AMPUTATION

Nursing management of patient with amputation

·                     Pain Management 
Managing pain is important. It is important to serve analgesia strictly. Assess patients’ response towards pain medication. 

·                     Psychological support 
Patients undergoing amputation will be under tremendous stress. Anxiety level will be escalated. It is important that patient understands the reasons for surgery and how to deal with it postoperatively. Consistent support and encouragement from family members and healthcare workers are important towards patients’ recovery.

·                     Rehabilitation
Rehabilitation plays an important role towards patients’ recovery. Exercise should be initiated early. Patients will be seen by a Physiotherapist postoperatively and is responsible to teach some range of motion (ROM) exercises, muscle strengthening, stump exercises, balancing exercises etc to patient. The Occupational Therapist will be teaching patient wheelchair transfer, safe transferring techniques and conduct activities of daily (ADL) assessment.

Dos and Don’ts to prevent muscle tightening, or contractures.

Prescribed exercises should be done regularly, and the positions shown be avoided if the greatest benefit is to be obtained from the prosthesis.

Preparation for Fitting the Prosthesis

In general, the earlier a prosthesis is fitted, the better it is for the amputee. One of the most difficult problems facing the amputee and the treatment team is edema, or swelling of the stump, owing to the accumulation of fluids. Edema is present to some extent in all cases, and it makes fitting of the prosthesis difficult, but measures can be taken to reduce edema.

Elastic bandages are used to keep edema from developing. The patient is taught the proper technique for bandaging and is generally expected to do this for himself. The stump should be bandaged constantly, but the bandage should be changed every four to six hours. It must never be kept in place for more than 12 hours without re-bandaging. If throbbing should occur, the bandage must be removed and rewrapped.

Special elastic "shrinker socks" are available for use instead of elastic bandages, and while not considered by some to be as effective as a properly applied bandage, "shrinker socks" is better than a poorly applied elastic bandage. Whether an elastic bandage or shrinker socks is used, it should be removed at least three times daily and the stump should be massaged vigorously for 10-15 minutes. The bandage or socks must be reapplied immediately after the massage. After surgery, fitting as soon as possible also helps to combat edema. A preparatory prosthesis is frequently used for several weeks or months until the stump has stabilized before the "permanent", or definitive, prosthesis is provided.

The socket of the preparatory prosthesis may be made of either plaster-of-Paris or a plastic material, and is usually attached to an artificial foot by an aluminium tube often called a "pylon". The aluminium pylons are usually designed so that the position, or alignment, of the foot with respect to the socket can be changed when necessary. Although a variety of shoes may be worn with artificial limbs, the patient should consult with the prosthetist before selecting the shoes because heel height is a major factor in alignment of the artificial leg.A belt about the waist is usually used to help keep the prosthesis in its proper place on the stump. At least one prosthetic sock is worn between the socket and the body to provide for ventilation and to protect the skin from rubbing. Most prosthetic socks are made of woven virgin wool, but socks of synthetic yarns are also used. Three thicknesses are available: 3 ply, 5 ply, and 6 ply.Additional socks can be used to compensate for stump shrinkage if the amount of shrinkage is not too great. The prosthetist and therapist can suggest the sock or socks to be used, but only the patient can determine the proper selection. Prosthetic socks must be changed daily to reduce the chance of irritation of the skin and dermatitis. Additional socks can be used to compensate for stump shrinkage if the amount of shrinkage is not too great. The prosthetist and therapist can suggest the sock or socks to be used, but only the patient can determine the proper selection. Prosthetic socks must be changed daily to reduce the chance of irritation of the skin and dermatitis.

Prosthetic socks require special care in laundering. The manufacturers provide instructions. A specially woven nylon sock known as a prosthetic sheath is used by many amputees between the skin and the regular prosthetic sock to provide additional protection from abrasion. The sheath also allows perspiration to escape to the prosthetic sock and thus to the atmosphere.

Donning Your Prosthesis and Socks

·                     Be sure the prosthesis and socks have been cleaned and thoroughly dried before donning. Wear a fresh sock everyday. Your residual limb should be clean and dry as well. Before donning the prosthesis, inspect the leg with a mirror for any areas of redness, breakdown or tender to the touch Place a sock over the end of your residual limb before donning prosthesis. The socks protect your skin from injury and sores. Apply each sock one at a time. Place all seams facing out and away from bony areas. Wear enough socks to hold your socks properly down in the prosthesis, and to prevent movement up and down inside the prosthesis. Be sure that your socks fit closely, without any folds or wrinkles. Folds and wrinkles cause increased pressure on the skin that can lead to skin irritation and breakdown and decrease circulation.

·                     Do not put band-aids or tape on your leg before wearing your prosthesis. Once the socks are on, the prosthesis may be donned slowly and gently.

Care of Your Remaining Leg

·                     Inspection skin frequently especially your feet for signs of redness, skin breakdowns and areas tender to touch

·                     Do not wear socks with holes or darns

·                     Changes socks daily

·                     Break in new shoes slowly

·                     Do not cut on corns or calluses

·                     Have a podiatrist cut your nails 

·                     Wash feet in warm water, not hot, and pat dry with a soft towel 

·                     Avoid walking barefoot

·                     Wear only well fitting shoes

Care of Your Residual Limb

·                     Wash your residual limb every evening with lukewarm water and a mild soap. Bathing may cause the residual limb to swell, which could affect the fit of the prosthesis. Therefore, evening bathing is recommended.

·                     To eliminate bacteria growth, thoroughly clean skin folds using cotton swabs. Completely rinse and towel dry. Inspect your residual limb after wearing your prosthesis; carefully watch for such skin changes as redness, breakdown or areas tender to the touch. This can be accomplished with the use of a long-handled mirror.

·                     Gently massage your residual limb daily. This will help decrease sensitivity and increase pressure tolerance. Do not apply oils, creams or alcohol to your residual limb because your skin must toughen for you to wear your prosthesis. Creams cause your skin to soften, and alcohol causes your skin to become dry. Avoid prolonged dependent positioning of residual limb

·                     Avoid prolonged pressure to the stump site to avoid skin breakdown

Sock Hygiene

·                     Wash all residual limb covering materials (ace wrap, shrinker, socks) daily in lukewarm water and a mild soap or Woolite Gently squeeze the soap through your socks. Do not twist or rub. Rinse thoroughly.

·                     To dry, roll your socks in a towel and place on a flat surface or over an empty bleach bottle that has holes poked in it.

Prosthetic Care

·                     Wipe out the prosthetic socket daily with a damp cloth and a mild soap or alcohol. Dry the socket thoroughly with a clean towel.

·                     The prosthesis should be placed on its side on the floor when not in use so that it does not fall over and crack.

Bandage Care

·                     Wash elastic bandages with mild soap and warm water. Rinse thoroughly

·                     Do not hang up to dry – this may spoil the elastic. Lay out on a flat surface. Keep away from heat and sunlight, which may also harm the elastic.

Equipment Training

·                     Amputee should be trained for use of following equipment which should be procured for ease in activities of daily living. Bath-seat shower hosenon-skid mat or strips long bath spongetoilet rails

·                     other - commode, sliding board

BASIC TYPE OF PROSTHETICS FEET

There are two basic type of prosthetic feet; non-articulating (non-movable feet / rigid)  and articulating feet (movable feet). 

Examples of non-movable feet are SACH (Single Axis Cushion Heel) foot  and elastic keel foot.

SACH

Elastic keel feet.
Basically elastic keel feet is just the same to SACH foot. The keel is more elastic in compare to the wooden keel of SACH foot.

The SACH foot is the simpler of the two. It is rigid and cannot bend. It has a rubber heel wedge that compresses under the user’s weight, allowing a little ankle movement early in the stance phase of walking (at the beginning of a step). It provides stability, but little lateral movement, in mid-stance (when walking). The SACH foot comes in several heel heights so it can be worn with different types of shoes. Elastic keel feet are a little more flexible than SACH feet. They allow the front part of the foot to adjust to varied walking conditions but stay stiff and stable while standing or walking.

The second type of prosthetic feet is articulated foot. There are three types of articulated feet: single-axis, multi-axis and dynamic-response feet. Both allow motion in one or more planes, much like the movement of a human foot.

 

Single-axis feet 

·              Have an ankle joint that allows the foot to move up and down, which adds knee stability.

·              Are often used by people with higher levels of amputation (from the knee to the hip).

·              Reduce the effort needed to control a prosthesis and keep the knee from buckling.

·              Add weight to the prosthesis, need periodic repair and cost a little more than most basic feet.

·              Are often used by people who need stability.

Multi-axis feet 

·              Are similar to single-axis feet in terms of weight, need for repair, and cost.

·              Move up and down as well as side to side to conform to uneven surfaces better than single-axis feet.

·              Have ankle motion, which absorbs some of the stress of walking, protecting a person’s skin and reducing wear and tear on the prosthesis.

·              Are often used by hikers, golfers, dancers and others who need a lot of foot movement.

Dynamic-response feet 

·              Store and release energy during the walking cycle.

·              Give a sense of push-off, a more normal range of motion and balanced gait.

·              May have a split-toe design to add stability.

·              May lessen the impact on the heel of the person’s other foot.

·              Are so comfortable and responsive that amputees might increase their level of activity.

·              Are responsive and good for active amputees who vary their walking speed, change direction quickly, or walk long distances.

As technology in Prosthetics and Orthotics field is enlarge in mass, there are much more high technology of prosthetic foot can be invent in future.

CAUSES OF AMPUTATION

3 main causes :

1) Trauma
The major cause of amputation around the world. In developed nations, trauma usually occurs as a result of industrial accidents, farming accidents, or motor vehicle accidents, which include automobiles, motorcycles and trains.

2) Disease
The major diseases that contribute to amputation are vascular diseases, diabetes and tumors.

foot gangrene causes by diabetes

3) Conginetal deformities
Accounts for a small portion of reported amputations. In these cases a child is born with an abnormally shortened, malformed limb or no limb at all.

PERCENTAGE OF LIMB AMPUTATION AT ALL LEVEL

transtibial amputation

transfemoral amputation