Traumatic amputation is the loss of a body part -- usually a finger, toe, arm, or leg -- that occurs as the

result of an accident or injury.

Considerations
If an accident or trauma results in complete amputation (the body part is totally severed), the part
sometimes can be reattached, especially when proper care is taken of the severed part and stump.
In a partial amputation, some soft-tissue connection remains. Depending on the severity of the injury, the
partially severed extremity may or may not be able to be reattached.
There are various complications associated with amputation of a body part. The most important of these
arebleeding, shock, and infection. See also: Wounds
The long-term outcome for amputees has improved due to better understanding of the management of
traumatic amputation, early emergency and critical care management, new surgical techniques, early
rehabilitation, and new prosthetic designs. New limb replantation techniques have been moderately
successful, but incomplete nerve regeneration remains a major limiting factor.
Often, the patient will have a better outcome from having a well-fitting, functional prosthesis than a
nonfunctional replanted limb.

Causes
Traumatic amputations usually result directly from factory, farm, or power tool accidents or from motor
vehicle accidents. Natural disasters, war, and terrorist attacks can also cause traumatic amputations.

Symptoms

A body part that has been completely or partially cut off

Bleeding (may be minimal or severe, depending on the location and nature of the injury)

Pain (the degree of pain is not always related to the severity of the injury or the amount of
bleeding)

Crushed body tissue (badly mangled, but still partially attached by muscle, bone, tendon, or skin)

Assessment
Before surgery, the nurse must evaluate the neurovascular and functional status of the

extremity through history and physical assessment. If the patient has experienced a
traumatic amputation, the nurse assesses the function and condition of the residual limb. The
nurse also assesses the circulatory status and function of the unaffected extremity. If
infection or gangrene develops, the patient may have associated enlarged lymph nodes,
fever, and purulent drainage A culture is taken to determine the appropriate antibiotic
therapy.
The nurse evaluates the patients nutritional status and creates a plan for nutritional care, if
indicated. For wound healing, a balanced diet with adequate protein and vitamins is
essential.
Any concurrent health problems (eg, dehydration, anemia, cardiac insufficiency, chronic
respiratory problems, diabetes mellitus) need to be identified and treated so that the patient
is in the best possible condition to withstand the trauma of surgery. The use of
corticosteroids, anticoagulants, vasoconstrictors, or vasodilators may influence management
and wound healing.
The nurse assesses the patients psychological status. Determination of the patients
emotional reaction to amputation is essential for nursing care. Grief response to a permanent
alteration in body image is normal. An adequate support system and professional counseling

can help the patient cope in the aftermath of amputation surgery.

Diagnosis
NURSING DIAGNOSES
Based on the assessment data, the patients major nursing diagnoses may
include the following:
Acute pain related to amputation
Risk for disturbed sensory perception: phantom limb pain related to amputation
Impaired skin integrity related to surgical amputation
Disturbed body image related to amputation of body part
Ineffective coping, related to failure to accept loss of body part
Risk for anticipatory and/or dysfunctional grieving related to loss of body part
Self-care deficit: feeding, bathing/hygiene, dressing/grooming, or toileting,
related to loss of extremity
Impaired physical mobility related to loss of extremity
COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS
Based on the assessment data, potential complications that may develop include
the following:
Postoperative hemorrhage
Infection
Skin breakdown
Planning and Goals
The major goals of the patient may include relief of pain, absence of altered
sensory perceptions, wound healing, acceptance of altered body image,
resolution of the grieving process, independence in self-care, restoration of

physical mobility, and absence of complications.

Nursing Interventions
RELIEVING PAIN
Surgical pain can be effectively controlled with opioid analgesics,
nonpharmaceutical interventions, or evacuation of the hematoma or
accumulated fluid. Pain may be incisional or may be caused by inflammation,
infection, pressure on a bony prominence, or hematoma. Muscle spasms may add
to the patients discomfort. Changing the patients position or placing a light
sandbag on the residual limb to counteract the muscle spasm may improve the
patients level of comfort. Evaluation of the patients pain and responses to
interventions is an important part of the nurses role in pain management. The
pain may be an expression of grief and alteration of body image.
MINIMIZING ALTERED SENSORY PERCEPTIONS
Amputees may experience phantom limb pain soon after surgery or 2 to 3
months after amputation. It occurs more frequently may in above-knee
amputations. The patient describes pain or unusual sensations, such as
numbness, tingling, or muscle cramps, as well as a feeling that the extremity is
present, crushed, cramped or twisted in an abnormal position. When a patient
describes phantom pains or sensations, the nurse acknowledges these feelings
and helps the patient modify these perceptions.
PROMOTING WOUND HEALING
The residual limb must be handled gently. Whenever the dressing is changed,
aseptic technique is required to prevent wound infection and possible
osteomyelitis
ENHANCING BODY IMAGE
Amputation is a reconstructive procedure that alters the patients body image.
The nurse who has established a trusting relationship with the patient is better
able to communicate acceptance of the patient who has experienced an
amputation. The nurse encourages the patient to look at, feel, and then care for
the residual limb It is important to identify the patients strength and resources to
facilitate rehabilitation. The nurse assists the patient to regain the previous level
of independent functioning. The patient who is accepted as a whole person is
more readily able to resume responsibility for self-care; self-concept improves,
and body-image changes are accepted. Even with highly motivated patients, this
process may take months.
HELPING THE PATIENT TO ACHIEVE PHYSICAL MOBILITY
Positioning assists in preventing the development of hip or knee joint contracture
in the patient with a lower extremity amputation. Abduction, external rotation,
and flexion of the lower extremity are avoided. Depending on the surgeons
preference, the residual limb may be placed in an extended position or elevated
for a brief period after surgery. The foot of the bed is raised to elevate the

residual limb.
PROMOTING HOME AND COMMUNITY-BASED CARE
Teaching the Patient to Manage Self-Care
Before discharge to the home or to a rehabilitation facility, the nurse encourages
the patient and family to become active participants in care. They participate, as
appropriate, in skin care and residual limb care and in the management of the
prosthesis The patient receives ongoing instructions and practice sessions in
learning how to transfer and how to use mobility aids and other assistive devices
safely.
Continuing Care in the Home and Community
After the patient has achieved physiologic homeostasis and has demonstrated
achievement of major health care goals, rehabilitation continues either in a
rehabilitation facility or at home Continued support and supervision by the home
care nurse are essential.
Before the patients discharge to the home, the nurse should assess the home
environment. Modifications are made to ensure the patients continuing care,
safety, and mobility. An overnight or weekend experience at home may be tried
to identify problems that were not identified on the assessment visit. Physical
therapy and occupational therapy may continue in the home or on an outpatient
basis. Transportation to continuing health care appointments must be arranged.
The social service department of the hospital or the community agency
managing continued health care may be of great assistance in securing personal
assistance and transportation services.
During follow-up health visits, the nurse evaluates the patients physical and
psychosocial adjustment. Periodic preventive health assessments are necessary.
Frequently, an elderly spouse is unable to provide the assistance required, and
additional help at home is needed. Modifications in the plan of care are made on
the basis of such findings. Often, the patient and family find involvement in an
amputee support group to be of value; here, they are able to share problems,
solutions, and resources. Talking with those who have successfully dealt with a
similar problem may help the patient develop a satisfactory solution.
Because patients and their family members and health care providers tend to
focus on the most obvious needs and issues, the nurse reminds the patient and
family about the importance of continuing health promotion and screening
practices, such as regular physical examinations and diagnostic screening tests.
Those patients who have not been involved in these practices in the past are
instructed in their importance and are referred to appropriate health care
providers.
Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:

1. Experiences absence of pain

a. Appears relaxed
b. Verbalizes comfort
c. Uses measures to increase comfort
2. Experiences absence of phantom limb pain
a. Reports diminished phantom sensations
b. Uses distraction techniques
c. Performs stump desensitization massage
3. Achieves wound healing
a. Controls residual limb edema
b. Achieves healed, nontender, nonadherent scar
c. Demonstrates residual limb care
4. Demonstrates improved body image and effective coping
a. Acknowledges change in body image
b. Participates in self-care activities
c. Demonstrates increasing independence
5. Exhibits resolution of grieving
a. Expresses grief
b. Works through feelings with family and friends
c. Focuses on future functioning
d. Participates in support group
6. Achieves independent self-care
a. Asks for assistance when needed
b. Uses aids and assistive devices to facilitate self-care
c. Verbalizes satisfaction with abilities to perform ADLs
7. Achieves maximum independent mobility
a. Avoids positions contributing to contracture development
b. Demonstrates full active ROM
c. Maintains balance when sitting and transferring
d. Increases strength and endurance
8. Exhibits absence of complications of hemorrhage, infection, skin breakdown
a. Does not experience excessive bleeding
b. Maintains normal blood values
c. Is free of local or systemic signs of infection
d. Repositions self frequently

Nursing Priorities
1.

Support psychological and physiological adjustment.

2.

Alleviate pain.

3.

Prevent complications.

4.

Promote mobility/functional abilities.

5.

Provide information about surgical procedure/prognosis and treatment needs.

Discharge Goals
1.

Dealing with current situation realistically.

2.

Pain relieved/controlled.

3.

Complications prevented/minimized.

4.

Mobility/function regained or compensated for.

5.

Surgical procedure, prognosis, and therapeutic regimen understood.

6.

Plan in place to meet needs after discharge.

Nursing Care Plans

Impaired Physical Mobility
Related to:

Loss of a limb (particularly a lower extremity); pain/discomfort; perceptual impairment

(altered sense of

balance)

Possibly evidenced by

Reluctance to attempt movement

Impaired coordination; decreased muscle strength, control, and mass

Desired Outcomes:

Verbalize understanding of individual situation, treatment regimen, and safety

measures.

Maintain position of function as evidenced by absence of contractures.

Demonstrate techniques/behaviors that enable resumption of activities.

Display willingness to participate in activities.

Nursing Interventions

Rationale

Provide stump care on a routine basis, Provides opportunity to evaluate healing and
e.g., inspect area, cleanse and dry
thoroughly, and rewrap stump with

note complications (unless covered by immediate

prosthesis). Wrapping stump controls edema and helps

elastic bandage or air splint, or apply a form stump into conical shape to facilitate fitting of
stump shrinker (heavy stockinette
prosthesis. Note: Air splint may be preferred, because
sock), for delayed prosthesis.
Measure circumference periodically

it permits visual inspection of the wound

Measurement is done to estimate shrinkage to
ensure proper fit of sock and prosthesis.

Rewrap stump immediately with an

elastic bandage, elevate if
immediate/early cast is
accidentally dislodged. Prepare for
reapplication of cast.

Edema will occur rapidly, and rehabilitation can be

delayed

Assist with specified ROM exercises for

Prevents contracture deformities, which can develop
both the affected and unaffected limbs
rapidly and could delay prosthesis usage.
beginning early in postoperative stage.
Increases muscle strength to
Encourage active/isometric exercises facilitate transfers/ambulation and promote mobility
for upper torso and unaffected limbs. and more
normal lifestyle.
Provide trochanter rolls as indicated.

Prevents external rotation of lower-limb stump

Instruct patient to lie in prone position

Strengthens extensor muscles and prevents flexion
as tolerated at least twice a day with
contracture of the hip, which can begin to develop
pillow under abdomen and lowerwithin 24 hr of sustained malpositioning.
extremity stump.
Caution against keeping pillow under Use of pillows can cause permanent flexion
lower-extremity stump or allowing BKA contracture of hip; a dependent position of stump
limb to hang dependently over side of impairs venous return and may increase edema
bed or chair.
formation.
Demonstrate/assist with transfer

Facilitates self-care and patients independence. Proper

techniques and use of mobility aids,

e.g., trapeze, crutches, or walker.

transfer techniques prevent shearing abrasions/dermal

injury related to scooting.

Assist with ambulation.

Reduces potential for injury. Ambulation after lowerlimb amputation depends on timing of prosthesis
placement.

Hardens the stump by toughening the skin and altering

Instruct patient in stump-conditioning
feedback of resected nerves to facilitate use of
exercises
prosthesis.
Provides for creation of exercise/activity program to
meet individual needs and strengths, and identifies
Refer to rehabilitation team

mobility functional aids to promote independence.

Early use of a temporary prosthesis promotes activity
and enhances general well-being/positive outlook.
Note: Vocational counseling/retraining also may be
indicated.
Reduces pressure on skin/tissues that can

Provide foam/flotation mattress.

impair circulation, potentiating risk of tissue

ischemia/breakdown

Risk for Infection

Risk factors may include

Inadequate primary defenses (broken skin, traumatized tissue)

Invasive procedures; environmental exposure

Chronic disease, altered nutritional status

Desired Outcomes

Achieve timely wound healing; be free of purulent drainage or erythema; and be

afebrile.

Nursing Interventions

Rationale

Maintain aseptic technique when changing

dressings/caring for wound.

Minimizes opportunity for introduction of

bacteria.

Inspect dressings and wound; note

Early detection of developing infection

provides

characteristics of
drainage.

opportunity for timely intervention and

prevention of
more serious complications.
Hemovac, Jackson-Pratt drains facilitate

Maintain patency and routinely empty

drainage device.

Cover dressing with plastic when using the

bedpan or if
incontinent.

removal of
drainage, promoting wound healing and
reducing risk of
infection.
Prevents contamination in lower-limb
amputation.

Expose stump to air; wash with mild soap and Maintains cleanliness, minimizes skin
water after
dressings are discontinued.

contaminants, and
promotes healing of tender/fragile skin.

Monitor vital signs.

Temperature elevation/tachycardia may reflect

developing sepsis.

Obtain wound/drainage cultures and

sensitivities as

Identifies presence of infection/specific

organisms and

appropriate.

appropriate therapy.
Wide-spectrum antibiotics may be used

Administer antibiotics as indicated.

prophylactically,
or antibiotic therapy may be geared toward
specific
organisms.

Risk for Ineffective Tissue Perfusion

Risk factors:

Reduced arterial/venous blood flow; tissue edema, hematoma formation

Hypovolemia

Desired Outcomes:

Patient will Maintain adequate tissue perfusion as evidenced by palpable peripheral

pulses, warm/dry skin, and timely wound healing.

Nursing Interventions

Rationale

Monitor vital signs. Palpate peripheral General indicators of circulatory status and adequacy
pulses, noting strength and equality. of perfusion.
Perform periodic neurovascular
assessments (sensation, movement,

Postoperative tissue edema, hematoma formation, or

restrictive dressings may impair circulation to stump,

pulse, skin color, and temperature).

resulting in tissue necrosis.

Inspect dressings/drainage device,

Continued blood loss may indicate need for additional

noting amount and characteristics of

drainage.

fluid replacement and evaluation for coagulation defect

or surgical intervention to ligate bleeder.

Apply direct pressure to bleeding site

if hemorrhage occurs. Contact

Direct pressure to bleeding site may be followed by

application of a bulk dressing secured with an elastic

physician immediately.

wrap once bleeding is controlled.

Investigate reports of
persistent/unusual pain in
operative site.
Evaluate nonoperated lower limb for
inflammation, positive Homans sign.

Encourage/assist with early

ambulation.

Hematoma can form in muscle pocket under the flap,

compromising circulation and intensifying pain
Increased incidence of thrombus formation in patients
with preexisting peripheral vascular disease/diabetic
changes.
Enhances circulation, helps prevent stasis and
associated complications. Promotes sense of general
well-being.

Administer IV fluids/blood products as Maintains circulating volume to maximize tissue

indicated.
perfusion.
Apply antiembolic/sequential
compression hose to non-operated

Enhances venous return, reducing venous pooling and

leg, as indicated.

risk of thrombophlebitis.

May be useful in preventing thrombus formation

Administer low-dose anticoagulant as
without increasing risk of postoperative
indicated.
bleeding/hematoma formation.
Monitor laboratory studies,
e.g.:Hb/Hct;

Indicators of hypovolemia/dehydration that can

impair tissue perfusion.

PT/activated partial thromboplastin

Evaluates need for/effectiveness of anticoagulant

therapy and identifies developing complication,

time (aPTT).

e.g., posttraumatic disseminated intravascular

coagulation (DIC)

Situational Low Self-Esteem

May be related to

Loss of body part/change in functional abilities

Possibly evidenced by

Anticipated changes in lifestyle; fear of rejection/reaction by others

Negative feelings about body, focus on past strength, function, or appearance

Feelings of helplessness, powerlessness

Preoccupation with missing body part, not looking at or touching stump

Perceived change in usual patterns of responsibility/physical capacity to resume role

Desired Outcomes

Begin to show adaptation and verbalize acceptance of self in situation (amputee).

Recognize and incorporate changes into self-concept in accurate manner without

negating self-esteem.

Develop realistic plans for adapting to new role/role modifications.

Nursing Interventions

Rationale

Assess/consider patients
preparation for and view of

Research shows that amputation poses serious threats

to patients psychological and psychosocial

adjustment.Patient who views amputation as life-saving

or reconstructive may be able to accept the new self
amputation.

more quickly.Patient with sudden traumatic amputation

or who considers amputation to be the result of failure
in other treatments is at greater risk for self-concept
disturbances.

Encourage expression of fears,

Venting emotions helps patient begin to deal with the
negative feelings, and grief over loss
fact and reality of life without a limb.
of body part.
Reinforce preoperative information
including type/location of
Provides opportunity for patient to question and
amputation, type of prosthetic fitting
assimilate information and begin to deal with changes in
if appropriate (i.e., immediate,
body image and function, which can facilitate
delayed), expected postoperative
postoperative recovery.
course, including pain control and
rehabilitation.
Assess degree of support available to Sufficient support by SO and friends can
patient.
facilitate rehabilitation process.
Ascertain individual strengths and
identify previous positive coping
behaviors.
Encourage participation in ADLs.
Provide opportunities to view/care
for stump, using the moment to
point out positive signs of healing.

Helpful to build on strengths that are already available

for patient to use in coping with current situation.
Promotes independence and enhances feelings of self
worth. Although integration of stump into body image
can take months or even years, looking at the stump and
hearing positive comments (made in a normal, matterof-fact manner) can help patient with this acceptance.

Encourage/provide for visit by

another amputee, especially one

A peer who has been through a similar experience

serves as a role model and can provide validity to

who is successfully rehabilitating.

comments and hope for recovery and a normal future.

Note withdrawn behavior, negative

self-talk, use of denial, or over
concern with actual/perceived
changes.

Identifies stage of grief/need for interventions.

Provide open environment for

patient to discuss concerns about

Promotes sharing of beliefs/values about sensitive

subject, and identifies misconceptions/myths that may

sexuality.

interfere with adjustment to situation.

Discuss availability of various

resources, e.g., psychiatric/ sexual
counseling, occupational therapist.

May need assistance for these concerns to

facilitate optimal adaptation and rehabilitation.