Caring for amputees...post op and in general

Kittyfeet · Oct 11, 2009

I have taken care of a lot of foot and toe amputees due to diabetes. Following post op, usually the most important things are of course pain management, and making sure the vitals are staying within normal range. You need to carefully read the orders to find out if they want the foot elevated on a pillow, whether or not they can be weight bearing, fit them for a surgical shoe, and see if they need a physical therapy evaluation. Another important thing is to find out if the wound was cultured and see if they need to be on isolation for MRSA. They will probably have a strong antibiotic drip like Vancomycin, so be on the look out for things like kidney trouble and ototoxicity and pay attention to when it's time for a vanc trough. Another very important aspect of Diabetes and amputation is to educate them on their diet and managing their disease because usually that's why they had to have an amputation... non compliance. Make sure they know they need to have foot care with a podiatrist, and they may want to get diabetic shoes.

Last but not least you need to evaluate how they are coping. An amputation can be an emotional loss along with worrying about work and home life. They may need a social worker/case manager to help them with their resources so they don't become non compliant again and lose more toes or damage other things like their kidneys and retinas.

I hope this helps!

cardiacmadeline, RN · Oct 11, 2009

Never elevate an AKA on a pillow. This can cause contractures making it difficult for a prosthetic. We don't do this at my hospital, but laying a patient prone helps stretch out those muscles in the stump, helping to prevent contractures. Pain management is a big issue. In addition to narcs, I have occasionally given valium for muscle spasms in post op amps. I have also found some people don't have an understanding of phantom pain, so making sure they understand that concept is important. I have heard somewhere that if amputees having phantom pain look in a mirror at their stump, this somehow helps the pain. It is like your brain is able to see you don't have a foot there and it can then process that information better. Has anyone else heard of this?

NotFlo · Oct 11, 2009

I have heard somewhere that if amputees having phantom pain look in a mirror at their stump, this somehow helps the pain. It is like your brain is able to see you don't have a foot there and it can then process that information better. Has anyone else heard of this?

I haven't specifically heard of that but it makes sense to me.

The other day I had a gentleman a couple years post-op with a BKA begging me to rub the cramp out of the sole of his foot. This is totally weird but I tried rubbing the stump...he said no, rub where the sole of his foot would be. I rubbed the air where his foot would be and he stated he got relief. He is a+o and knows there's no foot there but says someone rubbing down where his foot would be helps when he gets that cramp in the sole of his foot.

nopainNurse · Oct 11, 2009

The mirror idea is called "mirror box therapy." If you saw the recent House episode, he actually used it. However in the TV version the healing of the pain was miraculous and instant. In reality the pain will likely not be cured with this treatment, but can be significantly decreased. It takes a long time though. There is some research reporting on studies of pts exercising with the mirror for 1 hour a day for 1 month and then starting to have a decrease in pain intensity.

This is a relatively new tx that is still be studied, but it is very interesting.

http://www.mirrorboxtherapy.com/

Anisettes, BSN, RN · Oct 11, 2009

I have had huge experience dealing with fresh amputees of every sort - seeing as every kid blown up in Iraq & Afghanistan comes through my hospital before s/he goes home - usually to Walter Reed. They are doing AMAZING things for amputees at Walter Reed these days and I wish I knew somebody there to refer you to. Some of it cutting edge stuff.

Among other things, they are doing mirror therapy (unless both limbs were lost) with great success - where the pt exercises the remaining limb while viewing it through a mirror. They have found that this significantly reduces (in older injuries) or eliminates (in new ones) 'phantom pain' in the residual limb. Since the pain the patient usually experiences is the last pain that limb experienced before it was removed. And it is real pain, the limb is gone, but the neural pathways to the brain are still intact. Logically, the mind knows the limb is gone, but the brain itself doesn't since it's sensory pathways are intact.

There has also been breakthroughs in prosthetics, people who just 10 years ago would have been confined to wheelchairs are now able to be fitted with lightweight, responsive prosthetic devices - and I mean HIGH AKA - nearly upper thigh, though to my knowledge they still can't do anything about the ones whose injuries extend into the hip.

This probably sounds 'niche' and not of much value to most nurses - but as these people are rehabilitated and leave acute care and are disseminated back out into their communities, all nurses will be seeing a lot more amputee patients - esp. as they age and need care for other problems, I doubt the VA is up to the task, because the numbers are mind-boggling. For every death you hear about, there are 5 or more injuries, most of them significant and at least 1 or 2 resulting in a partial or complete amputation of a limb. Sometimes the numbers are higher.

For the longest time we never knew what happened to them when they left us and for most nurse/docs/techs there was a lot of depression as we wondered what we were sending them home to, then one day one of the new docs from Walter Reed brought in this little video of what was going on back home and I can't tell you how it perked everybody up. We saw guys who we thought would be home contemplating suicide, running around! One guy with bilateral AKA was running around a track. Most of us were bawling we were so happy to see it.

Human ingenuity, human spirit, and the Grace of God. It's a beautiful, humbling thing.

belgarion · Oct 11, 2009

The patient's attitude is everything. As a student, I was assigned to a patient who was scheduled for a BKA that afternoon. He was already setting up an appointment to be fitted for his "pegleg" and making plans to go back to work. His job was installing fire sprinkler systems in buildings - lots of ladder climbing and scaffold work. I heard through the grapvine that he was doing great and you can hardly tell that he is missing a leg unless he's wearing shorts.

On the other hand, I have seen amputees who think the end of the world has come and go into a slow, downhill slide; never to fully function again. Like I said, attitude is everything.