musculoskeletal amputation and hip anthroplasty

Question 1

amputation

Answer 1

This is the removal of body part like digit or limb.,
- Therapeutic- relieve symptoms, improve function, save or improve quality of life
Causes: effect of vascular disease like DM; trauma

Question 2

how/why amputation

Answer 2

This is performed at the most distal point that will heal successfully – far away from body as possible

• –> determined by circulation in the area, and functional usefulness
• Circulatory status must be evaluated! (As much as possible, the limb must be saved)

Angiography- performed to see where the circulation ends

Question 3

examples of amputation

Answer 3

1. Syme amputation-modified ankle disarticulation amputation: Aim –durable residual limb (it must be able to stand full weight bearing)
2. BKA (below the knee amputation)
3. AKA (above the knee amputation
4. “Staged” amputation- this is done when gangrene and infection exist

Question 4

staged amputation

Answer 4

First, guillotine amputation is done (above the necrotic tissue)- > wound is debrided and allowed to drain -> sepsis is treated- > once infection is treated, definitive amputation is done with skin closure

Question 5

amputation complications

Answer 5

Hemorrhage
Infection
Skin breakdown
Phantom limb pain- pain perceived in the amputated section
Joint contracture

Question 6

phantom limb pain

Answer 6

caused by severing peripheral nerves

Question 7

joint contractures

Answer 7

due to positioning and protective flexion withdrawal pattern assoc. w/ pain and muscle imbalance

Question 8

management of amputation goal

Answer 8

Goal: achieve healing of the amputated wound-> nontender residual limb with healthy skin for prosthetic use

Question 9

management of amputation

Answer 9

gentle handling of residual limb, control residual limb edema, proper wound care, relieve pain, help pt resolve grieving/achieve physical mobility, lower limb amputation

Question 10

controlling residual limb edema

Answer 10

Rigid cast dressing, removable rigid dressing, or elastic residual limb shrinker- > to provide uniform compression, support soft tissue and control edema.

Question 11

pain relief management amputation

Answer 11

• Nurse must acknowledge the complaint of phantom limb pain as real
• Phantom limp pain gradually diminishes over time (can be as long as 2 years)

Question 12

help patient resolve grieving

Answer 12

5 stages of grief (DABDA)- Denial- no health teachings during this stage, anger, bargaining, depression, acceptance

Question 13

help patient achieve physical mobility

Answer 13

upper limb amputation, lower limb amputation, use of prosthesis

Question 14

lower limb amputation

Answer 14

Proper positioning prevents hip or knee joint contractures
Avoid: abduction, external rotation, and flexion of the lower limb
no “man spreading”
ROM exercises should be started early

Question 15

BKA

Answer 15

you need to exercise above knee and hip

Question 16

lower limb amputation

Answer 16

Note: after the first 24 hours after surgery, residual limb should not be placed on a pillow because flexion contracture of the hip may happen!
–Patient with AKA- > lie prone for 20-30 minutes, 3x a day

Encourage patient to turn from side to side and prone position- to prevent contractures
Discourage prolonged sitting

Question 17

upper limb amputation

Answer 17

Muscles of both shoulders must be exercised

Patient should be taught to perform ADLs with one arm

Question 18

general amputation nursing

Answer 18

• transfer pt out of bed from unaffected side
• orthopedic surgeon is the one that determines weight bearing status
• avoid flexion of hip > 90 degrees
• avoid low chairs!!!
• use elevated seating or raise toilet seat
• prevent DVT

Question 19

prepare patient on the use of prothesis

Answer 19

Elastic bandages, or elastic residual limb shrinker- used to condition and shaped the residual limb.
Problems that can delay fitting:
-Flexion deformity; non-shrinkage of residual limb; abduction deformity of hip
start with: soft pillow then firm pillow finally hard surface

Question 20

emergency management of traumatic amputation

Answer 20

1. Apply direct pressure using gauze (or clean cloth)
2. Elevate the extremity above the level of the heart
3. Wrap the severed extremity in dry sterile gauze (or clean cloth)- > place it in sealed plastic bag- > submerge the bag in ice-water- > send it with the patient.

Question 21

monitor and treat pain

Answer 21

Differentiate Phantom limb pain vs. incisional pain

• Incisional pain- analgesic
• Phantom limb pain- opioid analgesic +
  1. Beta blockers (propranolol)- can relieve dull and burning pain
  2. Anti epileptics - gabapentin (Neurontin); carbamazepine ( Tegretol): can relieve sharp, stabbing and burning pain

Question 22

Total hip arthoplasty (THA)

Answer 22

This is the replacement of severely damaged hip with artificial joint.
Indication: osteoarthritis; rheumatoid arthritis; femoral neck fracture

Question 23

geriatric consideration THA

Answer 23

• Early THA surgery (within 24-36 hours) for most patients once medical assessment has been made and the patient’s condition has been stabilized.
• If no contraindication, patients should receive LMWH for DVT prophylaxis (mechanical devices should be used for those who cannot receive anticoagulants and anti platelets).
• Plan for early assisted mobilization and ambulation.

Question 24

prevent discoloration of hip prothesis

Answer 24

• Correct positioning at all time!!!*
  1. Supine with head slightly elevated, affected leg in neutral position
  2. Use abduction splint (wedge pillow)
  3. When turning to the unaffected side, keep the operative hip in abduction position.
  4. Do not turn to the operative site
  5. Hip should never be flexed more than 90 degrees

Question 25

Prevent dislocation of hip prosthesis (continuation)

Answer 25

• When patient is being assisted out of bed/ambulating!!!!*
  1. Keep abduction pillow between the legs
  2. Keep affected hip in extension
  3. Transfer out of bed from unaffected side to chair
  4. Pivot on unaffected leg with assistance from the nurse
  5. Avoid low chairs; avoid hip flexion greater than 90 degrees
  6. Use elevated seating/raised toilet seat

Question 26

s/s of prothesis dislocation

Answer 26

Shortening of the affected extremity
Abnormal external or internal rotation
“Popping” sensation in the hip

Question 27

nursing dislocation

Answer 27

1. notify doc immediately
2. hip must be reduced (placed in proper position) ASAP to prevent circulatory and nerve damage → prepare for immediate surgery
3. prevent PE

Question 28

Promote ambulation

Answer 28

Weight-bearing status- crutches, walker

Question 29

prevent DVT

Answer 29

SCD, TED, heparin (anticoagulants)

Question 30

prevent infection