Amputation and Joint replacements

Common causes of amputations include:

1. Trauma - such as accidents or injuries.
2. Vascular diseases - including diabetes and peripheral artery disease.
3. Infections - severe infections that cannot be controlled.
4. Tumors - malignant or benign tumors affecting limbs.
5. Congenital conditions - present at birth that affect limb development.

Relevant nursing diagnoses for patients with amputations include:

1. Impaired physical mobility - related to loss of limb.
2. Acute pain - related to surgical procedure or phantom limb sensations.
3. Risk for infection - due to surgical site or prosthetic use.
4. Disturbed body image - related to changes in physical appearance.
5. Ineffective coping - related to loss and adjustment to new lifestyle.

Important nursing interventions for patients with amputations include:

1. Pain management - using medications and alternative therapies.
2. Wound care - monitoring and caring for the surgical site.
3. Mobility assistance - helping with mobility aids and rehabilitation exercises.
4. Patient education - teaching about prosthetic use and care.
5. Emotional support - providing counseling and support for adjustment.

The primary medical causes of amputation include:

• Diabetes
• Peripheral vascular disease
• Cancer
• Gangrene
• Infection
• Obesity

These conditions usually lead to amputations of the lower extremity, accounting for 74% of all amputations.

Types of trauma that can lead to amputation include:

• Accidents (e.g., crushing injuries, burns, frostbite)

These traumatic amputations often affect the upper extremities and account for 23% of all amputations.

Congenital anomalies refer to conditions present at birth that can lead to amputation. These can affect either upper or lower extremities and account for 3% of all amputations.

By 2050, there will be an estimated 3.6 million amputees in the US.

The peak age for amputations is between 41 and 70 years old.

The major cause of amputations is poor circulation, particularly due to peripheral vascular disease (PVD) associated with diabetes mellitus (DM).

Over 50% of amputations occur in individuals with diabetes.

The most common type of amputation is lower extremity amputations.

Over 80% of lower extremity amputations are due to vascular disease.

A patient with body image disturbances will often avoid looking at the amputated area.

The two types of amputations discussed are Above the Knee (AKA) and Below the Knee (BKA).

The ideal shape of a stump for successful prosthesis fitting is cone-shaped. If the stump does not have this shape, the patient may not be able to wear a prosthesis.

Factors that can affect the shape of the stump include:

1. The surgical technique used by the surgeon.
2. The way nurses wrap the stump post-surgery.

Complications associated with amputations include:

• Infection: Prophylactic antibiotics are recommended prior to surgery.
• Pain: Due to nerve endings at the site.
• Edema: Can increase pain and pressure on the stump.
• Wound healing issues: Delayed healing can occur.
• Skin breakdown: Improper wrapping can lead to skin issues.
• Phantom limb pain: Pain can occur when peripheral nerves are detached.

60-70% of new amputees experience phantom limb pain.

The best intervention for phantom limb pain is to have the patient put on the prosthesis, which helps with pain relief.

Potential causes of residual limb pain include:

1. Poor prosthetic fit due to swelling.
2. Bruising from fluid retention.
3. Neuroma formation in unprotected areas.
4. Chafing or rubbing of the skin.
5. Poor circulation.
6. Nerve damage, often from diabetes.

Nurses can teach patients to rub, tap, or strike the stump to help desensitize it.

Phantom limb pain decreases in severity over time but may flare up at various times due to factors like certain foods or swelling/use.

Phantom limb pain is more prevalent in those with traumatic amputations than in those with peripheral vascular disease (PVD).

The recommended shape for a residual limb is a conical shape. This shape helps in reducing the risk of late phantom limb pain and is essential for the successful fitting of a prosthesis.

The key objectives for stump conditioning include:

1. Conical Shape
2. Maximum shrinkage depends on how the stump is wrapped
3. Absence of tenderness
4. Freely movable scar
5. Firm skin
6. Normal muscle strength and range

Avoiding clips on ace wraps is important because it helps in achieving a better conical shape and reduces the risk of complications such as contractures and phantom limb pain.

A patient should lie on their stomach with their legs extended straight and no pillows underneath the stump to prevent the knee from dropping and creating a contracture.

A strong and dedicated mindset is crucial for a patient to successfully wear a prosthesis. Body image disturbance can hinder their willingness to engage with the prosthetic, even if the stump is well-shaped.

1. Client Motivation: The client must be motivated to learn and possess self-care skills.

2. Family Support: The client and/or family should be capable of learning and have the necessary skills for self-care.

3. Absence of Contractures: There should be no hip or knee contractures present.

4. Medical Conditions: Other medical issues (e.g., respiratory, cardiac, stroke, or visual problems) should not hinder the use of the prosthetic limb.

5. Mindset: A negative mindset can interfere with the use of the prosthetic limb, along with physical limitations.

6. Positioning: The patient should lie on their stomach for 30 minutes to keep the knees straight.

• Normal muscle power and range is essential.
• Prone position for stump extension is advised.
• Focus on prevention of complications such as contractures.

Patients should assess their stump every day for any skin breakdown using a mirror. Any minor cuts or skin limitations must heal before wearing a prosthesis.

For patients with below the knee amputation complaining of foot pain, the nurse can:

1. Provide pain medication.
2. Explain the concept of phantom limb pain.

Patients may experience an altered body image; therefore, it is crucial to provide emotional support and encouragement throughout their recovery process.

• Use of assistive devices such as walkers, canes, or crutches.
• Nutritional counseling for wound healing.
• Vocational counseling to discuss returning to work with a prosthesis and necessary modifications.

• Focus on community reintegration and home safety/adaptations.
• Discuss necessary adaptations to the home environment to ensure safety and accessibility.

The purpose of residual limb wrapping or using a shrinker is to reduce swelling, shape the limb for prosthetic fitting, and promote healing. Proper wrapping techniques help in maintaining the residual limb's shape and preventing complications such as contractures.

1. Clean the prosthesis daily with mild soap and water.
2. Inspect the prosthesis for any signs of wear or damage.
3. Ensure that all components are functioning properly.
4. Store the prosthesis in a safe, dry place when not in use.
5. Follow the manufacturer's instructions for maintenance and care.

Linear or special socks are used to provide cushioning, improve comfort, and help with the fit of the prosthesis. They also assist in moisture management and can help prevent skin irritation or breakdown.

Donning a Prosthesis:

1. Prepare the residual limb by cleaning and drying it.
2. Apply any necessary liners or socks.
3. Position the prosthesis correctly.
4. Secure the prosthesis in place.

Doffing a Prosthesis:

1. Loosen any straps or fasteners.
2. Carefully remove the prosthesis from the limb.
3. Clean the residual limb and prosthesis as needed.

The goals of total joint replacement include:

1. Pain relief: Alleviating chronic pain associated with joint conditions.
2. Improved function: Enhancing the range of motion and overall functionality of the joint.
3. Restoration of mobility: Allowing patients to return to daily activities and improve their quality of life.
4. Correction of deformity: Addressing any structural abnormalities in the joint.
5. Long-term durability: Providing a lasting solution to joint issues.

Indications for total joint replacement typically include:

1. Severe joint pain: Persistent pain that limits daily activities.
2. Joint stiffness: Reduced range of motion that affects mobility.
3. Joint deformity: Structural changes in the joint that impair function.
4. Failure of conservative treatments: Ineffectiveness of medications, physical therapy, or other non-surgical interventions.
5. Degenerative joint diseases: Conditions such as osteoarthritis or rheumatoid arthritis that severely impact joint function.

Care-planning needs after total joint replacement include:

1. Pain management: Developing a strategy for effective pain control post-surgery.
2. Physical therapy: Implementing a rehabilitation program to restore mobility and strength.
3. Monitoring for complications: Regular assessments for signs of infection, blood clots, or other post-operative issues.
4. Patient education: Informing the patient about activity restrictions and precautions.
5. Follow-up appointments: Scheduling regular check-ups to assess recovery progress.

Hip precautions after joint replacement typically include:

1. Avoiding hip flexion: Keeping the hip from bending beyond 90 degrees.
2. Avoiding crossing legs: Preventing the legs from crossing at the knees or ankles.
3. Avoiding internal rotation: Not turning the operated leg inward.
4. Using assistive devices: Employing walkers or crutches as needed for stability.
5. Following activity guidelines: Adhering to specific recommendations from healthcare providers regarding movement and activity levels.

The primary goals of total joint replacement are to decrease pain and to increase or restore function, which typically requires surgical intervention.

The most common form of arthritis that may lead to joint replacement is Osteoarthritis. It affects 15.9% of adults aged 25 and older and 39.6% of adults aged 65 and older.

Contributing factors to the need for joint replacement include age, genetics, gender, previous injuries, muscle weakness, and obesity.

Nurses should perform assessments to check for nerve damage, with one indication being numbness in the affected area.

Non-surgical interventions to consider before knee replacement include:

1. Anti-inflammatory medications
2. Weight management
3. Physical therapy (10 sessions)
4. Assistive devices (canes, walkers)
5. Activity modification to relieve pain
6. Acupuncture
7. Massage

These are typically explored before considering surgery as a last resort.

Typical symptoms of osteoarthritis include:

• Joint edema
• Pain
• Stiffness Rest usually relieves these symptoms.

X-rays of patients with osteoarthritis typically show:

• Joint space narrowing
• Osteophytes
• Bony sclerosis

Both osteoarthritis and rheumatoid arthritis affect women more than men, with a ratio of approximately 3:5 for osteoarthritis.

In rheumatoid arthritis, the finger joints can become deformed, leading to changes in their shape.

Avascular necrosis is the death of bone tissue due to ischemia or loss of blood supply. It can occur due to major trauma, such as hip fractures or dislocations, or through other means including intraluminal obliteration, increased marrow pressure, or cytotoxicity.

X-rays and MRIs are important for assessing the status of the bone in cases of avascular necrosis. They help visualize the necrosis that first forms in the yellow bone marrow.

Understanding the types of prosthesis and fixative is crucial for rehabilitation care as it helps healthcare professionals determine and estimate precautions related to healing and the efficacy of the materials used, such as whether a hip prosthetic is cemented or non-cemented, which can influence weight-bearing status.

• Always follow the prescribed weight-bearing status.
• Weight-bearing status is determined by the surgeon based on the condition of the bone and type of surgery.
• The rehab nurse should be aware of the weight-bearing status before transfers or ambulation to prevent complications.
• Use a fracture bedpan to avoid strain.
• Place a pillow between the knees to prevent adduction, which can lead to dislocation of the prosthesis.

Failure to follow weight-bearing precautions can result in:

• Refracture of the bone
• Dislocation of the prosthesis

To prevent complications, the patient should maintain abduction and avoid adduction. This means:

• Do not cross legs.
• Avoid bending more than 90 degrees at the hip.

1. Give pain medications
2. Take vital signs
3. Measure the legs
4. Pull the joint back

• Loosening of dislocation
• Infection (e.g., UTIs)
• Blood clots (patients must go home with anticoagulants to decrease thrombus formation)
• Pain (assess leg lengths for dislocation)

Do:

• Sit with legs 3-6 inches apart
• Keep 2 pillows between legs when lying or turning
• Inform professionals of having a prosthesis
• Continue leg strengthening and ROM exercises
• Report signs of infection

Don't:

• Cross legs or ankles
• Bend past 90 degrees at the waist
• Bear full weight on the operative side until permitted by the physician

1. Do not bend the operated hip greater than 90 degrees while sitting.
2. Avoid crossing legs or bringing the operated leg past the midline of the body.
3. Do not turn or twist the operated leg inward.

• Redness around the wound
• Swelling or increased warmth
• Increased pain at the site
• Pus or drainage from the wound
• Fever or chills

Patients with joint replacements will go home with anticoagulants to decrease the risk of thrombus formation (blood clots).

The nurse should assess for scatter rugs in the house to prevent falls.