Amputation: reasons, level, and nursing support

• Amputation involves the removal of a limb or part of a limb, due to vascular disease (e.g., peripheral artery disease, diabetes), trauma, infection, tumor, or congenital defects.
• Levels of amputation depend on tissue damage, blood supply, healing potential, and functional needs.
• Common amputation levels are toe, transmetatarsal, Syme's (ankle disarticulation), below-knee (transtibial), and above-knee (transfemoral).
• Psychological and emotional support for patients undergoing amputation is crucial.
• Patients may experience grief, body image issues, anxiety, and depression.
• Nursing interventions should focus on therapeutic communication, active listening, and coping mechanisms.
• Phantom limb pain is pain felt in the amputated limb, and can be chronic and debilitating.
• Phantom limb pain treatment includes analgesics, antidepressants, anticonvulsants, nerve blocks, TENS, massage, and mirror therapy.
• Phantom limb sensation is the feeling that the amputated limb is still present, without pain and typically diminishes over time.
• Wound care after amputation is essential for preventing infection and promoting healing, with nursing interventions including wound assessment for infection signs (redness, swelling, drainage, odor), sterile dressing changes, and monitoring for dehiscence or delayed healing.
• Compression dressings or elastic bandages, applied in a figure-eight pattern with more distal pressure, reduce edema, promote shaping, and protect the incision.
• Proper positioning prevents contractures, especially hip and knee flexion contractures in lower extremity amputations, with interventions including prone positioning several times a day and avoiding prolonged sitting.
• Strengthening exercises such as upper body strengthening, core strengthening, and exercises for the remaining limb are important to prepare the patient for prosthetic use and mobility.

Preoperative Care

• Assess overall health, including cardiovascular, respiratory, and renal function, and identify comorbidities.
• Assess understanding of the procedure, outcomes, and rehab, provide information, and address concerns.
• Evaluate nutritional status, provide dietary counseling, and ensure adequate protein intake.

Postoperative Care: Pain Management

• Administer pain medications as prescribed and assess their effectiveness with a multimodal approach, including opioids, non-opioid analgesics, and adjuvant medications.
• Assess pain characteristics regularly using a pain scale and encourage prompt reporting.
• Implement non-pharmacological pain management techniques, such as positioning, massage, heat or cold therapy, and relaxation exercises.

Postoperative Care: Wound Care

• Monitor the wound for signs of infection (redness, swelling, drainage, odor) and report any abnormalities. Change dressings as prescribed, using sterile technique.
• Ensure adequate circulation to the residual limb by assessing skin color, temperature, and capillary refill. Report any signs of compromised circulation.
• Handle the residual limb gently to avoid trauma, using aseptic technique when changing dressings or providing wound care.

Postoperative Care: Prevention of Complications

• Monitor for infection signs (fever, chills, elevated WBC count) and administer antibiotics as prescribed.
• Assess respiratory status and encourage deep breathing and coughing exercises to prevent pneumonia.
• Monitor fluid balance and electrolyte levels, and correct any imbalances promptly.
• Evaluate nutritional status and provide dietary counseling, ensuring adequate protein intake to promote wound healing.

Rehabilitation

• Physical therapy helps improve strength, balance, coordination, and mobility while occupational therapy focuses on adapting activities of daily living to promote independence.
• Assistive devices (walkers, crutches, or wheelchairs) may be needed to enhance mobility/independence, and education on proper use and safety precautions should be provided.
• Prosthetic fitting/training are essential for restoring function and mobility, which involve working with a prosthetist to ensure proper fit, alignment, and function.

Diet

• A balanced diet rich in protein, vitamins, and minerals is essential for promoting wound healing, maintaining muscle mass, and supporting overall health.
• Encourage adequate calorie consumption to meet energy needs during healing.
• Protein-rich foods (meat, poultry, fish, eggs, dairy products, beans, and lentils) are important.
• Vitamin C, zinc, and other micronutrients play a crucial role in wound healing and immune function.
• Drink plenty of fluids to stay hydrated and prevent constipation.

Psychological Considerations

• Assess emotional state and coping mechanisms, provide emotional support and encouragement.
• Encourage expressing feelings/concerns and provide a safe/non-judgmental environment.
• Educate about community resources and support groups, encourage connecting with others.
• Address body image, self-esteem, and sexuality issues, provide counseling and support as needed.

Stump Care

• Wash the stump daily with mild soap and water, dry thoroughly, and inspect for skin breakdown signs.
• Change the stump sock daily, wash in mild soap, rinse thoroughly, and dry.
• Consult with a prosthetist regarding any fit issues or discomfort.
• Report any open areas or skin breakdown to the provider immediately.

Prevention

• Control underlying diseases such as diabetes and peripheral vascular disease.
• Manage pain effectively to improve function and quality of life.
• Promote smoking cessation.
• Teach meticulous foot care to patients with diabetes

Key Nursing Interventions

• Pain management: includes administering analgesics, assessing pain levels, and implementing non-pharmacologic interventions.
• Wound care: includes assessing wound healing, changing dressings, and monitoring for infection.
• Mobility: includes assisting with ambulation, transfers, and range of motion exercises.
• Emotional support: includes providing counseling, active listening, and resources for coping.
• Patient education: includes teaching stump care, prosthesis use, exercise programs, and lifestyle modifications.

Common Complications

• Infection: requires monitoring for signs of infection, administering antibiotics, and maintaining sterile technique.
• Skin breakdown: requires inspecting skin regularly, providing pressure relief, and ensuring proper stump hygiene.
• Phantom limb pain: involves administering medications, implementing alternative therapies, and providing emotional support.
• Contractures: involves encouraging range of motion exercises, proper positioning, and splinting.

Discharge Instructions

• Include medication regimen and pain management strategies.
• Wound care and stump hygiene techniques.
• Exercise program and mobility plan.
• Prosthesis care and wearing schedule.
• Follow-up appointments with healthcare providers.
• Community resources and support groups.
• Signs and symptoms to report to the healthcare provider.

Amputation involves limb removal due to vascular issues, trauma or infection. Levels are determined by damage extent and healing potential. Nursing care focuses on emotional support and managing phantom limb pain.