VI Degree in Nursing The Amputee Patient 0 - INTRODUCTION amputation is the surgical removal of a member or segment membe rship of the

body to which it belongs, by section of his bony parts, with conser vation, variable depending on the case of certain soft tissues (muscles, skin fl aps) for formed on the stump. Usually a result of trauma or disease. The inciden ce of amputation has been declining in recent years, however, the typical patien t remains the diabetic male, middle-age advanced, with a long history of smoking . It is a drastic decision and final and last resort to save a life. However, it is a situation in which a particularly disfiguring body image is deeply distort ed. It is the loss of part of the 'EU' can not be minimized. This always involve s a permanent physical handicap, by changing the satisfaction of physiological n eeds, psychological and social. Thus, it is easy to understand, a marked degree of support that these patients need, regardless of their age group. Traumatic am putations are generally considered a surgical emergency as requested by the situ ation of the affected vessels, and amputations in cases of massive trauma take p lace as soon as possible to prevent the extent of contamination and therefore in fection. Amputation may be considered a reconstructive surgery, intended to impr ove the quality of life of patients and was recommended to eliminate symptoms an d facilitate the improvement of the function. The establishment of a rehabilitat ion program is essential to help the amputee to adjust to a new situation and pr ovide care and appropriate means in order to make it as independent as possible, within his disability. It should be noted that it is perceived that the patient has of his disability that will determine the ability to adapt to new circumsta nces. As such, the complete rehabilitation of the amputee requires work of a mul tidisciplinary team of health. If the 1 VI Degree in Nursing The Amputee Patient care team is able to convey a positive attitude, the patient will adjust to the amputation and participate actively in the rehabilitation plan. Surgeon (or Orth opedist), the Nurse (possibly with the specialty of rehabilitation), the Physiat rist, the prosthesis, the Physiotherapist and Occupational Therapist, a Psycholo gist and Social Worker unite all their efforts to condition and train the patien t to make an adjustment satisfactory to the prosthesis. 2 VI Degree in Nursing The Amputee Patient 1 - Brief History Amputation is the oldest surgical procedures of the medical ar ts, the word itself refers to the first attempts at surgical intervention of a h uman being over another. The amputation was first described by Hippocrates in an cient Greece, referring to a case of knee disarticulation. In the year 100 AD, C elsius, among other teachings, described the vessel suture in amputation surgery . However, the dark years of the Middle Ages, where the conheciemento was cloist ered in the hands of monks in religious convents, resumed the practice of cauter ization, a method in which the barbarian in stemming the bleeding got up from th e application of oil to boil or a hot iron. Only in 1510 is that Ambroise Pare, an eminent French military surgeon, reimplanted the technique of ligation of ves sels, which led to better results and increase the likelihood of survival in thi s type of surgery. Note that this time he did not know antisepsis and as such, w

as not used any kind of mechanism to control pain, there were times when, to avo id pain, amputation was done by necrotic tissue. When this technique was abandon ed and became to amputation through the tissue bleeding, which cut the bone and soft tissues that cover the bone, the survival of patients has increased signifi cantly. The pain that caused such an intervention, as long represented a sufferi ng so great that the patient easily went into shock and died. Hence the time of surgery was essential in order to prevent this from happening this type of surge ry had to be extremely fast. Only with the discovery of techniques of asepsis an d antisepsis. The limb amputation surgery was more frequent in the century. XVI, leprosy, ergotism and the punishments were the main causes of this practice. Be fore the amputation was strangled to amputate the limb in order to reduce bleedi ng, and as already mentioned, the bone was sawed off and the bleeding was initia lly contained by the compression and scarring of the vessels that were bleeding, and later by suture vessels.€Finally introduced to the stump within a bladder o f an ox or pork tightly around the limb amputated. 1 VI Degree in Nursing The Amputee Patient Also in the maiming of justice (1515) the executioners of Venice utmost jerking the skin to the root of the limb would be amputated so that they could cover the stump with excess skin and suturing it then. So hemostasr and healing of the st ump was easier. Currently the leading causes of amputation are trauma, cancer an d vascular diseases. Cirúrugicas new techniques for amputation, the function hav e been developed during the last half century. XIX, always associated with medic al progress in the field of general anesthesia and the principles of asepsis. As well as methods of coping emerged as the bones, muscles, nerves and skin that r emain appropriate today. For many years the amputation was performed, with regre t, always seeking to save life and limb in the literal sense, is only resorted t o this practice after months of pain, impairment and expenses, and even then, th e amputation was done with regret and an enormous sense of failure. This is beca use the surgical loss was visible for all and therefore has a strong emotional i mpact. There was even a denial of the amputees and these were forced to self-reh abilitation without medical support, without specialized knowledge and without a defined plan of action. Currently there has been increased media publicity made amputees who "overcame their handicaps and being restored to active members of society. Amputation is followed by prosthetic restoration and rehabilitation of the amputee progressed through ups and downs until after the Second World War. A t that time the large number of amputees returning from military stimulated the U.S. Army and the Veterans Administration to take seriously the state of the art . Passed to provide funds for research and for the first time, doctors and engin eers engaged in deep study of the problems of the amputee. The results of these studies included a new and detailed information about the mechanics of gait, ene rgy expenditure, the principles of prosthetic alignment, recognition of the caus es of the effects of motion, hand function and the development of improved prost hetic components and techniques . For the first time, appeared a definite progra m of treatment for the amputee that was meant to prepare it to use a prosthesis. This program emphasized during a period of weeks or months, the prevention of c ontracture, the strengthening of the muscles that would control the stump and th e wrapping elastic bandages on the stump in an effort to stabilize their second VI Degree in Nursing The Amputee Patient size, accelerating muscle atrophy which would no longer be used. Implementing th is program was influenced by economic factors and physiological. It was importan t, especially in civil practice, prepare each amputated at the right time to avo id unnecessary waste of limited funds with devices that may or may not be used.

The prostheses were available at that time ordinarily made of wood with leather snap carved or cast that was attached to a leather cord existing in the thigh. M ost of the patient's weight was applied to the proximal stump, leaving the dista l end of the same free, mobile and subject to being compressed by the weight. Th e skin changes that resulted imposed many restrictions on the location of the sc ar, the length and shape of the stump. Some amputees received a permanent prosth esis with only six weeks after surgery, but the average interval between amputat ion and prosthesis adaptation up to 1960 was 7.2 months. The single factor that most influenced the fate of the amputee since 1950 was the use of plastics and r eliable modeling techniques, making possible the construction of a prosthetic so cket that would adapt to the stump lately for its entire length. The fit with fu ll contact, with a favorable distribution of pressure, a sensory perception from the end of the stump and the potential use of the entire length of the stump as a lever arm and area able to bear weight made it possible to adapt almost any s tump. The length is no longer an important consideration and the scar can be loc ated anywhere, allowing the surgeon to use all of the viable skin to get the gre atest benefits. Previously, amputation was the last therapeutic resource to be u sed and always had a connotation of defeat. However, despite the marked changes that occurred in the midst of humanity,€amputation continues to be seen as a def eat, by the health team, because the patient lost one end of the body. It is imp ortant to note that behind the whole people and wounds treated solution treatmen t proposal should consider the life that these people face. 3 VI Degree in Nursing The Amputee Patient 2 - AMPUTATION Amputation of upper or lower limbs is an act of restoring a sick body and not mutilation. Regarding the pathophysiology, as the movement graduall y decreases until the end, the body tries to compensate by sacrificing collatera l vessels to maintain a minimum infusion. Develops intermittent claudication (cr amp that occurs with exercise and is relieved by rest) when the collateral circu lation fails to meet the needs of infusion. The ischemia may become so severe th at the pain compromises patient mobility and be present even at rest. In the cas e of amputation the most important is the person and not the injured limb, thus becomes an indispensable global approach to patient to ensure the maximum of the ir potential physical and psychological. Surgery should be planned with knowledg e of the prosthesis that will be adapted, although not the surgeon to direct the rehabilitation phase of treatment. As the postoperative period is an emotionall y difficult, it is essential that there is an integrated work of various types o f professionals involved in the rehabilitation of the patient to stimulate and e nhance the residual capacity of the person affected and thus seek a full recover y. 2.1 ETIOLOGY amputation may be from two different etiologies: • • Congenital Acq uired 12 VI Degree in Nursing The Amputee Patient Amputations Amputation for congenital birth defects are the cause of 75% of limb amputation, ranging in age from birth to ten years. In these type of malformati ons usually be the individual to decide whether the abnormality fits with orthos es compensation or if you prefer adaptation to amputation and a prosthesis (must be accompanied by rehabilitation).

Acquired Amputation Amputation of upper limb segments in children under ten year s of age is rare, motor vehicle accidents, tumors and injuries from natural disa sters such as earthquakes are among the etiological agents. Malignancies constit ute half of the causes of diseases related to amputation of the arm and appear p redominantly in the age group from ten to twenty years. Trauma is the cause of a mputation of upper limb in 70% of patients over eighteen years. The disease is r esponsible for only 6% of all amputations of the arm, which is in sharp contrast to lower limb amputations, 40% of which are made necessary by peripheral vascul ar syndromes. In turn, the main causes of amputation are acquired: 1. For peripheral vascular disease (about 85% of cases) as in arteriosclerosis, thr ombosis or diabetes. It is the largest group of patients who require amputation of most of them elderly, which increases the risk of complications. 2. For acute infection, which can be measured amputation to save life (eg in gas ga ngrene). For chronic infection that endangers the patient's general condition ca using long periods of disability and subjecting it to many operations and many s orrows. 3. 4. Malignant neoplasia, eg osteosarcoma. 13 VI Degree in Nursing in May. The Amputee Patient By trauma in which there is extensive tissue destruction, especially of the bloo d supply: • • • • • • electrical burns, chemical and thermal freeze Explosions A rmed conflicts Road traffic accidents Accidents at work 6. For deformity correction is not likely when patients are able to take a more act ive lifestyle and a better cosmetic result with a prosthesis. 7. Moved by a member and useless after injury plexobraquial: amputation may be atta ched to the scapular-humeral ortrodese. 2.2 - LEVELS OF AMPUTATION The site said the "election" for amputation should be decided by the health team treating the patient, which conform to certain basic rules. There are places where the amputation is not advisable, they are partial amputation of the foot at different levels of transmetatarsal level, well below the knee amputation, disarticulation of the knee and elbow are not advisable. T hese findings are the result of a long study, resulting from broad experience wi th prosthetics. The goal of surgery is to conserve the maximum possible length o f the extremity€compatible with the eradication of the disease process and it is desirable to preserve the knee and elbow. Amputation is performed in the more d istal able to heal satisfactorily, and the location is determined by two factors : • • Movement in the affected area; requirements imposed by the prosthesis.

For example a patient with vascular disorders, gangrene, current or possible, al ways represents a problem for the selection of amputation level. No 14 VI Degree in Nursing The Amputee Patient reliable clinical tests exist to make such a determination, and this becomes a m atter of trial. The uptake of radioactive isotopes, infrared photography and the determinations of skin temperature provide some data, but are usually insuffici ent. Right now the best test objective, the active bleeding of the skin at the t ime of amputation. One should also take into account the energy needs and demand s necessary to activate the cardiovascular stent, which are much higher the high er the level of amputation, or amputation below the knee there is a lower energy expenditure (25% energy) that the energy expended in amputation above the knee (65% of energy). However, it is the surgeon the final decision, taken in the ope rating room to ensure good vascularity of skin flap vitality and healing of the residual limb. Amputation of lower limb amputations of the lower extremity physical deficit and produce some degree of disability is directly related to the level of amputatio n, ie the location where the amputation is performed. Amputations done at any le vel below the knee will allow most normal activities. The degree of success depe nds not only on the level of amputation as well as a program for active rehabili tation and adaptation and precise alignment of the prosthesis. This should alway s be adjusted to the individual and the business which it exercises on a daily b asis, with a view to improving quality of life after amputation. The most common amputation of lower limbs are: 1. Symes amputations, the ankle joint, using the heel pad as the support area of we ight; amputation below the knee. In this case the placement of a prosthesis caus e minimal restrictions on the activity of the patient, the knee amputation. It i s not appreciated by the prosthetic joint because the mechanism is placed outsid e of the prosthesis, 15 2. 3. VI Degree in Nursing 4. The Amputee Patient Amputation of the middle thigh. It is the most likely location for the elderly w hen the amputation is carried out by peripheral vascular disease; the thigh. The dislocation of the thigh is carried out by malignant disease when it is necessa ry to remove the entire affected bone; A hemipelvectomy is a much more radical p rocess involving the removal of one of the iliac, invariably malignant disease. In more detail there are other levels of amputation, 5. 6. characterized by six points of reference: • Amputation above 1 should be fitted with a prosthetic hip dislocation due to the short stump. • The area between one and two, is equipped with the prosthesis above the knee joint with a concave qu adrilateral with full suspension and pelvic or suction. • Amputations between tw

o and the knee joint did not have enough space on the prosthesis for a mechanism controlling the swing phase and must be fitted with balancer out free joints. • 3 and 4 are the locations of choice for conventional low-knee amputations. • Am putations between 4 and 5 are more difficult for the prosthetic, but offer some advantages to the amputee. • Amputations below 6 require little in regards to pr osthesis: a filling for the toes and a pad of steel in the shoe will suffice. 16 VI Degree in Nursing The Amputee Patient Amputation of upper limb amputation of upper extremities is performed to preserv e the maximum functional length, and the prosthesis adapted early to obtain the maximum function. The psychological impact of amputation is even greater than in lower limb amputation. The hand is not only used to manipulate the environment but also to communicate and express emotions. Aesthetics are very important beca use the hand is always in sight of the public and therefore some amputees prefer to get a better replacement than aesthetics better functionality of the prosthe sis. Amputation of upper limb determines the loss of two critical functions: sen sitivity terminal and the ability to grasp and manipulative ability. The most co mmon amputation of upper limb are: 1. Finger (s) (total and transmetacarpianas transcarpianas) in the case Finger average amputee, the empty space between fingers becomes anti-elastic, preventin g the proper handling and grip in the palm of the hand, especially for small obj ects. In these cases, sometimes it is also necessary to resect the metacarpal in order to provide greater stability, as this decreases the space between fingers , by improving the aesthetics and functionality of the hand. 2. Disarticulation of the wrist, this level of amputation is unsightly because the prosthesis makes the area of the wrist quite bulky. However it is very favorable for it can to preserve all or most of the movements of pronation and supination . 3. Below the elbow (very short, short and long) as it does not sacrifice the elbow joint, allows the prosthesis is more functional and that there is a greater rang e of motion (especially flexion), thus being easier rehabilitation. 4. Dislocation of the elbow; 17 VI Degree in Nursing in May. The Amputee Patient Above the elbow (short and long), this presents a great disadvantage in terms pr osthetic therefore becomes necessary to implant a mechanical linkage elbow.

6. Neck of the humerus, is even more lacking in functionality and the prosthesis us ed in this amputation is very limited in terms of suspension and stability. Disl ocation of the shoulder and scapulothoracic, these are performed only in cases o f neoplasms. The use of prosthesis for this level of amputation is quite limited . In more detail there are other levels of amputation, 7. characterized by six points of reference, as in the lower limbs: • upper limb am putations above require a concavity changed over the shoulder, and the active movement of the shoulder joint becomes impossible. • Between one and two, you can adjust a p rosthetic elbow. • Between two and elbow, you should use an extracorporeal elbow joint, but it is impossible to active humeral rotation. • Amputations forearm a bove 3 produces a very short lever arm, and in some cases, you should use a gear linkage elbow, • • to provide sufficient bending segment of the forearm. Betwee n 3:04, we use a conventional prosthesis below the elbow. Amputations below 4 al low some active pronation and supination. 18 above the conventional VI Degree in Nursing The Amputee Patient • Amputation transcarpiana (6) requires a prosthesis, but some hook function is pr ovided only by the stump. Both in lower limb amputation as in amputations of the upper limb, the higher th e level of amputation, more disabling amputation becomes more limited and become s the prosthesis. 2.3-SURGERY After surgery aims to achieve a clean scar, painless and suitable fo r the implementation of a prosthesis without complications arise. After all appe ar, sometimes the following complications: • • • • • • • • • Dehiscence of sutur e Edema Ulceration of the stump Inflammation Infections Retraction of the scar Neuromas Bony spicules Phantom pain - perceived sensations, usually painful in parts of the State which were removed at surgery, this phenomenon is present in 95% 19 VI Degree in Nursing The Amputee Patient

patients. Can be severe and intense, sometimes resist various forms of treatment and can even prevent the rehabilitation program. The appearance can be given ea rly or late amputation with unpredictable duration. These types of problems usua lly affect the stump of the second to third week after the surgical procedure. T he problems arising from such causes as neuromas, muscle contractures and atroph y, among others, occur later, although the pain may appear at any age, presentin g features of the most diverse. Other complications, especially in the lower lim bs are the amputation neuroma or nerve endings in the stump that make a small ne ural tumor that gives pain or shock to the touch. In the case of elderly patient s with vascular disease, are particularly susceptible to other complications mor e generally, in addition to those referenced, they are: • • • • Pneumonia, pulmo nary thrombosis embolism Pressure sores. • 20 VI Degree in Nursing The Amputee Patient 3. NURSING CARE The patient's adaptation to disability caused by an amputation depends not only good physical condition and use of a prosthesis, but also its perception and dis ability. An amputation produces a permanent disability which will affect a great er or lesser extent some of the physiological, psychological and social.€The hea lth team, particularly nurses, is responsible for performing an adequate physica l and psychological preparation for surgery, as well as the consequences it coul d bring to your life, with the primary aim to encourage the independence of the individual in activities of daily living. 3.1 - CARE Preoperative preparation and psychological support This depends on th e cause of amputation and state whether physical or mental patient. The traumati c amputee patient is usually a young adult who loses his edge because of an auto mobile accident or otherwise. There is little opportunity to prepare psychologic ally. This patient needs time to internalize and their feelings about the perman ent loss that your body had. The reactions of these patients are unpredictable a nd can vary between a bitter hostility until a complete euphoria. A realistic ap proach and support, which includes the patient actively in self-care and rehabil itation activities, helps the user to accept their loss. Also the support and ac ceptance by the family helps the patient to adjust to the loss of an extremity. 12 VI Degree in Nursing The Amputee Patient Amputations have been therapeutic, as opposed to traumatic, to stop the pain, di sability and dependency. These patients had time to internalize their feelings r elated to amputation, the best-facing amputation or traumatic in origin or sourc e of therapy leads to a change in body that must be internalized so as not to lo se self-esteem should be this is the main objective of the nurse. The nurse can only act effectively knowing all the reactions that the patient may have. Above all, the patient should know that it will occur and thus, due to the news, the p atient may react with apathy, or refuse to accept the truth, believing only what they want. Can also react with anger translated aggression against all that sur rounds it, which can cause family instability if they are not alerted to what ma y occur. Then there is a negotiation phase where we try to postpone the inevitab le and seek to guarantee that can not be given. Next comes a phase of depression , which is when the patient finally internalized the reality and realize that am

putation is inevitable and that its image and the more your life is changed. Fin ally comes acceptance where there is the awareness of your new life ahead. Phant om sensation Much of our information sensory afferents are related to specific a reas in the post-central cortex, so allow the construction of a sensory map. As a result, each of us has an "image" the internal, which is representative of our own physical being, known as "body image". This body image, neuro-psychological , it develops from birth, but is only truly internalized some of the 6 / 7 years , when we have the notion of our body as a whole. The loss of body part, as a me mber or a breast, is often associated with the persistence of this part of the b ody image for some time, but eventually the "ghost" of the lost part tends to sh rink and disappear. In about three percent of individuals who undergo amputation of a limb, are described persistent unpleasant sensations or pain, which is usu ally very intense and the kind of tightness or burning in connection with 13 VI Degree in Nursing The Amputee Patient phantom limb. Up to about thirteen percent of cases, such symptoms occur, but ar e only temporary. Sometimes the phantom pain is presented with pain in the amput ation stump, but this is not always the case. It is interesting that those who s uffer from persistent pain in a phantom limb have in common certain characterist ics in terms of events leading to amputation, the nature of their constitutions and emotional amputation. They often describe a history of physical disability o r illness of the member, usually painful, before there was amputation. Others re port the sudden loss of the member in circumstances emotionally dramatic. Those who undergo amputation and phantom limb pain have a look, often have a rigid per sonality and confidence with more previous episodes of depressive illness than t hose who have no symptoms persisted. About the third week after surgery most obv ious perception ghost of a normal member and painless, however, some have referr ed to as deformed member from the first week. For those patients in the first gr oup mentioned, the last two or three weeks of surgery,€the amputated limb gives the impression of being contorted and disproportionate and should not be painful . The perception by the patient, a phantom limb pain may occur in normal or defo rmed phantom limb. This pain can be mild to moderate, tolerable, responding well to physical therapy or medication. Its duration may occur for weeks or years. P hantom pain (perception of sensations, usually painful in parts of the State whi ch were removed at surgery) is always serious and intense, sometimes resist vari ous forms of treatment and can even prevent the rehabilitation program. The appe arance can occur early or late amputation with unpredictable duration. Already s tump pain has a specific location, presenting characteristics of displeasure mil d, moderate or intense as a result of various types of complications. "Whatever the cause," said Cavalcanti, "every effort should be made to abolish the pain an d complications should be corrected or eliminated so that the process of rehabil itation of amputee normally be given." The loss of a member not only involves th e relearning of motor activity but also leads to the development of regret for t he loss of body part. The emotion can also influence the intensity of phantom li mb pain. It should be 14 VI Degree in Nursing The Amputee Patient inform the patient that the pain occurs after amputation in most cases and will decrease over time if conducted active postoperative rehabilitation that is to m obilize "mentally" toes amputated. Moreover, the early active mobilization and p lacement of the prosthesis reduces this. In many cases, the phantom sensation an d pain go away without treatment after having spent a few months. In all cases t here are effective treatments against this disease. There is the fitness standar d as general preparation for any surgery - analysis and routine radiographs, dia

gnostic procedures for evaluating the vascular permeability to amputate the limb (arteriography, Doppler), notice by the cardiologist in the elderly and patient s with compromised cardiovascular function, replacement of nutritional status, a dequate hydration and careful shaving and disinfecting the operative field, rout ine preoperative (enema cleansing and preoperative analgesia). Also has to do wi th teaching them how to prevent respiratory complications with respiratory physi otherapy exercises (abdominal-diaphragmatic exercise, coughing directed) to impr ove oxygenation in pre-and postoperatively. In a specific physical preparation: • • You should encourage the patient to stay out of bed all the time as possible if your state permits before amputation; Teaching active exercises to strengthe n the muscles of the upper trunk and abdomen, so needed to walk with crutches or crutches: • In bedridden patients put a trapeze suspended in bed and motivate you for that s tarting position from lying to raise the trunk; In prone position, exercise lift ing the trunk, do isometric exercises of the upper limbs, face and hands in fron t of the chest and push against each other; Flex and extend your arms while hold ing weights, sitting on the bed with two books, one on each side and his hands r esting on them, raising the river bed of the plan. 15 • • • • VI Degree in Nursing The Amputee Patient All these exercises should be performed with monitoring of respiratory function in order to avoid maneuvers Vassalva that in elderly patients with cardiovascula r problems and can be dangerous. The patient should also contact the aids to reh abilitation. Initially the wheelchair and the second stage or the Canadian crutc hes. One should realize their educational transfer from bed to chair and vice-ve rsa, and walk with crutches. 3.2 - ASSISTANCE IN POSTOPERATIVE comprehensive and integrated treatment of the patient will determine the success of all work rehabilitational scheduled. The u ltimate goal is to enable the patient to make better use of their capabilities s o that it can be independent in activities of daily living. To do so, include th e treatment of the stump (no pain), with good muscle strength, without edema, an d therefore able to receive the prosthetic socket. For the proper planning, phys iatric must contain pharmacological aspects, physical during the pre, during and after placement of the prosthesis, psychosocial and vocational education; funda mental to the satisfactory performance of the program. The assessment includes p hysiatric rehabilitation and prosthetics.€As the overall therapeutic rehabilitat ion procedure that transcends the physical, while the prosthesis is the use of s pecial technical features aimed at the partial replacement of a member. Therefor e, rehabilitation may be considered more complete if it is followed by placement of a prosthesis. The immediate application of a prosthetic device at the time o f amputation has been advocated in recent years. In selected situations, this te chnique has some definite benefits to the amputee. The immediate use of the limb decreases the psychological impact of limb loss and immediately start the rehab ilitation phase. Nursing care of postoperative aim to: • • • Getting a great phy sical and emotional state in order to minimize problems with adaptation and use of prosthesis prevent complications, prevent prolonged disability. 16 VI Degree in Nursing

The Amputee Patient The patient should be received in a warm bed, with broken equipment, which will provide a correct positioning and facilitates mobilization. One must make an ass essment of vital signs, from 15 to 15 minutes during the first two hours 30minut es and 30 in the next two hours and then evaluated on an hourly or as needed by the patient, and have the care with transfusions such as surveillance of allergi c reactions or hemolytic, making the control and dribbling. One should also take care of the drains of the stump, evaluating the quantity and color of drainage and register. The early ambulation and a psychological help can contribute to an early rehabilitation and prevention of some complications. However one should m ake the monitoring of complications that can arise after surgery that are: • Gen eral complications: • • • • pneumonia, thrombosis, pulmonary embolism, pressure ulcers; Elderly patients with vascular disease are particularly susceptible to these com plications; • local complications: • • • flexion deformity in the joint below; infection that can happen to a hematoma, d eformation of the stump that can be caused by incorrectly applied a ligature, pr essure ulcers that can result from a poorly placed prosthesis. evaluate and moni tor the stump drainage catheter as the color and quantity; communicate the incre ased drainage positioning the patient, avoiding bending the hip or knee to avoid contractures, encourage the prone position, to support the stump with a cushion in the first 24 hours, avoiding bending, put a roll along the outer surface to prevent external rotation, evaluation and monitoring of respiratory function of the excretory function, fluid intake and eating lightly and appropriate will be encouraged; 17 • The main nursing care after amputation are: • • • • • • VI Degree in Nursing • The Amputee Patient encourage exercise, to prevent thromboembolism (if lower limb amputation): • active movements of the lower limb not affected, rotation and dorsiflexion of th e foot, use of a trapeze above support the bed when it mobilizes, raise and lowe r the bed's head; strengthening quadricep as will be described during the prepar ation of teaching for high, lifting the stump and buttocks on the bed when in a supine position (to strengthen the abdominal muscles). • • •

• • Promote wound healing: • monitor potential problems in relation to peripheral vascular disease, nutrition al or health attendant and Associates; edema is controlled by a compressive dres sing with plaster and helping to restore circulation and lymphatic drainage, res idual limb must be handled gently, and always that the dressing is renewed shoul d be respected aseptic technique to prevent wound infections or osteomyelitis po ssible, the modeling of the residual limb is important for the adaptation of the prosthesis. The patient will need to learn how to perform ligation of the stump and when the incision healed, the patient is oriented to take care of it. • • • • Pain relief: • Surgical pain is located within the incision and can be controlled by painkiller s or by drainage of the hematoma or fluid buildup. The expression of pain is ind ividual and can be interpreted as minimal and controlled by analgesics, the pain may be inversely associated with changes in body image, and will not change in an appropriate manner by the use of analgesics. The pain can be by excessive pre ssure on a bony prominence or a hematoma. Usually within a few days, surgical pa in is effectively controlled with oral analgesics and techniques to change the p erception of pain. 18 VI Degree in Nursing • The Amputee Patient Muscle spasms can cause major discomfort during convalescence, and the change in position, applying heat or placing a sandbag on mild residual limb in order to counteract the spasm may improve the level of patient comfort. • Independent self-care: • patient should be encouraged to become an active participant in self care. For t his the patient and the nurse should maintain positive attitudes, minimizing fat igue and frustration during the learning process. The independence to dress up, urinating / defecating and bathing depends on the balance, the ability to transf er tolerance and physiological activities. • It is fundamental to the integration of multidisciplinary treatment of amputees to identify in time, any signal that might compromise the outcome of the rehabil

itation process. 3.3 - EDUCATION FOR HIGH amputated the patient education is a continuous and gra dual in accordance with state and rehabilitation phase in which the patient is. Before the patient is discharged is advised on the proper way to care for the st ump, such as: • • • • the hygiene of the stump should be careful using water and mild soap making gestures and dry well, avoid alcohol, oils and creams, perform a soothing massage in the direction of venous return, half of wool is used espe cially for stump with the prosthesis and the patient is informed about the impor tance of keeping it in place without bending, and changing daily; • examine the stump every day for early detection of erythema, folliculitis, blisters that ins talling itself may prevent the use of a prosthesis for a while. 19 VI Degree in Nursing The Amputee Patient The patient should be instructed to avoid certain positions vicious very common in amputees, such as bending, for example when sitting or supports the stump of his arm crutch, and the abduction when the patient keeps the stump away from the other member. And elsewhere should be encouraged to strengthen the muscles, suc h as: • • • • • the patient supine, the limb is bent, push the stump for bed, in full extension; sick in the lateral side are member are flexed, flexion and hyperextension of making lame-femoral, insisting on this; patient prone, to hyperextension of the stump associated with hyperextension of the spine; patient leaning on a table member are supported on the floor, making hyperextension of the femoral hip, in the standing position to actively extension, hyperextension, flexion, adduction and internal and external rotation of femoral hip. In the lo wer limb amputee patients should begin to move in parallel bars to gain confiden ce. It then must use a support structure and then crutches, depending on your co ndition and abilities. In lower limb amputations, one should encourage the patie nt to walk properly with the aid of crutches or crutches: • • • • • keep elbows in extension; limiting flexion of the elbow 30 degrees, maximum; avoid underarm pressure ; support the weight on the palms, not the armpits, maintaining an upri ght posture (head up, chest lifted, contraction of the abdomen and pelvis, foot line). Although the care of the stump are important it is vital not to neglect t he so-called good leg. Inevitably it will have more work to be done and should b e made a careful observation of the movement, state of the skin and nails, and a void excessive heat or cold, using hot water bottles, the use of elastic stockin gs with strong, maintain the position of sitting for long periods or in any othe r position that compresses the popliteal region. They should also be taught musc le exercises that allow a good blood supply and better venous return. 20 VI Degree in Nursing The Amputee Patient Education should also include important aspects of exercise, environment, diet, risks of smoking and emotional stress. 21 VI Degree in Nursing The Amputee Patient 4 - CARE PRE-prosthesis Contraindications to the use of a prosthesis The individ ual who will undergo an amputation, should achieve maximum independence with the use of a prosthesis, despite the use of a prosthesis requires patient cooperati

on, good coordination movements and a strong will. There are patients who are un able to adapt to a prosthesis either by age or by the underlying disease, as: • • • • • • • serious neurological diseases, renal failure, disorientation, senili ty, psychosis or mental retardation, heart disease and cardio- lung;€risk of gan grene of the other member, lack of motivation; Wound healing difficult. Given th ese patients with such problems in order for their rehabilitation is to achieve the greatest degree of independence in a wheelchair. Prosthesis intraoperative g raft versus late Individuals who were subjected to an amputation before 1960 wai ted many months for the scars and surgical suture the stump stayed shaped to rec eive the prosthesis. After 1961 a French surgeon insert the prosthesis during su rgery this problem was overcome with it the rehabilitation of the amputee has be come much faster and more gratifying. Today used two options: A. Place an intraoperative prosthesis. B. Placing an implant two to three weeks after surgery, wh en the points can be removed and healing is complete. 12 VI Degree in Nursing The Amputee Patient The pre-prosthetic care begin before the operating room where used an intraopera tive stent. It applied a patch that can be a bandage or wool crepe shaped bandag e for stumps, may still be cast. This allows you to control the swelling, reduce s pain with movement, helps shape the stump and promotes healing, making possibl e an early adaptation to the prosthesis and reduce the time interval between amp utation and walking (can happen 48 hours after surgery ). The sutures are remove d after about 14 days. The fitting of a prosthesis will be postponed until the s tump has diminished in size and swelling has subsided. The type of prosthesis sh ould be chosen according to age, patient's ability, length and shape of the stum p. Fits permanent prosthesis after two or three months being observed periodical ly as the stump is altering its shape. If the individual choose to adapt a prost hesis later, the first step toward a speedy recovery is to make a stump ligation in the operating room. For the stump is functional, it must: - be molded into a cone pair not difficult to adapt to fit the prosthesis - is painless - be firm - has muscle to activate the prosthesis - has long needed; - not have the scar a dhesions or scar tissue. All these aspects depend on: - good surgical technique - careful hygiene - massage for takeoff adhesions - active demonstrations - liga tion of the stump. Characteristics of ligation of the stump ligation of the stum p in the postoperative period as well as help to reduce swelling can help shape the stump. This training works best with the latest methods of amputation. 13 VI Degree in Nursing The Amputee Patient Some surgeons do not advocate the ligation of the risk of further harm the blood supply, as a ligature misapplied can cause a strain on the stump that will brin g problems to the placement of the prosthesis. By using the ligature, it must be very tough and elastic, about 10-15 cm. The li gature has the functions: • • • • • avoid hemorrhage and edema, reduce and shape the stump taper to receive the prosthesis under the best conditions, facilitati ng a good venous return, the pain, get used stump remain obscured. The force exe rted when applying the ligature of the stump should be moderate to avoid compres sion that can lead to a further amputation. It must be because: • • • • • applyi ng the bandage firmly by increasing pressure from proximal to distal; never make circular, or at the beginning or end; make ligation with the patient in lateral position to avoid bending the coxofemural; ligation should be used continuously (24 h), the ligature should be redone at least twice a day during the first yea

r after surgery and placed in the intervals in which the prosthesis is not being used; • must be ligation resumed if, for whatever reason, the patient is to rem ain bedridden for some time, and whenever any injury stump prevents the use of t he prosthesis. 14 VI Degree in Nursing The Amputee Patient 5 - REFERENCES SUDDARTH and BRUNNER, Interamericana, Rio de Janeiro, 1977. Kottk e, Frederic J., Stillwell, G. Keith; LEHMANN, Justus F. - Krusen: Treaty of phys ical medicine and rehabilitation. 3rd ed. São Paulo: Editora Manole Ltda., 1984. MACKAY, William A. - Neurophysiology without Tears-Fundação Calouste Gulbenkian , Lisbon, 1999. MANUILA, L.; Lewalle, P. - Diccionario Medico-3rd Edition, Clime psi Publishers, Paris, 2003. MERTENS, Joan Mary - The nurse and the patient ampu tated. "Serving". Lisbon. ISSN 0871-2370, vol. 38, No. 6 (1990), 298-307. PHIPPS , Wilma J., [et. al] - medical-surgical nursing - concepts and clinical practice . vol. 2, s.l.: Lusodidacta, 1990. PINNEY, Edward,€Orthopaedic Nursing, 1st edit ion, Orthopedic Hospital Santana (HOSA), Wall, 1985. PORTUGAL, Ministry of Healt h, Directorate General of Health, Living with Amputation of Leg - Self-Care in H ealth and Disease, 1st edition, Volume 8, 1990. Sabiston, David C., MD, Jr. - Tr eaty of Surgery - The Biological Basis of Modern Surgical Practice - 14th Editio n, Volume 2, Guanabara Koogan, 1993. Enfernagem Medical-Surgical, 3rd edition, 15 VI Degree in Nursing The Amputee Patient SMELTZER, L.C.; BARE, Brenda G. - Brunner and Suddarth (1994). - Treaty of Medic al Surgical Nursing. 7th edition. Ed Guanabara Koogan. Rio de Janeiro. 16