1. Amputation

2. Definition It is the removal of a body part usually extremity Or
Removal of a body extremity by trauma, prolonged constriction or surgery

3. Incidence
age – years
The middle and older age groups have the highest incidence of amputation because of the effects of PVD, atherosclerosis, and vascular changes related to DM
Amputation in young peoples is due to trauma (RTA)
Gender- men(75%) and females (25%)

4. Causes /Indication
Circulatory impairment resulting from a peripheral vascular disorder
atherosclerosis
Vascular changes
Traumatic and thermal injuries
Malignant tumors
Uncontrolled or wide spread infection of the extremity (gas gangrene)
Osteomyelitis
Congenital disorders
Vascular changes related to diabetes mellitus

5. Diagnostic features History and physical examination Skin temperature
Sensory function
Presence of peripheral pulses
Arteriography
Venography
Plethysmography – study which records variations in volume and pressure of blood passing through tissue

6. Types Closed amputation
This is done most of the time as an elective procedure and may be above knee or below knee, above elbow and below elbow
It is performed to create a weight bearing residual limb or stump
An anterior skin flap with dissected soft tissue padding cover the bony part of the residual limb.
The skin flap is sutured posteriorly so that it will not be positioned in a weight bearing area.

8. Open amputation /guillotine amputation
In this the wound is left open over the amputation stump and is not covered with skin
This is done in emergency situation in which threaten the life of the patient
The wound is usually closed later by a second surgical procedure or closed by skin traction surrounding residual limb

9. Amputation levels Upper limb
Forequarter amputation -Forequarter amputation is amputation of the arm, scapula & clavicle.
Shoulder disarticulation (amputation performed through a joint)
Above elbow amputation (transhumeral)
Elbow disarticulation
Below elbow amputation (transradial)
Wrist disarticulation
Ray amputation – amputation of digits

11. Lower limb
Hemicorporectomy – removal of half of the body from pelvis and lumbar areas. (conduits should maid, from colon for fecal discharge, ileal conduit for urine discharge)
Hemi pelvectomy
Hip disarticulation
Above knee amputation (trans femoral)
Short above knee
Medium above knee
Long above knee
Knee disarticulation
Below knee amputation (transtibial)
Amputation of the foot between metatarsus and tarsus (hey’s or lisfracs amputation)
Syme’s amputation – it is a form of disarticulation at the ankle

15. Complication
Hematoma - This delays the wound healing and acts as a culture media for the growth of the organism
Infection – more common in peripheral vascular disease and diabetics
Necrosis – this is due to insufficient circulation
Contractures – this is largely preventable by positioning the stump properly
Neuroma (tumor of nerve) – it form always on the end of a cutaneous nerve

16. Phantom limb sensation
This is pseudo feeling of the presence of the amputated limb (occurs in 50% of amputees).
The patient may complains of feelings of coldness and heaviness, cramping, burning and crushing pain
Phantom limb pain
Phantom limb pain is when a person experiences sensations of pain that seem to be coming from the limb that has been amputated.
It is estimated that 50-80% of people develop phantom limb pain after an amputation. The condition is more common in women than men and more common in upper limb amputation

17. Collaborative care Medical management
Appropriate management of underlying disease
Stabilization of trauma victim
Surgical management
Goal –
To preserve extremity length and function while removing all infected pathologic or ischemic tissue
Improves the possibility of good prosthetic, cosmetic and functional satisfaction

18. Nursing management
The disruption in body image caused by an amputation often causes a patient to go through the psychological stages of the grieving process
Allow the patient to go through grieving process and recognizing it as a normal consequence may do much to aid the patient’s acceptance of the amputation

19. Pre operative mgt
Reinforce information that the patient and family have received about the reasons for the amputation, proposed prosthesis and the mobility training programme
Explain about the level of amputation, type of post surgical dressing to be applied, type of prosthesis to be utilized
Instruct the patient about upper extremity exercise such as push ups in bed or the wheel chair to promote arm strength.
This is essential later for crutch walking and gait training

20. Inform the patient about phantom limb sensation, occurs 80% of amputees .
If the patient is having pain in the extremity before surgery, after surgery also patient will feel the pain.
Patient may complain feelings of coldness, heaviness, cramping, shooting, burning or crushing pain
As recovery and ambulation progress the sensation and pain subside

21. Post operative mgt Based on patient the nurse must take care
Old persons –need Monitoring of respiratory status
RTA patients -Neurological assessment
Traumatic injury – post traumatic stress disorder
Watch for hemorrhage – a surgical tourniquet must be available for the emergency use.
Immediate prosthetic fitting may be performed in the OT after the amputation
Delayed prosthetic fitting may be best choice for certain patient

22. Careful monitoring of patients vital signs and dressings can alert to hemorrhage in surgical site
Sterile technique during dressing to minimize infection
care of stump
Position patient with no flexion at hip or know to avoid contractures
Support with pillow for first 24 hours to minimize edema
Inspect for redness, blister and abrasions
After healing of wound - Wash stump with mild soap, rinse with water, and pat dry
Avoid use of alcohol, oils and creams
Remove stump bandage or stump socks and reapply as needed, use firm smooth figure of 8 wrap
It will reduce swelling and promote shape

23. Immediate prosthetic fitting
It can be performed in the operation room after the amputation
Ex – lower extremity amputation, - a rigid cast like bandage is applied around the closed residual limb with a prosthetic pylon and an ankle-foot assembly

24. Indication for delayed prosthetic fitting
Patient who have had amputation above the knee or below the elbow, older adults, debilitated individuals and those with infection usually have delayed prosthetic fittings
A temporary prosthesis may be used for partial weight bearing once the sutures are removed.
3 months after the amputation patient can bear full weight on permanent prosthesis
Compression bandage to be applied immediately after surgery to support the soft tissue, reduce edema. Hasten healing, minimize pain and promote residual limb shrinkage and maturation

25. This bandage may be an elastic roll applied to the residual limb, which is an elastic stockings that fits tightly over the residual limb and lower trunk area
Compression bandage is initially worn at all times except during physical therapy and bathing
The bandages is taken off and reapplied several times daily
Shirnker bandage should be changed daily
Encourage stump movement to prevent second disability especially tightening of the muscle tendon, ligaments or skin

27. As overall condition improves, the nurse begins instruction in the principles and techniques of transferring form bed to chair and back
Active exercise are essential in developing ambulation skills
Crutch walking is started as soon as patient are physically able.
Initial periods of ambulation should not exceed 5 mts to prevent dependent edema

28. Nursing diagnosis…………
Pre and post operative
Acute pain
Disturbed body image related to amputation
Activity intolerance
Self care deficit
Impaired skin integrity related to immobility
Low self esteem
Imbalanced nutrition
Chronic pain related to phantom limb sensation
Ineffective therapeutic regimen
Impaired physical mobility related to amputation of lower limb
Insomnia
Anxiety
risk for infection
Impaired skin integrity

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41. Prolapsed intervertebral disks or IVDP.
Displacement of intervertebral disk material from its normal location referred to as prolapse or herniation of disk

42. Normal Disc herniated Disc

43. CAUSES Traumatic injury to lumbar discs
Repetitive mechanical activities – Frequent bending, twisting, lifting, and other similar activities without breaks and proper stretching can leave the discs damaged.
Living a sedentary lifestyle
Traumatic injury to lumbar discs
Natural degeneration with age
Weak abdominal and back muscles
Age group years are common
CAUSES

44. Obesity – Spinal degeneration can be quickened as a result of the burden of excess body fat.
Practicing poor posture – Improper spinal alignment while sitting, standing, or lying down strains the back and neck.
Tobacco abuse – The chemicals commonly found in cigarettes can interfere with the disc’s ability to absorb nutrients, which results in the weakening of the disc.
Mutation- in genes coding for proteins involved in the regulation of the extracellular matrix, such as MMP2 and THBS2, has been demonstrated to contribute to lumbar disc herniation.

45. Triggering factors - sneezing, awkward bending, or heavy lifting in an awkward position may cause some extra pressure on the disc

46. Classifications Of Herniations
Degeneration
Loss of fluid in nucleus pulposus
Protrusion
Bulge in the disc but not a complete rupture
Prolapse
Nucleus forced into outermost layer of annulus fibrosis- not a complete rupture
Extrusion
A small hole in annulus fibrosus and fluid moves into epidural space
Sequestration
Disc fragments start to form outside of the disc area.
Classifications Of Herniations

48. Changes of the Intervertebral Disc

49. Pathophysiology
due to etiological factors Structural changes occurs in the intervertebral discs A tear can develop which cause inflammatory reactions Nucleus pulposus will prolapsed through annulus fibrosus Compression of the nerve root Back pain occurs due to nerve compression as well as release of chemical mediators of inflammation follows other symptoms

50. Clinical manifestations
Low back pain
Radicular pain that radiates down the buttocks and below the knee, along the distribution of the sciatic nerve. Pain aggravated by action and usually relieved by rest
L3-L4 – back to buttocks to posterior thigh to inner calf
L4-L5 – back to buttocks to dorsum of foot & big toe
L5-s1 – back to buttocks to sole of foot and heel

51. sensory changes such as numbness, tingling, muscular weakness, paralysis, paresthesia, and affection of reflexes.
Pain in the buttock, posterior thigh and calf (sciatica).
pain from a herniated disc is usually continuous or at least is continuous in a specific position of the body.
A large central rupture may cause compression of the cauda equina (bundle of spinal nerves).
Sometimes a local inflammatory response with oedema aggravates the symptoms.
The patient usually stands with a slight deviation to one side(‘sciatic scoliosis’).

52. Bladder and bowel incontinence Perineal numbness Bilateral sciatica .
FEATURES OF CAUDA EQUINA SYNDROME
Bladder and bowel incontinence
Perineal numbness
Bilateral sciatica
Lower limb weakness
straight-leg raising sign

53. Location
The majority of spinal disc herniation cases occur in lumbar region (95% in L4-L5 or L5-S1).
 The second most common site is the cervical region (C5-C6, C6-C7).
The thoracic region accounts for only 0.15% to 4.0% of cases.

54. Cervical
Cervical disc herniations occur in the neck, most often between the fifth & sixth (C5/6) and the sixth and seventh (C6/7) cervical vertebral bodies.
Symptoms can affect the back of the skull, the neck, shoulder girdle, scapula, shoulder, arm, and hand.
The nerves of the cervical plexus and brachial plexus can be affected.
Thoracic
Thoracic discs are very stable and herniations in this region are quite rare.

55. Lumbar
Lumbar disc herniations occur in the lower back, most often between the fourth and fifth lumbar vertebral bodies or between the fifth and the sacrum.
Symptoms can affect the lower back, buttocks, thigh, anal/genital region (via the Perineal nerve), and may radiate into the foot and/or toe.
The sciatic nerve is the most commonly affected nerve, causing symptoms of sciatica.
The femoral nerve can also be affected and cause the patient to experience a numbness, tingling feeling throughout one or both legs and even feet or even a burning feeling in the hips and legs.

56. Diagnostic studies History and physical examination X ray CT scan MRI
Myelogram
Diskogram

57. Management Pain medications. Bed rest Oral steroids .
Nerve root block .
Surgery

58. Non-steroidal anti-inflammatory drugs (NSAIDs).
Oral steroids (e.g. prednisone or methylprednisolone).
Epidural cortisone injection.
Intravenous sedation, analgesia-assisted traction therapy ,anti-depressants.
Weight control, Tobacco cessation, Lumbosacral back support.
Patient education on proper body mechanics.
Physical therapy and may include modalities to temporarily relieve pain (i.e. traction, electrical stimulation massage).
Medications

59. POSITIONS
Semi sitting position is usually comfortable and promote forward lumbar spine flexion
Other positions
Supine position with pillows under the knees or legs
Lateral position, lies on the unaffected side with a thin pillow between the knees and with the painful leg flexed to reduce tension on sciatic nerve
Avoid
Lying in a prone position and sleeping with the pillow under the head

60. The indications for surgery
Surgical management
The indications for surgery 1
persistent pain and signs of sciatic tension (especially sciatic tension) after 2–3 weeks of conservative treatment. 2
a cauda equina compression syndrome – this is an emergency 3
neurological deterioration while under conservative treatment;

61. Goals of surgical treatment
relief of nerve compression.
allowing the nerve to recover.
relief of associated back pain.
restoration of normal function.

62. Chemonucleolysis-
Chemonucleolysis is the term used to denote chemical destruction of nucleus pulposus [Cehmo+nucleo+lysis].
This involves intradiscal injection of chymopapain which causes hydrolysis of the cementing protein of the nucleus pulposus.
This causes decrease in water binding capacity leading to reduction in size and drying the disc.
Chemonucleolysis is one of the methods to treat disc herniation not responding to conservative therapy

63. Intradiscal electrothermal plasty (IDET) – minimally invasive technique in which percutaneous threading of a flexible catheter (composed of thermal resistive coil) under fluoroscope causing contraction of collagen fibers and reducing back pain

66. Discectomy/Microdiscectomy -
Diskectomy / discectomy – is the surgical removal of herniated disc material that presses on a nerve root or the spinal cord.
Microdiscectomy – removing herniated fragments of disk

68. Laminectomy/ Hemilaminectomy
Is a surgical procedure that removes a portion of the vertebral bone called the lamina
Minimally invasive procedure
By excision of the lamina (posterior arch of the vertebra) will helps to access the part of or the entire protruding disk to remove it.

70. Lumbar fusion
Anterior lumbar fusion is an operation done on the front (the anterior region) of the lower spine. Fusion surgery helps two or more bones grow together into one solid bone. Fusion cages are new devices, essentially hollow screws filled with bone graft, that help the bones of the spine heal together firmly. Surgeons use this procedure when patients have symptoms from disc degeneration, disc herniation, or spinal instability.
lumbar fusion is only indicated for recurrent lumbar disc herniations, not primary herniations

71. Disc arthroplasty
Artificial Disc Replacement (ADR), or Total Disc Replacement (TDR), is a type of arthroplasty.
It is a surgical procedure in which degenerated intervertebral discs in the spinal column are replaced with artificial devices in the lumbar (lower) or cervical (upper) spine.

72. Inter spinous process decompression system – minimally invasive procedure in which an implant (made of titanium)is placed between the disc levels.
Effective in patient with lumbar spinal stenosis

73. Nucleoplasty
Nucleoplasty is the most advanced form of percutaneous discectomy
Nucleoplasty uses a unique technology to remove tissue from the center of the disc.
Tissue removal from the nucleus acts to “decompress” the disc and relieve the pressure exerted by the disc on the nearby nerve root . As pressure is relieved the pain is reduced
A needle or catheter is inserted into the disc nucleus and radio frequency energy is directed into the disc to ablate tissue

74. Complications Cauda equina syndrome Chronic pain
Permanent nerve injury
Paralysis

75. Nursing management Reassure that it will not weaken the back
Teach breathing and coughing excercise
Demonstrate log rolling technique – the patients arm will be crossed and the spine is aligned.
To avoid twisting.
spine, head, shoulder, knees and hips are turned at the same time so that the patient rolls over like a log.

76. Nursing diagnosis Back pain related to disease condition
Activity intolerance
Self care deficit
Insomnia related to back pain
Anxiety related to disease condition or surgical outcome
Knowledge deficit related to the management of the disease condition
Low self esteem