Upper Extremity Amputation

• Amputation is described by its location relative to the extremity and designated joint.
• Disarticulation is an amputation performed through a joint.
• A higher amputation level requires more effort to use a prosthesis.
• Adequate blood flow is necessary for healing, and determines the level of amputation.
• Body image changes post-amputation require attention during peri-operative and rehab phases.

Pathophysiology

• Amputation involves removing all or part of a limb due to traumatic injury or surgery.
• Peripheral vascular disease is the most common cause of limb amputation, stemming from smoking, diabetes, or atherosclerosis.
• Tissue viability determines the amputation level; the goal is to preserve as much tissue as possible while removing infected or necrotic areas.
• Upper or lower limbs may be amputated.
• Partial upper limb amputations may include partial or full digits, the hand up to the wrists, or up to the elbow.

Upper Extremity Amputation

• Complete upper limb amputation involves removing the entire arm from the shoulder.
• Upper extremity amputations include those above and below the elbow, wrist, shoulder disarticulations, and finger amputations.

Lower Extremity Amputation

• Partial lower limb amputations can include partial or full toes, partial foot, the foot up to the ankle and the leg below or above the knee.
• Lower extremity amputations include above and below the knee amputations (removal of foot with ankle saved), mid-foot, and toe amputations.
• Losing even the big toe can significantly affect balance, gait, and push-off ability.
• Preserving the knee in a below-the-knee amputation improves function compared to an above-the-knee amputation.
• Amputation can result in decreased or absent limb perfusion.

Disease Prevention

• Diabetic clients should monitor and maintain glucose within the expected range.
• Use safety measures around heavy machinery or areas with electrocution/burn risks.
• Encouraging clients to quit or not start smoking, maintain a healthy weight and exercise regularly
• Clients should maintain good foot care and seek early medical attention for non-healing wounds.

Risk Factors

• Traumatic injuries such as MVAs, industrial accidents, and war-related injuries.
• Thermal injuries like frostbite, electrocutions, and burns.
• Risk factors include, malignancy, uncontrolled diabetes, and smoking
• Older adults face a higher risk of peripheral vascular disease and diabetes, which leads to decreased tissue perfusion and peripheral neuropathy, increasing the risk of lower extremity amputation.
• Infection (osteomyelitis) can increase the risk for amputation.

Comorbidities

• Diabetes can cause nerve damage and poor blood flow in the extremities due to its microvascular effects.
• The first sign of concern is developing a foot ulcer
• Maintaining blood sugar levels within normal ranges reduces diabetes-associated complications.
• Clients with diabetes are at higher risk of developing peripheral artery disease, increasing the chance of limb amputation.

Peripheral Artery Disease

• Peripheral artery disease is the primary reason for amputation and occurs due to narrowing or occlusion of blood vessels, reducing limb blood flow.
• Vascular disease is a common cause.

Expected Findings

• Phantom pain: Pain sensation in the amputated limb can cause problems with prosthesis training.
• Medications like anti-epileptics and antidepressants can alleviate phantom pain.
• Phantom limb pain: The sensation of pain in the location of the extremity following the amputation.
• Phantom limb pain is related to severed nerve pathways and is a frequent complication in clients who have experienced chronic limb pain before the amputation.
• Phantom limb pain can be experienced immediately after surgery, up to several weeks, or indefinitely.
• It occurs less frequently after a traumatic amputation.
• Phantom limb pain is often described as deep and burning, cramping, shooting, aching, and is treated differently from incisional pain.
• Calcitonin administration during the first week post-amputation can decrease phantom limb pain.
• Beta-blockers (propranolol) can relieve the continual dull, burning sensation associated with the amputated limb
• Anti-epileptics (gabapentin or pregabalin) can relieve sharp, stabbing, burning phantom limb pain.
• Some clients report relief from antispasmodics (baclofen) and antidepressants.
• Recognizing and managing the pain is an important part of nursing care.
• Alternative treatments for phantom limb pain include non-pharmacological methods like massage, heat, transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, biofeedback, acupuncture, and relaxation therapy.
• Teach the client how to push the residual limb down toward the bed while supported on a soft pillow to help reduce phantom limb pain and prepare the limb for a prosthesis.
• Amputation can lead to depression and alterations in self-esteem.
• Clients may worry about their ability to be mobile, continue employment, or be a burden to family members.
• Decrease ​​or absence of perfusion to the limb
• History of injury ​or disease process precipitating amputation
• Altered peripheral pulse compared to the clients expected skin tone (can need to use Doppler)
• Differences in temperature of extremities (note the level of leg at which temperature becomes cool)
• Altered color of extremities (pallor, cyanosis, gangrenous skin),presence of infection and open wounds, lack of sensation in the affected extremity
• Signs/symptoms include pale or necrotic limb, absent pulse, and the area may not ​​blanch
• Presence of foul odor if the cause is infection or gangrene

Diagnostic Procedures

• Angiography: allows visualization of peripheral vasculature and areas of impaired circulation
• Doppler laser and ultrasonography studies: measures speed of blood flow in an extremity
• Doppler studies confirm the lack of perfusion to the affected limb and will determine the lack of blood flow to the limb
• Invasive angiograms are associated with risks and complications
• Transcutaneous oxygen pressure (TcPO2): measures oxygen pressures in an extremity to indicate blood flow in the extremity, which is a reliable indicator for healing.
• Ankle-brachial index: measures the difference between ankle and brachial systolic pressures to identify arterial disease by comparing systolic blood pressure in ankle and arm.
• A higher or lower result in the arm indicates stiffening or blockage of the arteries in the leg

Safety Considerations

• Address safety concerns as the client navigates their home environment and activities.
• During surgery, the surgeon will ensure adequate muscle covering over any residual bone to provide for proper fitting of the prosthesis.
• A properly fitting prosthesis allows for safe movement
• Avoid propping the residual limb on pillows, as this can lead to contracture.

Nursing Care

• Monitor capillary refill by comparing the extremities; however, this can be difficult in older adults with thickened and opaque nails.
• Observe for edema, necrosis, and lack of hair distribution in the extremity due to inadequate peripheral circulation
• Main pain, recognize the presence of pain when it occurs
• Prevent surgical site infection
• Prevent post-op complications (hypovolemia, pain, infection)
• Assess the surgical site for bleeding. Monitor vital signs frequently.
• Monitor tissue perfusion of the end of the residual limb.
• Palpate the residual limb for warmth; heat can indicate infection.
• Compare pulse most proximal to incision with pulse in other extremities.
• Monitor for signs/symptoms of infection and non-healing of the incision, which can lead to osteomyelitis.
• Amputation may not heal if performed below the level of adequate tissue perfusion
• Position the affected extremity in a dependent position to promote blood flow/oxygenation.
• Administer antibiotics and change dressings as prescribed if open amputation was performed
• Record characteristics of drainage (amount, color, odor)
• After implementation, evaluate and reassess for effectives of the insertion. Goals and intervention should be reevaluated if the client has swelling in the residual limb that is not relieved with compression.
• Reevaluation should occur if the client develops a contracture in the residual limb or if their phantom pain is unrelieved with interventions.

Therapeutic Procedures

• Prosthesis: Once the surgical incision has healed, and the edema has subsided, the client may be fitted for a prosthetic device, usually occurring about 7 to 10 weeks after surgery.
• The initial prosthetic device is a temporary device as the residual limb will undergo changes in size and shape for about 18 months after surgery.
• After this time, the client will be fitted for a permanent prosthesis
• Physical therapy (being progressive load bearing on the limb)
• Maintain range of motion of the residual limb; ROM will help to prevent contracture formation and prepare the limb for prosthesis.
• Ambulate when possible
• When able, the client should be encouraged to desensitize the residual limb, done through massage, tapping, vibration on the residual limb
• Improving or maintaining overall strength and general condition and managing the edema of the residual limb
• Early rehabilitation is important after an amputation to improve recovery; rehab should begin BEFORE amputation OR as soon as possible after surgery.
• Closed amputation: this is the most common technique used. A skin flap is sutured over the end of the residual limb, closing the site
• Open amputation: This technique is used when an active infection is present.
• A skin flap is NOT sutured over the end of the residual limb, allowing for drainage of infection. The skin flap is closed at a later date

Medication

• Medications such as certain anti-epileptic (Gabapentin) and anti-depressants can alleviate some of phantom pain
• Gabapentin: changes signals in the brain for those with nerve damage
• Non-pharmacologic interventions
• Repositioning and desensitization of the residual limb

Desensitization Techniques

• Desensitization techniques: massaging, tapping on the amputation site, progressive load bearing on the limb

Client Education

• Allow for the client and family to grieve for the loss of the body part and change in body image
• Feelings can include depression, anger, withdrawal, and grief
• Rehabilitation should include adaptation to a new body image and integration of prosthetic and adaptive devices into self-image.
• Maintain mobility in the residual limb
• Maintain a compressing dressing on the residual limb and manage pain
• Include instructions on how to bandage the amputation site
• AVOID the use of body oil or lotions as it can interface with the fitting of a prosthesis
• Massaging the residual limb, assessing the amputation site daily including the use of a mirror to see all areas of the site
• Client should observe for the presence of a rash, blisters, abrasions, swelling, drainage
• Verbalize your feelings and attend support groups

Pre-Op

• Education about the amputation
• Meeting with another amputee can be helpful
• Smoking cessation is advised
• Control of diseases that compromise perfusion

Post-Op

• In the immediate period after amputation, the client will have a pressure dressing on the amputation site and should be observed for bleeding at the site
• The residual limb should be assessed regularly for circulation: color, temperature, pulse, blanching.
• Circulation is compromised if the residual limb is pale, cool, and has an absence of a pulse or blanching.

Interprofessional Care

• Physical therapist: will train the client in the application and care of the prosthesis and mobility aids
• Surgeon
• Prothetist: will fit the client with a prosthesis after the wound is healed, and the residual limb has shrunk.
• Social workers: will assist the client who has financial issues and can refer the client to resources and a support group or organization for people who have had amputations
• Counselors
• Psychiatrists
• Psychologists: can be needed to help with adjustment to the loss of the extremity

Complications

• After amputation, be aware of cues, including phantom pain
• Symptoms of infection: redness, drainage, and warmth
• Observe the residual limb for edema and the presence of contracture
• Flexion contractures: are more likely with the hip or knee joint following amputation due to improper positioning
• Prevention includes ROM exercises and proper positioning immediately after surgery
• To prevent hip or knee flexion contracture, some providers do not advocate elevating the residual limb on a pillow.
• However, other provides allow elevation for the first 24 hours to reduce swelling and discomfort

Nursing Actions for Flexion Contractures

• Have the client lie prone for 20 to 30 minutes several times a day to help prevent hip flexion contractures.
• Discourage prolonged sitting

Client Education About Flexion Contractures

• Practice exercises that will prevent contractures
• Stand using good posture with the residual limb in extension; this will also aid in balance