Before surgery, the nurse must evaluate the neurovascular and functional status of the extremity through history and physical assessment. If the patient has experienced a traumatic amputation, the nurse assesses the function and condition of the residual limb. The nurse also assesses the circulatory status and function of the unaffected extremity. If infection or gangrene develops, the patient may have associated enlarged lymph nodes, fever, and purulent drainage A culture is taken to determine the appropriate antibiotic therapy.
The nurse evaluates the patient’s nutritional status and creates a plan for nutritional care, if indicated. For wound healing, a balanced diet with adequate protein and vitamins is essential.
Any concurrent health problems (eg, dehydration, anemia, cardiac insufficiency, chronic respiratory problems, diabetes mellitus) need to be identified and treated so that the patient is in the best possible condition to withstand the trauma of surgery. The use of corticosteroids, anticoagulants, vasoconstrictors, or vasodilators may influence management and wound healing.
The nurse assesses the patient’s psychological status. Determination of the patient’s emotional reaction to amputation is essential for nursing care. Grief response to a permanent alteration in body image is normal. An adequate support system and professional counseling can help the patient cope in the aftermath of amputation surgery.
Based on the assessment data, 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
• 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.
Surgical pain can be effectively controlled with opioid analgesics, nonpharmaceutical 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.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching the Patient to Manage Self-Care
Before discharge to the home or to a rehabilitation facility, the nurse encourages the patient and family to become active participants in care. They participate, as appropriate, in skin care and residual limb care and in the management of the prosthesis The patient receives ongoing instructions and practice sessions in learning how to transfer and how to use mobility aids and other assistive devices safely.
Continuing Care in the Home and Community
After the patient has achieved physiologic homeostasis and has demonstrated achievement of major health care goals, rehabilitation continues either in a rehabilitation facility or at home Continued support and supervision by the home care nurse are essential.
Before the patient’s discharge to the home, the nurse should assess the home environment. Modifications are made to ensure the patient’s continuing care, safety, and mobility. An overnight or weekend experience at home may be tried to identify problems that were not identified on the assessment visit. Physical therapy and occupational therapy may continue in the home or on an outpatient basis. Transportation to continuing health care appointments must be arranged. The social service department of the hospital or the community agency managing continued health care may be of great assistance in securing personal assistance and transportation services.
During follow-up health visits, the nurse evaluates the patient’s physical and psychosocial adjustment. Periodic preventive health assessments are necessary. Frequently, an elderly spouse is unable to provide the assistance required, and additional help at home is needed. Modifications in the plan of care are made on the basis of such findings. Often, the patient and family find involvement in an amputee support group to be of value; here, they are able to share problems, solutions, and resources. Talking with those who have successfully dealt with a similar problem may help the patient develop a satisfactory solution.
Because patients and their family members and health care providers tend to focus on the most obvious needs and issues, the nurse reminds the patient and family about the importance of continuing health promotion and screening practices, such as regular physical examinations and diagnostic screening tests. Those patients who have not been involved in these practices in the past are instructed in their importance and are referred to appropriate health care providers.
EXPECTED PATIENT OUTCOMES
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