Chapter 43

Amputations

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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

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
Hemorrhage and hematoma Necrosis Wound dehiscence Gangrene Edema Contracture Pain Infection Phantom limb sensation Phantom limb pain

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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 patients usual activities Patients psychosocial background may offer insight into how the patient will tolerate treatments and procedures

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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 patients understanding of the illness and its implications

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Interventions
Anxiety Anticipatory grieving

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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 patients 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 patients pain, including type, location, severity, and response to treatment

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Postoperative Nursing Care

Interventions
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 Ringers 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
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 patients 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 patients fear and anxiety Accept the patients 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 limbs 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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 A 68-year-old patient has been brought back to the surgical unit following a below-theknee amputation for complications associated with peripheral vascular disease. What are the most common postoperative complications in a patient with an amputation? What nursing interventions would be indicated in the immediate postoperative period?

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 Guidelines: The most common complications associated with amputation are hemorrhage, hematoma, edema, pain, and infection. The nurse should frequently monitor the patient during the postoperative period. The assessment should include vital signs, which can indicate fluid volume loss, infection, and other complications. The nurse should assess the surgical area for signs of drainage and bleeding, as well as the surrounding areas. The patient should also be assessed and medicated for pain and the incision should be monitored for signs and symptoms of infection, such as foul-smelling drainage, redness, swelling, and warmth, and the nurse should offer continued emotional support to the patient.

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 Question: What are the four most common incidences that lead to amputation? Explain your answers.

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 Answer: The first incidence is trauma, which is the most common cause of upper-extremity amputation. Some examples of trauma are automobile, motorcycle, explosives, firearms, and machinery accidents. The next most common cause of amputations is vascular disease. Vascular disease is the leading cause of lower-extremity amputation. Some examples of disease are diabetes mellitus, peripheral vascular disease, and arteriosclerosis. Tumors are the third most common indication for amputation. Tumors of the bone that are large and invasive can necessitate amputation. Finally, congenital defects can result in amputation or missing limbs (congenital amputation) at birth as a result of improper development in utero.

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 A 19-year-old patient presents to the emergency department with a severe crushing injury to his right forearm following an automobile accident. The patient will require amputation due to the severity of the injury. What diagnostic tests will likely be performed before the surgery, and what type of surgery would most likely be indicated for this patient?

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 Guidelines: The patient will undergo diagnostic tests to determine the extent of damage to the arm and to determine the blood flow to the extremity. These are considered vascular tests. The patient will likely undergo an angiography before surgery to determine if there is any damage to the arteries and also to determine at what level the amputation needs to be performed. Because of the traumatic nature of the injury, the patient is at risk for infection in the bone and tissues that surround it. Therefore, the patient will likely undergo an open or staged amputation to monitor for signs of infection. The surgeon will attempt to amputate at the lowest possible level that will promote tissue healing and adequate blood supply.

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