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Let the healing begin. (Wound Care).

Joe Green, a 73-year--old widower who underwent a below-the-knee amputation three days ago, is being admitted to your unit tomorrow. Mr. Green's amputation was the result of severe peripheral vascular disease. The past few years have been especially difficult for him because of chronic tissue ischemia, persistent leg ulcers that resisted healing, and progressive leg pain. Eventually it was decided that a below-the-knee amputation was necessary. Mr. Green has limited financial resources; he has been living alone in a small second-floor apartment and his only child, a son, lives with his family 300 miles away. Since his physical condition limited his socialization, he has become discouraged and found managing his daily living increasingly difficult. Because of these factors, Mr. Green anticipates remaining in the long term care facility permanently.

According to Phipps, Sands, and Market, (1) 91.7 percent of the more than 110,000 amputations performed annually involve the lower extremity. Statistics collected by the Amputee Coalition of America indicate that of amputations secondary to dysvascular reasons, 53.4 percent are of the below-the-knee type, 54.9 percent occur in males and 25.7 percent occur in the age group of 65-74. Mr. Green is a prime example of these statistics. Although diabetes was not a factor in his situation, it potentially could have had a major influence if present. Phipps et al. say that there is a 15 times greater rate of amputation in diabetics.

Mr. Green's preoperative preparation included diagnostic testing to determine healing potential and teaching about pain, exercise, positioning, stump care, and psychological factors associated with limb loss. The surgical procedure was of the closed variety in which a skin flap, cut longer than the bone, is secured with sutures or staples in a posterior position. The closed method results in a stump that facilitates weight bearing with a prosthesis. An alternative open method might be used when infection is present and a drainage mechanism is required after surgery. Wound closure is carried out when the drainage is no longer present. If a prosthesis is to be used, a temporary device of rigid plastic may be fitted at the time of surgery and a permanent one fitted later. Mr. Green has opted not to use a prosthesis.

Edema and flexion

After surgery the dressings, commonly Kerlix covered with an elastic compression bandage wrapped in a figure-eight pattern, are changed at least once daily, according to Patricia Stoneberg, BS, CCRN, a surgical nurse clinician at Regions Hospital, a Level I trauma center in St. Paul, Minn. The compression bandage controls edema, helps shape the stump, keeps the dressing in place, and aids circulation. The incision site is assessed for redness, swelling, and bleeding, and the stump is supported on pillows to decrease edema. While some sources discourage the use of more than one pillow because of the dangers of stump flexion, Stoneberg says that two might be necessary in some instances to ensure that edema is reduced. However more rigorous attention must then be paid to positioning to prevent flexion, she emphasized.

Analgesics to control the surgical pain are initiated. Occupational and physical therapy are involved immediately after surgery to facilitate exercise and proper positioning. The patient is up in the wheelchair soon after surgery, making sure that the stump is kept level with the buttocks while up, Stoneberg adds.

The fact that Mr. Green is being discharged so soon post-operatively is not unusual. While in the past a hospitalization of two or three weeks would have been common, a patient is frequently transferred to a sub-acute unit or nursing home on the second or third day post-op if there are no complications, according to Stoneberg. Poorly controlled diabetes, bleeding, or infection will delay the discharge, she said.

Promote healing

Proper stump care is very important after transfer from the hospital to facilitate healing and shaping. Dressing changes at least daily and rewrapping of the Ace bandage should continue until the staples or sutures are removed three weeks post-operatively. The incision should not be submerged in water during this interval, the nurse clinician emphasized. However the stump should be washed daily and thoroughly dried once healing is complete. Lotions, oils, or powders are nor used unless ordered specifically by the physician.

Exercises and positioning begun in the hospital must continue in the long term care setting. In addition to changes of position every two hours, Phipps et al. encourage at least two sessions each day of 20- to 30-minute prone positioning to promote hip extension. The resident must be instructed to avoid positions that could result in flexion contractures. Muilenburg and Wilson, writing in A Manual for Below-Knee Amputees, give these as examples of what the resident should not do: hang the stump over the edge of the bed, sit in a wheelchair with the stump flexed, place a pillow under the hip or knee, flex knees when lying down, place a pillow between the thighs or sit with the knees crossed. (2) A trapeze on the bed will help the resident change position and will strengthen the upper extremities for transfer techniques and activities of daily living.

Dietary considerations

The resident's changing nutritional needs must be given close attention. Linda Kautz Osterkamp, PhD, RD, FADA, CNSD, writing in the Consultant Dietitian, says that the first step is an assessment based on physical changes resulting from the amputation. It is preferable to use the actual weight but if that cannot be obtained, a pre-amputation weight minus the weight of the amputated part is used. Because "segmental weight standards" consider the calf and foot combined to be 5.9 percent of total body weight, she subtracts this amount from the pre-amputation weight to determine an adjusted new weight. If the thigh has also been removed she adds an additional segmental weight standard of 10.95 percent. (3)

Osterkamp emphasizes how energy expenditures change after amputation and thus affect caloric needs. One must consider not only the change in resident activity level, but also the type of amputation.

Over time, adjustments in the caloric intake must be made if increased muscle mass or fluid retention have affected the resident's weight. New daily lifestyle patterns will be established as the resident is rehabilitated; these changes potentially affect body mass. For example, a resident may develop increased arm muscle mass from wheeling his chair.

Bridget Doyle, PhD, MPh, RDLD, clinical dietitian at Minnesota Veteran's Home, Minneapolis, and an independent dietary consultant, individualizes the nutritional plan after conducting a resident interview. Doyle establishes goals according to either the actual weight or the ideal weight, whichever is desired by the resident. Weekly and monthly strategies are then set up to meet the goals. She involves families by suggesting snacks or restaurant meals to bring in. If there is poor fluid intake, stress, or slow wound healing, Doyle recommends a powdered or liquid supplement high in amino acids and nitrogen. "Collaboration with other disciplines such as recreational therapy and nursing is critical if the resident is to be treated as a whole," she says. "And don't forget to celebrate the successes along the way."

Painful reminders

Many amputees experience phantom sensations and phantom pain. A phantom sensation is a feeling that the missing limb is still there; when the sensations become painful they are referred to as phantom pain. According to the UCLA Medical School neurosurgery Web site, the pain may vary from "continuous cramping, aching, and burning to electric shock-like and intermittent." UCLA sources maintain that 5-10 percent of amputees experience the pain and that it appears to occur more frequently when the amputation has occurred at an older age. (4) And while factors such as touch, urination, smoking, infection, sunburn, or exposure to cold may trigger the pain, other factors such as anxiety, depression, anger, and sleeplessness may aggravate it. (5)

Although many therapies have been used to treat phantom pain, none has been consistently effective. UCLA sources advocate first eliminating factors that appear to increase the pain, then following with medication. If there is no improvement, the medication should be discontinued. Other therapies ranging from acupuncture to complex surgical procedures have less than a 30 percent success rate a year later.

Finding a medication regimen successful in treating phantom pain is frequently a case of trial and error according to David Guay, PharmD, Professor, Institute for the Study of Geriatric Pharmacotherapy, College of Pharmacy, University of Minnesota, and Clinical Specialist at PartneringCare Senior Services, HealthPartners, Minneapolis. He says that if a particular regimen doesn't work because of ineffective pain relief or toxicity, "the practitioner will need to go to Plan B."

"Tricyclic antidepressants have formed the backbone of pain therapy of chronic neuropathic pain disease states for a number of years," writes Guay. (6) Since the secondary amines (e.g. desipramine, nortriptyline) exhibit fewer anticholinergic and sedative effects than the tertiary amines (e.g. amitriptyline, imipramine) they may be more desirable in the elderly population, he advises.

Adverse effects associated with tricyclic antidepressants have led to increased use of antiepileptic drugs for their analgesic activity. Those found useful in treating neuropathic pain include carbamazepine, gabapentin, and lamotrigine.

Grieving and self-image

After amputation the resident will need help in adjusting to a changed body image. Staff Chaplain Leonard Pankuch of Mayo Medical Center in Rochester, Minn., says that staff must provide a "listening presence," allowing the resident opportunity to grieve. "At first the sense of loss focuses on the missing body part but then there is a delayed reaction as the patient gradually becomes aware of the lost lifestyle," he says.

While Pankuch sees some patients follow the classic pattern of Elizabeth Kubler-Ross's grief stages, he notes that others skip stages or go through them in a different order. The patient may express anger and self-loathing, especially if negative health behaviors may have been a factor leading to the amputation. There may be anger toward God or family members. Staff may receive the brunt of the anger. But the key to resolution is that this anger needs to be expressed, he states.

Pankuch also sees patients who express a sense of relief after the amputation because their severe pain is now gone. But staff still must be alert to delayed grief reactions.

Caring for Mr. Green will present numerous challenges that will require tapping into the expertise of all disciplines. But the result can mean a quality life for Mr. Green within the caring environment of the long term care unit.

Reference

(1.) Phipps W, Sands J, Marek J. Medical-Surgical Nursing: Concepts and Clinical Practice. 6th ed. St. Louis: Mosby; 1999; 770-774

(2.) Muilenburg A, Wilson A. A Manual for Below-Knee (Trans-Tibial) Amputees. 5th ed. Topping, (VA): Rehabilitation Press; 1996; 5

(3.) Osterkamp L. Assessing the nutritional needs of the amputee. The Consultant Dietitian. Summer 1996. volume 21 (1): 1.

(4.) UCLA Neurosurgery: <http://neurosun.medsch.ucla.edu/Diagnoses/Pain/PainDis_2.html>

(5.) Bryant, G. Stump care. American Journal of Nursing. February 2001. Volume 101 (2): 67.

(6.) Guay D. Adjunctive agents in the management of chronic pain. Pharmacotherapy. In press, 2001.

Woodbury, Minn.-based Janice K. Olson, RN, MS, MEd, is a member of CLTC's advisory board.
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Author:Olson, Janice K.
Publication:Contemporary Long Term Care
Geographic Code:1USA
Date:May 1, 2002
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