Amputation

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Amputation

• Amanda Huston, Heather Rasmussen, Kelley Moore

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http//www.youtube.com/watch?v0GN9dANKe_Y
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Objectives

• After the presentation, students will be able to
  
• Define amputation.
• Understand what populations are at risk of
  needing amputations.
• Understand pathophysiology of main diseases
  leading to amputations and prevention.
• Acquire knowledge of the levels of amputations
  and potential complications of amputations.
• Identify various treatments, medical management
  and rehabilitation
• Discuss the nursing process
• Describe various prosthesis and financial aid

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Amputation
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What is Amputation?

• Amputation is the removal of a body extremity by
  either trauma or surgery.
• It is used to relieve symptoms, improve function,
  and save or improve the patients quality of
  life.
• Day, Rene, A., Paul, P., Williams, B., Smeltzer,
  S.C, Bare, B. 2007

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Statistics

• It is believed that every 30 seconds a lower limb
  is lost somewhere in the world as a consequence
  of diabetic foot
• The life time risk of an individual with diabetes
  developing a foot ulcer could be as high as 25
• Amputations are preceded by foot ulcers in 75-85
  of cases, usually in association with infections
  and gangrene

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Stats Cont

• Individuals with diabetes are 15X more likely to
  have PAD and 22X more likely to have foot
  ulceration or gangrene than the non-diabetic
  population
• A person who has diabetes or smokes is 3-4 times
  more likely to develop PAD compared to their
  non-diabetic or non-smoking counterparts.
• Despatis, M. A., Diabetes Care in Nova Scotia,
  2005 Routledge, 2005

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Amputation Epidemiology

• Incidence 43/100,000 in Canada
• Etiology
• Lower Extremity
• 1)Vascular 70-90(DM
  70-80)
• 2)Trauma 10
• 3)Malignancy 5
• 4) Congenital 3
• Upper Extremity
• Trauma 90

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What individuals are at risk?

• Individuals with
• Peripheral arterial disease (PAD)
• Diabetes mellitus
• Inactive individuals
• Hypertension
• Hyperlipidemia
• Day, Rene, A., Paul, P., Williams, B., Smeltzer,
  S.C, Bare, B. 2007

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Cont

• Smokers

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Factors leading to an amputation

• Diabetic foot infection or gangrene
• Cancerous bone or soft tissue tumours
• Severe limb injuries in which the limb cannot be
  spared or attempts to spare the limb have failed
• Circulation problems
• Congenital deformities of digits and/or limbs
• Extra digits and/or limbs
• Any advanced cancers
• Day, Rene, A., Paul, P., Williams, B., Smeltzer,
  S.C, Bare, B. 2007

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Factors Con't

• Bone infection (osteomyelitits)
• Traumatic amputation
• Amputation in utero (amniotic band)
• Punishment/Torture
• Sometimes professional athletes may choose to
  have a non-essential digit amputated to relieve
  chronic pain and impaired performance.
• Day, Rene, A., Paul, P., Williams, B., Smeltzer,
  S.C, Bare, B. 2007

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Diabetes and vascular disease

• Chronic elevation of blood glucose level leads to
  damage of blood vessels.
• The endothelial cells lining the blood vessels
  dont depend on insulin and take in more glucose
  than normal.
• It causes the basement membrane to grow thicker
  and weaker.
• They then form more surface glycoproteins than
  normal
• In diabetes, the resulting problems are grouped
  under "microvascular disease" (due to damage to
  small blood vessels) and "macrovascular disease"
  (due to damage to the arteries).

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Case Study

• Meet Mr. Kendry

Medical History Diabetes (Type II)
Name Norman Kendry
Age 54
Occupation Carpenter Journeyman
Medications Metformin, Insulin
Marital Status Divorced
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Prevention

• Prevention of Diabetes Mellitus
• Screening
• Monitor blood glucose levels
• Use insulin as prescribed or as PRN
• Maintain an adequate diet

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Cont

• 4)Exercise
• 5) Control hypertension and hyperlipidemia
• 6) Quitting smoking
• 7) Maintain medication regime
• Day, Rene, A., Paul, P., Williams, B., Smeltzer,
  S.C, Bare, B. 2007

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Peripheral Arterial Disease

• PAD is a progressive atherosclerotic disease
  characterized by occlusion and stenosis.
• It most often involves the arteries of the lower
  extremities
• Risk factors include advancing age, hypertension,
  dyslipidemia (elevation of cholesterol), and
  sedentary lifestyle.
• Results in decreased blood flow to the legs and
  feet resulting in pain, functional impairments,
  tissue loss, gangrene and amputation
• Routledge, 2005

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Prevention of Peripheral Arterial Disease

• 1)Positioning the extremity below the level of
  the heart
• 2)Walking or other moderate or graded isometric
  exercises.
• 3)Arterial dilation promotes increased blood flow
  to the extremities
• 4)Quitting smoking
• http//www.youtube.com/watch?vUx_m5S-fMyM
• (Day, Rene, A., Paul, P., Williams, B., Smeltzer,
  S.C, Bare, B. 2007)

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(No Transcript)
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Con't

• 5)Reduce emotional upsets
• 6) Avoid constrictive clothing and accessories

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Case Study

• Mr. Kendry, post assessment

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Levels of Amputation

• Two factors are considered
• Circulation
• Functional usefulness

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Levels of Amputation

• We want to the patient to be able to keep as much
  of their limb as possible.
• If possible we want to preserve joints.
• Lower Limb Amputations
• Toe
• Forefoot transmetatarsal
• Symes ankle disarticulation
• Below knee transtibial
• At knee knee disarticulation
• Above knee transfemoral
• At hip hip disarticulation
• (Kelly, M., Dowling, M.
  2008).

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Levels of Amputation

• Staged amputation
• Performed when gangrenous or infected.
• Remove necrotic tissue.
• Debride and drain.
• Treat with antibiotics.
• Once infection dealt with, full amputation is
  performed.

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Below knee amputation

• http//www.youtube.com/watch?vQcqfe1V1smg

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Complications of Amputation

• Hemorrhage
• Infection
• Skin breakdown
• Joint contracture
• Phantom limb pain

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Phantom Limb Pain

• Occurs after the cutting peripheral nerves.
• 50-80 incidence (Richardson, 2008)

• Background pain constant, mild
• Exacerbations intermittent,
  moderate-severe

(Richardson, C. 2008).
(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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(Richardson, C. 2008).
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• Difficult to treat no gold standard
• First line antidepressants
  anticonvulsants.
• Some success using N-methyl-D-asparate
  antagonists, gabapentin, calcitonin,
  mexiletine, opiates.

Little to no success using NSAIDs, paracetamol,
beta-blockers, capsaicin, local anesthetic blocks.
(Richardson, C. 2008).
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Medical Management

• Goal non-tender healthy residual limb for
  prosthetic use.
• Promote healing - careful handling -
  controlling edema - preventing infection

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Medical Management

• Types of dressings- closed rigid dressing-
  removable rigid dressing- soft dressing

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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• Wrapping of residual limbs

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Case Study

• Mr. Kendry, after surgery

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Rehabilitation

• Need time to grieve their loss permanent change
  in body image
• May feel angry, bitter, hostile, denial,
  withdrawal, depression, anxiety
• Multidisciplinary rehabilitation team Who would
  this include?
• Goal help client achieve optimal functioning

Psychological Support
(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
(Horgan, MacLachlan in Kelly, Dowling, 2008)
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Nursing implications post surgery

• Assessment
• Neurovascular, functional status and condition of
  the residual limb.
• Circulatory status and function of unaffected
  limb
• Lymph nodes, fever, purulent drainage
• Nutritional status
• Any concurrent health
• problems
• Psychological status

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Case Study

• What Nursing Diagnoses would be appropriate for
  Mr. Kendry?

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Nursing Dx

• Disturbed body image
• Disturbed self-concept
• Impaired physical mobility
• Ineffective sexuality patterns
• Feeding self-care deficit
• Acute pain

• Toileting self-care deficit
• Bathing/Hygiene self-care deficit
• Risk for hemorrhage
• Risk for infection
• Risk for disuse syndrome
• Risk for disturbed sensory perception

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Planning Goals

• Relief of pain
• Absence of altered sensory perceptions
• Acceptance of altered body image
• Independence of self-care
• Absence of complications
• Restoration of physical mobility
• Wound healing

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Readiness for prosthesis

• Depends on
• Physical status
• Wound healing
• Endurance
• Balance

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Prosthesis

• Artificial extension
• Custom molded
• Specific designs
• Consistent adjustments

(Day, Rene, A., Paul, P., Williams, B., Smeltzer,
S.C, Bare, B. 2007)
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Financial Aid

• Private insurance, government agencies or private
  organizations will fund some or all of the
  appliances
• Champs/War Amps of Canada
• Workers Compensation Board
• Blue Cross
• Veterans Affairs

War Amps. ca, 2008
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• A Fort McMurray, Alta., man says he plans to
  turn his prosthetic leg into a walking billboard
  to raise money for an upgraded prosthesis that
  will make it easier to maintain an active
  lifestyle.
• Cbcnews.ca

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Do you recognize?
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Do you recognize?
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Do you recognize?
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In conclusion

• What are the main diseases that may result in an
  amputation?
• What factors may contribute to an amputation?
• Name a few preventative measures for the
  diseases.

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References

• Carpenito-Moyet, L. J. (2006). Nursing diagnosis
  Application to clinical practice. New Jersey
  Lippincott.
• CBC News (2008). Alberta man plans to sell ad
  space on his prosthetic leg. Retrieved November 2
  2008 from http//www.cbc.ca/consumer/story/2008/05
  /20/prosthetic.html
• Day, R. A., Paul, P., Williams, B., Smeltzer, S.
  C., Bare, B. (2007). Textbook of
  medical-surgical nursing (1st ed.). Philadelphia,
  PA Lippincott Williams Wilkins.
• Despatis, M. A. (2005). Assessment and treatment
  of peripheral arterial disease in diabetes.
  Diabetes Care in Nova Scotia, 15(2). Retrieved
  from www.diabetescareprogram.ns.ca
• Kelly, M., Dowling, M. (2008). Patient
  rehabilitation following lower limb amputation.
  Nursing Standard, 22(49), 35-40. Retrieved on
  October 30th, 2008 from EBSCO database.
• Richardson, C. (2008). Nursing aspects of phantom
  limb pain following amputation. British Journal
  of Nursing, 17(7). Retrieved on October 30th,
  2008 from EBSCO database.
• Routledge, F. (2005). Assessment and treatment of
  peripheral arterial disease in diabetes. Diabetes
  Care in Nova Scotia, 15(2). Retrieved from
  www.diabetescareprogram.ns.ca
• The War Amps (2008). Retrieved November 2 2008
  from http//www.waramps.ca/home.html