Amputation

66 Amputation




Overview/pathophysiology


Amputation, the removal of part or all of a limb through bone, is now less commonly performed as an orthopedic surgical intervention than it was before advances in antibiotic therapy, treatment for musculoskeletal neoplasms, and microsurgery/limb salvage techniques. Lower extremity amputation may still be the treatment of choice for complications of diabetes mellitus (DM) such as peripheral vascular disease (PVD) and for osteomyelitis or severe trauma. Persons with PVD account for approximately 80% of lower extremity amputations in the Western world. On rare occasions, amputation may be necessary because of congenital limb deficiencies in infants and children.


While the majority of lower extremity amputations are performed due to disease, most upper extremity amputations are the result of trauma. Amputation and prosthesis use may offer the patient improved functional ability.



Health care setting


Critical care unit, acute care surgical unit, orthopedic rehabilitation unit



Assessment




Chronic disease:


Patients with advanced PVD often complain of extremity pain in a definable muscle group (usually calf muscles) precipitated by exercise and promptly relieved by rest. This pain is distinguished from that of diabetic neuropathy, which is distributed along dermatomes rather than confined to a specific muscle group; neuropathy is also constant and unrelated to exercise. The affected limb is often a dark red color (rubor) when it is dependent; atrophy of skin and subcutaneous tissue may be apparent. Amputation also may be needed because of metabolic disorders (e.g., osteosarcoma of Paget’s disease), or massive muscle necrosis that results from an acute thromboembolic event or untreated compartment syndrome. The patient also may have a tumor of bone or soft tissue, but amputation in this case is much less common than in the past because of the advent of sophisticated limb salvage procedures.



Trauma:


A mangled extremity is common with high-energy injuries. The patient may have multiple injuries, and surgical priority must be given to those injuries that may be life threatening. Trauma may result in a complete amputation, a near or partial amputation, or a segmental amputation of an extremity.



Diagnostic tests




Ankle-arm (ankle-brachial) index:


The most widely used noninvasive test for evaluating PVD. Blood pressure is measured at the ankle and in the arm while patient is at rest. Measurements are then repeated at both sites after patient has walked 5 min on a treadmill. Ankle-brachial index (ABI) is calculated by dividing the highest blood pressure at the ankle by the highest recorded pressure in either arm. A decrease in the ABI result with exercise can aid in predicting severity of the vascular disease and is a sensitive indicator that significant PVD is present.



Doppler ultrasound:


Evaluates blood flow to the extremities. It can reliably distinguish exercise-related effects from severe ischemia.



Transcutaneous O2 pressure:


Measured after oxygen sensors are applied to the skin. By determining oxygen tension (desired value is 30-50 mm Hg), the surgeon can identify areas of lesser perfusion in the affected extremity. This test offers the most accurate assessment of blood supply and the best prediction of residual limb healing potential.



Angiography:


Confirms circulatory impairment to determine appropriate level for amputation. This invasive study involves radiographic imaging after injection of a radiopaque substance into a blood vessel. It is most useful if patient is a candidate for angioplasty or arterial reconstruction.



Xenon-133:


A radioactive isotope injected intradermally at the midpoint of the intended incision for amputation. Skin clearance of this agent reflects skin blood flow as a measure of the appropriate level of amputation.





Nursing diagnoses:


Acute pain


Chronic pain

related to phantom limb sensation


Desired Outcome: Within 24 hr of intervention, patient’s subjective perception of pain decreases as documented by pain intensity rating scale.































ASSESSMENT/INTERVENTIONS RATIONALES
Assess patient’s pain using a pain intensity rating scale (0 = no pain, 10 = worst pain imaginable). The patient provides a personal baseline report, enabling nurse to more effectively assess subsequent increases and decreases in pain.
Administer simple analgesics, nonsteroidal antiinflammatory drugs, opioid analgesics, and adjuncts as prescribed and reassess their effectiveness in approximately 1 hr using pain intensity rating scale. Document preintervention and postintervention pain scores.
Although opioids provide effective treatment of incisional pain, they may be ineffective for phantom limb sensation because they do not alter response of afferent nerves to noxious stimuli. Higher opioid doses are often required to treat phantom limb sensation.

Anticonvulsants such as gabapentin and topiramate may be effective for neuropathic pain, and baclofen may be used to control spasms and cramps in the phantom limb. Tricyclic antidepressants (e.g., amitriptyline) not only offer analgesia but also may be used to elevate mood and alleviate insomnia. A lidocaine patch also may be helpful when applied near the surgical wound. Beta-blockers such as propanolol have been used as adjuncts but their efficacy is unclear.
Ensure adequate pain management before elective amputation surgery. This measure decreases the likelihood that phantom limb sensation will develop. Patients with unrelieved preoperative pain are more likely to experience phantom limb sensation.
Explain that continued sensations often arise postoperatively from the amputated part and may be painful, irritating, or simply disconcerting. This information prepares patient for the potential experience of phantom limb sensation.
Teach patient to use counterirritation to manage painful sensations. Counterirritation is based on the gate control theory of pain. It may manage painful sensations by providing a new stimulus to compete with the patient’s pain. The simplest form of counterirritation involves systematic rubbing of the painful part.
As indicated, use transcutaneous electrical nerve stimulation (TENS) on the contralateral limb. TENS may provide effective short-term management of phantom limb sensation. Use on the residual limb has been associated with exacerbation of pain and should be avoided.
Also consider interventions such as distraction, guided imagery, relaxation, and biofeedback. These nonpharmacologic methods augment pharmacologic pain relief.
Instruct patient to begin to massage residual limb 3 wk postoperatively.
Massage will desensitize the area in preparation for prosthesis. Early prosthesis use may reduce incidence of phantom limb sensation.
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Jul 18, 2016 | Posted by in NURSING | Comments Off on Amputation

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