The Amputation Journey

An amputation is defined as the ‘partial or complete surgical removal of a limb’ (Mauk 2012).

Artificial limbs have been found to date back to over 2000 years ago, making amputation surgery one of the oldest surgical procedures in history (ANZSVS 2018).

Lower limb amputations are more common than upper limbs. In Australia, more than 8,000 lower limb amputations are performed every year (Dillon et al. 2017).

Causes of Amputations

Amputations are caused by both medical conditions and trauma. Medical conditions resulting in amputation are often those that restrict blood flow to extremities, usually by atherosclerosis forming in the arteries. This can be from conditions such as diabetes, hypertension, hypercholesterolaemia and renal failure.

Between 50 to 70% of amputations are completed in patients whith diabetes, and these amputations tend to be of lower limbs (ANZSVS 2018).

Accidental trauma causing crush injuries, burns or frostbite can also lead to amputations, usually of the upper limbs. Traumatic amputations account for about 20 to 50% of total amputations (Mauk 2012).

Amputations can be classed as either minor or major depending on how much of the body part is removed. For example, a forefoot amputation is classed as a minor amputation, whereas a below-knee amputation is classed as a major amputation (ANZSVS 2018).

Psychological Aspects of Amputation

The amputation of a body part has a huge impact on an individual’s perception of their body and affects their physical and psychological condition, as well as their quality of life (Holzer et al. 2014). There are many psychological consequences for the individual, including feelings of loss, depression, fear and anxiety, as well as changes in their body image and sometimes their role within the community (Holzer et al. 2014; Mauk 2012).

Following amputation surgery, the person may be afraid to look at their remaining limb and may take time to adjust to the change. This disturbance in body image can also leave the person unwilling to participate in their own care relating to their new amputation (Mauk 2012).

There will be periods of grief for the loss of their body part, their loss of function and potentially their independence (Mauk 2012). This can also impact their ability to assist in self-care activities.

Physical Therapy and Physical Aspects, Mobility and Function

It is important for people with amputations to participate in physical therapy. Physiotherapy helps the individual to regain their physical and functional abilities and improve their quality of life. Functional training is one of the key aspects of rehabilitation in patients with an amputation (Mauk 2012).

Physiotherapists will assess the patient's functional mobility, strength, range of motion, balance and skin integrity to set up a program individualised for the patient and regularly perform reassessments and evaluate care to change the program as the patient progresses (Mauk 2012).

Care of the Remaining Limb

Following amputation, patients are taught to monitor the skin of their remaining limb, especially those who have diabetes. A knee immobiliser, for instance, can be used initially to help prevent contracture and protect the area in case of a fall in those with a lower limb amputation (Mauk 2012).

Oedema may also be present in the limb, which can make fitting the prosthesis difficult. If oedema is significantly impacting the prosthesis fitting, compression can be used to help decrease the amount of oedema present. This can help shrink and reshape the limb, making prosthetic use more comfortable for the individual. Prosthetic socks can also be worn to compensate for residual limb shrinkage as well as provide comfort to the individual (Mauk 2012).

Pain Management and Phantom Limb Pain

Pain is problematic in a patient when it has been present for more than six months following their amputation. This pain can be classed as nociceptive pain, which may be a result of a poorly fitting prosthesis. Phantom limb pain is also referred to as residual limb pain or neuropathic pain (Uustal & Meier 2014).

Most patients with an amputation will experience phantom limb pain, generally during the acute postoperative period, with it easing significantly as they recover. The patient will experience sharp episodes of pain sporadically throughout the course of their life. Phantom limb pain will usually decrease following the surgery and doesn’t require any treatment after three months. However, some people may continue to experience phantom limb pain following the acute stage of their amputation, which can then result in chronic pain (Uustal & Meier 2014).

If the patient is experiencing phantom limb pain, the following interventions may assist in its treatment:

• Controlling any oedema present in the stump
• Establishing a restful sleep pattern
• Decreasing anxiety
• Decreasing stress
• Restoring control to the person
• Restoring meaningful function
• Using desensitisation techniques for the remaining limb
• Managing depression
• Cessation of smoking.

(Uustal & Meier 2014)

The most common cause of pain after amputation is issues with the prosthetic fit. This can be due to the prosthetic putting pressure on the remaining part of the limb that was never meant to be pressure-bearing, leaving these pressure points to become painful (Uustal & Meier 2014).

Secondary Complications

Some secondary complications that may occur following amputation can relate to falls, skin breakdown and problems associated with prosthetic use (Mauk 2012).

One in five lower limb patients with an amputation will experience a fall during their hospital stay, with 18% of those people becoming injured (Mauk 2012). This is why balance training and fall recovery are incorporated into the patient's physical therapy treatment.

Skin breakdown can occur on the residual limb, which is why patients are promptly taught about how and when to perform regular skin assessments following surgery. If the skin is compromised, this may be a result of an ill-fitting prosthesis that may need to be altered to provide a better fit (Mauk 2012).

Nursing Interventions

Nurses have many roles when looking after a patient following an amputation. Patient and family education is important in their treatment and often will be completed by the nurse who may be assisting the patient with their prosthesis.

Assisting with self-care deficits is also part of the role of the nurse. This may mean reinforcing instructions from the interprofessional team and also encouraging the patient's independence.

The nurse must be able to differentiate between different pains and implement strategies to assist in the patient's comfort (Mauk 2012).

The nurse is also essential in assisting the patient and their family with disturbances to the way they may be feeling as a result of the change in body image. The nurse can provide support not only to the patient but also to their family.