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Right Foot Amputation
1
- The first step in preparing the patient for this surgery is making sure the reason for surgery and the procedure its self is fully understood. This is the responsibility of the surgeon, however it is the nurse’s job to reinforce this understanding and if understanding is not fully met we need to contact the physician.
- The next step in preparing the patient for surgery is obtaining consent. As nurses we can ask the patient to sign and witness the signature; however it the surgeon’s responsibility to explain the procedure before consent can be obtained.
- Drug and alcohol use, respiratory function, cardiovascular function, hepatic and renal function, endocrine function, immune function, previous medication use, psychosocial factors, and spiritual and cultural beliefs should all be assessed and reviewed
- Inflammatory and blood thinning medications may need to be stopped a week prior to surgery
- The day of the surgery, the patient should be NPO for 8 hours.
- The site should be washed with a special antibacterial soap.
- Verification of the correct person, procedure and site should occur with the patient awake and aware.
- At the time of surgery/procedure is scheduled
- At the time of pre-admission and testing
- At the time of admission or entry into the facility
- Anytime the responsibility for care of the patient is transferred to another caregiver
- Before the patient leaves the preoperative area or enters the procedure/surgical room
- Marking the site should take place with the patient involved. Final verification of the site mark should take place during the "time out."
You will have pain for several days after surgery that can be controlled by the hospital through the use of medications. You may also have the feeling that your foot is still there, this is called phantom sensation. Phantom sensation is normal for anyone who undergoes amputation.
You may feel sad or depressed because of the surgery. These feelings are normal and you should express them to the staff and your family members. Your patient care team will be there to help you along the way. You may also want to consider seeing a counselor to help you through this emotional time.
You need to keep your glucose levels within normal range to prevent further amputation or complications.
- Every 15 Minutes Until Stable
- Every 1-2 Hours for First 24 hrs
- Every 4 Hours After That
- Respiratory Status
- Cardiovascular Status
- Fluid Status
- Maintaining Airway
- Nausea/Vomiting
- Hemorrhage Symptoms
- Vitals
- Blood Glucose Monitoring
Wear your elastic bandage or shrinker sock on the stump all the time. If you are using an elastic bandage, rewrap it every 2 to 4 hours. Make sure there are no creases in it. Wear your stump protector whenever you are out of bed.
- Impaired physical mobility related to change in ambulation, change in gait, and pain, secondary to left food amputation.
- Disturbed body imagine related to change on seeing appearance secondary to left foot amputation.
- Risk of ineffective tissue perfusion related to reduced blood flow in limb, secondary to diabetes.
- Risk for infection: Incision, Break in skin integrity, Secondary to history of diabetes
- Situation self-esteem related to change in role in household and at work.
- Acute pain related to trauma, secondary to left food amputation
Answer:: a and d
Answer: b.
N-Clex Questions
The patient verbalizes understanding of discharge instructions when they know to do what if their wound starts having a foul smell?
a. Soak in the bathtub
b. Call the doctor
c. Lather wound with a scented lotion
d. Scrub the wound cleann
Right Foot Amputation
Nursing Diagnoses
Pre-op
Intra-op
Post-op
Care
Teaching
Patient Preparation
Variances
Complications
Assessment
Positioning
Foot Amputation
Sources
Bowering, C. Keith. "Diabetic Foot Ulcers." Canadian Family Physician 47 (2001): 1007-017. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2018500/pdf/11398715.pdf
Diabetic Foot Amputations." Johns Hopkins Medicine, Based in Baltimore, Maryland. N.p., n.d. Web. 12 Oct. 2013.
Many Diabetic Foot Amputations Are Preventable. Diabetic Forecast, 2009. Web. 14 Oct. 2013. <http://forecast.diabetes.org/news/many-diabetic-foot-amputations-are-preventable>.
Wheeless, Clifford R. Wheeless' Textbook of Orthopedics. Duke Orthopedics, 14 May 2012. Web. 14 Oct. 2013. <http://www.wheelessonline.com/ortho/foot_and_ankle_amputation>
Bloodwork
- Chemistry Panel
- Liver Function Panel
- PT/PTT/INR
- Arterial Blood Gas (ABG)
- CBC
- Cross Type and Matching
Other Tests
- X-ray of Foot
- Bone Scan
- Tests to Evaluate Blood Circulation and Help the Doctor Determine How Much of the Foot Needs to be Amputated
Guillotine Amputation
- Performed Rapidly
- Narrowest Part of Ankle
- Circular Sweep of Knife
- Cut of a Saw
- Nerves Severed with a Scalpel
- Careful Hemostasis of All Vessels
- Left Open for Dressing
Chopart Amputation
- Removes Forefoot and Midfoot
- Saves the Talus and Calcaneus,
- Not Performed for Ischemia
- Very Unstable Amputation
- Heel Remains Unstable
- Some Loss of Normal Arch of the Foot
- Tibialis Anterior Tendons are Detached at Insertion
- Passed Through a Hole and Drilled in the Neck of the Talus
- Tendon is then Sutured Upon Itself
- Extensor Tendons Sutured to the Fascia and Soft Tissues of the Sole
Syme's Amputation
- Allows Excellent Gait with a Prosthesis
- Will Not Heal Without a Palpable Posterior Artery Pulse
- May be Performed in Two Stages
- Ankle is Disarticulated in the First Stage
- Amputation is Revised 6 Weeks Later
- Resection of the Malleoi Flush with Joint Surface
- Fixation of the Fat Pad to Residual Bone
- Revision of Redundant Skin
- Allows for Intermittent Weight Bearing
- Skin Break Down May Occur
Pirogoff Amputation
- The Lower Articular Surface of the Tibia and Fibula are Sawed Through
- Ends Covered with a Portion of the Calcis That Has Been Sawed Through From Above Posteriorly Downward and Forward
Goals
- Maintain Airway
- Maintain Circulation
- Prevent Nerve Damage
- Expose Surgical Site
- Safety and Comfort
Assessment
- Procedure Length
- Required Position
- Risk Factors
Supine Position
- Most Common, least amount of harm
- Place On Back, Legs Extended
- Arms On Arm Boards Abducted <90* Palms Up
- Spinal Column In Alignment with Legs Parallel to the Bed
- Padding Under Head, Arms, Heels
- Pillow Under Knees
- Safety Belt 2" Above Knees
Concerns
- Circulation
- Pressure Points
- Nerve Damage
Multi-Cut Utility Scissors
Dissecting Scissors
Crile Forceps
Ochsner Forceps
Scalpel Handle
Hegar Needle Holder
Tissue Forceps
Amputating Knife
Stille-Liston Rongeur
Bruns Bone Curette
Key Elevator
Langenbeck Elevator
Wire Loop Handle for Gigli Saw
Putti Bone Raspatory
Satterlee Bone Saw
Amputation Retractor
Steel Ruler
Sterilizing Tray/Rack
Nausea and Vomiting
- Turn Patient on Side
- Lower the Head of the Table
- Provide a Basin to Catch Vomitus
- Suction Out Remainder Contents
Aspiration
- Will Cause Asthma Like Attack
- Bronchial Spasms
- Wheezing
Respiratory
- Inadequate Ventilation
- Occlusion of the Airway
- Inadvertent Intubation of the Esophagus
- Hypoxia
- Asphyxia
Anaphylaxis
• Response to Medications, Latex, or Other Substances Coming in Contact with the Patient
• Can Happen Immediately or Have a Delayed Reaction
Hypothermia
- Anesthesia Can Decrease Body Temp
- Glucose Metabolism is Reduced (Metabolic Acidosis)
- Core Body Temp of < 98.0 F or 36.3 C
- Warm Gradually Not Rapidly
- Monitor ECG, BP, ABG, and Serum Electrolyte levels
Pain
- Phantom Limb Sensation
- Painful, Burning Sensation
- Neurons Become Adherent
- No Treatment
Positioning
- Supine Position with Leg and Hips Flat
- Switch Position Every 2 Hours if Possible
- Keep Knee Cap Pointed at Ceiling
- Decreases Swelling
Wound Healing
- Slow Healing in Diabetics
- Assess for Drainage, Amount, Consistency and Color
- Assess for Signs of Infection
Limb Dressing: Soft, Soft with Pressure Wrap, Semi Rigid, Rigid
- Elevated blood glucose levels in post op care can increase the risk for infection.
- Levels of 111- 140 mg/DL were 3.61 times more likely to develop infection
- Insulin contains anti inflammatory- anti infective activity, when blood sugars are low those properties aren't present.
Do NOT use your limb until your doctor tells you it is okay to use it again. This will be at least 2 weeks or longer after your surgery. Do not put any weight at all on your wound. Do not even touch it to the ground, unless your doctor says so.
Do NOT drive.
Keep the wound clean and dry. Do not take a bath, soak your wound, or swim. If your doctor says you can, clean the wound gently with mild soap. Do not rub the wound, but allow water to flow gently over it.
Inspect your limb every day. Use a mirror if it is hard for you to see all around it. Look for any red areas or dirt.
Helpful Home Techniques
Call Your Doctor If...
- Your stump looks redder, or there are red streaks on your skin going up your leg.
- Your skin feels warmer to touch.
- There is swelling or bulging around the wound.
- There is new drainage or bleeding from the wound.
- There are new openings in the wound, and the skin around the wound is pulling away.
- Your temperature is above 101.5° F more than once.
- Your skin around the stump or wound is dark or is turning black.
- Your pain is worse, and your pain medicines are not controlling it.
- Your wound has gotten larger.
- A foul smell coming from the wound.
- Diabetic patients, mainly because of peripheral neuropathy, vascular disease, and infection mostly precipitated by traumatic foot ulceration.
- Factors that affect development & healing of diabetic patients’ foot ulcers include the degree of metabolic control, the presence of ischemia or infection and continuing trauma to feet from plantar pressure or ill-fitting shoes.
- Nerve deterioration caused by hyperglycemia is a main cause for ischemia in the extremities, making diabetics more susceptible to ulceration and infection.
- Splaying of the foot due to muscle loss changes the foot size causing shoes to be ill fitted and creating ulcerations on the foot.
- Loss of sweat & oil glands allows the foot to be more vulnerable to bacterial infections.
- Additionally, loss of foot sensation such as pain or discomfort aggravates this condition.
- Appropriate wound care for diabetic patients that address these issues and optimal ulcer therapy with debridement of necrotic tissue and provision of a moist wound healing environment could prevent amputation.
- When appropriate wound care is ignored or fails, amputation of the foot to prevent further necrosis of tissue is warranted.
Patient Teaching
Pathology
A patient that will be getting a foot amputation will show understanding of post surgical expectations by verbally understanding the following...(select all that apply)
a. Phantom Pains are common among all amputations
b. I will be able to drive when I feel comfortable
c. I can soak in a bath to relieve the pain
d. I have to maintain a good glucose level