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Survival following lower-limb amputation in a veteran population. Jennifer A. Mayfield, MD, MPH; Gayle E. Reiber, PhD, MPH; Charles Maynard, PhD; Joseph M. Czerniecki,. MD; Michael T. Caps, MD, MPH; Bruce J. Sangeorzan, MD. Center of Excellence in Am
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Apr 1, 2001 - Lower limb amputation Part 2: Rehabilitation - a 10 year literature review ..... (n=107) with a transmetatarsal amputation often present with a ...
Psychosocial adjustment to lower-limb amputation: A review article. Behrouz Dadkhah1, Sousan Valizadeh2, Eissa Mohammadi3, Hadi Hassankhani4. 1 School ...
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knee fusion. Pain in the limb continued, and was treated unsuccessfully by neurectomy of the saphenous nerve, lumbar sympathectomy and eventually the patient persuaded his surgeon to perform an above-knee amputation, in the mistaken belief that this
Sep 8, 2017 - Objective: To investigate whether the use of statin is associated with a risk reduction in lower-extremity amputation in type 2 diabetes mellitus ...
age, had a lower-limb amputation, and were either prosthesis or wheelchair users. ... gender, ownership of a wheelchair, higher levels of physical disability ...
May 21, 2016 - How to cite: Sharma V, Rattan KN, Sharma N. In-utero limb amputation. J Neonat Surg. 2017; 6:18. This is an open-access article distributed ...
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identified based on the presence of an associated ICD-9 procedure code (toe amputation [84.11], transmetatarsal and below-knee amputation [84.12â84.16], ...
Development and Heliomare Rehabilitation Centre, Wijk aan Zee, W Polomski, JR Slootman Heliomare, ... walking ability during rehabilitation following lower limb amputation should not be discouraged ...... The elderly amputee: rehabilitation.
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120 lower-limb amputations in a regional hospital in ... Outcome after amputation of lower limb 103 ... prosthesis equipped with a Syme-type SACH foot.
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Amputation By reading this article and writing a practice profile, you can gain ten continuing education points (CEPs). You have up to a year to send in your practice profile and guidelines on how to write and submit a profile are featured immediately after the continuing professional development article every week.
Lower limb amputation NS83 Gibson J (2001) Lower limb amputation. Nursing Standard. 15, 28, 47-52. Date of acceptance: January 12 2001. Aims and intended learning outcomes This article focuses on the nursing care of patients undergoing a major lower limb amputation. The aetiology of the underlying condition, involving the patient in the decision to amputate, pre- and post-operative care, pain management, rehabilitation and health education are all considered. After reading this article you should be able to: ■ Identify the common causes of lower limb amputation. ■ Describe the levels of lower limb amputation and the advantages and disadvantages of each in relation to the patient’s recovery. ■ Outline the physical and psychological nursing care of patients undergoing amputation. ■ Identify the components of a successful amputation rehabilitation programme. ■ Discuss the ongoing health education needs of patients undergoing amputation. Introduction The two most common causes of major amputation are peripheral arterial occlusive disease (PAOD) and infection secondary to diabetic foot ulceration (Ham and Cotton 1991). Other less common causes are trauma, malignancy and congenital malformations. Upper limb amputation is much less commonly performed because PAOD and diabetic ulceration mainly affect the lower limbs. The main symptom of mild PAOD is intermittent claudication – pain on walking, due to arterial insufficiency. If the disease progresses, rest pain, ulceration and ultimately irreversible ischaemia and gangrene might develop. It is estimated that
only 3 per cent of those who experience intermittent claudication will progress to critical limb ischaemia and amputation (Dormandy and Ray 1997), with those who are diabetic or who smoke at higher risk (Palumbo et al 1991). Other patients present with acute critical ischaemia due to occlusion of an artery without having had intermittent claudication. Chronic critical limb ischaemia (CLI) is defined as the presence of severe rest pain for at least two weeks, or ulceration or gangrene, in a limb with an ankle pressure of less than 50mmHg or toe pressure less than 30mmHg (EWGCLI 1992). The annual incidence of CLI is 500 to 1,000 per million, of whom around a quarter will undergo a major amputation (Hallett et al 1997, Price and Fowkes 1999). Although there have been major increases in the volume of reconstructive surgery undertaken for CLI (Hallett et al 1997), there appears to be a point at which increased surgical activity does not lead to a continued reduction in amputation rates (Fyfe 1999). Critical ischaemia is characterised by severe pain with a typical burning sensation. The pain is often worse at night due to the drop in systemic blood pressure and tissue perfusion that occurs when the patient is recumbent. Patients might try sleeping in a chair or sitting on the edge of the bed to relieve the pain (Gibson and Kenrick 1998). This can lead to dependent oedema, which will further reduce tissue perfusion. Diabetic foot ulceration can exist alongside arterial occlusive disease or in its absence. There are three main contributing factors to diabetic foot disease: sepsis, arteriopathy and denervation or diabetic neuropathy (Macfarlane and Jeffcoate 1999).
Lower limb amputation 47-52 Multiple-choice questions and submission instructions 54 Practice profile assessment guide
In brief Author Jo Gibson MSc, BSc(Hons), CertCouns, RGN, is Vascular Nurse Practitioner, Southport and Ormskirk Hospital NHS Trust. Summary The decision to amputate is a difficult one, but in some cases, amputation can greatly improve the patient’s quality of life. Jo Gibson discusses the nursing care of patients undergoing amputation, with a view to helping them adjust to their changed circumstances. Keywords ■ Amputation ■ Pain and pain management ■ Rehabilitation These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review.
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Amputation Box 1. Case studies Mrs Hill*, 80, had undergone a femoro-popliteal bypass graft using autologous vein. When this occluded after two years, she underwent a repeat bypass graft using prosthetic material. The new graft also failed, leading to critical ischaemia with rest pain. Mrs Hill faced the prospect of above-knee amputation (AKA). After discussion with her husband, the surgeon and the vascular nurse specialist, she decided to go home, as she was not ready to accept AKA. She understood the severity of her condition and was not in immediate risk of deterioration as there was no gangrene or sepsis to her leg. For the next two weeks her pain was controlled with opiate analgesia and the vascular nurse specialist kept in regular contact. Mrs Hill then decided to return to hospital because the pain was becoming more severe. She underwent AKA and had an uncomplicated recovery. Two years later she is mobile with a prosthetic limb. Mr Grant*, 60, had insulin dependent diabetes from childhood and had managed his condition well. He had the fifth toe on his left foot amputated due to necrosis following a non-healing ulcer, but the amputation site did not heal and became infected. The surgeon initially wanted to perform a forefoot amputation. Mr Grant said he would prefer a below-knee amputation (BKA) as he was aware that the forefoot amputation was not guaranteed to heal and wanted to avoid further operations. A BKA allowed him to avoid more operations and a prolonged hospital stay. He made a successful recovery, gaining full mobility on a prosthetic limb. (*Names have been changed)
Some patients with diabetic neuropathy present late with severe diabetic foot infections, as they are initially unaware of the presence of an ulcer. It is common for a diabetic foot ulcer to be the first indication that an individual has diabetes mellitus. Many patients with PAOD or diabetes are older and have co-existing illnesses, such as coronary artery disease, cerebrovascular disease or chronic obstructive airways disease. Cardiac failure might contribute to inadequate tissue perfusion and critical ischaemia. TIME OUT 1 Think of a patient whom you have cared for before or after a lower limb amputation. What factors led to the need for amputation? Could any of these have been prevented? Reflect on the patient’s illness history. How might these factors affect his or her recovery from surgery and rehabilitation?
Deciding to amputate Patients who have had lengthy treatment for atherosclerosis or diabetes often fear amputation. For others with more recent symptoms, the prospect of amputation might come as a shock. In any case, it can be hard for patients to accept the decision to amputate a limb and this is often seen as a last resort. The challenge for the healthcare team is to foster the more positive view that amputation is a means of restoring function by removing a diseased limb. However, it should not be forgotten that, for this group of patients, immediate postoperative mortality and long-term survival are affected, with higher mortality in older patients and those undergoing above-knee amputation (Pell and Stonebridge 1999). It is unfair to promise the patient a return to good quality and length of life if this is not a realistic prospect. The timing and level of amputation must also be considered. Nurses must ensure that patients’ views are heard and respected. Box 1 describes two case studies in which the patients’ participation in the decision to amputate was an important factor in their adjustment and rehabilitation. TIME OUT 2 Think of a patient you have cared for who underwent amputation. Who was involved in the decision to amputate? What influence did the patient’s views have? Reflect on another patient who had irreversible ischaemia and did not have an amputation. What factors were involved in this decision? What influence did the patient’s views have?
A patient with irreversible ischaemia might be too ill to give informed consent, because systemic infection, toxin release from necrotic tissue and opiate analgesia can lead to an acute confused state. In this case, the consultant and a second doctor should make and document the decision. While the views of relatives should be sought and considered, they should not override the consultant’s opinion of what is in the patient’s best interest. If the patient has previously expressed any views about the prospect of amputation, these should be considered in the decision (Donohue 1997a). A decision not to amputate a limb where there is irreversible ischaemia and necrosis will inevitably lead to death. This might be the most appropriate option if there is a high risk of perioperative mortality and little or no chance of a return to an acceptable quality of life. Such decisions are best made in close consultation with the patient and his or her family (Campbell et al 2000). Level of amputation The choice of the level of an amputation is a compromise between ensuring primary wound healing and maximising the patient’s function post-operatively. If an AKA is performed, healing is more likely to occur, but this might be at the expense of the patient’s future mobility, since the knee joint is a vital structure in walking. The levels of lower limb amputation are shown in Figure 1. TIME OUT 3 List the factors that might influence the decision to perform an above- or below-knee amputation. The choice of the appropriate level is determined by the need to remove all devitalised tissue while optimising future mobility. For below-knee amputation (BKA), the stump must extend 1112cm below the patella, and for AKA, it must be 22-28cm below the tip of the greater trochanter to fit a functional prosthesis (Green and Rob 1994). Occasionally a through-knee amputation is performed. This makes fitting a functional prosthesis difficult but this is not an important consideration in a previously immobile patient. Through-knee amputation is quicker and heals more readily than BKA. It provides better leverage than AKA, assists balance and aids transfers from bed to chair (Shearman et al 1998).
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Amputation Assessment for the appropriate level of amputation involves clinical signs, such as the extent of necrosis, and potential function post-operatively. A patient with a fixed contracture of the knee joint will not benefit from having a BKA as he or she will not be able to use an artificial limb. The stump wound in this case is unlikely to heal, as it is difficult to position the patient to avoid pressure on the stump when the knee is contracted (Helt and Jacobsen 1999). Other methods of assessing the appropriate level include transcutaneous oxygen measurements (TcO2), photoplethysmography and ankle Doppler pressures, but there is no evidence that these are more accurate than clinical assessment (Dwars et al 1992, Shearman et al 1998). The surgeon might make the decision based on the appearance of the tissues.
Fig. 1. Common levels of lower limb amputation
Pre-operative nursing care The aims of preparation for amputation are to ensure that the patient accepts the need for surgery and is as comfortable and pain-free as possible pre-operatively. It is also important to optimise his or her overall condition. Many patients undergoing amputation are older and have co-existing health problems. They might have been in considerable pain for some time. These factors will affect their fitness to undergo surgery. TIME OUT 4 Many amputations are carried out on emergency theatre lists at short notice rather than as an elective procedure. Make brief notes about how this might affect the patient’s care and how problems could be addressed. An important factor to be considered is the skill of the surgeon and anaesthetist. Amputation has traditionally been viewed as a technically simple operation and might previously have been left to be carried out by a junior member of the team at the end of the operating list. However, the technical performance of the surgery is a vital factor in fashioning a well-formed stump that can be fitted with a prosthesis. An experienced surgeon should always undertake or supervise the operation. A planned operation might be cancelled at short notice. This can result in prolonged periods of fasting before surgery and in the deterioration of the patient’s condition due to progression of sepsis. It is also demoralising for the patient to prepare for surgery only for it to be cancelled.
Patient information and support is an essential part of pre-operative nursing care. The nurse needs to assess the patient’s understanding of the condition, the proposed surgery and anaesthetic, and the plan for rehabilitation including the environment and the individual’s goals. Patient educational materials are useful, but are only a supplement to talking to the patient about his or her concerns. Nutrition and fluid balance need close attention pre- and post-operatively. The patient might be malnourished due to poor oral intake as a result of prolonged pain and immobility, as well as having additional post-operative nutritional requirements for wound healing and for the additional energy expended in mobilising. Referral to a dietician should be considered (Helt and Jacobsen 1999). Patients undergoing amputation are at high risk of pressure sores, due to immobility and poor blood supply. Risk assessment should be carried out pre- and post-operatively. It is advisable to obtain a specialised pressure-relieving mattress or overlay pre-operatively if it is likely to be needed, as even a few hours’ delay could result in pressure sore development (Herbert 1997). Pre-theatre checks include routine chest X-ray
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Amputation Box 2. Components of successful recovery after amputation ■ Recovery from surgery and anaesthesia without complications ■ Wound healing to form a well-shaped stump ■ Pain management ■ Rehabilitation to enable safety in the home environment ■ Psychological and social adaptation and electrocardiogram, full blood count, urea and electrolytes and blood glucose (Herbert 1997). Blood is ‘group and saved’ as transfusion is not routinely necessary unless the patient is found to be anaemic. Amputation can be performed under general or epidural anaesthesia. The latter reduces the risk of post-operative myocardial infarction and is often used for less fit patients. Pain control before surgery is vital to enable the patient to rest and be as comfortable as possible. Many patients will have experienced severe pain and lack of sleep for some time, especially if they have delayed seeking medical attention. Pain control is usually with opiates such as oral morphine for severe pain or simple oral analgesics for mild pain. Other methods to consider are relaxation, patient-controlled analgesia and epidural analgesia. Fundamental nursing measures to control pain include the use of a bed cradle and foam gutter, since the patient might be unable to tolerate the weight of bedclothes on his or her leg. Careful assistance to change position, lowering the foot of the bed to aid blood flow, and the use of an appropriate dressing and careful dressing technique on any ulcers are vital. Phantom pain after surgery is related to the intensity and duration of pre-operative pain (Nicolajsen et al 1997a) and is more common in patients whose amputation is due to PAOD than to other causes (Weiss and Lindell 1996). Since phantom pain is difficult to manage, it is important to try to prevent it by alleviating the patient’s pain before surgery. Epidural analgesia is sometimes used pre-operatively for this reason, although it is of unproven benefit in preventing phantom pain (Nicolajsen et al 1997b). Perhaps the most important factor is to emphasise that the patient must inform staff if he or she is in pain. You should also frequently ask patients if they are in pain. If pain is not identified, nothing can be done to alleviate it. Post-operative care There are five important components for recovery after amputation (Box 2). Recovery from surgery Haemodynamic status
is assessed through regular observations of pulse, blood pressure and urine output (Donohue 1997b). Oxygen is given by face mask as prescribed. The patient will have an intravenous infusion in situ, but can eat and drink as soon as he or she feels able. Patients undergoing AKA are usually catheterised, but in all cases it is important to monitor the patient’s urine output because shock and renal failure are possible post-operative complications. Unfortunately, many patients undergoing amputation are unfit and major post-operative complications, such as myocardial infarction or chest infection, are common. Wound healing The theatre dressing, usually consisting of a non-adherent dressing, orthopaedic wool and crepe bandage, is left undisturbed for several days as long as there is no leakage or sign of infection. The stump wound is usually closed with a continuous absorbable suture. There might be a drain in situ, which will be removed on the first or second post-operative day. After 72 hours, the wound might be left exposed. If necessary, a non-adherent dressing can be applied and secured with a stockinette. It is best to avoid applying adhesive tape to the skin, which might be very fragile. A specially made stump-shrinker (an elasticised, sock-like appliance) should be fitted around 14 days post-operatively. This helps to shape the stump in readiness for a prosthesis, but should only be applied once the wound has healed (Herbert 1997). Any sign of infection or necrosis at the wound margins should be reported promptly. BKA needs revision in up to 30 per cent of cases, while 90 per cent of AKAs heal without further intervention (Dormandy et al 1999). Pain management Incisional stump pain in the first few days is usually controlled with an epidural infusion, patient-controlled analgesia pump or intermittent opiate analgesia. The patient should be encouraged to report any persistent or worsening stump pain, as it might be a sign of wound infection or continuing necrosis. Phantom pain affects nearly 80 per cent of people who have had an amputation, with varying duration and degree of severity, and with little relief from conventional analgesia – even strong opiates (Houghton et al 1994). Its aetiology is not well understood. It might originate in the pain-transmitting neurones of the dorsal horn (Davis 1993). Another theory is that it is due to discordance of movement, sensation and proprioception (Harris 1999). The term ‘phantom pain’ should be used with care. It can imply to the patient that it is an imaginary pain of psychological rather than physiological origin. In fact
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Amputation the pain is real, but the body part is ‘phantom’ (Williams and Deaton 1997). Back pain is another common symptom after amputation, probably arising from the patient’s changed posture and centre of gravity (Smith et al 1999). TIME OUT 5 Talk to a patient who has been experiencing phantom pain. Discuss how it affects him or her and what measures he or she has found helpful. Reflect on measures that you might take to help this patient cope with phantom pain. One measure that might be employed to relieve phantom pain is administration of oral carbemazepine. This can take a week or more to take effect. Transcutaneous electrical nerve stimulation (TENS) is also helpful, and is either applied to the stump, or occasionally to the opposite leg at the level of the stump (Carabelli and Kellerman 1985). Other patients receive some relief from gentle massage, or when they begin to become mobile with the use of a prosthesis. The incongruence of experiencing pain in a non-existent limb is often difficult for patients to cope with, especially when the main reason for having the limb amputated was because of pain. The support of other patients who have had similar experiences can be useful, and the nurse might be able to direct patients towards a peer visitation scheme or support group (Fitzgerald 2000, Jacobsen 1998). The nurse’s role Rehabilitation Many members of the multidisciplinary team are involved in rehabilitation after amputation. Nurses are often seen as the members of the rehabilitation team who simply co-ordinate and deputise for others, since they are present 24 hours a day, unlike other therapists (O’Connor 1993). Alternatively, the nurse’s role in rehabilitation can be viewed more positively as providing care, helping personal recovery and mediating (Burton 2000), ensuring that the contributions of the other team members are congruent with the patient’s individual goals. Mobilisation and physiotherapy The mobilisation programme focuses initially on preventing complications of immobility, such as pressure sores, chest infection and contractures, before moving on to teaching safe transfer techniques, mobilising with a walking frame and then with elbow crutches. A pneumatic postamputation mobility (PPAM) aid is often used in early mobilisation.
The patient will be at risk of falling due to an altered centre of gravity and phantom sensations in the limb. He or she should be advised to transfer and get up slowly to reduce the risk of falls, particularly at night. If a fall occurs there could be some trauma to the stump, which might delay wound healing. Post-operative mobility will depend largely on the level of the amputation, but another important factor is the patient’s fitness. Walking with an artificial limb takes considerably more energy than walking normally – up to 30 per cent more for a single BKA and up to 100 per cent more for an AKA (Helt and Jacobsen 1999). A patient with co-existing cardiac or pulmonary disease might have insufficient reserve to walk far with a prosthesis. By contrast, a fit patient who loses a limb as a result of trauma or congenital abnormality will usually manage well with a prosthesis. Other factors that might affect the patient’s mobility are the condition of the remaining limb, ability to put on and take off a prosthesis, and motivation (Fyfe 1999). You can assist the patient in building up motivation by fostering a positive but realistic attitude, ensuring the rehabilitation programme takes all the above factors into account and the patient understands the rehabilitation process, as well as helping him or her to identify and focus on specific individual goals. Anticipated recovery pathways for amputation need to be designed and used with care as the patient’s progress towards discharge can be very variable (Schaldach 1997). Using a pathway ensures that all interventions are completed in an appropriate time and helps patients to keep sight of their goals. Psychological and social adaptation There are few surgical procedures that will have such a dramatic impact on a patient’s future physical, psychological and social functioning as amputation. Losing a limb will affect every activity of daily life. Along with this functional change, there will be a major change in the patient’s body image. Body image consists of three essential components (Price 1990). Body reality refers to the body as it is; body ideal is how the individual wishes it to be; and body presentation refers to the efforts an individual makes to find a compromise between body reality and body ideal. For patients who have had an amputation, the combination of adjusting body presentation and changed physical function is particularly challenging. Patients who have had prolonged ischaemia and ulceration might view the alteration in body image as a positive one.
REFERENCES Burton CR (2000) A description of the nursing role in stroke rehabilitation. Journal of Advanced Nursing. 32, 1, 174-181. Campbell WB et al (2000) Non-operative treatment of advanced limb ischaemia: the decision for palliative care. European Journal of Vascular and Endovascular Surgery. 19, 3, 246-249. Carabelli RA, Kellerman WC (1985) Phantom limb pain: relief by application of TENS to contralateral extremity. Archives of Physical Medicine and Rehabilitation. 66, 7, 466-467. Davis RW (1993) Phantom sensation, phantom pain, and stump pain. Archives of Physical Medicine and Rehabilitation. 74, 1, 79-91. DePalma RG, Schwab FJ (1991) Vasculogenic impotence. In Young JR et al (Eds) Peripheral Vascular Diseases. St Louis MO, Mosby. Donohue SJ (1997a) Lower limb amputation 4: some ethical considerations. British Journal of Nursing. 6, 22, 1311-1314. Donohue SJ (1997b) Lower limb amputation 3: the role of the nurse. British Journal of Nursing. 6, 20, 1171-1174, 1187-1191. Dormandy JA, Ray S (1997) The natural history of peripheral vascular disease. In Tooke JE, Lowe GDO (Eds) A Textbook of Vascular Medicine. London, Arnold. Dormandy J et al (1999) Major amputations: clinical patterns and predictors. Seminars in Vascular Surgery. 12, 2, 154-161. Dwars BJ et al (1992) Criteria for reliable selection of the lowest level of amputation in peripheral vascular disease. Journal of Vascular Surgery. 15, 3, 558-563. European Working Group on Critical Leg Ischaemia (1992) Second European consensus document on chronic critical leg ischaemia. European Journal of Vascular Surgery. 6, Suppl A, 1-32. Fitzgerald DM (2000) Peer visitation for the preoperative amputee patient. Journal of Vascular Nursing. 18, 2, 41-45. Fyfe NCM (1999) Amputation and rehabilitation. In Davies AH et al (Eds) Essential Vascular Surgery. London, WB Saunders. Gibson JME, Kenrick M (1998) Pain and powerlessness: the experience of living with peripheral vascular disease. Journal of Advanced Nursing. 27, 4, 737-745. Green RM, Rob CG (1994) Amputations of the lower extremity. In Jamieson CW, Yao JST (Eds) Concise Vascular Surgery. London, Chapman and Hall. Hallett JW Jr et al (1997) Impact of arterial surgery and balloon angioplasty on amputation: a population-based study of 1155 procedures between 1973 and 1992. Journal of Vascular Surgery. 25, 1, 29-38. Ham R, Cotton L (1991) Limb Amputation. London, Chapman and Hall.
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Amputation Harris AJ (1999) Cortical origin of pathological pain. Lancet. 354, 9188, 1464-1466. Helt J, Jacobsen J (1999) Amputation in the vascular patient. In Fahey VA (Ed) Vascular Nursing. Third edition. Philadelphia PA, WB Saunders. Herbert L (1997) Caring for the Vascular Patient. London, Churchill Livingstone. Houghton AD et al (1994) Phantom pain: natural history and association with rehabilitation. Annals of the Royal College of Surgeons of England. 76, 1, 22-25. Jacobsen JM (1998) Nursing’s role with amputee support groups. Journal of Vascular Nursing. 16, 2, 31-34. Kubler-Ross E (1969) On Death and Dying. New York, Macmillan. Macfarlane RM, Jeffcoate WJ (1999) Classification of diabetic foot ulcers: the S(AD) SAD system. The Diabetic Foot. 2, 4, 123-131. Nicolajsen L et al (1997a) The influence of preamputation pain on postamputation stump and phantom pain. Pain. 72, 3, 393-405. Nicolajsen L et al (1997b) Randomised trial of epidural bupivicaine and morphine in prevention of stump and phantom pain in lower limb amputation. Lancet. 350, 9088, 1353-1357. O’Connor SE (1993) Nursing and rehabilitation: the interventions of nurses in stroke patient care. Journal of Clinical Nursing. 2, 1, 29-34. Palumbo PJ et al (1991) Progression of peripheral occlusive arterial disease in diabetes mellitus. What factors are predictive? Archives of Internal Medicine. 151, 4, 717-721. Pell J, Stonebridge P (1999) Association between age and survival following major amputation: the Scottish Vascular Audit Group. European Journal of Vascular and Endovascular Surgery. 17, 2, 166-169. Price B (1990) Body Image: Nursing Concepts and Care. London, Prentice Hall. Price JF, Fowkes FGR (1999) Epidemiology of peripheral vascular disease. In Davies AH et al (Eds) Essential Vascular Surgery. London, WB Saunders. Schaldach DE (1997) Measuring quality and cost of care: evaluation of an amputee clinical pathway. Journal of Vascular Nursing. 15, 1, 13-20. Shearman CP et al (1998) Treatment of chronic lower limb ischaemia. In Beard JD, Gaines PA (Eds) Vascular and Endovascular Surgery. London, WB Saunders. Smith DG et al (1999) Phantom limb, residual limb, and back pain after lower extremity amputations. Clinical Orthopaedics and Related Research. 361, 29-38. Thompson D, Haran D (1984) Living with an amputation: what it means for patients and their helpers. International Journal of Rehabilitation Research. 7, 3, 283-292. Weiss SA, Lindell B (1996) Phantom limb pain and etiology of amputation in unilateral lower extremity amputees. Journal of Pain and Symptom Management. 11, 1, 3-17. Williams AM, Deaton SB (1997) Phantom pain: elusive, yet real. Rehabilitation Nursing. 22, 2, 73-77.
Altered body image has a particular impact on patients’ expression of sexuality. You might need to broach the subject to give a patient ‘permission’ to discuss it, or the topic might come up in discussion of other subjects, such as a partner’s reaction to the amputation. Many men with peripheral vascular disease or diabetes also have erectile dysfunction (DePalma and Schwab 1991). In this case, referral to an andrologist might be needed. The nurse needs to be sensitive to the stages of grieving (Box 3) experienced by a patient with an amputation and must ensure that his or her physical rehabilitation programme is congruent with his or her emotional state. For example, anger might manifest itself as a difference of opinion with members of the rehabilitation team and a refusal to participate in rehabilitation. The nurse should have well-developed listening and counselling skills to help the patient work through these feelings. If the patient’s grief reaction is prolonged, he or she might benefit from referral to a clinical psychologist. Depression is a common reaction to amputation. If this is prolonged, antidepressant medication and specialist counselling might help. In the early days after an amputation, the patient might not wish to see the stump. The nurse should support the patient in looking at the stump and handling it when ready. It is also important to respect the patient’s personal space. Sitting in the place on a patient’s bed where his or her amputated leg would have been would be highly insensitive and could even cause phantom pain (Donohue 1997b). Most patients use the familiar term of ‘stump’. The term ‘residual limb’, which is found in the literature, is not often used in the UK and can be misunderstood to mean the opposite leg. Be guided by the patient’s terminology. Loss of a limb might also lead to social losses, such as loss of employment and leisure activities and changes in personal relationships. It could even precipitate loss of the home. Many older patients have unrealistic views about their potential to return to their homes (Thompson and Haran 1984). Early referral to a medical
social worker is essential. Occupational therapists also play a major part in enabling patients to adapt safely to their changed circumstances. A home visit to assess how the patient is likely to function at home is vital. TIME OUT 6 Look at your own home environment. If you were to have a lower limb amputation, how would this affect your daily routine? How would you and your family be likely to feel about this?
Ongoing care After the patient is discharged, follow up is arranged with the limb-fitting centre and the surgical outpatients’ clinic to assess his or her overall recovery and wound healing. Outpatient physiotherapy or other agencies might also be involved. Community nursing services might be required for wound care. For some older patients, amputation can precipitate a move to residential care. The most important person in the patient’s ongoing care is the patient. Health education encompasses advice on stump care, risk factor modification, such as control of hyperlipidaemia and smoking cessation, and care of the other foot. It is sobering to note that two years after a BKA, 40 per cent of patients are well and using a prosthesis, 30 per cent have had a further major amputation and 30 per cent have died (Dormandy and Ray 1997). Conclusion The nurse is essential to the physical recovery and successful rehabilitation of those who have an amputation. Equally important is the nurse’s contribution to helping the patient to adjust psychologically to their changed status. With intelligent, sensitive nursing care, amputation can be a constructive operation, which leads to improved quality of life and successful adjustment on the part of the patient
TIME OUT 7 Now that you have completed the article, you might like to think about writing a practice profile. Guidelines to help you write and submit a profile are on page 55.