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According to Hoffstad, Mitra, Walsh, and Margolis (2015), a patient who undergoes LEA and has diabetes has a three times greater risk of dying than a patient with diabetes who does not have an LEA. The surgeon, nurses, primary care physician, pain management team, rehabilitation team (occupational, vocational, and physical therapy), prosthetist, social worker, and the patient's family must be involved actively in the patient's care (Ertl, 2016; Gulanick & Myers, 2014; Virani, Werunga, Ewashen, & Green, 2015). Assessment of the residual limb, previously identified as the stump (Gulanick & Myers, 2014), should include the most distal pulse, movement, sensation, and skin color and temperature with comparison to the unaffected limb. Because variances in neurovascular condition can indicate compromised circulation and lead to necrosis of the residual limb, immediate reporting to the physician is critical (Daniels & Nicoll, 2012). Impaired Skin Integrity and Risk for Infection Wound management and infection prevention are critical nursing foci for the amputee, with consistent hand hygiene the first step toward achieving these goals (Ertl, 2016; Rossbach, 2017).
The earliest literary proofs of amputation exist from 1700 BCE in the Babylonian code of Hammurabi and from 385 BCE in Plato's Symposium. Stone Age (Neolithic period) caves have been found with imprints of hands with missing fingers; human remains have been discovered, some with a prosthetic lower extremity, that reveal amputations were performed early in time (Ertl, 2016). Ertl also noted lower extremity amputations (LEAs) now compose approximately 85% of all amputations performed. Irreversible ischemia related to peripheral vascular disease (PVD) is the primary cause of amputation (Daniels & Nicoll, 2012; Gulanick & Myers, 2014; Vetra, Lacis, Raipalis, Legzdina, & Logins, 2016). Trauma to a limb is the second leading cause of amputation (Gulanick & Myers, 2014). Key considerations for the nurse's role during care following LEA will be explored in this article.
Case Study
Mrs. M. was on Christy's list of patient care assignments for the first time. When she walked in Mrs. M.'s room, she saw a 57-year-old woman covering her eyes with her hands as tears streamed down her cheeks. She was going to be discharged to a rehabilitation facility at the end of the week. Mrs. M. had both legs amputated below her knees because of severely compromised circulation secondary to diabetes mellitus. She was experiencing severe phantom pain in her lower legs. She was anxious and afraid, and said she felt "incomplete." Cindy comforted Mrs. M., encouraging the patient to express her feelings, and began performing an in-depth assessment of pain and the patient's residual limbs. Cindy assisted Mrs. M. to a different position, started to play a compact disc of Mrs. M.'s favorite music at her bedside, and administered analgesia as ordered. Cindy knew pain management interventions, emotional support, and patient education would be central to her patient care today. Mrs. M.'s physical healing and emotional acceptance were just beginning. She could not visualize how a positive outcome would ever be a part of her life again.
Nursing Considerations
Nursing care of the patient following amputation is complex. In-depth and ongoing assessments, pain management, wound care, awareness of possible postoperative complications, education, safety, range of motion and mobility, and emotional needs are nursing priorities during the initial postoperative period (Ertl, 2016; Gulanick & Myers, 2014). See Table 1 for key nursing diagnoses for a patient following LEA. Associated comorbidities also must be monitored closely because they can complicate wound healing and the patient's recovery; for example, 50% of patients are diagnosed with PVD due to diabetes mellitus (Ertl, 2016). According to Hoffstad, Mitra, Walsh, and Margolis (2015), a patient who undergoes LEA and has diabetes has a three times greater risk of dying than a patient with diabetes who does not have an LEA.
Crucial to achieving optimal outcomes is the ability to combine interprofessional resources for the amputee. The surgeon, nurses, primary care physician, pain management team, rehabilitation team (occupational, vocational, and physical therapy), prosthetist, social worker, and the patient's family must be involved actively in the patient's care (Ertl, 2016; Gulanick & Myers, 2014; Virani, Werunga, Ewashen, & Green, 2015). An amputee can have a long, full life when appropriate care, support, and resources are available (Vetra et al., 2016).
Ineffective Tissue Perfusion and Acute Pain
Vital signs and neurovascular condition must be assessed frequently for the postoperative patient based on physician order and prudent nursing judgement (Gulanick & Myers, 2014; Virani et al., 2015). Assessment of the residual limb, previously identified as the stump (Gulanick & Myers, 2014), should include the most distal pulse, movement, sensation, and skin color and temperature with comparison to the unaffected limb. Because variances in neurovascular condition can indicate compromised circulation and lead to necrosis of the residual limb, immediate reporting to the physician is critical (Daniels & Nicoll, 2012).
Pain management is a priority. Nurses must use a nonjudgmental approach, providing frequent pain assessment, appropriate intervention, and accurate documentation (Virani et al., 2015). The patient can have different types of pain after LEA, with skin, muscle, nerve, and bone as possible sources (Ertl, 2016; Gulanick & Myers, 2014). Incisional pain can be accompanied by erythema and edema. It should begin to decrease by the end of the first postoperative week (Gulanick & Myers, 2014).
Nerve stimulation proximal to the amputation site causes the patient to sense the amputated part still is attached. This phantom limb sensation (PLS) is felt more in the foot than in the leg, and in the great toe more than the additional toes (Gulanick & Myers, 2014). Patients can have ongoing PLS with the sensations slowly diminishing over time (Ertl, 2016).
Up to 87% of amputees have phantom limb pain (PLP) (Melville, 2016). PLP is significant PLS, intensely uncomfortable and sensed as pain in the amputated part of the extremity (Gulanick & Myers, 2014). Patients describe PLP as burning, throbbing, cramping, twisting, and stabbing (Amputee Coalition, 2017; Ertl, 2016). Patients can experience PLP for brief or lengthy periods, with decreased duration and frequency of episodes expected during the initial 6 months after amputation (Amputee Coalition, 2017; Gulanick & Myers, 2014). The nurse must acknowledge PLP, and provide appropriate interventions and follow up (Virani et al., 2015).
The nurse also must perform an in-depth assessment to determine the type of pain to intervene appropriately. Effective pain management includes patient education regarding the types of pain experienced (Scottish Intercollegiate Guidelines Network [SIGN], 2013). Pain management plans for the patient following LEA include pharmacological and nonpharmacological methods (Gulanick & Myers, 2014; Knotkova, Cruciana, Tronnier, & Rasche, 2012; SIGN, 2013). For severe pain immediately after surgery if patient-appropriate, patient-controlled analgesia (PCA) may be ordered (Virani et al., 2015). As the PCA is withdrawn, combination medication regimes of opioids and nonsteroidal anti-inflammatory medications with an anticonvulsant (e.g., gabapentin [Neurontin®]) or an antidepressant are used to achieve improved pain management (Knotkova et al., 2012; SIGN, 2013). Numerous nonpharmacological modalities also can be used to manage pain. See Table 2 for invasive and noninvasive nonpharmacological modalities for pain management.
Impaired Skin Integrity and Risk for Infection
Wound management and infection prevention are critical nursing foci for the amputee, with consistent hand hygiene the first step toward achieving these goals (Ertl, 2016; Rossbach, 2017). The nurse must assess the surgical dressing for drainage and bleeding.
A drain can be placed during surgery to promote healing and prevent infection by removing excess drainage and blood from the surgical site. Frank bleeding at the surgical site must be reported immediately (Gulanick & Myers, 2014; Virani et al., 2015). Antibiotics are administered prophylactically, and daily dressing changes to the residual limb are performed using aseptic technique, with type of dressing determined by physician order (Ertl, 2016; Gulanick & Myers, 2014; Virani et al., 2015). Sutures or staples maintain closure at the operative site and remain in place approximately 2-3 weeks (Ertl, 2016). See Table 3 for types of dressings for the residual limb.
Elastic bandages must be applied with equal and consistent pressure to minimize pain and promote healing. To avoid complications from ischemia, the nurse must ensure the fit is not tight along any area of the stump (Virani et al., 2015). Rewrapping is required four to five times daily to sustain appropriate compression and ensure the bandage does not become too loose (Rossbach, 2017). An elastic compression sock (shrinker) is another option to reduce residual limb edema and can help shape the limb for possible prosthesis fitting (Rossbach, 2017; Virani et al., 2015). A shrinker, which can be used with or without elastic bindings, is pulled over the end of the residual limb for a snug fit with no gap; the elastic sock is pulled up evenly as far as possible on the limb (Rossbach, 2017).
Positioning and Mobility: Impaired Physical Mobility and Risk for Falls
The goal for LEA is optimal function of the affected limb, assisting the patient to regain independence (Ertl, 2016; Vetra et al., 2016). Below-the-knee amputation allows a lower demand for energy and oxygen, and can enhance the patient's speed of mobility (Ertl, 2016). General fatigue remains an issue, however, for any level of amputation related to the burden on the patient's nervous system (Vetra et al., 2016), and comorbidities can have a direct effect on the patient's success with mobility (Ertl, 2016).
Proper positioning of the residual limb after surgery is vital to prevent problems (Daniels & Nicoll, 2012). The limb should be elevated for 24 hours after amputation to enhance venous return and decrease edema (Daniels & Nicoll, 2012; Gulanick & Myers, 2014). After this period, continued elevation of the affected extremity increases the risk for contracture (e.g., hip flexion contracture after above-the-knee amputation) and should be avoided. The patient should not sit with the affected extremity dangling or in a dependent position to prevent edema (Virani et al., 2015). Education regarding positioning should include strategies for contracture prevention. For example, the patient should lay supine and extend the hip joints for defined periods; lay prone for 30 minutes several times daily and extend the affected extremity; and prevent external hip rotation by using the trochanter roll in bed. Range-of-motion exercises to unaffected extremities also should be included for joint mobility and strengthening (Gulanick & Myers, 2014). The nurse should promote and assist with hourly position changes (Virani et al., 2015).
Anxiety, Disturbed Body Image, and Ineffective Coping
Because many factors can influence the way a patient responds to loss of a limb, the nurse must make every effort to engage the patient in self-care as early as possible (Virani et al., 2015). Nutrition also is an important inclusion in patient education. Following LEA, the patient has specific protein and nutritional needs for wound healing. Far more calories are necessary due to the energy required for transfers and daily activities when using a prosthesis (Gulanick & Myers, 2014).
The range of psychological and emotional needs can be vast, and resource planning by the interprofessional team is imperative (Daniels & Nicoll, 2012). Patient education and goal setting must be realistic and individualized (Virani et al., 2015). One patient may embrace the learning and the challenges presented, while another patient may have notable barriers to acceptance and require more intensive support (Ertl, 2016; Gulanick & Myers, 2014; Vera, 2013). When the patient's grief for a lost limb is challenging and coping is ineffective, additional referrals for emotional needs must be made (Daniels & Nicoll, 2012; Vera, 2013). The social worker is a key participant in providing information about available support groups as well as additional local and extended resources (Daniels & Nicoll, 2012).
Discharge Planning
The amputee typically is moved to a rehabilitation facility after acute hospitalization. More recently, however, tele-rehabilitation has become available in some areas to assist the patient with rehabilitation in the home environment versus a rehabilitation facility (Vetra et al., 2016). Introducing additional resources is critical for ongoing support of the patient's rehabilitation needs and preparedness to re-enter community life (Daniels & Nicoll, 2012).
Conclusion
The nurse's role is to assist the patient and family members through numerous challenges presented with the loss of a limb. The healing process is physical and emotional, presenting ever-changing needs and priorities. Emphasis on individualizing patient care is crucial to diminish or avert potential problems during the postoperative period. The interprofessional team must provide comprehensive and consistent interventions to achieve optimal goals for the patient following this lifechanging event (Virani et al., 2015).
REFERENCES
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Melville, N.A. (2016). Brain stimulation effective for phantom limb pain. Retrieved from http://www.medscape.com/viewarticle/867946
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Scottish Intercollegiate Guidelines Network (SIGN). (2013). Management of chronic pain: A national clinical guideline. Retrieved from http://www.sign.ac.uk/pdf/SIGN136.pdf
Vera, M. (2013). 4 amputation nursing care plans. Retrieved from https://nurseslabs.com/4-amputation-nursing-care-plans/
Vetra, A., Lacis, K., Raipalis, G., Legzdina, E., & Logins, V. (2016). Screening of patients for first time prostheses after amputation of lower limbs. SHS Web of Conferences, 30. Retrieved from https:// www.shs-conferences.org/articles/shsconf/abs/2016/09/shsconf_ shw2016_00034/shsconf_shw2016_00034.html
Virani, A., Werunga, J., Ewashen, C., & Green, T (2015). Caring for patients with limb amputation. Nursing Standard, 30(6), 51-60
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