AMPUTATION

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.
Definitions:
Amputation –removal of part of
the body, limb, or part of a limb

Stump – Aka residual limb; part

of a limb that remains after
amputation

Purpose:
 Relieve symptoms
 Improve function
 Improve QOL
 Save life!
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
Figure 43-1
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
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
 Traumatic Injury

Or partial laceration
Can be complete amputation
requiring surgical
from an accident
amputation
 Progressive Arterial Disease

Often due to Diabetes

Can lead to ulcers that may

require amputation

Amputation is four times

more likely in diabetics than
non-diabetics
 Gangrene

May require staged

amputations
Initially a guillotine amputation
is done to remove the necrotic
and infected tissue
Sepsis is treated with systemic
antibiotics
After the infection is controlled
and the patient’s condition has
been stabilized, a definitive
amputation with skin closure is
performed
Diagnostic Tests and Procedures
• Vascular studies
• Pulse volume recording
• Thermography
• Doppler ultrasound
• Biopsy
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
 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
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
Figure 43-2
Figure 43-3
Complications
• Hemorrhage and hematoma
• Necrosis
• Wound dehiscence
• Gangrene
• Edema
• Contracture
• Pain
• Infection
• Phantom limb sensation
• Phantom limb pain
Pre Operative
 Assessment
• 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
Physical Examination
• 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
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
Post Operative
 Postoperative Nursing Care
• Assessment
• 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
• 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
 The patient’s major nursing diagnoses may
include the following:

• Acute pain related to amputation

• Risk for disturbed sensory perception: phantom limb pain related to
amputation
• Impaired skin integrity related to surgical amputation
• Disturbed body image related to amputation of body part
• Ineffective coping, related to failure to accept loss of body part
• Risk for anticipatory and/or dysfunctional grieving related to loss of body part
• Self-care deficit: feeding, bathing/hygiene, dressing/grooming, or toileting,
related to loss of extremity
• Impaired physical mobility related to loss of extremity
COLLABORATIVE PROBLEMS/ POTENTIAL
COMPLICATIONS
• Based on the assessment data, potential complications that
may develop include the following:
• Postoperative hemorrhage
• Infection
• Skin breakdown
Planning and Goals
• The major goals of the patient may include relief of pain,
absence of altered sensory perceptions, wound healing,
acceptance of altered body image, resolution of the grieving
process, independence in self-care, restoration of physical
mobility, and absence of complications.
Nursing Interventions
• RELIEVING PAIN
Surgical pain can be effectively controlled with opioid analgesics, non
pharmaceutical interventions, or evacuation of the hematoma or
accumulated fluid.
• Pain may be incisional or may be caused by inflammation, infection,
pressure on a bony prominence, or hematoma.
• Muscle spasms may add to the patient’s discomfort.
• Changing the patient’s position or placing a light sandbag on the residual
limb to counteract the muscle spasm may improve the patient’s level of
comfort.
• Evaluation of the patient’s pain and responses to interventions is an
important part of the nurse’s role in pain management.
• The pain may be an expression of grief and alteration of body image.
• MINIMIZING ALTERED SENSORY PERCEPTIONS
Amputees may experience phantom limb pain soon after surgery or
2 to 3 months after amputation. It occurs more frequently may in
above-knee amputations. The patient describes pain or unusual
sensations, such as numbness, tingling, or muscle cramps, as well as
a feeling that the extremity is present, crushed, cramped or twisted
in an abnormal position. When a patient describes phantom pains
or sensations, the nurse acknowledges these feelings and helps the
patient modify these perceptions
• PROMOTING WOUND HEALING
The residual limb must be handled gently. Whenever the
dressing is changed, aseptic technique is required to prevent
wound infection and possible osteomyelitis
• ENHANCING BODY IMAGE
Amputation is a reconstructive procedure that alters the patient’s body image.
• The nurse who has established a trusting relationship with the patient is better
able to communicate acceptance of the patient who has experienced an
amputation.
• The nurse encourages the patient to look at, feel, and then care for the residual
limb It is important to identify the patient’s strength and resources to facilitate
rehabilitation.
• The nurse assists the patient to regain the previous level of independent
functioning.
• The patient who is accepted as a whole person is more readily able to resume
responsibility for self-care; self-concept improves, and body-image changes are
accepted. Even with highly motivated patients, this process may take months.
• HELPING THE PATIENT TO ACHIEVE PHYSICAL MOBILITY
Positioning assists in preventing the development of hip or knee joint
contracture in the patient with a lower extremity amputation.
Abduction, external rotation, and flexion of the lower extremity are
avoided.
• Depending on the surgeon’s preference, the residual limb may be
placed in an extended position or elevated for a brief period after
surgery.
• The foot of the bed is raised to elevate the residual limb.
Evaluation
Expected patient outcomes may include:

• 1. Experiences absence of pain

• a. Appears relaxed
• b. Verbalizes comfort
• c. Uses measures to increase comfort
• 2. Experiences absence of phantom limb pain
• a. Reports diminished phantom sensations
• b. Uses distraction techniques
• c. Performs stump desensitization massage
• 3. Achieves wound healing
• a. Controls residual limb edema
• b. Achieves healed, nontender, nonadherent scar
• c. Demonstrates residual limb care
• 4. Demonstrates improved body image and effective coping
• a. Acknowledges change in body image
• b. Participates in self-care activities
• c. Demonstrates increasing independence
•
• 5. Exhibits resolution of grieving
• a. Expresses grief
• b. Works through feelings with family and friends
• c. Focuses on future functioning
• d. Participates in support group
• 6. Achieves independent self-care
• a. Asks for assistance when needed
• b. Uses aids and assistive devices to facilitate self-care
• c. Verbalizes satisfaction with abilities to perform ADLs
• 7. Achieves maximum independent mobility
• a. Avoids positions contributing to contracture development
• b. Demonstrates full active ROM
• c. Maintains balance when sitting and transferring
• d. Increases strength and endurance
• 8. Exhibits absence of complications of hemorrhage,
infection, skin breakdown
• a. Does not experience excessive bleeding
• b. Maintains normal blood values
• c. Is free of local or systemic signs of infection
• d. Repositions self frequently
Figure 43-4