue/Skin Integrity
    1. Healing after surgery
    2. Maintaining intact skin
  3. Mobility
    1. Adjustment after amputation
  4. Patient-Centered Care
    1. Depending on where amputation is, plan care accordingly

Patient Education

  1. Home ADLs –> encourage activity
    1. Walker
    2. Wheelchair
    3. Prosthesis
  2. Encourage family/friend support
  3. Call doctor if red or warm to touch
  4. Phantom sensations may occur –> look for distractions

Reference Links

Study Tools

Video Transcript

Hey guys! Welcome to the lesson about amputation where we’ll explore what an amputation is, when a patient may need one, and how to care for the patient that has one.

Amputation involves the removal or loss of a limb. This could be because of a disease like diabetes where the patient has poor circulation and feeling in the feet. They may more likely develop wounds and if their diabetes is unmanaged they could end up needing an amputation. Peripheral vascular disease and arterial disorders result in the lack of blood flow to the tissue and wounds, making wound healing very difficult and increasing the possibility of needing an amputation. A person might need an amputation if they have a severe injury that cannot be repaired, or a severe tumor. If a patient has wounds that spread to the bone which is called osteomyelitis, the surgeon may decide that amputation of the limb is the best option to prevent further spreading. 

Okay, so here are some examples of body parts that might be amputated depending on the situation and diagnosis. Leg amputations may be above or below the knee. Arms may be amputated above or below the elbows. Hands, fingers, feet, and toes may all be removed as well. 

A patient may have a partial amputation or a full amputation. For example, they may only have half of the finger removed. A bilateral amputation would be of both legs where a single would be just one of them. Surgery for an amputation could be urgent or planned. If planned, the patient would be stabilized first. An example would be if a patient has a severe wound infection and the doctor orders antibiotics to try and treat the infection less invasively first. The patient’s nutritional status should be considered as well as high protein intake is necessary for healing. 

If there is suspected osteomyelitis or abscesses, the doctor will probably order an MRI to view infection and fluid buildup. It will also be necessary to view where the surgeon will amputate at. 

So if the surgeon determines the patient does need the amputation procedure, it’s super important that a time-out is performed before the surgery. This ensures that the right surgery is performed on the right limb on the right patient and is charted correctly.

If you get a patient that just recently had the amputation procedure done, you need to assess the surgical site at least every 24 hours for bleeding and necrosis. Necrosis is when the tissue dies and begins turning black. If there is bleeding present, apply pressure by wrapping the stump and call the surgeon for further orders. Sometimes the patient will come back from surgery with a drain present, especially if the amputation was due to infection. The drain needs to be emptied and measured about every 8 hours. The drainage should decrease over time and eventually the drain will be removed. If you are caring for a patient that had an amputation in the past that is completely healed, you still want to assess the location. Patient positioning should be discussed with the patient to ensure comfort and support skin integrity. Next let’s talk about pain with amputations.

The patient may have pain in the stump after surgery that may require pain medications and positioning. Phantom pain could occur in the body part removed where they feel like the body part still hurts even though it’s been removed. This happens because of the nerve stimulation in their brain.  It could be temporary or permanent, and it may come and go. Medications may help with phantom pain, but if treatment doesn’t seem to help, the doctor may discuss spinal cord stimulation where electrical impulses are provided to the spinal cord. This may be implanted so that the patient may use it as needed. 

When caring for a patient with an amputation, it is a priority to prevent infection by caring for the wound. The skin should always be assessed on the stump, and a stump shrinker might be used to decrease the selling. Be sure to assess the patient’s pain and provide medications as needed. So, when a patient loses a part of their body they are likely going to experience psychological stress. Psychological support may be provided by the nurse, and many health care facilities have chaplains that may help talk to the patient. The patient will need rehab to help get them back to their normal ADLs with new ways of functioning. 

Be sure to educate your patient with a new amputation to continue working on activity for home ADLs. They may need a walker, wheelchair, or prosthesis to help them get around. Encourage them to reach out to family and friends for support. They should call the doctor if they see any redness or if the site is warm to touch. Remind them that the phantom sensations might occur, and if they do they should try to distract themselves. If it gets to be severe and constant, they should talk to the doctor about other options. 

The priority nursing concepts for the patient with an amputation include grief, mobility, and tissue/skin integrity. 

Okay, so now lets review the key points from this lesson. Amputation is the loss or removal of a limb. The patient may have the removal of an arm, leg, foot, hand, fingers, or toes. As the nurse, you should assess the skin integrity of the patient. The surgical wound should be assessed at least daily and let the doctor know if there are any changes like excess bleeding, redness, or black skin. You will assess the patient’s pain level and medicate as needed. The surgeon should provide orders on what type of dressings to apply and how often to change them. You’ll want to position the patient to best support the stump and avoid injury. ADLs must be addressed as the patient will be living without a body part that they previously had. Make sure you educate your patient to actually look over their stump daily to make sure there isn’t any redness or wounds forming, and if they find something unusual they should call the doctor. And lastly, let them know about phantom pain where the limb used to be and that they should find distractions to help. 

Thanks for listening to the lesson on amputation! I hope you have a better understanding on what amputation is and the different considerations for patient care. Now go out and be your best self today, and as always, happy nursing!

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