Transcript Chapter 34

Chapter 43
Amputations
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Learning Objectives
• Identify the clinical indications for amputations.
• Describe the different types of amputations.
• Discuss the medical and surgical management of the
amputation patient.
• Identify appropriate nursing interventions during the
preoperative and postoperative phases of care.
• Assist in developing a nursing care plan for the
amputation patient.
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Amputation
• Can occur through a joint (between the bones)
or through a bone itself
• Disarticulation: term used for an amputation
through the joint
• The general site of the amputation is described
by the joint nearest to it
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Figure 43-1
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Indications and Incidence
• Trauma
• Common types of accidents and injuries leading to
amputation include those involving motorcycles and
automobiles, farm machinery, firearms and
explosives, electrical equipment, power tools, and
frostbite
• Disease
• Peripheral vascular disease, diabetes mellitus,
arteriosclerosis, and chronic osteomyelitis
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Indications and Incidence
• Tumors
• Bone tumors that are very large and invasive
• Congenital defects
• Convert a deformed limb into a more functional one
that can be fitted with a prosthetic device
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Diagnostic Tests and Procedures
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Vascular studies
Pulse volume recording
Thermography
Doppler ultrasound
Biopsy
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Medical Treatment
• Must include appropriate treatment and control
of underlying diseases or injuries
• Diet, medication, and exercise help patients with
diabetes and poor peripheral circulation
• If peripheral vascular disease, encourage to stop
smoking; nicotine causes vasoconstriction
• Trauma patient may have to be stabilized to
maintain normal heart rate and blood pressure
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Surgical Treatment
• Amputation at the lowest level that will preserve
healthy tissue and favor wound healing
• Surgeon chooses one of two procedures, depending
on condition of the extremity and the reason for the
surgery
• Closed amputations
• Create a weight-bearing residual limb, important for lower
extremity amputations
• Open amputations
• The severed bone or joint is left uncovered by a skin flap
• Required when an actual or potential infection exists, as may
occur with gangrene or trauma
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Prostheses
• Artificial substitutes for missing body parts
• Prosthetist creates and supervises use of prosthesis
• A limb prosthesis may be placed while the patient is
still in the operating room
• With lower extremity amputations, older or debilitated
patients, and infection, prosthesis fitting delayed until
residual limb heals
• Can usually bear full weight on permanent prosthesis
about 3 months after amputation
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Figure 43-2
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Figure 43-3
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Complications
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Hemorrhage and hematoma
Necrosis
Wound dehiscence
Gangrene
Edema
Contracture
Pain
Infection
Phantom limb sensation
Phantom limb pain
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Assessment
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Record conditions that resulted in need for amputation
Preexisting cardiovascular problems
Family history of diabetes, hypertension, and vascular diseases
Signs and symptoms that relate to the vascular condition or other
chronic and acute problems
• Diet and fluid intake, intake of salt and alcohol, and use of tobacco
• Exercise and rest and sleep habits as well as the effects of the
current symptoms on the patient’s usual activities
• Patient’s psychosocial background may offer insight into how the
patient will tolerate treatments and procedures
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Physical Examination
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Height, weight, and vital signs
Assess neurovascular status
Skin color, texture, temperature, and turgor
Palpate peripheral pulses for quality, symmetry
Assess capillary refill
Sensation; ask patient to identify touch on extremities
Mental and emotional status and general cognitive
abilities; determines patient’s understanding of the
illness and its implications
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Interventions
• Anxiety
• Anticipatory grieving
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Postoperative Nursing Care
• Assessment
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Monitor vital signs frequently in the first 48 hours
Inspect the dressing frequently for bleeding
If drain receptacle, note color and amount of drainage
Monitor patient’s temperature for elevations that may indicate
infection
• Note any foul odor from the dressing
• After the dressing is removed, inspect the residual limb for
edema
• Document patient’s pain, including type, location, severity, and
response to treatment
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Postoperative Nursing Care
• Interventions
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Decreased Cardiac Output
Pain
Risk for Infection
Impaired Skin Integrity and Risk for Impaired Skin Integrity
Disturbed Sensory Perception
Risk for Injury
Impaired Physical Mobility
Activity Intolerance
Self-Care Deficit
Anxiety, Fear, and Ineffective Coping
Disturbed Body Image
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Figure 43-4
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The Older Adult Amputee
• May have needs that should be taken into consideration when
planning and providing care
• Completely capable of learning but often requires smaller units of
information, more repetition, more time
• During teaching process patients with glasses or hearing aids
should have them in place
• Remind that phantom sensations are not uncommon or bizarre;
this can reduce fear or anxiety of these sensations
• Many have one or more chronic health problems
• The loss of a limb can be especially difficult; it is important to
provide psychological support
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Replantation
• Involves the use of a microscope and highly
specialized instruments to reanastomose
(reconnect) blood vessels and nerve fibers in a
severed limb
• Limb sutured into its correct anatomic position
• Advances in microsurgical techniques and
preservation of severed limbs have made this
technique increasingly successful
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Indications
• For amputations through the hand or wrist
• Amputated thumbs are reattached whenever possible because of
their importance in hand function
• In severely injured hand in which two or more fingers are
detached, surgeon restores as many fingers as possible
• Amputations above the wrist do not lend themselves as readily to
replantation because of the extensive tissue, muscle, and bone
damage accompanying the injury
• In general, the greater the muscle mass injury, the less likely
replantation is possible
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Emergency Care
• Wrap amputated parts in a clean cloth saturated with normal
saline or Ringer’s lactate
• Put in a sealed plastic bag that is placed in ice water
• Direct contact between the amputated part and the ice can lead to
further tissue damage and cell death
• Partially amputated parts should remain attached to the patient
and be kept cool if possible
• Extra care to avoid detaching any parts since even small
connections increase the chances for successful repair
• Patient may require treatment for shock due to blood loss
• Tourniquets should not be used unless absolutely necessary
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Assessment
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Assess circulatory status
Closely monitor vital signs
Inspect the residual limb (or dressing) for bleeding
Assess pain at the site of the injury and at other
locations
• Measure and record fluid intake and output
• Note patient’s emotional status, and assess
understanding of the preoperative activities and
postoperative routines
• Identify sources of support
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Preoperative Nursing Care
• Interventions
• Administer intravenous fluids and blood as ordered
• If the dressing becomes saturated with blood, reinforce the
dressing
• Report continued or excessive bleeding to the physician
• Even though preparations for replantation are hurried, be
sensitive to the patient’s fear and anxiety
• Accept the patient’s feelings
• Provide brief, simple explanations
• Administer analgesics as ordered for pain
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Postoperative Nursing Care:
Assessment
• Monitor vital signs, intake and output, and level
of consciousness
• Hourly neurovascular assessment of limb
• Doppler device or pulse oximeter to evaluate
circulation
• Note and record the limb’s color, capillary refill,
turgor, temperature, and sensation
• Assess limb for edema because massive
edema often accompanies replantation
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Postoperative Nursing Care:
Interventions
• Elevate the limb
• Abstain from nicotine- and caffeine-containing products
for 7 to 10 days postoperatively
• Enforce a strict ban on cigarette smoking
• Room at 80° F to prevent compensatory
vasoconstriction of peripheral tissues
• Loosen tight or restrictive gowns or pajamas
• Administer ordered drugs; monitor effects
• Discuss thoughts and feelings about the replantation,
disfigurement, and loss of function
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