Problems Related to Musculoskeletal & Coordination

Amputation
Removal of a body part Causes
Peripheral vascular disease-80% [75% Diabetics]vascular changes/atherosclerosis due to DM

Congenital deformities Infection Malignant tumors Traumatic

Unexpected severing of body part Accidents, land mines, farm related injury Common in young secondary to trauma

Clinical Indications
Circulatory impairment [PVD] Traumatic & Thermal injuries Malignant tumors Uncontrolled widespread infection of extremity-gas gangrene, osteomyelitis Congenital disorders

Amputation
Psychosocial aspects of the procedure: devastating as the physical impairments that result. Loss of limb: complete and permanent and Lead to traumatic change in body image and often in selfesteem. Necessitates major life style changes & adjustments

Pathophysiology: Amputations
Elective
Related to complications of PVD & arteriosclerosis Result in ischemia in distal areas of lower extremities.i.e. Diabetes Considered only after other interventions have not restored circulation to lower extremitiesLimb salvage

Pathophysiology: Amputations
Traumatic primary cause of upper extremity loss of limb Accidents [MVA, industrial machine, war time from land mines & bombs [Iraq] Severe crushing of tissues & significant blood vessel damage Limb must be amputated in order to preserve function of residual limb Today some body parts can be salvaged

Levels of Amputation
Lower extremity (LE) amputations: more frequently done 5 types of amputations Above the knee [AKA] Below the knee [BKA] Midfoot amputations (e.g., the Lisfranc and the Chopart amputations) and the Syme Toe Amputation

Common levels of lower extremity amputation.

Cultural Awareness
The incidence of lower extremity amputations is greater in black and Hispanic populations because the incidence of major diseases leading to amputation, such as diabetes and arteriosclerosis, is greater in these populations.

Complications
Most common complications of elective or traumatic amputations are: Hemorrhage-hypovolemic shock from too much blood loss Infection- osteomyelitis

Phantom limb pain

Neuroma-tumor of damaged nerve cells Flexion contractures

Phantom Limb Pain

Painful sensation felt in amputated limb after its removed immediately Described as intense burning, crushing, cramping, shooting, coldness, heaviness Experience numbness & tingling-phantom limb sensation Anxious because pt knows limb is gone but pain is felt Subsides over time Nurse should recognize pain as REAL & treat it aggressively-Ask pain level 0/10 More common in the above the knee amputation [AKA]

Diagnostics
H&P Physical appearance soft tissues Skin temperature, sensory function Presence of peripheral pulses

ANKLE BRACHIAL INDEX

Arteriography, venography plethymography Doppler studies

Routine blood work: elevated WBC w/abnormal differential-infectious process

Physical Assessment/Clinical Manifestations

Monitor Neurovascular status in affected extremity Check circulation in bilateral legs if PVD Assess skin color, temperature and pulses in both affected & unaffected Check capillary refill [not a reliable indicator]-in elderly w/thick, opaque nails, check skin near nail bed Observe & document any discoloration of skin, edema, presence of necrosis and hair on distribution of lower extremity

Psychosocial Assessment
Evaluate their psychological preparation for a planned amputation, and expect them to go through the grieving process. Assess the patient's feelings about himself or herself to identify areas in which he or she needs emotional support. Refer the patient to the certified hospital chaplain, other spiritual leader, or social worker Determine the patient's willingness and motivation to withstand prolonged rehabilitation after the amputation assess the family's reaction to the surgery or trauma Assess the patient's and family's coping abilities, and help them identify personal strengths and weaknesses.

Assess the patient's religious, spiritual, and cultural

Pre-Hospital Care Emergency Care Traumatic Amputation-Critical Rescue

Call 911 Assess ABCs

Examine site & Apply direct pressure to amputation with layers of dry gauze or other cloth
Elevate extremity above heart to decrease bleeding Do not remove dressing For finger, wrap in dry sterile gauze [if available] or clean cloth & place in watertight, sealed plastic bag Place bag in ice water & never directly on ice, at 1 part ice and 3 parts water Transport part to hospital w/patient

Collaborative Care
The goal of amputation surgery is to preserve extremity length and function while removing all infected, pathologic, or ischemic tissue.

Closed amputation-creates weight-bearing residual limb [stump]

Disarticulation-amputation performed through a joint [Syme] Open amputation-leaves a surface on the residual limb that is not covered with skin-done for control of actual or potential infection
Wound closed later by surgical procedure or closed by skin traction surrounding limb-Guillotine amputation