Case Study on Amputation

Our Lady of Fatima University Antipolo Campus College of Nursing

A Case Study on: Multiply Physical Injury; Traumatic Amputation of the Left Upper Extremity

In Partial Fulfillment Fu lfillment of the Requirements in the Related Learning Experience 104 Orthopedic Ward Rotation

Table of Contents

Introduction«««««««««««««««««««««««««««««««««3 I. Demographic Data II. Medical Management a. Medicines  b. Laboratory Data III. Diagnostic Results IV. Surgical Management V. Nursing Management VI. Drug Study

Introduction

³I have two hands, the left and the right´ is a song which cannot be sung by an amputated  patient. A patient who¶s upper extremity has been amputated because of one of the following reasons: (1) accident (2) in born or (3) sickness. This study will revolve around the field of nursing, specifically, orthopedic nursing. The  patient focused in this study was amputated due to a motor vehicle accident (MVA). Definition of term According to the freedictionary.com, amputation is defined as the intentional surgical removal of a limb or body part. It is performed to remove diseased tissue or relieve pain. Arms, legs, hands, feet, fingers, and to es can be amputated. Most amputations involve small  body parts such as a finger, rather than an entire limb. About 65, 000 amputations are performed in the United States each year. Amputation is performed for the following reasons: y y y

to remove tissue that no longer has an adequate blood supply to remove malignant tumors  because of severe trauma to the body part

The blood supply to an extremity can be cut o ff because of injury to the blood vessel, hardening of the arteries, arterial embolism, impaired circulation as a complication of diabetes mellitus, repeated severe infection that leads to gangrene, severe frostbite, Raynaud's disease, or  Buerger's disease. More than 90% of amputations performed in the United States are due to circulatory complications of diabetes. Sixty to eighty percent of these operations involve the legs or feet. Although attempts have been made in the United States to better manage diabetes and the foot

I.

Demographic Data

  Name Age Address Religion Occupation Time and date of Admission Admitting Diagnosis

Present History

II.

: RMR  : 18 y/o : SitioMacopa, BagongNayon 1, Antipolo City : Roman Catholic : Tricycle Driver  : 4AM 04-07-11 : Mangled Left upper extremity, fracture closed complete left femur secondary to vehicular accident. : Few minutes prior to confinement, patient got into a vehicular accident. The patient was riding a tricycle when he was hit by a truck.

Medical Management

A. Medicine

B. Laboratory Data Result WBC: 3.0

Normal Findings 3.7-10.6

Interpretation White blood cell (WBC) count. White blood cells  protect the body against infection. If an infection develops, white blood cells

Hbg: 12.2

12.5-16.0

Hct: 37.1

38.8-49.7

the count is too high (a condition called polycythemia vera), there is a risk that the red blood cells will clump together and block tiny blood vessels (capillaries). Hemoglobin (Hgb). Hemoglobin is the major  substance in a red blood cells. It carries oxygen and gives the  blood cell its red color. The hemoglobin test measures the amount of hemoglobin in  blood and is a good indication of the blood's ability to carry oxygen throughout the body. Hematocrit (HCT, packed cell volume, PCV). This test measures the amount of space (volume) red blood cells occupy in the blood. The value is given as a percentage of red  blood cells in a volume of   blood. For example, a hematocrit of 38 means that 38% of the blood's volume is composed of red cells

III.

Diagnostic Results

Examination 1. Chest X-ray

2. Complete Blood Count with Blood Typing

IV.

Surgical Management

Result Purpose Normal chest X-ray shows To note if the lung has been normal size and shape of the affected and so as to answer  chest wall and the main questions of there is presence structures in the chest. White of DOB. shadows on the chest X-ray signify solid structures and fluids such as, bone of the r ib cage,vertebrae, heart, aorta, and bones of the shoulders. The dark background on the chest X-rays represents air  filled lungs. These lung fields are seen on either side of the heart and the vertebrae located in the center of the film WBC: 30 For baseline and monitoring of  RBC: 3.96  blood clotting factors and Hbg: 12.2 infection and for possible Hct: 37.1  blood transfusion. Platelet: 494 Blood Type: O

Before an amputation is performed, extensive testing is do ne to determine the proper level o f  amputation. The goal of the surgeon is to find the place where healing is most likely to be complete, while allowing the maximum amount of limb to remain for effective rehabilitation. The greater the blood flow through an area, the more likely healing is to occur. These tests are designed to measure blood flow through the limb. Several or all of them can be done to help choose the proper level of amputation. measurement of blood pressure in different parts of the limb xenon 133 studies, which use a radiopharmaceutical to measure blood flow oxygen tension measurements in which an oxygen electrode is used to measure oxygen  pressure under the skin (If the pressure is 0, t he healing will not occur. If the pressure reads higher than 40mm Hg [40 milliliters of mercury], healing of the area is likely to be satisfactory.) laser doppler measurements of the microcirculation of the skin skin fluorescent studies that also measure skin microcirculation skin perfusion measurements using a blood pressure cuff and photoelectric detector  1 infrared measurements of skin temperature y y y

y y y y

C. Post-operative Phase  prevent edema (raise extremity with pillow support for first 24 hours) observe stump dressing frequently for signs of hemorrhage ensure that stump bandages fit tightly and are applied properly (change dressing as indicated)  promote wound healing, manage pain help the patient to achieve physical mobility ( promoting independent self-care) monitor for and manage complications if the patient has a drain, note the location and type of fluid that ought to be draining from the drain, monitor drainage for color, consistency, and quantity y y y

y y y y

Part V.

Nursing Management

 Nursing Care Plan Assessment Subjective: ³Masakitparinyungpinagputulanngkamayko, gusto konanganginuminlahatnggamotnapampatanggalngsakit´ as verbalized by the pat ient

Objective: >PR: 108 bpm >facial grimace >guarding behavior 

Plan Diagnosis Acute pain After 1 hour of  related to nursing surgical intervention, the  procedure:  patient will be amputation as able to feel manifested by relief regarding facial grimace the pain he is experiencing.

Intervention Evaluation 1. Observe nonverbal After 1 hour of  cues (e.g. how client nursing walks, holds body, intervention, the sits; facial epression,  patient was able cool fingertips/toes) to feel relief  and other objective. regarding the 2. Monitor vital signs  pain he is 3.Encourage experiencing. verbalization of  feelings about pain 4. Instruct in/ encourage use of  relaxation exercises, such as focused  breathing, commercial or  individualized tapes 5. Identify ways of  avoiding/minimizing  pain 6. Administer  analgesics as indicated to maximal dosage as needed 7.Assis in treatment of underlying disease  processes causing  pain 8. Encourage adequate rest periods 8

to prevent fatigue

Assessment Plan Diagnosis Subjective: Impaired After 1 hour of  ³Siempremahihirapannaakongmagtrabaho,  physical nursing ngayonnganahihirapanakongmaglakaddahilsabalisapaa mobility intervention, the ko´ as verbalized by the patient related to  patient will be able loss of  to demonstrate Objective: extremity techniques/behavio >limited range of motion as rs that enable the >slowed movement manifeste resumption of  >movement-induced shortness of breath/tremor  d by activities. slowed movement s

Intervention 1. Assess degree of   pain, listening to client¶s description. 2. Determine degree of   perceptual/cognitiv e impairment and ability to follow directions 3.Assess nutritional status and energy level 4. Assist/have client reposition self on a regular  schedule as dictated by individual situation 5.Instruct in use of  siderails, overhead trapeze, roller pads 6. Support affected  body parts/joints using pillows/rolls, foot supporters/shoes, air mattress, water   bed and so forth.

Evaluation After 1 hour of  nursing intervention, the  patient was able to demonstrate techniques/behavio rs that enable the resumption of  activities.

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7.Administer  medications prior  to activity as needed for pain relief  8.Provide regular  skin care to include pressure area management

Assessment Diagnosis Subjective: Self-care deficit ³Kapagnagbibihis, related to loss of  kelanganko pa si mama o extremity si papa ko, kasinaninibago  pa akodahilwalanakamayko.´ as verbalized by the  patient

Objective: >amputated left upper  extremity

Plan After 1 hour of nursing intervention, the patient will be able to demonstrate techniques/lifestylechanges to meet self-care needs.

Intervention 1. Identify degree of  individual impairment /functional level according to scale 2.Determine individual strengths and skills of  the patient 3. Develop a plan of  care appropriate to individual situation, scheduling activities to conform to client¶s normal schedule. 4. Provide privacy during personal care activities. 5. Identify energysaving behaviors (e.g. sitting instead of  standing when possible) 6.Review safety

Evaluation After 1 hour of nursing intervention, the patient was able to demonstrate techniques/lifestyle changes to meet selfcare needs.

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concerns. Modify activities/environment to reduce risk for injury

Assessment

Plan Diagnosi Intervention Evaluatio s n Subjective: Disturbed After 1 1. Assess After 1 ³Ayawniyangmagpadalawsamgakaibiganniyagawangwalanasiyangisang  body hour of  mental/physical hour of  kamay.´ as verbalized by the mother of the patient image nursing influence of  nursing related to interventio illness/condition to interventio Objective: amputatio n, the the client¶s n, the >amputated left upper extremity n of body  patient will emotional state  patient was > over-exposing of body part  part as  be able to 2. Recognize able to evidenced verbalize  behavior indicative verbalize  by overacceptance of overconcern acceptance exposure of self in with body and its of self in of body situation  processes situation  part 3.Have client describe self, noting what is  positive and what is negative 4. Discuss meaning of loss/change to client 11

5. Discuss the availability of   prosthetics, reconstructive surgery and  physical/occupatio nal therapy or other  referrals as dictated  by individual situation 6.Help client to select and use clothing 7.Offer positive reinforcement for  efforts made

Assessment Subjective: ³Kahitwalanayungkamayko, nararamdamanko paring sumasakitsiya, minsanngakakamutinkosana, sakakomaaalalangwalanangapalasiya´ as verbalized by the pat ient

Diagnosis Risk for disturbed sensory perception:  phantom limb pain related to amputation

Plan After 1 hour of  nursing intervention, the patient will be able to verbalize awareness of sensory needs and presence of overload and/or  deprivation

Intervention 1. Identify underlying reason for alterations in sensory perception 2. Note degree of  alteration/involvement 3. Explain  procedures/activities, expected sensations and outcomes 4. Provide undisturbed sleep/rest periods 5. Provide diversional activities as able

Evaluation After 1 hour of  nursing intervention, the patient was able to verbalize awareness of sensory needs and presence of overload and/or  deprivation

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6. Identify and encourage use of  resources/prosthetic devices 7. Provide safety measures 8.Ambulate with assistance/devices 9. Monitor drug regimen postsurgically.

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