CARE OF THE PATIENT WITH AN AMPUTATION

DEFN-REMOVAL OF THE DISEASED,NON FUNCTIONING,PROTRUDING BODY PART-DERIVED FROM LATIN WORD “AMPUTARE” MEANING ‘CUTTING AROUND’

Indications to Amputations

1. Trauma and its complications (anaerobic infection, osteomyelitis)

2. Malignant tumors of skeleton and soft tissues of limbs

3. Vascular diseases (thrombosis, diabetic angiopathy, obliterating endarteritis)

Classification of Amputations

Primary amputation (within first 24 hours)

Secondary amputation (7-8 days after injury)

Re-amputation (repeated amputation)

Steps of AmputationI. Cutting of soft tissue- All amputations are

divided into closed and circular amputation in according to cutting of soft tissue.

II. Treatment of periosteum and cutting of bone <A)   aperiosteal B)   subperiosteal>

III. Stump treatment-This stage includes treatment of vessels, nerves and stitching of soft tissues above the bone stump.

Types of Amputations

1. Flap amputations: Flaps are fashioned and are closed primarily along with surgery.

- single-flap amputation - double-flap amputation

2. Circular amputations: - one-step (guillotine) amputation All the tissues are cut at the same level.

Cutting of a bone on the same level.

two-step amputation (variety – “cuff” method of forearm

amputation)Soft tissues are cut in two motions (stages): first – skin, subcutaneous tissue,

superficial and proper faciae, second – cutting of muscles at level of

contracted skin. Deficiency of this method is forming of a

scar at bearing or working surface of the stump.

three-step (conical-circular) amputation

As usual, this type of amputation is performed on thigh or arm (where just one bone is present). In this case soft tissues are cut in three motions on different levels. First step – cutting of skin,

subcutaneous tissue, superficial and proper faciae.

Second step – cutting of superficial muscles at level of contracted skin.

Third step – cutting of deep muscles.As result of different levels cutting we’ll have cone-shaped stump with apex situated on bone-stump.

Levels of Amputations

The most common complications of amputation are:

massive haemorrhage that occurs when a suture becomes loose

infection rash, blisters, and skin breakdown caused by

immobility, pressure, and other sources of irritation

pneumonia, blood clots, and breathing problems associated with immobility

formation of nerve cell tumors (neuromas) at severed nerve endings

Chronic osteomyelitis caused by secondary infection inside a wound

Phantom limb sensation Feelings that the amputated part is still

present Sensations of warmth,cold,itching,or

pain Caused by intact peripheral nerves

proximal to the amputation site that carried messages between the brain and the amputated part

Gradually decrease over the next 2 yrs

Osteo-plastic Amputations(Gritti-Stokes and Sabanajeff amputations)

Pirogoff Amputation

Callander Amputation (this gives an excellent end-bearing stump)

Below-knee Amputation

Amputation in Middle Third of Leg

Schemes of Foot Amputations

Syme Amputation

Sites of Election for Amputations of Upper Extremity

Finger Amputation

Different Types of Prosthesis

Nursing Priorities Support psychological and physiological

adjustment. Alleviate pain. Prevent complications. Promote mobility/functional abilities. Provide information about surgical

procedure/prognosis and treatment needs.

First Aid1. Check the person's airway (open if necessary); check

breathing and circulation. If necessary, begin rescue breathing, CPR, or bleeding control.

2. Try to calm and reassure the person as much as possible. Amputation is painful and extremely frightening.

3. Control bleeding by applying direct pressure to the wound. Raise the injured area. If the bleeding continues, recheck the source of the bleeding and reapply direct pressure, with help from someone who is not tired. If the person has life-threatening bleeding, a tight bandage or tourniquet will be easier to use than direct pressure on the wound. However, using a tight bandage for a long time may do more harm than good.

4. Save any severed body parts and make sure they stay with the patient. Remove any dirty material that can contaminate the wound, if possible. Gently rinse the body part if the cut end is dirty.

5. Wrap the severed part in a clean, damp cloth, place it in a sealed plastic bag and place the bag in ice cold water.

6. Do NOT directly put the body part in water without using a plastic bag.

7. Do NOT put the severed part directly on ice. Do NOT use dry ice as this will cause frostbite and injury to the part.

8. If cold water is not available, keep the part away from heat as much as possible. Save it for the medical team, or take it to the hospital. Cooling the severed part will keep it useable for about 18 hours. Without cooling, it will only remain useable for about 4 to 6 hours.

9. Keep the patient warm.10. Take steps to prevent shock. Lay the person flat, raise the feet

about 12 inches, and cover the person with a coat or blanket. Do NOT place the person in this position if a head, neck, back, or leg injury is suspected or if it makes the victim uncomfortable.

11. Once the bleeding is under control, check the person for other signs of injury that require emergency treatment. Treat fractures, additional cuts, and other injuries appropriately.

12. Stay with the person until medical help arrives.

Nursing Care PlansAnxietyDesired Outcome: The client will openly discuss feelings and reduced anxiety before surgery.Intervention: Establish open, honest communication. Allow free expression of fears and negative feelings about the loss of a limb. Provide and reinforce information. Prepare the client for phantom limb sensation that their missing limb is still present.

Delayed Surgical RecoveryDesired Outcomes: The risk of delayed surgical recovery will be minimized.Interventions: Clients with diabetes mellitus are a high risk surgical group and require careful preoperative assessment about their metabolic status.Clients w/ ulcerated leg/osteomyelitis may be treated with wound packing, antibiotics,and leg elevation with bed rest.Malnourished clients- given high protein diet and supplementsSeverely Anemic clients- given Iron supplements or Blood transfusionDehydrated clients- should receive preoperative IV fluids to restore fluid balance.

Knowledge DeficitDesired Outcomes: The client will express an understanding of the usual postoperative regimen.Interventions: Teach clients to Exercising legs and arms several times a day Strictly limiting weight bearing (for leg

amputation) Learning the intricacies of stump and

prosthesis care Mastering the use of prosthesis

PainDesired Outcomes: The client will express understanding of the sensations present and recognize that they are normaland usually diminish in time.Interventions: Emphasize that phantom sensation is usual and, more important, subsides in time. It is not helpful to correct clients by telling them that the limb cannot be hurting because it is absent.

Ineffective Individual CopingDesired Outcomes: The client openly verbalizes fears about the changes in body image and loss of independence and begins to speak optimistically and realistically about the futureInterventions: Listen to the client. The client may express concerns that it will be impossible to return to a previous lifestyle, including job, leisure activities, or intimate relationships. With advancements in prosthetic devices, many clients can have both functional and aesthetic prosthetic devices.

References:Kent M. Van De Graff, Stuart Ira Fox, Karen

M. Lafleur. Synopsis of Human Anatomy and Physiology /WCB McGraw-Hill/, 2004.-675p  Philip Thorek. Anatomy In Surgery /J.B.Lippincott Company/,1996.-935p.