A Case Presentation on Below the Knee Amputation

A Case Presentation on Below the Knee Amputation

OBJECTIVES

GENERAL OBJECTIVE

• Within the two-hour case presentation, the level III nursing students shall gain adequate knowledge, develop competent nursing skills, and manifest desirable attitudes towards the care of patients undergoing below the knee amputation.

SPECIFIC OBJECTIVES• At the end of the two-hour case

presentation, the level III nursing students will be able to:

1. Review the anatomy and physiology of the lower extremity.

2. Define the related terms correctly.3. Trace the pathophysiology of diabetes

mellitus.4. Identify the types of amputation

appropriately.5. Described below the knee amputation

satisfactorily. 6. Discuss its indications correctly.

7. Appreciate the responsibilities of the nurse during below the knee amputation.

8. Formulate a nursing care plan for patients undergoing below the knee amputation comprehensively.

INTRODUCTION

INTRODUCTION

• Amputation is the removal of a body extremity by trauma, prolonged constriction, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene.

• There are many types of amputation, specifically:• for the arms:

- we have amputation of digits-metacarpal amputation -wrist disarticulation -forearm amputation (transradial) -elbow disarticulation-above-elbow amputation (transhumeral)-shoulder disarticulation and forequarter amputation

• We also have on the lower extremeties namely:

-amputation of digits-partial foot amputation-ankle disarticulation-below-knee amputation (transtibial) -knee-bearing amputation -above-knee amputation (transfemoral)

ANATOMY AND PHYSIOLOGY

DISCUSSION OF THE SURGICAL

PROCEDURE

Below the Knee Amputation

• Below the knee amputation is a surgery or a type of amputation which is to remove all or part of the foot or of the leg below the knee cap. It is also called BKA (Thomson, 2012).

INDICATIONS• A person may need a BKA for a health

problem that causes poor blood flow, such as diabetes or a severe infection. A person may have been in an accident that injured his/her leg beyond repair. BKA may also be indicated for patients with cancer, or were born with a deformed leg. Amputations are either planned or done in an emergency.

COMPLICATIONS• Infection• Blood Clot• Phantom Limb• Joint Contracture• Wound Complications

Nursing Responsibilities

PREOPERATIVE RESPONSIBILITIES

• Evaluate the neurovascular and functional status of the extremity through history and physical assessment.• Assess the circulatory status and function of the unaffected extremity.

• Any concurrent health problems (eg, dehydration, anemia, cardiac insufficiency, chronic respiratory problems, diabetes mellitus) need to be identified and treated so that the patient is in the best possible condition to withstand the trauma of surgery.

• The nurse assesses the patient’s psychological status. Determination of the patient’s emotional reaction to amputation is essential for nursing care.

INTRAOPERATIVE• Identify the patient. • Position the patient. • Ensure safety of the patient. • Maintain surgical asepsis. • Proper handling of equipment.

POSTOPERATIVE

• Changing the patient’s position or placing a light sandbag on the residual limb to counteract the muscle spasm may improve the patient’s level of comfort.

• Keeping the patient active helps decrease the occurrence of phantom limb pain. Early intensive rehabilitation and stump desensitization with kneading massage brings relief. Distraction techniques and activity are helpful.

• The residual limb must be handled gently. Whenever the dressing is changed, aseptic technique is required to prevent wound infection and possible osteomyelitis.

• The nurse who has established a trusting relationship with the patient is better able to communicate acceptance of the patient who has experienced an amputation. The nurse encourages the patient to look at, feel, and then care for the residual limb.

• The nurse acknowledges the loss by listening and providing support.• The patient is encouraged to be an active participant in self-care.

• Positioning assists in preventing the development of hip or knee joint contracture in the patient with a lower extremity amputation. Abduction, external rotation, and flexion of the lower extremity are avoided.

• The nurse assesses body systems (eg, respiratory, gastrointestinal, genitourinary) for problems associated with immobility (eg, pneumonia, anorexia, constipation, urinary stasis) and institutes corrective management. Avoiding problems associated with immobility and restoring physical activity are necessary for maintenance of health.•  

HypotheticalNursing Care

Plans

PREOPERATIVE

Nursing Dx: Anxiety related to impending loss of limb secondary

to below the knee amputation

CUES AND EVIDENCE

S

OUTCOME

CRITERIA

INTERVENTION

S

RATIONALE

EVALUATION

Subjective data:

“Nakulbaan ko sa mahitabo nako inig putlon na ni akong tiil”, as verbalized.

At the end of our nursing care the client will manifest reduced anxiety as evidenced by:

1. Verbalization of reduced anxiety before surgery.

Independent:

1. Continue to assess anxiety level of the patient.

2. Establish open and honest communication.

-To monitor progress of his anxiety.

-For the patient to be aware of his real present condition.

At the end of our nursing care the client manifested reduced anxiety as evidenced by:

1. “Wa na kayo ko nakulbaan karon, salamat sa pagtabang” as verbalized.

CUES AND EVIDENCE

S

OUTCOME

CRITERIA

INTERVENTION

S

RATIONALE

EVALUATION

Objective data:

Restless Poor eye

contact

Increased perspiration

RR= 25cpm

PR=104bpm

BP=140/90mmHg

2. More relax and able to rest

3. Absence of perspiration

4. Return of RR to normal rate of 12-20cpm

3. Encourage the patient to express his anxiety or fears and negative feelings about the loss of a limb.

- To allow the patient to express his hidden feelings and feel much better.

2. More relaxed.

3. Absence of perspiration.

4. RR=19cpm

5. PR=87bpm

CUES AND EVIDENCE

S

OUTCOME

CRITERIA

INTERVENTION

S

RATIONALE

EVALUATION

4. Encourage the patient to ask questions if he has any that he didn’t understand or reinforce accurate information.

- To let the patient understand more what he will go through, helps him to identify what is reality based and to decrease anxiety.

CUES AND EVIDENCE

S

OUTCOME

CRITERIA

INTERVENTION

S

RATIONALE

EVALUATION

5. Provide a calm/quiet environment.

- Allows relaxation and decreases anxiety level.

INTRAOPERATIVE

Nursing Dx: