Understanding Amputation: Levels and Risk Factors

• Amputation involves removing a body part, typically a limb, and can be elective or due to trauma.
• Elective amputations often result from peripheral vascular disease, arteriosclerosis, congenital issues, chronic osteomyelitis, or tumors.
• Traumatic amputations are usually due to accidents.

Amputation Level

• Determined by tissue viability, aiming to preserve as much tissue as possible while removing infected/necrotic areas.
• Can involve upper or lower limbs, with upper limb amputations ranging from digits to the arm up to the elbow.

Risk Factors

• Trauma, including motor vehicle crashes, industrial accidents, and war injuries.
• Thermal injuries like frostbite, electrocution, and burns.
• Malignancy.
• Older adults are at higher risk due to peripheral vascular disease and diabetes, leading to decreased tissue perfusion and neuropathy.
• Peripheral vascular disease can cause ischemia and gangrene.
• Diabetes mellitus can result in peripheral neuropathy and vascular disease.
• Infection, especially osteomyelitis, increases amputation risk.
• Uncontrolled diabetes and smoking contribute to the risk.

Comorbidities

• Diabetes' microvascular effects can cause nerve damage and poor blood flow, with foot ulcers as an early sign.
• Maintaining normal blood sugar levels helps reduce diabetes-related complications and the risk of peripheral artery disease.
• Peripheral artery disease is a primary reason for amputation, reducing blood flow to the limb due to vessel narrowing or occlusion.

Health Promotion

• Diabetics should monitor and maintain blood glucose within the expected range.
• Use safety measures around heavy machinery and electrical/burn risks.
• Encourage smoking cessation, maintaining a healthy weight, and regular exercise.
• Good foot care and prompt medical attention for non-healing wounds are essential.

Perioperative Nursing Actions

• Safety concerns should be addressed as the client navigates their home environment and activities.
• Surgeons ensure adequate muscle covering over residual bone for proper prosthesis fitting, enabling safe movement.
• Avoid propping the residual limb on pillows to prevent contractures.

Management of Traumatic Amputation

• Activate EMS immediately.
• Apply direct pressure to prevent hemorrhage.
• Elevate the extremity above the heart to reduce blood loss.
• Wrap the severed extremity in sterile gauze or a clean cloth, seal in a plastic bag, and submerge in ice water (1 part ice, 3 parts water) for transport with the client.

Diagnostic Procedures

• Angiography visualizes peripheral vasculature and impaired circulation areas.
• Doppler laser and ultrasonography measure blood flow speed.
• Transcutaneous oxygen pressure (TcPO2) indicates blood flow through oxygen pressure.
• Ankle-brachial index measures systolic pressure differences.

Expected Findings

• Phantom pain is a pain sensation in the amputated limb, potentially hindering prosthesis training, which anti-epileptic and antidepressant prescriptions can alleviate
• Phantom limb pain is the sensation of pain in the amputated extremity, often related to severed nerve pathways.
• Phantom limb pain is common in clients with pre-amputation chronic limb pain.
• Phantom limb pain can start immediately post-surgery, lasting weeks or indefinitely, and is less frequent in traumatic amputations.
• Phantom limb pain is often described as deep, burning, cramping, shooting, or aching and is treated differently than incisional pain.

Phantom Limb Pain Treatments

• Calcitonin during the first week post-amputation.
• Beta blockers like propranolol can relieve continual, dull burning pain.
• Antiepileptics like gabapentin or pregabalin address sharp, stabbing, burning pain.
• Antispasmodics like baclofen and antidepressants can help.
• Alternative treatments includes massage, heat, TENS, ultrasound, biofeedback, acupuncture, relaxation therapy.
• Clients should push the residual limb down toward the bed on a soft pillow to reduce phantom pain and prepare for a prosthesis.

Other Findings

• Phantom limb pain can lead to depression and altered self-esteem, mobility concerns, employment worries, and being a burden to family.
• Assess differences in temperature of extremities and altered skin color (pallor, cyanosis, gangrene).
• Decreased perfusion can lead to pain, altered pulses, temperature differences, color changes, infection, open wounds, and lack of sensation.

Nursing Actions

• Compare capillary refill between extremities, noting that it is difficult to monitor on older adults due to thickened and opaque nails.
• Observe extremities for edema, necrosis, and hair distribution, which indicates inadequate circulation.

Nursing Care

• Prevent postoperative complications like hypovolemia, pain, and infection.
• Monitor the surgical site for bleeding and vital signs frequently.
• Assess tissue perfusion of the residual limb end and palpate for warmth, which indicates infection.
• Compare the pulse proximal to the incision with the other extremity's pulse.
• Monitor for infection and non-healing, which can lead to osteomyelitis
• If an open amputation was performed, administer antibiotics and change dressings as prescribed, recording drainage characteristics.
• Differentiate between incisional and phantom limb pain, treating incisional pain with analgesics.

Addressing Limb Shrinkage

• The residual limb must be shaped and shrunk for prosthetic training.
• Wrap the residual limb with elastic bandages (figure-eight) to prevent restricted blood flow and decrease edema.
• Use a shrinker sock or an air splint to protect and shape the limb, allowing wound inspection.

Client Education

• Care for and wrap the residual limb, performing limb-strengthening exercises.
• Learn to properly apply and care for the prosthesis.
• Learn to safely transfer and use mobility devices and adaptive aids.
• Understand how to manage phantom limb pain.

Client Perception and Feelings

• Allow the client and family to grieve for the loss, with feelings including depression, anger, withdrawal, and grief.
• Assess psychosocial well-being, feelings of altered self-concept and self-esteem, and motivation for rehabilitation.
• Facilitate a supportive environment and refer the client to religious/spiritual advisers, social workers, or counselors.
• Rehabilitation should include adaptation and integration.

Flexion Contractures

• Flexion contractures are more likely to happen with the hip or knee following amputation due to improper positioning.
• Prevention: ROM exercises and proper positioning immediately after surgery.
• Have the client lie prone for 20 to 30 minutes several times a day to prevent hip flexion contractures and discourage prolonged sitting.
• Practice exercises to prevent contractures and stand with good posture and the residual limb in extension.

Infection Risk

• Clients with diabetes, who are older, or have PVD have an increased Risk of infection.
• Monitor for manifestations of infection (redness, edema, heat, purulent drainage, increased pain, fever, chills) and report to provider.
• Provide good skin hygiene and maintain aseptic technique during dressing changes and assist with antibiotics as ordered.

Delayed Wound Healing Risk

• Clients with diabetes, who are older, or have PVD have an increased risk of delayed wound healing.
• Notify provider of manifestations of delayed wound healing and monitor dressing and output from wound drain.

Pre-Op Education

• Discuss the amputation procedure, encourage meeting with another amputee, advise smoking cessation, and control diseases that comprise perfusion.

Post-Op Pain Relief

• Certain anti-epileptic prescriptions (gabapentin) and anti-depressants alleviate phantom pain, changing signals in the brain for those with nerve damage.
• Non-pharmacologic interventions includes repositioning and desensitization of the residual limb.
• Desensitization techniques are is done through massaging, tapping, and progressive load bearing on the site.

Therapeutic Procedures

• Closed amputation: A skin flap is sutured over the residual limb end, closing the site.
• Open amputation: Used when there is an active infection, skin flap is not sutured, allowing for drainage and is closed at a later date.
• Prosthesis: After the incision has healed and edema has subsided, usually 7 to 10 weeks post-surgery, the client may be fitted; the initial device is temporary due to limb changes for about 18 months.
• Physical therapy facilitates progressive load bearing, ROM, ambulation when possible, and desensitization through massage, tapping, and vibration.
• Support groups are valuable.
• Early rehab is important.