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44 Cards in this Set
- Front
- Back
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Pre-operative Care
Education and prevention of further adversity Introduction to the rehabilitation team General medical care Sound limb care Supportive services Share information Teach bed positioning, transfers Explain post-op dressings and exercises So much easier for when after surgery, so they know what to expect, and easier to do transfers |
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Five Steps of Loss
Elisabeth Kubler-Ross Denial Bargaining Anger – mean as a snake. Normal for people to be angry Depression Acceptance |
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So What happens in the first year?
Healing Grief Rehabilitation Adjustment Integration Re-Integration |
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Timeframe
Amputation to Healed from Surgery (Day 0 to ___ weeks)--some manner of post operative management Healed to Matured Limb [shaped, shrinks in size, not going to change much anymore] (6 weeks to ___ months)—Preparatory Prosthesis – going to be revised a lot Matured Limb(final form and shape) forward—Definitive prostheses. – get cover when everything is done |
Amputation to Healed from Surgery (Day 0 to 4-6 weeks)--some manner of post operative management
Healed to Matured Limb [shaped, shrinks in size, not going to change much anymore] (6 weeks to 6 months)—Preparatory |
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Dressing Selection Criteria
Level of amputation Surgical technique Healing requirements Patient compliance Physician preference |
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___ Dressings
Sterile gauze, cotton padding, elastic bandage Advantages: Ease of application Inspection of wound easy Disadvantages: Slippage occurs frequently Movement of dressing over wound causes pain May create tourniquet effect Don’t protect from bumps Can cut off blood supply if put on incorrectly More common b/c less work for staff Ace wraps |
Soft Dressings
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Semi-rigid and Rigid Dressings
Semi-rigid: Materials include unna paste, felt, cotton or polyurethane pads Rigid: Materials include plaster bandages, fiberglass casting materials, copolymer plastics and felt, cotton or polyurethane pads |
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Rigid dressings
Def: Hard ___, usually made from ___ or fiberglass, that encompasses an amputated limb – worn w/ belt around waist b/c heavy Worn with a waist belt and fork strap for suspension Usually lasts ___ to ___ days Second cast is then applied Does not accommodate to limb shrinking, change once per week. Helps protect the area |
Def: Hard cast, usually made from plaster or fiberglass, that encompasses an amputated limb – worn w/ belt around waist b/c heavy
Usually lasts 7 to 10 days |
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Rigid Dressing Advantages:
Rapid, optimal wound healing. Hospital time is reduced. Reduces phantom pain(?). Controls post-surgical ___. Protection of residual limb. Prevents ___. |
Controls post-surgical edema.
Prevents contractures. |
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Rigid Dressing Disadvantages:
Easy access to wound not possible. Inability to observe residual limb. Correct application of cast requires skill. Cumbersome removal and reapplication of cast. Cannot provide progressive shrinkage. 7 days before they make a new one, does not accommodate Time consuming, if problem develops must be able to take cast off |
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Removable Rigid Dressings
Advantages: It is removable and allows for evaluation of residual limb healing and maturation. It prevents the development of post-surgical edema and protects the limb. It is more effective than elastic bandages and shrinkers in controlling edema. Provides some protection against injury. ___ can be increased by adding socks. |
Compression can be increased by adding socks.
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Removable Rigid Dressings
Disadvantages: Since it is removable, the patient has the responsibility of keeping it on. If left off, the residual limb can swell beyond the point of redonning. Does not prevent against contractures. |
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Picture 1 – to keep rigid dressing on. Transtibial amputation – should always see a board (w/c board) so limb is out straight, to prevent knee flexion contracture (difficult to put on prosthesis)
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Post Operative Removable Rigid Dressing System’s Benefits
Provides easy access to dressings. Adjustable designs accommodate compression and swelling area. Use with elastic wrap or shrinkers, to reduce swelling. Ventilated system helps enhance postoperative healing. Helps maintain correct extension alignment Can have foot/pylon installed for early ambulation Provides contracture prevention, too! |
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Post Operative Prostheses
IPOP vs. EPOP psychological benefits independence return to work earlier discharge Attach pylon and a foot = immediate post op prosthesis – put on in OR EPOP – not put on in OR, put on a day later |
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Post Operative Prostheses Management
wear waist belt at all times remove pylon in bed touch down weight bearing as tolerated foot wear? No need. |
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Post-operative Alerts!!
Loose cast, cast slippage, rotation. Patient reports sharp localized pain. Patient reports severe tightness or pain. Patient febrile with no other known cause. The subtle yet unmistakable aromatic presence of an infection. Biggest one – smell something terrible |
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Timeline
Day 1-2: Surgery, RD (with pylon & foot) applied. Minimal weight bearing. Day 7-10: 1st cast removed. 2nd RD applied with pylon and foot. Partial weight bearing. Week 2-3: 2nd cast removed. (sutures may be removed) Check circumferences. May cast intermediate or RRD. |
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Timeline (cont’d)
Week 3-4: 3rd cast removed. Sutures removed. Cast for intermediate prosthesis. Week 4-6: Fit intermediate prosthesis. 8-12 Months: Cast for definitive prosthesis when residual limb atrophy stabilizes (no socks added for 3 weeks). |
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Adjustable Post-operative or Preparatory Protective Socket (non-custom IPOP)
Stuff that comes off the shelf Pic 1 – bladder that can be blown up These are not as good as a cast |
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Why doesn’t everyone get one?
Candidacy Complications Cost |
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Many Factors Have a Direct Bearing on Post-Operative Treatment
Some determinants include: Dysvascular vs. Traumatic Burns Age and Physical Status Tumor Sequelae Co-morbidities Discharge Plan |
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Post-operative management of the new amputee
Protection from falls and inadvertent contact Contracture prevention: NOW is the time Early ambulation: the sooner, the better RL Contouring Desensitization – massage it No hopping around on 1 foot – you will fall and open residual limb, and couldn’t use prosthesis for weeks Young people tend to do this |
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Goals of Post-Op Treatment
Reduce edema (wrapping) and promote healing Prevent loss of motion Increase upper & lower extremity strength Promote mobility & self care Assist with limb loss adjustment |
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What can we do? Educate
Positioning Prevent contractures: hip flexion, abduction, ext rot knee flexion Residual limb care (sound side too!) Mobility: transfers assistive devices Barriers Above knee amputee – flex, abd, ER, are common contractures for above knee – nothing anchoring. NO PILLOW under leg! Prone is a great position if they can do it Transtibial, - below knee – knee flexion contracture |
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Positioning
Goal: to maintain ROM while preventing contractures Standing (if safe) Trans___: No pillows under the knees. Extension boards on W-chairs. Trans___: No pillows under the thigh or knee. Prone time is critical. |
Transtibial:
No pillows under the knees. Extension boards on W-chairs. Transfemoral No pillows under the thigh or knee. Prone time is critical. |
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Residual Limb Care
Hygiene: Pre & Post suture removal Wound dressing skills “Airing” wound Protocol specific instructions: Ace wrap or shrinker application Rigid or Removable Rigid Dressing Post Operative Prostheses Wash, don’t keep using the same one |
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Physical changes to residual limb:
Early uncomplicated healing “First do no harm.” Balance the benefits of early ambulation with the risks Dehiscence |
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Physical changes to residual limb:
Edema: amputation severs muscles transverse to striation, muscle pumping action lost temporarily thus edema forms. Pain Reduction is directly related to ___ reduction. Pain has to do a lot w/ edema, less edema usually less pain |
Pain Reduction is directly related to edema reduction.
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Residual Limb Contouring/Limb Maturation
Application of localized gentle pressure to promote edema reduction and facilitate definitive socket fitting Progressive reduction in residual limb volume Maintain joint range of motion and strength |
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Post-operative protocols: Ace wraps
Ace wrapping is a fine motor skill that is difficult for many amputees. Exhibits the greatest range of pressures. Bandages must be reapplied. Skin breakdown. Ace wrap – constant even pressure all the way around Give tug around the bottom, do not constrict at the top. Always use figure 8 wrap. Never use those hooks for someone w/ an amputation. Whole limb must be covered, or else skin push out and get dog ears Must do this several times a day |
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Wrapping technique
Greatest pressure ___ Even pressure all around Figure of eight application pattern—diagonal turns Residual limb totally enclosed Beware of pointed clips and no folds or wrinkles in the wrap ___ to the patella in transtibial |
Greatest pressure distally
Proximal to the patella in transtibial |
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Post-operative protocols: Shrinkers
Ease of donning Even compression Don’t migrate Try to get two |
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Amputee Postoperative Rehabilitation Program
See handout from Gailey, Robert S., One Step Ahead: An Integrated Approach to Lower Extremity Prosthetics and Amputee Rehabilitation Amputee Post-op Rehab Program Amputee Acute Care Assessment & Progress Form Prosthetic Care Progress Form |
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Acute Rehab Review
Information Supportive services Increased perspiration – lost limb where they used to sweat, will perspire more at rest of body. (can also mean you are sick) Orientation & awareness Cardiopulmonary care Cardiovascular endurance Edema control |
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Acute rehab continued
Positioning Strengthening Sensation desensitization activities Balance, agility, coordination Bed mobility Transfer skills Equipment Bathroom aids Assistive device ambulation Wheelchair mobility |
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Phantom Limb Phenomena vs. Residual Limb Pain
85% of all amputees experience phantom sensation, phantom pain, or actual residual limb pain All patients w/ amp get phantom pain – normal – pain in what is gone Residual limb pain – pain in what is left |
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Phantom sensation
A non-painful sensation or awareness that occurs below the residual limb (in the part that is no longer there) The missing foot may have phantom sensation, real and not made up |
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Phantom pain
A painful sensation that occurs below the residual limb (in the part that is no longer there) Really bad pain, ice pick in the leg |
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Residual limb pain
Pain arising in the residual limb from a specific anatomical structure that can be identified |
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Phantom sensation:
Touch (when it is not there) Pressure Cold Wetness Itching Formication (feels ants crawling) Fatigue Telescoping limb (foot is going up and down) Ph movement |
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Phantom pain:
Dull aching Burning Knife-like stab Stick-squeeze Electric shock Leg is being pulled off Trauma pain |
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Residual limb pain:
Prosthetic Neuroma Sympathetic Referred Abn tissue Joint pain Bone pain Soft tissue Res limb change |
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Stages:
Pre-amputation: everything prior to amputation Pre-prosthetic: amputation to first outpatient fitting Transitional: first outpatient fitting to limb stabilization Mature: everything after limb stabilization |
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