A

Amputation

Description

An amputation is the removal of a body extremity by trauma or surgery. An estimated 2 million people in the United States are living with limb loss. The middle and older age groups have the highest incidence of amputation because of the effects of peripheral vascular disease, atherosclerosis, and vascular changes related to diabetes mellitus.

The most common reasons for amputations are peripheral vascular disease (PVD), trauma and thermal injuries, tumors, osteomyelitis, and congenital limb disorders. Most amputations performed are for PVD, especially in older patients with diabetes mellitus. These patients often experience peripheral neuropathy that progresses to trophic ulcers and subsequent gangrene. Although pain is often present, it is not usually the primary reason for an amputation.

■ The goal of amputation surgery is to preserve extremity length and function while removing all infected, pathologic, or ischemic tissue. (See Fig. 63-22 for the levels of amputation of the upper and lower extremities, Lewis et al.: Medical-Surgical Nursing, ed. 9, p. 1531.)

Nursing management

Control of causative illnesses such as peripheral vascular disease, diabetes mellitus, chronic osteomyelitis, and skin ulcers can eliminate or delay the need for amputation.

■ Teach patients with these conditions to carefully examine the lower extremities daily and report problems to the health care provider, such as changes in skin color or temperature, decrease or absence of sensation, tingling, burning pain, or the presence of a lesion.

■ Instruct people in proper safety precautions in recreational activities and the performance of potentially hazardous work. This is an especially important role for the occupational health nurse.

It is important for you to recognize the tremendous psychologic and social implications of an amputation. The disruption in body image caused by an amputation often results in a patient going through the grieving process. Use therapeutic communication to assist the patient and caregiver through this process to arrive at a realistic attitude about the future.

Preoperative care

Before surgery, reinforce information that the patient and caregiver have received about the reasons for the amputation, the proposed prosthesis, and the mobility-training program.

■ Instruct the patient in the performance of upper extremity exercises such as push-ups in bed or the wheelchair to promote arm strength. This instruction is essential for crutch walking and gait training.

■ If a compression bandage is to be used after surgery, instruct the patient about its purpose and how it will be applied. If an immediate prosthesis is planned, discuss general ambulation expectations.

Tell the patient that the amputated limb may feel like it is still present after surgery. This phenomenon, termed phantom limb sensation, occurs in many amputees.

■ As recovery and ambulation progress, phantom limb sensation and pain usually subside, although the pain can become chronic.

■ The patient may also complain of shooting, burning, or crushing pain and feelings of coldness, heaviness, and cramping.

Postoperative care

Prevention and detection of complications are important during the postoperative period. Carefully monitor the patient’s vital signs and dressing for hemorrhage in the operative area. Careful attention to sterile technique during dressing changes reduces the potential for wound infection.

■ If an immediate postoperative prosthesis has been applied, careful surveillance of the surgical site is required. A surgical tourniquet must always be available for emergency use. If excessive bleeding occurs, notify the surgeon immediately.

■ Not all patients are candidates for prostheses. The seriously ill or debilitated patient may not have the upper body strength or energy required to use a prosthesis. Mobility with a wheelchair may be the most realistic goal for this type of patient.

Flexion contractures may delay the rehabilitation process. The most common and debilitating contracture is hip flexion. Patients should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity.