Amputation Question

[OneWhisper]

I am SOOOO confused by this. If someone could just clarify this for me and tell me which is correct I would be SOOOO GRATEFUL!!

I Read This:

Care of Amputations (Mosby's)

Elevate FOB briefly (usually first 24 hrs) if ordered by HCP to decrease edema. AVOID elevation of residual limb on pillow to prevent hip flexion contractures.

So Mosby's is just referring to amputations in general – not specific to AKA or BKA. It says first 24 hrs, elevate FOB and AVOID elevating residual limb on pillow to prevent hip flexion contractures.

Amputation of Lower Extremity (Saunders)

During first 24 hrs after amputation, elevate FOB (residual limb IS supported with pillows but NOT elevated because of risk of flexion contractures) to reduce edema.

So, Saunders speaks of BKA – During first 24 hrs, elevate FOB (like Mosby's), but then it says residual limb IS supported with pillows (which Mosby's says NOT to do) but NOT elevated because of risk of flexion contractures.

So...

Mosby's says in first 24 hrs, elevate FOB. AVOID elevating residual limb on pillows.

Saunders says in first 24 hrs, elevate FOB. Support residual limb WITH pillows but do NOT elevate b/c of risk of flexion contractures.

So, they agree to elevate FOB. But then Mosby's says avoid elevating residual limb on pillows and Saunders says support residual limb with pillows but do NOT elevate.

AKA:

First 24 hrs after AKA, do NOT elevate stump as this may cause flexion contracture.

On NCSBN Learning Extension Website, an instructor says:

Using Brunner and Suddarth's Textbook of Medical-Surgical Nursing for BKA & AKA Post-Op Care:

• Residual limb is raised on 1 - 2 pillows

  for first 24 hrs after surgery (to decrease swelling)

  
  

• After first day, residual limb should be flat on bed to prevent contractures (may be ok to raise FOB – there will be orders for positioning pt and bed)

  
  

• Pt may sleep in supine position, but care should be taken to prevent flexion of knee (which will delay being fitted for a prosthetic)

  
  

• May be orders to assist pt to change positions (from supine to either side) but pt MUST be in prone position for about 20 mins, at least twice a day

  
  

• PT and ROM exercises begin almost immediately (usually post-op day 1)

  
  

Brunner and Suddarth's says (for BKA & AKA), raise residual limb on 1 – 2 PILLOWS for first 24 hrs. May be ok to raise FOB.

Saunders says elevate FOB. Support residual limb WITH PILLOWS but do NOT elevate

Mosby's says elevate FOB. Do NOT to support residual limb with pillows

Then, someone responds to this instructors post and says he/she read in another post where the instructor answered the same topic that said do NOT elevate residual limb on pillows. So, asked which was the correct action – Elevate on pillows or raise foot of bed.

Instructor replied: "Wouldn't you have to use 1 or more pillows to elevate the residual limb? If someone is missing a limb, then raising the FOB will do nothing for that residual limb...there's no foot/lower leg to elevate."

So, I don't understand?

They say elevate but do not elevate. Raise with pillows, do not raise with pillows. So, what do you do with AKA and BKA amputations? Elevate or note elevate? Raise with pillows or not raise with pillows?

[dianah, ASN]

Clear as mud, isn't it?

Probably postop orders, and practice IRL, will vary as much, depending on the perspective and training of the surgeon.

Understand the goals (decrease risk of contracture, decrease swelling, promote patient comfort, at least) and follow MD orders and facility's practice.

Good discussion for inservice!

[OneWhisper]

Oh yes! So clear! Hahaha!

[Double-Helix, BSN, RN]

Elevate so that the limb is above the heart. This promotes venous return and will decrease swelling and edema. But do so while taking care to keep the residual limb in alignment with the hip, thus reducing risk of contracture. This may require slightly elevating the hip or sacrum while keeping the torso low. Contrary to what your instructor said, raising the foot of the hospital bed doesn't simply raise the feet. It raises at about knee level, which (in a person with two whole legs) would angle the thigh upward and bend the leg at the knee. So a person with a BKA or AKA will absolutely have elevation of the limb by raising the FOB.

[OneWhisper]

Elevate so that the limb is above the heart. This promotes venous return and will decrease swelling and edema. But do so while taking care to keep the residual limb in alignment with the hip, thus reducing risk of contracture. This may require slightly elevating the hip or sacrum while keeping the torso low. Contrary to what your instructor said, raising the foot of the hospital bed doesn't simply raise the feet. It raises at about knee level, which (in a person with two whole legs) would angle the thigh upward and bend the leg at the knee. So a person with a BKA or AKA will absolutely have elevation of the limb by raising the FOB.

Okay, so it's just important to know to elevate and keep hip aligned to reduce contracture. So, do you elevate with pillows or by elevating FOB or either?

[Double-Helix, BSN, RN]

It doesn't matter. You can use pillows, towels, foam cushions, or bags of marshmallows. NCLEX isn't going to ask you that level of detail.

[meanmaryjean, DNP, RN]

I vote bags of marshmallows!

[Double-Helix, BSN, RN]

I vote bags of marshmallows!

I've got a lot of Peeps left over from Easter!