AMPUTATION PRESENTATION

AMPUTATION

 (i)  Draw and lable the femur:

      N.B Check diagram in Wilson and Ross page 390, Figure 15.38. 

      (12%.)

5 Indications of Amputation:

Infection such as gangrene

Vascular disease (peripheral)

Trauma crushing injuries

Burns (electric)

Congenital deformities

Chronic osteomyelitis

Identify and explain 4 investigations  (12%)

X-ray of the bone - to confirm diagnosis

Serum alkaline phosphate - will be elevated

Bone scan - to detect extent of cancer

Chest x-ray - to eliminate metastasis

Renal and liver function test to check effect on these organs

Bone biopsy - to confirm the diagnosis after identifying cancer cells.

DISCUSS THE POST OP CARE THE FIRST 72 HOURS; (50%)

Objectives (2%)

To prevent complications e.g. pain, haemorrhage

To maintain psychological stability

Breathing:

Ensure patent airway by good positioning

Patient lies flat on the bed with no pillows

Recumbent position with head tilted on one side (Give  3%)

Observations:

*1/4 hourly vital signs obs and general condition

Then 1/2 hourly, e.t.c.

Low blood pressure may demote passive bleeding or severe blood loss in theatre.  Give I.V fluids such as normal saline should the BP be low.

High pulse rate denotes bleeding or severe blood loss

Observe and watch for bleeding from the stump.

Observe for rest of stump by putting a well folded towel in between two said bags to rest the stump.

Observe for signs of pain and give appropriate measures.  Give 7%.

Pain Relief: 5%

Surgical be controlled by narcotics such as pethidine 100 mgs PRN

Evacuation of accumulating fluid and blood by a drain and bag help to relieve pain.

This is to prevent haematoma formation which causes severe pain

Change of position relieves discomfort and pain arising from bony prominence pressure.

Placing towel above the stump placed in position by two sand bags on each side reduces movement of stump which causes discomfort arising from spasm

Phantom pain on the removed part is prevented by keeping patient occupied.  Minor tranquillisers may be given.  Give 5%.

Care of stump - 7%

Elevate the foot of the bed to prevent swelling of the stump as elevation promotes drainage.

Observe for bleeding from the stump which could be from a loosed suture by collaborating with vital signs.

Bed cradle be placed on the bed to lift the weight of bed as this may spike spasms.

Observe the change of colour of bandage as this may indicate infection.

Don't open the dressing or bandage any how to prevent infection from setting in.

Prevent infection by administering prophylactic broad spectrum antibiotics as ordered.

The bandage is left intact in all the 72 hours.  Give 7%.

Psychological Care:

Loss of  limb causes severe grieving

Be understanding if change of behaviour is seen e.g. crying, withdrawal. Depression, etc.

As a nurse acknowledge the loss

Create an accepting and supportive atmosphere

Spiritual care by the clergy is very important

Be a good listener.

Allow the patient to ventilate

Explain the change of bed by cradles, sand bags, drains, bed elevation for co-operation.

Relief of pain will help greatly in reducing anxiety

Explain on the use of crutches.

Support patient in coping process.

Exercise and Ambulation: 4%

Patient will be bed ridden for a long time even in the whole of 72 hours.

Chest exercises to prevent pneumonia.

Passive exercises of other limbs to prevent contractures.

Turnings two hourly to prevent bed sores formation but also to prevent constipation.  Give 4%

Nutrition 3%

Patient begins to eat once he has fully recovered from anaesthesia.

Food rich in proteins and vitamins for healing of stump

Encourage a lot of fluids to encourage defecation and urination since bed riddeness causes stone formation.

Elimination: 2%

Promote urination by giving plenty oral fluids

Give a laxative to promote opening bowels

Hygiene - 3%

Bed bath for self esteem and blood circulation

Pressure area care to prevent bedsores and two hourly turnings

Encourage patient to do what he can e.g. mouth care.

Health education: 3%

Walking exercises with crutches

Teach how to wrap the residual stump

Advise patient to care for the other limb to prevent injury.  Total 50%.  For 

sub headings 1% - Objectives - 2%.

Four complications and prevention:

Oedema 1%

Fat embolism 1%

Gas gangrene of stump 1%

Deformity of stump 1%

Reactionary/secondary haemorrhage. 1%

Prevention:

1.  Haemorrhage: 3%

Prevention is by good ligating in theatre, prevention of  infection and resulting the stump.

2.  Fat Embolism: 3%

Good suturing in theatre will have to be ensured to prevent this.

3.  Gas Gangreme: 3%

This is prevented by ensuring sterility in theatre

Do not open the wound or bandage in the whole of 72 hours.

4.  Oedema of stump: 3%

Prevent this by keeping the bandage on the stump tight

If it comes out then re-tie it tight back

Elevation of foot bed.

5.   Deformity of stump: 3%

Avoid hip flexion

Good bandaging technique to ensure good alignment and narrowing of the distal stump for possible fixation of prosthesis.  Total = 16%, 1% for listing, 3% for prevention, for 4 total is 16%.

                                                    - 2 -

TOTAL MARKS 10%

7% FOR CORRECT LABELLING, 3% FOR GOOD DRAWING.

Explain contusion giving four (4) specific features that differiciate it from other head injuries (16%).

Contusion is a severe injury involving the brain structures which become bruised with possible surface haemorrhage.

The patient is unconscious for a longer period of time than in other minor brain shaking because of the bruising effect of the brain, coupled with convulsions in some patients.

The blood pressure and temperature are altered as a result of direct injury to the brain centres that regulate the functions of the heart, lung and heat regulation.

There may or may not be bleeding from the external auditary canal which may signify a basal skull fructure or laceration in the canal . Otorrhoea (CSF) from the ears also indicates basal skull fructures as is a source of meningitis.

Abnormal flexor and extensor posturing of extremities either spontaneously or on stimulation may be present.  There may be hemiparesis and cranial nerve dysfunction depending on the part of the brain affected.

                                         Give 4% for each correct point to make 16.

Describe in detail the management of Mr. Mumbi in the first 24 hours of his admission under the following headings. (64%).

(i)  Medical/Surgical management (20%)

       Objectives: (4%)

To maintain the clear airway

To reduce intracranial pressure

To resolve the unconscious state

To prevent complications like brain abscess, meningitis etc 2% for 2 objectives.

Investigations (5%)

Full physical assessment

Assessment of test of head injury (open or closed, cardiovascular assessment.

Cranial x-ray

Computed tomography

Neurological assessment using glasgow coma scale. 6 blood for blood sugar.

Rescussitation:

(i).  Reduce intracramial pressure and cerebral oedema by intravenous administration of:-

Frusemide 500 mg IV in the infusion

Mannital 10 to 20% 500 ml

Dexamethazone 12 mg IV stat to reduce cerebral oedema

                                                           - 3 -

Hyperventilate using a ventilator and intubation

Nasogastric tube insertion

Catheterisation

If there is depressed bone, craniotory and bone elevation are done

If closed injury with haematomas burr holes are done

If open injury -debridement of the lacerated outer tissue is done.

If open injury, antibiotic, benzyl penicillin 2 mega.units 6 hrly for 5 days and gentamycine 80 mg 8 hrly for 5 days.

Nursing Care - 44%:

Objectives -(2%)

To maintain physiological functions

To control or prevent intracranial pressure and cerebral oedema.

25

        MAINTAINING A PATIENT AIRWAY AND VENTILATION. (4%)

Establish a constant patient's airway with adequate respiratory exchange.

Prevent aspiration by proper positioning  lateral position or semi prone

Tracheostomy can be performed

Ventilator are applied to aid in ventilation

Insert an airway

endotracheal intubation are done to ensure patient air way.

This is all done to prevent cerebral anoxia which causes most deaths in head injury patients

Suctioning be done to prevent choking

To prevent hypoxia while suctioning the duration of suctioning should be only 15 seconds.

Assisted ventilation may be necessary to make sure the patient is adequately exchanging air.

Ensure maximum respiratory function by oxygen administration. (Give 10%).

Minimisation of  rise in intracranial pressure (3%).

Maintain proper positioning.

Keep head of bed elevated for venous drainage

Maintain patient's head in neutral position

No Pillows

Prevent head from tilting to the side as there may be spinal injuries.

Advise to exahale a lot of air on position changing.

Turn the patient all in one piece to prevent further injury.  Avoid severe hip flexion.

COMFORT AND REST ( 2 % )

Limit suction to 15 seconds or less.

Space nursing care activities to minimise duration of increase in intracranial pressure.

Avoid conversations at the bedside as the patient is able to hear.

ELIMINATION ( 2 %)

Decrease chance of valsava meneurers or feacal impaction.

                                                             - 4 -

Monitor frequency and consistency of patient's stools. Administer stool softeners PRN.         

Catheterise to prevent retention of urine or bed sore formation.

If patient is awake, do not allow him to assist with position changes.

Instruct him to exhale during changes in position.

TEMPERATURE RECULLATION (1%)

Maintain normothermia:

Administer antipyretic medication and provide external cooling promptly.

                VITAL SIGNS AND OTHER OBSERVATIONS (4%)

P, TPR - Rate, Depth of respiration

Pulse rate, heart sounds, blood pressure to monitor functioning of vital organs.

Observe colour of the skin, lips and finger nails for cyanosis

Look for evidence of in continence and catheterise if not done to protect skin .

Ensure the patient is breathing deeply enough to oxygenate his lungs and to eliminate CO

                                      2.

Check heart and blood pressure and look for evidence of possible sources for bleeding.

Be certain that cardiac output and blood volume are sufficient to supply brain's and kidneys metabolic requirements for effective excretion.

INTRAVENOUS INFUSION (2%)

Start IV line with a large bore needle on all patients in coma.

When starting infusion with a large bore needle on all patients in coma, collect blood samples for laboratory investigations at the same time.

ASSESSMENT OF LEVEL OF CONSCIOUSNESS:

Observe responses to skin stimuli using glasgow coma scale.

Examine pupil sizes and reactivity to light for indications of increased intracranial pressure.

Call his name and record and report response.

Try reaction to painful stimuli.

When pupils are delated and fixed alarm the doctor as it is an indication that there is more damage to the brain with a lot of cerenrooedema which requires emergency management.

Vital signs - intracramial pressure Bp rises, pulse is slow, respiration may be noisy and slow (chyne stokes).

Temperatures rises sometimes record and report findings.

Check limb rigidity.

                                      - 5 -

Speech

Testless

Causes can be pain, shock or a sign of improvement.

Fill bladder- urine retention

INVESTIGATION SPECIMENE COLLECTION (1%)

INVESTIGATION SPECIMEN COLLECTION (1%)

Assist in collection o specimen such as:-

Blood for blood sugar

Hypoglycaemia further causes  brain damage

GENERAL CARE (1%)  Very vital, patient can not do it alone.

Bed bath daily

Oral toilet

Hair care

Nail care:  All these are far body intergrity.

Pressure area care - change of position by frequent turnings

                                    -  change soiled linen.

         SAFETY AND PREVENTIVE MEASURES: (5%)

Nurse in cot bed or bed with side rails to maintain safety

Observe seisure precailtory for.

Give adequate support when turning the apatient

Remove dentures to prevent asyphyxia.

Any contact lenses, remove and store safety.

Prevent injury during convulsions and control them with short time e.g. padded side rails

Keep nails short and clean

Avoid over sedation in the unconscious patient it may mask the condition

        -     Do not leave   unconscious patient for along time alone.

Prevent hypoxaemia by effective

Avoid fluid over load.

EYE CARE (3%):

Freqquent inspections of eyes with a flashlight, shielding an open for partially open eye.

Simple eye irrigations, and 

Instilling protective eye drops to prevent corneal ulceration arising from drying, these can lead to keratitis, and blindness.

A covered tray for eye care be prepared, care be given four hourly.

The eye may be irrigated with normal saline solution.

If corneal reflex in absent, apply a protective shield.

                                                      - 6 -                                                   

BODY MOVEMENT:

Observe the extremities of a patient for the presence of rhythmic spontoneos movements indicative of a convulsive seisure.  Once this is detected, notify the doctor.

POSITIONING AND EXERCISES (3%):

Position the patient properly at all times.

Move the patient about periodically. 

Passively exercise him extremities to promote blood circulation

Combine, air ring on the bed, frequnt turnings, exercises and proper positioning in bed to prevent ducubitus formation.

EAR AND NOSE CARE (3%):

Nasal passages may be blocked by dried up mucus

Gently swab the nose with an applicator maintained with water or normal saline;

Next used one with a lubricant

Never suctions ears or nose of a patient with head injury.

MOUTH CARE (2%): 

Every 2 hours

Provide oral hygiene

Prevent excessive drying of the oral mucous membranes

Oral care prevents other complications such as parotitis, sordes, herpes simplex, aspirations and respiratory tract infection. The latter 2 are the commonest causes of death in unconscious patients.  During mouth care of the unconscious patient excess secretions should be removed with suctions to prevent choking.

MAINTAINING NUTRITION AND FLUID BALANCE (2%)

Unconscious patients can not swallow normally for fear of aspirating.

Tube feedings are the most desirable method of providing prolonged giving nutritious fluids.  Nourishment for unconscious patients intravenous fluids must run slowly to prevent further increased cerebral oedema and intracranial pressure.

PSYCHOLOGICAL CARE AND HEALTH EDUCATION (2%)   

The family needs psychological support - It may be upset because the patient can not communicate.

Or they may be anxious about possible death of their relative

Explain the condition to the family and the treatment and nursing care

Involve them in the care

Inform the family to be careful in their discussion near the patient as he/she is able to hear

They should be allowed access to the patient.