10.5 Amputation

Amputation refers to the surgical removal of a body part. The psychosocial impact of amputation often surpasses the physical impairment as individuals may experience emotional distress, body image concerns, and adjustments to their daily lives.

The two primary categories of amputation are elective and traumatic:

• Elective Amputation: Elective amputation is planned and performed due to medical conditions such as severe infection, tumors, or vascular diseases that compromise blood flow to the affected limb. It is often a proactive decision made by health care professionals and the client to prevent complications like sepsis and metastasis.^[1] Including the client during decision-making helps in the healing and acceptance stage after the surgery.
• Traumatic Amputation: Traumatic amputation occurs due to accidents, injuries, or severe trauma, resulting in the sudden loss of a limb. Traumatic amputations can significantly impact an individual’s ability to cope with the loss due to its unexpected and immediate impact on their life.^[2]

Amputations are classified based on the location in the upper or lower extremity. Lower extremity amputations include the following^[3]:

• Toe or Partial Foot Amputation: Removal of toes or a part of the foot that preserves the foot structure, aiding in maintaining balance and mobility
• Ankle Disarticulation: Amputation at the ankle joint, preserving the heel pad for weight-bearing and prosthetic fitting
• Below-Knee (Transtibial) Amputation: Amputation below the knee joint, providing a longer residual limb for better prosthetic control and energy-efficient walking
• Above-Knee (Transfemoral) Amputation: Amputation above the knee joint, requiring more energy for mobility due to the absence of the knee joint and increased leverage requirements

Upper extremity amputations are as follows^[4]:

• Finger or Partial Hand Amputation: Removal of fingers or part of the hand
• Wrist Disarticulation: Amputation at the wrist joint
• Below-Elbow (Transradial) Amputation: Amputation below the elbow joint
• Above-Elbow (Transhumeral) Amputation: Amputation above the elbow joint

After an amputation is performed and the incision site is healed, the client may receive an artificial body part called a prosthesis to promote mobility and/or function. See Figure 10.25^[5] for an illustration of a prosthesis used for an above-the-knee amputation.

Potential Complications

Several complications can occur after an amputation, including the following^[6],[7]:

• Hemorrhage: Hemorrhage refers to excessive bleeding during or after surgery. It can be caused by inadequate closure of blood vessels, clotting disorders, or medications that impact clotting.
• Infection: Infection can occur due to contamination during surgery or wound care. Symptoms include redness, swelling, tenderness, purulent discharge, and fever.
• Phantom Limb Pain: Phantom limb pain is the sensation of pain or discomfort in the limb that was removed. It is a common neurological phenomenon that occurs when the brain continues to perceive sensations from a limb that is no longer present.
• Flexion Contracture: Flexion contracture occurs when the residual limb remains in a flexed position for an extended period, leading to decreased range of motion and contracture of muscles and soft tissues.

Assessment

When caring for a client who has undergone an amputation, nursing assessment includes physical, functional, and psychosocial findings. See Table 10.5 for a summary of focused assessments following an amputation.

Table 10.5. Focused Assessments Post-Amputation^{[8],[9],[10],[11]}

Diagnostic Testing

Doppler ultrasound may be used to assess vascular status and blood flow to the residual extremity. Hemoglobin and hematocrit are also monitored postoperatively due to blood loss.

Nursing Problems and Diagnoses

Nursing problems and diagnoses following an amputation encompass physical, psychosocial, and functional challenges. Common nursing diagnoses for clients experiencing amputation include the following:

• Acute Pain
• Impaired Skin Integrity
• Disturbed Body Image
• Risk for Impaired Mobility
• Ineffective Coping

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. Sample expected outcomes for a client experiencing an amputation are as follows: 

• The client will demonstrate signs of healing of the surgical site within one week without redness, swelling, or purulent drainage.
• The client will express feelings related to the changes in their body image within one week.
• The client will demonstrate accurate use of assistive devices by the end of the teaching session.

Interventions

Medical Interventions

Medical interventions related to amputation include surgery, rehabilitation, wound care, and pain control.

• Surgical removal of the affected limb is performed at a specific level, as determined by the extent of damage or disease.^[12]
• Physical therapy and occupational therapy are prescribed for prosthetic evaluation and rehabilitation to regain strength, mobility, and independence. Clients receive custom fitting and training in the use of prosthetic devices.^[13]
• Wound care may include use of a wound vacuum-assisted closure or specialized dressings to facilitate healing. Wound care orders include cleansing and dressing changes.^[14],[15]
• Medication therapy typically includes pain medications and antibiotics:
  • Opioid and nonopioid medications are prescribed to help manage postoperative pain.
  • Prophylactic antibiotics are often prescribed to prevent postoperative infections.

Nursing Interventions

Nursing interventions include monitoring for complications, performing health teaching, and providing psychosocial support.

Monitoring for Complications

Nurses perform routine assessments on the residual limb to monitor vascular status and assess for signs of infection or skin breakdown. The client’s mobility, functioning, and home environment are assessed to plan interventions to reduce the risk of falls or other injuries at home.

Health Teaching

Nurses teach clients and their caregivers about post-amputation care, including wound care, signs of complications to immediately report to the health care provider, positioning, and care to prevent skin breakdown. Clients are taught to implement prone positioning as prescribed and to not use pillows under the limb to prevent contractures. For example, a client with a lower-extremity amputation is typically prescribed prone positioning for 20 to 30 minutes every 3 to 4 hours to prevent hip contracture until they are regularly out of bed and moving. Clients and caregivers may also be taught how to wrap the remaining limb to prevent friction and blistering. Specialized wraps may be used in collaboration with the physical therapist to decrease phantom limb pain.

Information is provided on rehabilitation programs, prescribed exercises, safe transfers, use of assistive devices, and home modifications for safety.

Psychosocial Support

Nurses actively listen and use therapeutic communication to encourage clients to verbalize feelings related to the loss of their limb and discuss coping strategies. Resources or referrals are provided for counseling, support groups, or other community resources.

Evaluation

During the evaluation stage, nurses determine the effectiveness of nursing interventions for a specific client. The previously identified expected outcomes are reviewed to determine if they were met, partially met, or not met by the time frames indicated. If outcomes are not met or only partially met by the time frame indicated, the nursing care plan is revised. Evaluation should occur every time the nurse implements interventions with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with other members of the interprofessional team.