AMPUTATION

Introduction:
Amputation: - Surgical removal of limb or part of the limb through a bone or multiple bones
Amputation is the removal of a body extremity by trauma or surgery. As a surgical measure,
it is used to control pain or a disease process in the affected limb, such as malignancy or
gangrene. In some cases, it is carried out on individuals as a preventative surgery for such
problems.
Removal of part or all of a body part enclosed by skin Removal of the peripheral part of the
limb or any other organ.
Amputation refers to the surgical or traumatic removal of the terminal portion of the upper or
lower extremity. Hemicorporectomy (trans lumbar amputation or "halfectomy") is a radical
surgery in which the body caudal to the waist is amputated, transecting the lumbar spine.
Amputation is the surgical removal of all or part of a limb or extremity such as an arm, leg,
foot, hand, toe, or finger.
About 1.8 million Americans are fiving with amputations, Amputation of the leg either above
or below the knee is the most common amputation surgery.
Incidence
Age, common in 50-75 years of age
traumatic- common in young age
Sex: approx. 75% male, 25% female
Limb; approx. 85%-lower limb, 15% -- upper limb
Indication
Trauma
Trauma is the leading indication for amputation in younger age group. The only absolute
indication for primary amputation is an irreparable vascular injury in an ischemic limb.
Peripheral vascular disease
 lower extremity 60-70% of amputations
 upper extremity 6%
 Arteriosclerosis
 Thromboembolism
 Most significant predictor of amputation in diabetes: - peripheral neuropathy
 Prior stroke
 Decrease ankle-brachial blood pressure index
 Vascular surgery consultation
Congenital limb deficiency
 LE <3% of all amputations, U/E 9%
 Failure of partial or complete formation of a portion of the limb.
  Congenital extremity deficiencies have been classified as longitudinal. transverse, or
intercalary.
 Radial or tibial deficiencies are referred to as preaxial, and ulnar and fibular
deficiencies are referred to as postaxial.
Tumor
Amputation is performed less frequently with the advent of advanced limb- salvage
techniques
Burns and frostbite:
Burns
 delayed amputation local infection
 systemic infection
 myoglobin induced renal failure
 death

Frost bite:-
 Typically occurs when one is trapped in extreme cold conditions for extended periods
 direct tissue injury- ice crystals in ECF
 Ischaemic injury- vascular endothelium
 Clot formation
 Inc. sympathetic tone
 limb kept at 40-44 degree C
 Wait 2–6-month demarcation
 Triple phase technetium bone scan

Signs and Symptoms

Subjective
 Pain
 Limited motion
 Malaise
Objective
 Local swelling
 Weight loss
 Anaemia
 Elevated serum alkaline phosphatase
 Fever
 Pre operative assessment
Haematocrit
Creatinine levels should be monitored. In individuals with muscle injury and necrosis,
myoglobin enters the systemic circulation and can lead to renal insufficiency and failure,
especially in individuals with thermal and electrical burns.
Potassium and calcium levels should be monitored. Elevated levels of these electrolytes may
lead to cardiac arrhythmias and seizures.
White blood cell count, C-reactive protein, and ESR Expect the C-reactive protein to be the
first laboratory value to respond to treatment.
Platelets
 Postoperative management
 Prompt, uncomplicated wound healing
 Control of oedema
 Control of Postoperative pain
 Prevention of joint contractures
 Rapid rehabilitation
 Care of stump
 keep the stump clean, dry, and free from infection at all times.
 If fitted with a prosthesis, you should remove it before going to sleep.
 Inspect and wash the stump with mild soap and warm water every night, then dry
thoroughly and apply talcum powder.
 Do not use the prosthesis until the skin has healed.
 The stump sock should be changed daily, and the inside of the socket may be cleaned
with mild soap.
Amputations are carried out:
Amputations can be carried out under general anaesthetic (where you're unconscious) or
using an epidural anaesthetic (which numbs the lower half of the body).
Once the limb has been removed, a number of additional techniques can be used to help
improve the function of the remaining limb and reduce the risk of complications.
These include shortening and smoothing the bone in your remaining limb so it's covered by
an adequate amount of soft tissue and muscle, and stitching the remaining muscle to the
bones to help strengthen your remaining limb (a technique known as myodesis).
After the amputation, wound will be sealed with stitches or surgical staples. It will be covered
with a bandage and a tube may be placed under your skin to drain away any excess fluid. The
bandage will usually need to be kept in place for a few days to reduce the risk of infection.
Assessment before surgery
Unless you need to have an emergency amputation, you'll be fully assessed before surgery to
identify the most suitable type of amputation and any factors that may affect your
rehabilitation.
The assessment is likely to include:
A thorough medical examination assessing your physical condition, nutritional status, bowel
and bladder function, your cardiovascular system (heart, blood and blood vessels) and your
respiratory system (lungs and airways).
An assessment of the condition and function of your healthy limb removing one limb can
place extra strain on the remaining limb, so it's important to look after the healthy limb.
A psychological assessment to determine how well you'll cope with the psychological and
emotional impact of amputation, and whether you'll need additional support
An assessment of home, work and social environments to determine whether any additional
provisions will need to be made to help you cope
Patient will also be introduced to a physiotherapist, who will be involved in your post-
operative care. A prosthetist (a specialist in prosthetic limbs) will advise you about the type
and function of prosthetic limbs or other devices available.
If patient is having a planned amputation, you might find it reassuring to talk to someone
who's had a similar type of amputation. A member of your care team may be able to put you
in touch with someone.
The Amputation Procedure
 An amputation usually requires a hospital stay of five to 14 days or more, depending
on the surgery and complications. The procedure itself may vary, depending on the
limb or extremity being amputated and the patient's general health.
 Amputation may be done under general anaesthesia (meaning the patient is asleep) or
with spinal anaesthesia, which numbs the body from the waist down.
 When performing an amputation, the surgeon removes all damaged tissue while
leaving as much healthy tissue as possible.
 A doctor may use several methods to determine where to cut and how much tissue to
remove. These include:
 Checking for a pulse close to where the surgeon is planning to cut
 Comparing skin temperatures of the affected limb with those of a healthy limb
 Looking for areas of reddened skin
  Checking to see if the skin near the site where the surgeon is planning to cut is still
sensitive to touch
 During the procedure itself, the surgeon will
 Remove the diseased tissue and any crushed bone
 Smooth uneven areas of bone
 Seal off blood vessels and nerves
 Cut and shape muscles so that the stump, or end of the limb, will be able to have an
artificial limb (prosthesis) attached to it
 The surgeon may choose to close the wound right away by sewing the skin flaps
(called a closed amputation). Or the surgeon may leave the site open for several days
in case there's a need to remove additional tissue.
 The surgical team then places a sterile dressing on the wound and may place a
stocking over the stump to hold drainage tubes or bandages. The doctor may place the
limb in traction, in which a device holds it in position, or may use a splint.
Recovery after an Amputation
After surgery, patient will usually be given oxygen through a mask and fluids through a drip
for the first few days while you recover on the ward.
A small flexible tube (a urinary catheter) may be placed in your bladder during surgery to
drain away urine. This means you won't need to worry about going to the toilet for the first
few days after surgery.
The site of the operation may be painful, so you'll be given painkillers if you need them Tell a
member of your care team if the painkillers aren't working, as you may need a larger dose or
a stronger painkiller. A small tube may be used to deliver local anaesthetic to the nerves in
your stump to help reduce pain.
Physiotherapist will teach you some exercises to help prevent blood ciots and improve your
blood supply while you're recovering in hospital.
Compression garments
Patient will notice swelling (oedema) of your stump after surgery. This is normal and it may
continue after you've been discharged.
Using a compression garment will help with swelling and the shape of the stump. It may also
reduce phantom pain and help support the limb.
Patient will be fitted with a compression garment once your wound has healed. It should be
worn every day, but taken off at bedtime. You should be given at least two garments, which
should be washed regularly.
Rehabilitation
Physical rehabilitation is an important part of the recovery process. It can be a long. difficult
and frustrating process, but it's important to persevere. After rehabilitation, you should be
able to return to work and other activities.
Rehabilitation programme will be tailored to your individual needs and requirements, and
will aim to allow you to carry out as many of your normal activities as possible.
Work closely with physiotherapists and occupational therapists who will discuss with you
what you'd like to achieve from rehabilitation so that some realistic goals can be set
Rehabilitation programme will usually start within a few days of surgery, beginning with
some simple exercises you can do while lying down or sitting. If you've had a leg amputation,
you'll be encouraged to move around as soon as possible using a wheelchair.
Patient will also be taught "transfer techniques" to help you move around more easily, such as
how to get into a wheelchair from your bed.
Once wound has started to heal, you may start working on an exercise programme with a
physiotherapist in the hospital gym to help you maintain your mobility and muscle strength.
If patient have a prosthetic limb fitted (see below), your physiotherapist will teach you how to
use it-for example, how to walk on a prosthetic leg or grip with a prosthetic hand.
Going home and follow-up
The length of time it will take before you're ready to go home will depend on the type of
amputation you've had and your general state of health.
Before you're discharged from hospital, an occupational therapist may arrange to visit you at
home to see whether your home environment needs to be adapted to make it more accessible.
For example, you may need a wheelchair ramp or a stairlift. If these types of modifications
are required, the issue can be referred to your local social services department. Read about
mobility, wheelchairs and scooters and assessing your care and support needs.
It can take several months before you're fitted with a prosthetic limb (if you're a suitable for
one), so you may be given a wheelchair to help you get around if you've had a lower limb
amputation.
Patient will probably need to attend a follow-up appointment a few weeks after being
discharged to discuss how well you're coping at home and whether you require additional
help, support or equipment.
At patient’ s appointment, he may also be given details of your nearest amputee support
group, made up of both healthcare professionals and people living with an amputation.

Type of amputation
Lower Limb Amputations
Lower limb amputations vary from the partial removal of a toe to the loss of the entire leg
and part of the pelvis. The following list provides a summary of the typical forms of lower
limb amputation:
Partial foot amputation this commonly involves the removal of one or more toes. This
amputation will affect walking and balance.
Ankle disarticulation an amputation of the foot at the ankle, leaving a person still able to
move around without the need for a prosthesis
Below knee amputations (transtibial) - an amputation of the leg below the knee that retains
the use of the knee joint.
Through the knee amputations the removal of the lower leg and knee joint. The remaining
stump is still able to bear weight as the whole femur is retained
Above knee amputation (transfemoral) - an amputation of the leg above the knee joint
Hip disarticulation the removal of the entire limb up to and including the femur. A variation
leaves the upper femur and hip joint for better shape/profile when sitting
Hemipelvectomy (trans pelvic) the removal of the entire limb and the partial removal of the
pelvic.

Upper Limb Amputations

Upper limb amputations vary from the partial removal of a finger to the loss of the entire
arm and part of the shoulder. The following list provides a summary of the typical forms of
upper limb amputation:
Partial hand amputation: amputations can include fingertips and parts of the fingers. The
thumb is the most common single digit loss. The loss of a thumb inhibits the ability to grasp,
manipulate or pick up objects grasping ability. When other fingers are amputated, the hand
can still grasp but with less precision.
Metacarpal Amputation this involves the removal of the entire hand with the wrist still
intact
Wrist disarticulation this form of amputation involves the removal of the hand and the wrist
joint
Below elbow amputation (trans radial) the partial removal of the forearm below the elbow
joint
Elbow disarticulation the amputation of the forearm at the elbow.
Above elbow amputation (trans humeral) - the removal of the arm above the elbow
Shoulder disarticulation and forequarter amputation is the removal of the entire arm
including the shoulder blade and collar bone.
Preventing from amputation
If patient currently have a serious, chronic wound, you may worry that amputation is your
next step. It doesn't have to be but if it is, rest assured that it is the best choice for you and
your medical team has made every possible consideration. If you would like to lower your
chances of undergoing an amputation procedure, there are a few things you can do
Take care to follow wound care routine to the letter. Keeping your wound free of infection
may mean you will not need an amputation. Ensure you have the proper wound care supplies
to perform wound care at home, and consider hiring medical help if you can't do everything
you need to on your own.
If patient have diabetes, regularly check your feet and legs for diabetic ulcers.
These must be addressed promptly to prevent complications, including infections that could
lead to amputation. You should also be working with a medical professional to keep your
blood sugar at a reasonable level to avoid neuropathy altogether and to keep your circulation
healthy.
Assessment
1. Neurovascular status of involved extremity,
2. History to determine causative factors and health problems that can compromise recovery.
3. Client's understanding of the extent of the surgery.
4. Client's coping status.
5. Client's support system.
Nursing Diagnosis
 Body image disturbance
 Constipation
 Diversional activity deficit
 Fear
 Risk for injury
 Impaired physical mobility
 Self-care deficit
 Risk for skin integrity
 Situation low self-esteem
Nursing Interventions
1. Provide care preoperatively by initiating exercise to strengthen muscles of extremities in
preparation for crutch walking.
2. Encourage coughing and deep breathing exercises.
3. Monitor vital signs and stump dressing for signs of haemorrhage.
4. Elevate stump for 12 to 24 hours to decrease oedema.
5. Maintain elastic bandage to shrink and shape stump in preparation for prosthesis
6. When wound is healed, wash stump daily, avoiding the use of oils which may cause
maceration.
7. Apply pressure to the end of the stump with progressively firmer surfaces to toughen
stump.
8. Encourage the client to move the stump.
[Link] the client with a lower extremity amputation in a prone position twice daily to stretch
the flexor muscles and prevent hip flexion contractures.
10. Teach the client about phantom limb sensation.
11. Support the client through fitting, application, and utilization of prosthesis
12. Encourage family to participate in care.
13. Allow the client to express emotional reactions.
Prosthetics

After an amputation, patient may be able to have a prosthetic limb fitted. Prosthetic limbis
aren't suitable for everyone who's had an amputation because an extensive course of
physiotherapy and rehabilitation is required. Adjusting to life with a prosthetic limb takes a
considerable amount of energy because you have to compensate for the loss of muscle and
bone in the amputated limb.
This is why frail people or those with a serious health condition, such as heart disease, may
not be suitable for a prosthetic limb. If you're able to have a prosthetic limb, the type of limb
that's recommended for you will depend on:
the type of amputation patient had
the amount of muscle strength in the remaining section of the limb
Patient general state of health
tasks the prosthetic limb will be expected to perform
whether patient want the limb to look as real as possible or whether you're more concerned
with function
If it's thought that he would find it difficult to withstand the strain of using a prosthetic limb,
a purely cosmetic limb may be recommended. This is a limb that looks like a real limb, but
can't be used. It's possible to have a prosthetic limb that's both physically realistic and
functional, but there may have to be an element of compromise between the two.

Stump care
It's very important to keep the skin on the surface of your stump clean to reduce the risk of it
becoming irritated or infected. Gently wash your stump at least once a day (more frequently
in hot weather) with mild unscented soap and warm water, and dry it carefully.
If you have a prosthetic limb, you should also regularly clean the socket using soap and warm
water. When taking a bath, avoid leaving your stump submerged in water for long periods
because the water will soften the skin on your stump, making it more vulnerable to injury. If
your skin becomes dry, use a moisturising cream before bedtime or when
Patient is not wearing your prosthesis. Some people find wearing one or more socks around
their stump helps absorb sweat and reduces skin irritation. The size of stump may change as
the swelling goes down, so the number of socks you need to use may vary. You should
change the socks every day.
Check stump carefully every day for signs of infection, such as:
 warm, red and tender skin
 discharge of fluid or pus
 increasing swelling
Complications
Like any type of surgery, an amputation carries a risk of complications. It also carries a risk
of additional problems directly related to the loss of a limb.
There are a number of factors that influence the risk of complications from amputation, such
as your age, the type of amputation you've had, and your general health.
The risk of serious complications is lower in planned amputations than in emergency
amputations.
Complications associated with having an amputation include:
 heart complications such as heart attack
 deep vein thrombosis (DVT)
 slow wound healing and wound infection
 pneumonia
 stump and "phantom limb" pain
In some cases, further surgery may be needed to correct problems that develop or to help
relieve pain. For example, if neuromas (thickened nerve tissue) are thought to be causing
pain, the affected cluster of nerves may need to be removed.
Psychological impact
The loss of a limb can have a considerable psychological impact. Many people who've had an
amputation report feeling emotions such as grief and bereavement, similar to experiencing
the death of a loved [Link] to terms with the psychological impact of an amputation is
therefore often as important as coping with the physical demands. Having an amputation can
have a considerable psychological impact for three main reasons:
Patient have to cope with the loss of sensation from your amputated limb
Patient have to cope with the loss of function from your amputated limb
Patient sense of body image, and other people's perception of your body image, has changed
Negative thoughts and emotions are common after an amputation. This is particularly true in
people who've had an emergency amputation because they don't have time to mentally
prepare for the effects of surgery.
Common negative emotions and thoughts experienced by people after an amputation include:
 depression
 anxiety
 denial (refusing to accept that they need to make changes, such as having
physiotherapy, to adapt to life with an amputation)
 grief
 feeling suicidal
People who've had an amputation as a result of trauma (particularly members of the armed
forces) also have an increased risk of developing post-traumatic stress disorder (PTSD).
Talk to care team about thoughts and feelings, particularly if you're feeling depressed or
suicidal. You may need additional treatment, such as antidepressants or counselling, to
improve ability to cope after having an amputation.
ABHILASHI COLLEGE OF NURSING
TANDA (MANDI)

MEDICAL SURGICAL NURSING

AMPUTATION

SUBMITTED TO: SUBMITTED BY:

[Link] MS. KOMAL
ASSISTANT PROFESSOR MSc. Nursing 1st year
MEDICAL SURGICAL NURSING

SUBMITTED ON:
22-03-24
 BIBLIOGRAPHY

 Brunner & Siddharth’s, “textbook of medical-surgical nursing”, 11 th edition published

by Elsevier, page no. 1422-1428.

 Smeltzer CS, Bare B. Brunner &Suddath’s Textbook of Medical Surgical Nursing.

10th ed. Philadelphia (PA): Lippincott Publishers; 2006 Page no. 232-234.

 Chintamani. Lewis’s Medical Surgical Nursing. 7 thed. New Delhi: Elsevier limited;
2010 Page no. 294-300.

 Black M Joyce, Types, Treatment and Fracture Healing, Medical Surgical Nursing, 7 th
edition, page no 1125-30.

Reference:
 [Link]
 [Link]
 [Link]