amputation final ppt (1).pptx

Medical and Surgical Nursing

1. amputation Supervised by: Presenter : Prof . Dr.Ram Sharan Mehta Sushila Hamal Medical Surgical Nursing M.Sc. Nursing 1 st year BPKIHS BPKIHS

2. Objective of This session At the end of this session, the participant will be able to; Introduce amputation State the epidemiology and incidence Describe the causes of amputation List down the indication of amputation Explain the types of amputation

3. Cont… State the diagnostic evaluation List out the principle of amputation List the complication of amputation Explain management (pharmacological ,nursing management , rehabilitation)

4. Amputation Introduction: The word amputation is derived from the Latin word amputare, “to cut away”. An amputation usually refers to the removal of the whole or part of an arm/hand or leg/foot. Amputation is a procedure where a part of the limb is removed through one or more bones. It should be distinguished from disarticulation where a part is removed through a joint.

5. Cont… Amputation should only be considered if the limb is non-viable (gangrenous or grossly ischemic, dangerous malignancy or infection), or non-functional . Amputation is always a last resort and it will not be done unless it is absolutely necessary for a person’s health.

6. EPIDEIMOLOGY   In 2017, 57.7 million people were living with limb amputation due to traumatic causes worldwide . (GBD 2017) Leading traumatic causes of limb amputation were falls (36.2%), road injuries (15.7%), other transportation injuries (11.2%), and mechanical forces (10.4 %). Approximately 150000 patients per year undergo a lower extremity amputation in the United States. The most common leading causes to amputation are diabetes mellitus, peripheral vascular disease, neuropathy and trauma. (Cesar S. Molina 2022)

7. EPIDEIMOLOGY Cont.. In India every year 23,500 amputees are added to the amputee population in India, of which 20,200 are males and 3,300 are females. There was a 54.1% increase in major amputations noted in the pandemic period more than the pre pandemic period . ( C OVID19 Pandemic in South India, 2021) In Nepal the average age of amputees was 33 years (7 to 90 years) 22% female and 78 % were males. 53 % were between 20 to 40 years. Most common level of amputation was below knee amputation (60.33%) followed by above knee (33.6 %) and through knee amputation (6%). Only 46 % of all amputees used a prosthesis. ( BBMed,2019)

8. INCIDENCE: Age: Common in 50-75 yrs of age Sex: Appro.75 % in male 25 % in female Involvement of limb: 85 % in lower limb 25 % in upper limb Age VS Indication Children- congenital anomalies Young adults- Injuries Elderly- Peripheral vascular disease (DM)  

9. CAUSES: Circulatory disorders : Diabetic foot infection or gangrene Neoplasm: Cancerous bone or soft tissue tumors Trauma Deformities : Deformities of digits and/or limbs, Extra digits and/or limbs Infection: Bone infection (osteomyelitis) Legal punishment: Amputation is used as a legal punishment in a number of countries, among them Iran, Yemen, Saudi Arabia, Sudan, and Islamic regions of Nigeria  

10. INDICATIONS : The S even d’s for amputation are as follows. A d ead limb: e.g. vascular gangrene. A d ying limb: e.g. TAO, frost bite, Burn etc. A d estroyed limb: e.g. crush injury. A d enervated limb: e.g. hereditary sensory neuropathy, brachial plexus injury. A d angerous limb: e.g. malignant bone tumor, gas gangrene. A d eformed limb: abnormalities in growth and development A d amned nuisance: loss of function, gross deformity, deformities of digits/limbs  

11. TYPES OF AMPUTATION Guillotine or Open Amputation: An amputation after which the stump is left unsutured  ( without skin flap closure) for several weeks while  debrid-ement  and antibiotic therapy are carried out.  Closing the stump before the wound is free from  bacteria or  debris increases the risk of infection and  compromises  healing.

12. Cont… Fig:Open amputation

13. Cont… Closed Amputation : Amputation in which flaps are made from skin and subcutaneous tissue and sutured over the bone end of the stump; called also flap amputation.

14. Cont… Fig:Close amputation

15. Types of Upper limb amputation Forequarter amputation : Scapula + lateral 2 /3 of clavicle + amputation of whole upper limb Shoulder disarticulation : Removal through the glenohumeral joint Above elbow amputation : Through the arm Elbow disarticulation : Through the elbow joint.

16. Cont… Below elbow amputation : Through the forearm bones Wrist disarticulation : Through the radiocarpal joint Ray amputation : Removal of a finger with respective metacarpal from carpometacarpal joint Krukenburg's amputation : Making 'forceps' with two forearm bones

17. Cont… Fig: Krukenburg amputation

18. Cont… Fig: Ray amputation

19. Types of Lower limb amputation Hindquarter amputation : Whole of the lower limb with one side amputation of the Ilium being removed Hip disarticulation: Through the hip joint Above knee amputation : Through the femur Knee disarticulation : Through the knee joint

20. Cont… Below knee amputation : Through the tibia-fibula Syme's amputation : Through the ankle joint Chopart's amputation : Through talonavicular joint Lisfranc's amputation : Through intertarsal joints

21. Cont…

22. Cont… Fig:Syme’s amputation

23. Cont… Fig: Chopart amputation

24. Cont… Fig: Lisfranc’s amputation

25. DIAGNOSTIC EVALUATION History collection Physical examination The diagnostic assessments include the usual preoperative blood studies and radiographs to determine the level of amputation.

26. Cont… Arteriography may be done to determine the level of blood flow in the extremity. Doppler studies are used to measure blood flow viscosity. Transcutaneous oxygen level may also be measured.

27. Principle of amputation Tourniquet is always used except in a case of vascular disease. Flaps are marked properly before the skin incision is made. Designing equal antero-posterior flaps is desirable. The procedure should aim at designing an ideal stump. Skin division is the farthest, followed by fascia, muscle and the bone.

28. Cont… Sharp spikes of bone are trimmed and made round . Skin flap: good skin coverage is important to helps in preventing from edema or swelling . Skin should be mobile and sensitive. Method of muscle suture: Myodesis : muscle is suture to bone through drill holes Myoplasty : The muscle is sutured to other muscle and then placed over the end of the bone .

29. Cont… The major vessels are to be perfectly ligated . Tourniquet is always released before closure and hemostasis achieved. Wound always closed over a drain. Regular stump exercises are to be done to prevent joint contractures Level of amputation: efforts should be made to preserve all the possible limb length, keeping in mind the prosthesis to be fit.

30. COMPLICATION OF AMPUTATION: Haematoma Infection Skin flap necrosis Deformities of the joints Neuroma Pantom sensation

31. Phantom limb sensation Phantom sensation are feelings that the amputated part is still present. Although these sensation are often referred to as phantom pain , not all of the sensation are painful. The patient may describe unusual sensations, such as numbness,, warmth, cold, itching as well as a feeling that the extremity is present, crushed, cramped, or twisted in an abnormal position

32. Cont… Phantom sensation are caused by intact peripheral nerves proximal to the amputation site that carried messages between the brain and the now amputated part. Amputees may experience phantom limb pain soon after surgery or 2 to 3 months after amputation. It occurs more frequently in above-knee amputations. Phantom sensations diminish over time. It gradually decreases over the next 2 years.  

33. Phantom pain Cont … Pain is usually burning, cramping, squeezing, or shooting in nature. May occur in large number of clients. It is thought to be caused by combination of physiologic and psychological components. Phantom pain occurs most often in clients who had pain in the limb before the amputation. Distraction techniques and activity are helpful.

34. Mechanism of phantom limb pain

35. Etiology of Phantom Limb Pain There are numerous theories about the causes of phantom limb pain including peripheral, central and spinal theories: Peripheral Theories Remaining nerves in the stump grow to form neuromas, which generate impulses. These impulses are perceived as pain in the limb which has been removed. After changes in the severity of phantom limb pain were noted in different temperatures, another theory says that cooling of the nerve endings increases the rate of firing of the nerve impulses, which are perceived by the patient as phantom limb pain

36. Etiology CONT.. Central Theories Melzack proposed that the body is represented in the brain by a matrix of neurons. Sensory experiences create a unique neuromatrix , which is imprinted on the brain. When the limb is removed, the neuromatrix tries to reorganise , but the neurosignature remains due to the chronic pain experienced prior to the amputation. This causes phantom limb pain after amputation. Spinal Theories When peripheral nerves are cut during amputation, there is a loss of sensory input from the area below the level of amputation. This reduction in neurochemicals alters the pain pathway in the dorsal horn

37. 39

38. STUMP The extremity of limb left after amputation. The distal end of a limb left after  amputation ; called    residual limb .  

39. IDEAL LENGTH OF STUMP In below-knee amputations: 10.0–12.5 cm from the Tibial tuberosity . In above-knee amputations: 22.5–25.0 cm from the greater trochanter . In above and below elbow amputations: 20.0 cm from the Acromion process and the Olecranon process respectively. These stump lengths recommended, are not constant. The length varies depending on the length of the limb. It is useful in determining the length of prosthesis

40. CRITERIA OF IDEAL STUMP Conical shape Ideal length Good muscle power Non-adherent scar No fixed deformity Absence of neuroma Bone well covered by muscles Muscular and not flabby Free of infection

41. Cont… Stump care Keep the skin on the surface of stump clean to reduce the risk of it becoming irritated or infected. Gently wash your stump at least once a day (more frequently in hot weather) with mild unscented soap and warm water, and dry it carefully. If you have a prosthetic limb, you should also regularly clean the socket using soap and warm water.

42. Cont… When taking a bath, avoid leaving your stump submerged in water for long periods because the water will soften the skin on your stump, making it more vulnerable to injury. Skin becomes dry, use a moisturizing cream before bedtime or when wearing your prosthesis. Wearing one or more socks around their stump helps absorb sweat and reduces skin irritation.

43. Cont… The size of your stump may change as the swelling goes down, so the number of socks you need to use may vary. Socks should be changed every day. Check your stump carefully every day for signs of infection, such as: warm, red and tender skin discharge of fluid or pus increasing swelling

44. MANAGEMENT Pharmacological management Nursing management Rehabilitation

45. PHARMACOLOGICAL MANAGEMENT Medications that may be used to help  relieve pain include: Non-steroidal anti-inflammatory drugs (NSAIDs): such as ibuprofen Anticonvulsants : such as carbamazepine or  gabapentin Antidepressants : such as amitriptyline or nortriptyline (these medications work directly on the nerves in your leg)  Opioids  : such as codeine or morphine Corticosteroid

46. NURSING MANAGEMENT: Pre-operative management: 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 circulatory status and function of the unaffected extremity. Build the patient's strength by implementing muscular exercise

47. Cont… E xercises for the unaffected limbs. Improve the patient's nutritional status by encouraging a balanced diet high in vitamins and minerals and with adequate protein to enhance wound healing. Maintain adequate hydration. Follow the physician's orders for therapeutic measures used to stabilize any chronic medical conditions such as diabetes, hypertension, that may interfere with surgery or rehabilitation .

48. Cont… If ordered, arrange preoperative counseling with the physical therapist. If a mobilization aid such as a walker or crutches is to be used postoperatively, it is easier to provide instruction in the preoperative period. The physical therapist will also inform the patient about his postoperative rehabilitation program. If authorized by the physician, schedule a visit from the prosthetic specialist

49. Cont… . This may help to alleviate some of the patient's anxieties about the fitting and wear of prosthetic devices . Hemodynamic evaluation is performed through testing: angiography, arterial blood flow Cultural and sensitivity test of draining wounds: to assist in control of infection preoperatively Evaluation of any concurrent health problems ( eg : dehydration, anemia)

50. Post-operative management NURSING DIAGNOSIS : Acute pain related to amputation. Impaired physical mobility related to loss of extremity. Situational Low Self-Esteem related to loss of body part/change in functional abilities. Disturbed body image related to amputation of body part Impaired skin integrity related to surgical amputation

51. Cont… Self-care deficit: feeding, bathing/hygiene, dressing/grooming, or toileting, related to loss of extremity . Risk for Infection related to post-operative procedure. Risk for disturbed sensory perception: phantom limb pain related to amputation . Risk for anticipatory and/or dysfunctional grieving related to loss of body part .

52. Cont… Nursing diagnosis: Acute pain related to amputation Nursing intervention: Assess the level of pain, intensity and duration. Keep patient in comfort position . Keep stump elevated . Measure stump size in every shift. Provide patient with diversional therapy. Administer analgesic as prescribed and patients need.

53. Cont… Nursing diagnosis: Impaired Physical Mobility related to loss of extremity Expected outcome: Client will demonstrate techniques/behaviors that enable resumption of activities Nursing intervention: Demonstrate and assist with transfer techniques and use of mobility aid like crutches/walker Provide stump care on a routine basis

54. Cont… Rewrap stump immediately with an elastic bandage, elevate if “immediate or early” cast is accidentally dislodged. Prepare for reapplication of the cast. Encourage active and isometric exercises for unaffected limbs. Provide trochanter rolls as indicated. Assist with ambulation.

55. Cont… Nursing diagnosis: Situational Low Self-Esteem related to loss of body part/change in functional abilities. Expected outcome: Client will develop realistic plans for adapting to new role/role modifications. Nursing intervention: Assess and consider patients preparation for and view of amputation. Help the amputee cope with his altered body image.

56. Cont… Encourage expression of fears, negative feelings and grief over the loss of body part. Provide psychological support to patient. Ascertain individual strengths and identify previous positive coping behaviors. Encourage and provide for a visit by another amputee especially one who is successfully rehabilitating. Note withdrawn behavior, negative self talk, use of denial.

57. Cont… Nursing diagnosis: Risk for Infection related to post-operative procedure. Expected outcome: Achieve timely wound healing; be free of purulent drainage or erythema , and be afebrile . Nursing intervention: Monitor vital signs, clean the wound and give tetanus prophylaxis and antibiotics as order Flush the wound with sterile saline solution, apply a sterile pressure dressing.

58. Cont… Maintain aseptic technique when changing dressing and caring for the wound. Inspect dressings and wound, note characteristics of drainage, and send for culture and sensitivity. Maintain patency and routinely empty drainage device. Expose stump to air; wash with mild soap and water after dressing are discontinued. Administer antibiotics as indicated.

59. Cont… Nursing diagnosis: Risk for Ineffective Tissue Perfusion related to reduced arterial/venous blood flow. Expected outcome: Client will maintain adequate tissue perfusion as evidenced by palpable peripheral pulses, warm/dry skin, and timely wound healing. Nursing intervention: Monitor vital signs, palpate peripheral pulse,assess neurovascular function Inspect dressings and drainage device ,noting amount and characteristics of drainage.

60. Cont… Apply direct pressure to the bleeding site if hemorrhage occurs. If the patient experience throbbing after the stump is wrapped the bandage may be too tight. Check the bandage regularly Report persistent or unusual pain in the operative site. Evaluate for homan’s signs Monitor PT and activated partial thromboplastin time. Encourage and assist with early ambulation. Administer low dose anticoagulant as indicated.

61. REHABILITATION: PROSTHESIS: Prosthetics is a unit of rehabilitation medicine dealing with the replacement of whole or a part of a missing extremity with an artificial device.

62. Cont… Commonly used prosthesis are: Above knee amputation: Quadrilateral socket prosthesis Below knee amputation: Patellar tendon bearing prosthesis Syme’s amputation: Canadian syme’s prosthesis Partial foot amputation: Shoe fillers

63. Cont… Fig:Quadrilateral and patellar tendon bearing prosthesis

64. Cont… Fig: Canadian syme’s prosthesis Fig:Shoes fillers

65. Cont… Fig: Above elbow amputation Fig:Below elbow amputation

66. Cont… Prosthesis care: Remove sweat and dirt from the prosthesis socket daily by wiping the inside of the socket with damp soapy cloth and dry thoroughly. Never attempt to adjust or mechanically alter the prosthesis. If problems develop, consult the prosthesist . Schedule a yearly appointment with the prosthesist .

67. Research article A Functional Outcome Study was conducted on, “Lower Extremity Amputations Around the Knee Joint” in 2019. A complete enumeration method was used, and all the amputees between 2005 and 2017 were included in the study. Of the 520 amputees, 275 trauma related amputees were available for interview. Structured questionnaire and SF-36 was used for the general information and functional outcome respectively. Telephone conversation was done to know the functional outcome and some of the participants were called to our center for the face to face interview.

68. Cont… Only above knee, through knee and the below knee amputation cases were included in the study. Of the 275 study participants 214 were male, 166 had below knee, 92 had above knee and 17 had through knee amputation . The result showed that the average age of amputees was 33 years (7 to 90 years) 22% female and 78 % were males. 53 % were between 20 to 40 years. Most common level of amputation was below knee amputation (60.33%) followed by above knee (33.6 %) and through knee amputation (6%). Only 46 % of all amputees used a prosthesis. Main reason for not using prosthesis was no access and poor economic status. Main complain among the prosthesis user was difficulty in walking for long distance.

69. Cont… 78 % of prosthesis users were involved in farming whereas 13% had their own business. 65% amputees belonged to literate group . The study concluded that trauma was found to be the most common cause of amputation around the knees. More than half the patients were not using prosthesis. Amputees using prosthesis, had better physical and mental health functional outcomes. ( Nitesh K Karn , Ishor Pradhan, Bibek Banskota. B & B Hospital, Gwarko , Lalitpur , Nepal and Hospital and Rehabilitation Centre for Disabled Children (HRDC), Janagal , Kavre , Nepal in 2019)

70. references Shenoy , RM..(2014) Essentials of ORTHOPEDICS 2 nd ed. Nepal: Jaypee Brothers medical publishers (p) Ltd. Maheshwari ,J. and Mhaskar V. (2015) Essential orthopaedics . 5 th edition, India: Jaypee Brunner and suddharth’s , (2009). Textbook of Medical – surgical Nursing ,.11 th edition. India: Wolters Kluwer http://hrdcnepal.org/Content/EditorImages/files/06_%20Dr_%20Nitesh%20Lower%20Extremities%20Amputation.pdf

71. references Järnhammer A, Andersson B, Wagle PR, Magnusson L. Living as a person using a lower-limb prosthesis in Nepal. Disabil Rehabil . 2018 Jun;40(12):1426-1433. doi : 10.1080/09638288.2017.1300331. Epub 2017 Mar 21. PMID: 28320228. Viswanathan V, Nachimuthu S. Major Lower-Limb Amputation During the COVID Pandemic in South India. Int J Low Extrem Wounds. 2021 May 28:15347346211020985. doi : 10.1177/ 15347346211020985. Epub ahead of print. PMID: 34047626 . Retrieved on Amputation causes, types of amputation and amputation complications (healthjade.net)