2-29-08 Mrs.

Batton

Amputation
Causes of

• Trauma (crushing injury where it can’t be repaired, burns, frostbite)

• Congenital deformities

• Chronic infection (osteomyelitis)

• Malignant tumors

o Usually with younger people

• Peripheral vascular disease (diabetes, cardiovascular disease)

o Have such bad circulation they develop stasis ulcers, no blood supply
to extremities, causes necrosis

Levels of Amputation

• Performed at most distal point that will heal

• Must have adequate circulation

• Needs to be best level to promote use of prosthesis

• Staged amputation

o After a big crushing trauma, quick amputation to be sure that part of

the body doesn’t cause infection, with the intention of taking you back
to surgery and do another amputation after you’ve stabilized

• Will try to amputate below a joint because it makes mobility easier

Diagnostic test to determine circulation

• Doppler flowmetry

• Segmental blood pressure determinations

• Transcutaneous partial pressure of oxygen

Complications

• Hemorrhage

o Monitor vital signs

 o Be prepared to intervene

• Infection

o At increased risk for septicemia

• Skin breakdown

o Prosthesis may cause breakdown

• Phantom limb pain

o Due to cutting through nerves

• Joint contracture – due to positioning, important to do ROM exercises, start

early post-op

Pre-op

• Assessment of extremity

o Neurovascular and function-compared to unaffected extremity

• History and Physical

• Assessment of psychosocial needs

o Important to be understanding of the patient, might be angry, upset,

etc.

• Teach about what to expect post-op

• Referrals to support group when needed

o Home health, social work, others who have already had the surgery to
come talk to them, etc.

Post-op

• Assess for hemorrhage

o Tourniquet at bedside

o Assess dressing

o Assess vital signs and labs

o Assess drains

o Assure compression dressing is intact

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 Keeps muscle and soft tissue firm and tight

 Begins to form a residual limb that is packed and intact for

prosthetic device

 Prevents edema

Provide for safety

• Side rails, call light, bed low position, leave low light on at night

• Check on client frequently and assist as needed

• Common for patient to forget about amputation and get up in the middle of
the night and try to go to the bathroom

• Balance is a big issue as well

Relieving Pain

• Residual limb/ incision pain

o Usually sever and has minimal if any relieve by non pharmacological

measures

o Still can reposition, distract, etc.

o If they continue to have unrelieved pain, think INFECTION

• Phantom Pain

o Real pain might not start for a week or two after amputation

o Usually must be treated with medications of TENS unit for actual relief

 It stimulates same nerves that gives impulses of phantom pain

o Cause not well understood

Infection Control

• Hand washing

• Aseptic technique

• Give antibiotics
 • Assess vital signs

• Provide adequate diet

• Control glucose levels

Skin breakdown prevention

• Repositioning and turning

• Keep dressing dry

• Assure that dressing is not causing irritation

• Adequate nutrition and hydration

Promote mobility/ independence

• Measures to decrease edema and form the residual limb to prepare

prosthesis

• Elevate residual limb for the first 24 hours post op then do not elevate

• Position prone 15-30 minutes twice a day if lower extremity amputation

• ROM, maintain good body alignment

• When incision healed press extremity against increasingly firm surface

• Assure client has mobility needs met at home prior to discharge

Provide psychosocial support

• Establish trusting relationship

• Encourage patient to look, touch and care for residual limb

• Create an accepting and supportive atmosphere

• Assist with dealing with immediate needs and realistic rehab and functional
goals

Nursing implications

• Prevent further loss of circulationto extremity

• Promote comfort

• Promote optimum level of mobility

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Stump wound care

• Discourage semi-fowlers position inc lient with above the knee amputation o
prevent contractures of the hip

Stump care after wound has healed

• Assess for skin breakdown

• Wash, rinse and dry stump daily

Client goals

• Relief of pain

• Absence of altered sensory perception

• Wound healing image

• Resolution of grieving process

• Independence in ADL’s

• Restoration of mobility

• Absence in complications

• Acceptance of body

Bone Neoplasms
Bone Tumors

• Benign

o Usually of bone or soft tissue directly around the bone

o Slow growing

o Well circumscribed

o May have few symptoms

o Not usually a cause of death

o Common Ones:
  Osteochondroma

• Most common benign bone tumor

 Endochondroma

• Effects hyaline cartilage

• Usually comes in for pathological fractures

 Bone cyst

• Lesions at the bone that get bigger and hurt badly

 Osteoid osteoma

• Very painful, usually seen in children and young adults

 Rhabdomyoma

 Fibroma

 Osteoclastoma (giant cell tumors)

• Can grow and invade local tissue around the bone

• If you leave them alone, they may become malignant and

metastasize

• Malignant

o More common than primary tumors

• Primary

o Rare

o Arise from connective and supportive tissue cells or bone marrow

o Metastasis to lungs is common

o Common types

 Osteogenic sarcoma (Osteoscarcoma)

• Mostly in children, adolescents, and young adults

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• One of the most fatal kinds

• Often seen in males 10-25

• Often metastasized to the lungs before treatment is

sought

• Treatment is usually amputation and chemotherapy, if it

has not gotten to the lungs yet

 Chondroscarcoma

• Hyaline cartilage (malignant)

• 2nd most common of primary malignant bone tumors in

adults

• Slow growing

• Treated with large block excision or amputation

• May recur

 Ewings Scarcoma

• Very common in children and adolescents

• 2nd most common malignant BT in children and

adolescents

• Usually between ages 4-25

• Treated with radiation and chemo

• Amputation not usually recommended but may be

considered if radiation causes problems in extremity

 Fibroscarcoma

 Rhabdomyosarcoma

• Solid malignant tumor seen in children less than 5

• Head and neck common sites

• S/S depends on location of tumor

• Highly malignant
 • Particularly bad because it effects striated muscle tissue,
seen in face

• Very deadly and devastating cancer

• Treatment-complete removal of primary tumor, radiation,

and chemotherapy

• Long term prognosis is very poor

• Metastatic

o Cancer originated somewhere else and metastasized to the bone

Clinical Manifestations

• Pain

• Obvious bone growth

• Disability

• Pathologic fractures

• Joint stiffness

• Neurologic deficits (with spinal metastasis)

Diagnostic tests

• CT

• Bone Scans

• Myelograms

• Arteriography

• MRI

• Biopsy

• Blood and urine studies

• Chest X-ray

Nursing Care

• If surgery-then usually pre/post op care

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• Pain relief

• Prevent pathologic fractures

• Skin care

• Nutrition

• Infection prevention

• Hypercalcemia recognition and treatment

• Promote coping skills

• Promote self esteem

• Teach