Our Lady of Fatima University Antipolo Campus College of Nursing

A Case Study on: Multiply Physical Injury; Traumatic Amputation of the Left Upper Extremity

In Partial Fulfillment of the Requirements in the Related Learning Experience 104 Orthopedic Ward Rotation

Submitted to: Mr. Alvin V. Arroyo, RN, MSN May 21, 2011

Submitted by: Armodia, Jean DelaPasion, Mary Romaine

Table of Contents Introduction3 I. Demographic Data II. Medical Management a. Medicines b. Laboratory Data III. Diagnostic Results IV. Surgical Management V. Nursing Management VI. Drug Study

Introduction I have two hands, the left and the right is a song which cannot be sung by an amputated patient. A patient whos upper extremity has been amputated because of one of the following reasons: (1) accident (2) in born or (3) sickness. This study will revolve around the field of nursing, specifically, orthopedic nursing. The patient focused in this study was amputated due to a motor vehicle accident (MVA). Definition of term According to the freedictionary.com, amputation is defined as the intentional surgical removal of a limb or body part. It is performed to remove diseased tissue or relieve pain. Arms, legs, hands, feet, fingers, and toes can be amputated. Most amputations involve small body parts such as a finger, rather than an entire limb. About 65,000 amputations are performed in the United States each year. Amputation is performed for the following reasons:
y y y

to remove tissue that no longer has an adequate blood supply to remove malignant tumors because of severe trauma to the body part

The blood supply to an extremity can be cut off because of injury to the blood vessel, hardening of the arteries, arterial embolism, impaired circulation as a complication of diabetes mellitus, repeated severe infection that leads to gangrene, severe frostbite, Raynaud's disease, or Buerger's disease. More than 90% of amputations performed in the United States are due to circulatory complications of diabetes. Sixty to eighty percent of these operations involve the legs or feet. Although attempts have been made in the United States to better manage diabetes and the foot ulcers that can be complications of the disease, the number of resulting amputations has not decreased. In Philippines, DOH states that amputation commonly happens to only three types of patients, a patient who has complications regarding his/her sickness (i.e. diabetes), congenital defects or a patient who has been in severe trauma causing the need to remove the affected limb. This case study will be discussing amputation due to a motor vehicle accident as evidenced by the patient who is the primary focus of this research. According to the World Health Organization, Motor vehicle accidents are among the top 5 risk factors of death and one of the top two reasons of amputation. In the Philippines however, vehicular accidents, which is also included in the general category of Physical Accidents, ranks as the second in causing the death of millions of Filipinos for the year 2010. The main reason for amputation in this study is: the severe trauma caused by the accident to the body part. The patient stated that a truck crashed into his left side severing his left arm and fracturing his left leg. Failure to fully remove his left arm would cause a large amount of blood loss, infection and death.

I. Demographic Data Name Age Address Religion Occupation Time and date of Admission Admitting Diagnosis : RMR : 18 y/o : SitioMacopa, BagongNayon 1, Antipolo City : Roman Catholic : Tricycle Driver : 4AM 04-07-11 : Mangled Left upper extremity, fracture closed complete left femur secondary to vehicular accident. : Few minutes prior to confinement, patient got into a vehicular accident. The patient was riding a tricycle when he was hit by a truck.

Present History

II. Medical Management A. Medicine B. Laboratory Data Result WBC: 3.0 Normal Findings 3.7-10.6 Interpretation White blood cell (WBC) count. White blood cells protect the body against infection. If an infection develops, white blood cells attack and destroy the bacteria, virus, or other organism causing it. White blood cells are bigger than red blood cells and normally fewer in number. When a person has a bacterial infection, the number of white cells can increase dramatically. Red blood cell (RBC) count. Red blood cells carry oxygen from the lungs to the rest of the body. They also carry carbon dioxide back to the lungs so it can be exhaled. If the RBC count is low (anemia), the body may not be getting the oxygen it needs. If
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RBC: 3.96

4.19-5.21

Hbg: 12.2

12.5-16.0

Hct: 37.1

38.8-49.7

Platelet: 494

1.5-4.5

the count is too high (a condition called polycythemia vera), there is a risk that the red blood cells will clump together and block tiny blood vessels (capillaries). Hemoglobin (Hgb). Hemoglobin is the major substance in a red blood cells. It carries oxygen and gives the blood cell its red color. The hemoglobin test measures the amount of hemoglobin in blood and is a good indication of the blood's ability to carry oxygen throughout the body. Hematocrit (HCT, packed cell volume, PCV). This test measures the amount of space (volume) red blood cells occupy in the blood. The value is given as a percentage of red blood cells in a volume of blood. For example, a hematocrit of 38 means that 38% of the blood's volume is composed of red cells Platelet (thrombocyte) count. Platelets (thrombocytes) are the smallest type of blood cell. They play a major role in blood clotting. When bleeding occurs, the platelets swell, clump together, and form a sticky plug that helps stop the bleeding. If there are too few platelets, uncontrolled bleeding may be a problem. If there are too many platelets, there is a risk of a blood clot forming in a blood vessel. Also, platelets may be involved in hardening of the arteries (atherosclerosis).

III. Diagnostic Results Examination 1. Chest X-ray Result Normal chest X-ray shows normal size and shape of the chest wall and the main structures in the chest. White shadows on the chest X-ray signify solid structures and fluids such as, bone of the rib cage,vertebrae, heart, aorta, and bones of the shoulders. The dark background on the chest X-rays represents air filled lungs. These lung fields are seen on either side of the heart and the vertebrae located in the center of the film 2. Complete Blood Count with WBC: 30 Blood Typing RBC: 3.96 Hbg: 12.2 Hct: 37.1 Platelet: 494 Blood Type: O Purpose To note if the lung has been affected and so as to answer questions of there is presence of DOB.

For baseline and monitoring of blood clotting factors and infection and for possible blood transfusion.

IV. Surgical Management A. Preoperative Phase

          

Insurance information and I.D.(for ex, a driver's licence must be available at the time of registration. Consume no solid food, no milk, and/or no orange juice after midnight before surgery. Do not smoke,chew gum or suck on hard candy sftermightnight before surgery. Stay away from asprin/aspirin products. No Advil or anti-inflammatory drugs at least 7-10 days prior to surgery. Wear NO makeup or nail polish. Wear NO jewelry. Leave valuable at home. We are not responsible for personal items, money,credit cards, wallets, jewelry, etc. Bring a case for contact lenses and/or glasses. Feel free to wear your dentures to the operating room. Wear no metal hair accessories. Wear loose fitting clothing appropriate for the type of surgery being performed. B. Intraoperative Phase
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Before an amputation is performed, extensive testing is done to determine the proper level of amputation. The goal of the surgeon is to find the place where healing is most likely to be complete, while allowing the maximum amount of limb to remain for effective rehabilitation. The greater the blood flow through an area, the more likely healing is to occur. These tests are designed to measure blood flow through the limb. Several or all of them can be done to help choose the proper level of amputation. y measurement of blood pressure in different parts of the limb y xenon 133 studies, which use a radiopharmaceutical to measure blood flow y oxygen tension measurements in which an oxygen electrode is used to measure oxygen pressure under the skin (If the pressure is 0, the healing will not occur. If the pressure reads higher than 40mm Hg [40 milliliters of mercury], healing of the area is likely to be satisfactory.) y laser doppler measurements of the microcirculation of the skin y skin fluorescent studies that also measure skin microcirculation y skin perfusion measurements using a blood pressure cuff and photoelectric detector 1 y infrared measurements of skin temperature C. Post-operative Phase y prevent edema (raise extremity with pillow support for first 24 hours) y observe stump dressing frequently for signs of hemorrhage y ensure that stump bandages fit tightly and are applied properly (change dressing as indicated) y promote wound healing, manage pain y help the patient to achieve physical mobility ( promoting independent self-care) y monitor for and manage complications y if the patient has a drain, note the location and type of fluid that ought to be draining from the drain, monitor drainage for color, consistency, and quantity y offer support/encouragement

Read more: Amputation - procedure, test, blood, removal, pain, complications, adults, time, infection, operation, medication, children, rate, Definition, Purpose, Demographics, Description http://www.surgeryencyclopedia.com/A-Ce/Amputation.html#ixzz1MmSTluJZ

Part V. Nursing Management Nursing Care Plan Diagnosis Subjective: Acute pain Masakitparinyungpinagputulanngkamayko, gusto related to konanganginuminlahatnggamotnapampatanggalngsakit surgical as verbalized by the patient procedure: amputation as Objective: manifested by >PR: 108 bpm facial grimace >facial grimace >guarding behavior Assessment Plan After 1 hour of nursing intervention, the patient will be able to feel relief regarding the pain he is experiencing. Intervention 1. Observe nonverbal cues (e.g. how client walks, holds body, sits; facial epression, cool fingertips/toes) and other objective. 2. Monitor vital signs 3.Encourage verbalization of feelings about pain 4. Instruct in/ encourage use of relaxation exercises, such as focused breathing, commercial or individualized tapes 5. Identify ways of avoiding/minimizing pain 6. Administer analgesics as indicated to maximal dosage as needed 7.Assis in treatment of underlying disease processes causing pain 8. Encourage adequate rest periods Evaluation After 1 hour of nursing intervention, the patient was able to feel relief regarding the pain he is experiencing.

to prevent fatigue

Assessment Subjective: Siempremahihirapannaakongmagtrabaho, ngayonnganahihirapanakongmaglakaddahilsabalisapaa ko as verbalized by the patient Objective: >limited range of motion >slowed movement >movement-induced shortness of breath/tremor

Diagnosis Impaired physical mobility related to loss of extremity as manifeste d by slowed movement s

Plan After 1 hour of nursing intervention, the patient will be able to demonstrate techniques/behavio rs that enable the resumption of activities.

Intervention 1. Assess degree of pain, listening to clients description. 2. Determine degree of perceptual/cognitiv e impairment and ability to follow directions 3.Assess nutritional status and energy level 4. Assist/have client reposition self on a regular schedule as dictated by individual situation 5.Instruct in use of siderails, overhead trapeze, roller pads 6. Support affected body parts/joints using pillows/rolls, foot supporters/shoes, air mattress, water bed and so forth.

Evaluation After 1 hour of nursing intervention, the patient was able to demonstrate techniques/behavio rs that enable the resumption of activities.

7.Administer medications prior to activity as needed for pain relief 8.Provide regular skin care to include pressure area management

Assessment Diagnosis Subjective: Self-care deficit Kapagnagbibihis, related to loss of kelanganko pa si mama o extremity si papa ko, kasinaninibago pa akodahilwalanakamayko. as verbalized by the patient Objective: >amputated left upper extremity

Plan After 1 hour of nursing intervention, the patient will be able to demonstrate techniques/lifestylechanges to meet self-care needs.

Intervention 1. Identify degree of individual impairment /functional level according to scale 2.Determine individual strengths and skills of the patient 3. Develop a plan of care appropriate to individual situation, scheduling activities to conform to clients normal schedule. 4. Provide privacy during personal care activities. 5. Identify energysaving behaviors (e.g. sitting instead of standing when possible) 6.Review safety

Evaluation After 1 hour of nursing intervention, the patient was able to demonstrate techniques/lifestyle changes to meet selfcare needs.

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concerns. Modify activities/environment to reduce risk for injury

Assessment Subjective: Ayawniyangmagpadalawsamgakaibiganniyagawangwalanasiyangisang kamay. as verbalized by the mother of the patient Objective: >amputated left upper extremity > over-exposing of body part

Diagnosi s Disturbed body image related to amputatio n of body part as evidenced by overexposure of body part

Plan After 1 hour of nursing interventio n, the patient will be able to verbalize acceptance of self in situation

Intervention 1. Assess mental/physical influence of illness/condition to the clients emotional state 2. Recognize behavior indicative of overconcern with body and its processes 3.Have client describe self, noting what is positive and what is negative 4. Discuss meaning of loss/change to client

Evaluatio n After 1 hour of nursing interventio n, the patient was able to verbalize acceptance of self in situation

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5. Discuss the availability of prosthetics, reconstructive surgery and physical/occupatio nal therapy or other referrals as dictated by individual situation 6.Help client to select and use clothing 7.Offer positive reinforcement for efforts made

Assessment Subjective: Kahitwalanayungkamayko, nararamdamanko paring sumasakitsiya, minsanngakakamutinkosana, sakakomaaalalangwalanangapalasiya as verbalized by the patient

Diagnosis Risk for disturbed sensory perception: phantom limb pain related to amputation

Plan After 1 hour of nursing intervention, the patient will be able to verbalize awareness of sensory needs and presence of overload and/or deprivation

Intervention 1. Identify underlying reason for alterations in sensory perception 2. Note degree of alteration/involvement 3. Explain procedures/activities, expected sensations and outcomes 4. Provide undisturbed sleep/rest periods 5. Provide diversional activities as able

Evaluation After 1 hour of nursing intervention, the patient was able to verbalize awareness of sensory needs and presence of overload and/or deprivation

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6. Identify and encourage use of resources/prosthetic devices 7. Provide safety measures 8.Ambulate with assistance/devices 9. Monitor drug regimen postsurgically.

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