Amputation Flashcards
What is Diabetic Foot Ulcers; Ax and Tx
Hyperglycemia (high blood sugar) leads to vasoconstriction →ischemia缺血
→neuropathy→impaired peripheral sensation
Ax
- Neurological Status: Presence of “protective sensation” (Sensate to10-g monofilament) test sensation
- Vascular Status: Checking pedal pulses/Capillary filling time to the digits
- Wound evaluation: Location, size, shape, depth, border, signs of infection
Tx
Patient Education and Prevention; Foot hygiene; Foot self-examination; Proper footwear; Shoe orthotics
矯形器(e.g. insoles) to distribute weight over the foot
Levels of Limb Amputation
- Above the elbow: transhumeral
- Below the elbow: transradial
- Below the wrist: transmetacarpal
- Above the knee: transfemoral (AKA)
- Below the knee: transtibial (BKA)
- Below the ankle: transmetatarsal
Goals of Preprosthetic training (From postsurgery until receives permanent prosthesis)
a. Assist the client in coping with psychological aspects of limb loss, including changed body scheme, reduced self-esteem and self-efficacy, shock, disbelief, anger, grief, guilt, denial, hopelessness, and depression
b. Optimize wound healing
c. Maximize residual limb shrinkage and shaping to achieve tapered distal end, the optimal
shape for a prosthetic socket
d. Desensitize residual limb
e. Maintain or increase range of motion (ROM) and strength
f. Facilitate independence in ADLs
g. Explore prosthetic options (if desired)
Information collected during Ax
- Pain
- Skin complications, including delayed healing, necrosis, and skin graft adherence to bone
- Edema of residual limb
- Bone spurs
- Neuroma 神經瘤 on distal end of residual limb
(Pain from a neuroma is usually caused by traction on a nerve when a neuroma is bound down by scar tissue) - Phantom limb pain, a sensation that appears to occur in the missing limb such as stabbing,
cramping, burning, or throbbing - Phantom sensation (the sensation of the missing limb; not painful)
OT intervention during pre-prosthetic training
- Limb hygiene
- Wound care and healing
- Stump shrinkage and shaping:
:) reduce edema
:) develop a tapered shape
:) reduce phantom sensation - Sensory reeducation
Phantom limb → Stump Desensitization (tapping, vibration, constant pressure, and rubbing with varying textures)
Phantom pain → Mirror visualization, imagery - Joint mobility and stretching
- Stump positioning to prevent contracture; AKA CG shift posteriorly → the large rear wheels should be placed further back to counterbalance missing limbs; antitippers
- Exercise program for ROM and strengthening muscle groups proximal to amputation and core strength
- ADL retraining and consideration of modifications of environment and activity, as well as adaptive strategies
- Psychosocial adjustment
- Exploration of optimal prosthesis to meet patient’s goals
Considerations when prescribing an upper limb prosthesis
a. Length, strength, flexibility, and skin integrity of the residual limb; level of amputation
b. Patient preference for cosmesis (appearance) and function
c. Hand dominance
d. Typical activities to be performed with the prosthesis (home, work, leisure, social)
e. Psychosocial adjustment
f. Cognition and ability to manage prosthesis care
Goals during Prosthetic training (Occurs after the client receives permanent prosthesis)
a. Teach the client to independently don and doff prosthesis.
b. Train the client in care of the prosthesis.
c. Increase the client’s wearing time to full day.
d. Provide prosthetic control and functional use training.
e. Encourage the client in independent use of the prosthesis.
Factors limiting performance during prosthetic training
a. Any changes in sensation in the residual limb, including hypersensitivity and sensation loss
b. Presence and severity of phantom sensations
c. Pain
d. Body image and self-image
e. Strength, flexibility, and endurance of the residual limb in preparation for prosthesis wearing; full body strength, flexibility, and endurance
f. Skin integrity
g. Performance patterns including habits, routines, and roles, that may have been affected by
amputation
h. Pressure injury as a result of ill-fitting prosthesis socket or wrinkles in prosthetic sock
i. Sebaceous cysts resulting from torque of prosthetic socket
j. Edema resulting from ill-fitting socket or too-tight prosthetic sock
k. Sensory changes such as loss of sensory information as a result of missing limb, residual
limb hyperesthesia (oversensitivity), areas of absent or impaired sensation, phantom limb or phantom sensations.
OT intervention during prosthetic training
- Client education about the prosthesis
- Training to don and doff the prosthesis; for a myoelectric prosthesis, training in alignment of
the electrodes to obtain good electrode contact - Prosthesis wearing schedule
- Limb hygiene
- Care of the prosthesis
- Upper limb prosthesis training
- Provision of adaptive equipment as needed
- Work with the client to develop the repertoire of skills needed to perform ADLs and IADLs
- Weight bearing training
- Advanced Activities
Psychosocial Issues
Negative mood
Mourning, lost, depressed, angry, anxious, fearsome, distressed, low self-esteem etc.
Altered self-perception
Negative self-image is a common phenomenon
Unrealistic body image
Assessments
Observation
Questionnaire on self-image on amputation
Trinity amputation and prosthesis experience scales (TAPES) e.g. Amputee Body Image Scale (ABIS) 截肢患者的体象量表
Prosthesis wearing schedule
a. Initial wearing time should be 15 to 30 minutes.
b. The prosthesis should then be removed, and the stump examined for reddened areas.
c. If no reddened areas are apparent after 20 minutes, the wearing time is increased in 15- to
30-minute increments until the client wears the prosthesis for a full day.
d. Any reddened areas that do not disappear after approximately 20 minutes should be
reported to the prosthetist so the prosthesis can be adjusted.
Limb hygiene
a. Daily cleansing
b. Inspection of stump for reddened areas, particularly insensate areas
c. If the client wears a prosthetic sock, they should wear a clean one daily
Care of the prosthesis
a. Clean the interior daily with mild soap and water.
b. Clean hook or cosmetic hand with soap and water. Additional cleaning may be needed if the prosthesis is heavily soiled.
c. Allow prosthesis to dry completely prior to donning.
d. Myoelectric prosthesis wearers must be taught to replace batteries.
e. Learn basic knowledge of the prosthesis: terminology, design, control systems, basic mechanics.
Upper limb prosthesis training
a. Prosthesis control training: operation of each component of the upper limb prosthesis
b. Prosthesis use training: integration of prosthesis components for efficient assist during functional use
i. Prepositioning training: identification of the optimal position of each positioning unit
(e.g., wrist, elbow) to perform an activity or grasp an object
ii. Prehension training: grasp activities
c. Functional training: functional activities
i. Incorporation of the TD as a functional assist
ii. Focus on a problem-solving approach
d. Adaptive sports and recreation: train the client in activity-specific prostheses if applicable.
e. Driver training: can make a referral for comprehensive driving eval and training when appropriate.
Work with the client to develop the repertoire of skills needed to perform ADLs and IADLs
a. For clients with lower limb amputations, functional mobility, including transfers; bed mobility; and wheelchair mobility
b. Methods to perform vocational and leisure activities; job site analysis and intervention
c. Home evaluation and intervention, if necessary
d. Emotional and psychosocial support
