REFERENCES

SUDDARTH and BRUNNER, Interamericana, Rio de Janeiro, 1977. Kottke, Frederic J., Stillwell, G. Keith;
LEHMANN, Justus F. - Krusen: Treaty of physical medicine and rehabilitation. 3rd ed. São Paulo: Editora
Manole Ltda., 1984.

MACKAY, William A. - Neurophysiology without Tears-Fundação Calouste Gulbenkian, Lisbon, 1999.

MANUILA, L.; Lewalle, P. - Diccionario Medico-3rd Edition, Clime

psi Publishers, Paris, 2003. MERTENS, Joan Mary - The nurse and the patient ampu

tated. "Serving". Lisbon. ISSN 0871-2370, vol. 38, No. 6 (1990), 298-307. PHIPPS

, Wilma J., [et. al] - medical-surgical nursing - concepts and clinical practice

. vol. 2, s.l.: Lusodidacta, 1990. PINNEY, Edward,€Orthopaedic Nursing, 1st edit

ion, Orthopedic Hospital Santana (HOSA), Wall, 1985. PORTUGAL, Ministry of Healt

h, Directorate General of Health, Living with Amputation of Leg - Self-Care in H

ealth and Disease, 1st edition, Volume 8, 1990. Sabiston, David C., MD, Jr. - Tr

Introduction

“I have two hands, the left and the right” is a song which cannot be sung by an amputated
patient. A patient who’s 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:

 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

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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 : RMR
Age : 18 y/o
Address : Sitio Macopa, Bagong Nayon 1, Antipolo City
Religion : Roman Catholic
Occupation : Tricycle Driver
Time and date of Admission : 4AM 04-07-11
Admitting Diagnosis : Mangled Left upper extremity, fracture closed complete
left femur secondary to vehicular accident.

Present History : Few minutes prior to confinement, patient got into

a vehicular accident. The patient was riding a tricycle when
he was hit by a truck.

II. Medical Management

A. Medicine

B. Laboratory Data

Result Normal Findings Interpretation

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WBC: 3.0 3.7-10.6 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.
RBC: 3.96 4.19-5.21 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 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).
Hbg: 12.2 12.5-16.0 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.
Hct: 37.1 38.8-49.7 Hematocrit (HCT, packed cell
volume, PCV). This test
measures the amount of space
(volume) red blood cells

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 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: 494 1.5-4.5 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 Result Purpose

1. Chest X-ray Normal chest X-ray shows To note if the lung has been
normal size and shape of the affected and so as to answer
chest wall and the main questions of there is presence
structures in the chest. White of DOB.
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

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 2. Complete Blood Count WBC: 30 For baseline and monitoring
with Blood Typing RBC: 3.96 of blood clotting factors and
Hbg: 12.2 infection and for possible
Hct: 37.1 blood transfusion.
Platelet: 494
Blood Type: O

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 sfter mightnight 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

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.
 measurement of blood pressure in different parts of the limb
 xenon 133 studies, which use a radiopharmaceutical to measure blood flow
 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.)
 laser doppler measurements of the microcirculation of the skin
 skin fluorescent studies that also measure skin microcirculation
 skin perfusion measurements using a blood pressure cuff and photoelectric detector

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  infrared measurements of skin temperature1

C. Post-operative Phase
 prevent edema (raise extremity with pillow support for first 24 hours)
 observe stump dressing frequently for signs of hemorrhage
 ensure that stump bandages fit tightly and are applied properly (change dressing as
indicated)
 promote wound healing, manage pain
 help the patient to achieve physical mobility ( promoting independent self-care)
 monitor for and manage complications
 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
 offer support/encouragement

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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

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 Part V. Nursing Management
Nursing Care Plan
Assessment Diagnosis Plan Intervention Evaluation
Subjective: Acute pain related to After 1 hour of nursing 1. Observe nonverbal After 1 hour of nursing
“Masakit parin yung surgical procedure: intervention, the patient cues (e.g. how client intervention, the patient
pinagputulan ng kamay amputation as will be able to feel relief walks, holds body, sits; was able to feel relief
ko, gusto ko na ngang manifested by facial regarding the pain he is facial epression, cool regarding the pain he is
inumin lahat ng gamot grimace experiencing. fingertips/toes) and experiencing.
na pampatanggal ng other objective.
sakit” as verbalized by 2. Monitor vital signs
the patient 3.Encourage
verbalization of feelings
Objective: about pain
>PR: 108 bpm 4. Instruct in/ encourage
>facial grimace use of relaxation
>guarding behavior 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 to prevent
fatigue

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 Assessment Diagnosis Plan Intervention Evaluation
Subjective: Impaired physical After 1 hour of nursing 1. Assess degree of pain, After 1 hour of nursing
“Siempre mahihirapan mobility related to loss intervention, the patient listening to client’s intervention, the patient
na akong magtrabaho, of extremity as will be able to description. was able to demonstrate
ngayon nga nahihirapan manifested by slowed demonstrate 2. Determine degree of techniques/behaviors
akong maglakad dahil movements techniques/behaviors perceptual/cognitive that enable the
sa bali sa paa ko” as that enable the impairment and ability resumption of activities.
verbalized by the resumption of activities. to follow directions
patient 3.Assess nutritional
status and energy level
Objective: 4. Assist/have client
>limited range of reposition self on a
motion regular schedule as
>slowed movement dictated by individual
>movement-induced situation
shortness of 5.Instruct in use of
breath/tremor siderails, overhead
trapeze, roller pads
6. Support affected body
parts/joints using
pillows/rolls, foot
supporters/shoes, air
mattress, water bed and
so forth.
7.Administer
medications prior to
activity as needed for
pain relief
8.Provide regular skin
care to include pressure
area management

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 Assessment
Subjective: Self-care deficit related
“Kapag nagbibihis, to loss of extremity
kelangan ko pa si mama
o si papa ko, kasi
naninibago pa ako dahil
wala na kamay ko.” as
verbalized by the
patient
Objective:
>amputated left upper
extremity
Diagnosis Plan Intervention Evaluation
After 1 hour of nursing 1. Identify degree of After 1 hour of nursing
intervention, the patient individual impairment intervention, the patient
will be able to /functional level was able to demonstrate
demonstrate according to scale techniques/lifestyle
techniques/lifestyle 2.Determine individual changes to meet self-
changes to meet self- strengths and skills of care needs.
care needs. the patient
3. Develop a plan of
care appropriate to
individual situation,
scheduling activities to
conform to client’s
normal schedule.
4. Provide privacy
during personal care
activities.
5. Identify energy-
saving behaviors (e.g.
sitting instead of
standing when possible)
6.Review safety
concerns. Modify
activities/environment to
reduce risk for injury
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 Assessment Diagnosis Plan Intervention Evaluation
Subjective: Disturbed body image After 1 hour of nursing 1. Assess After 1 hour of nursing
“Ayaw niyang related to amputation of intervention, the patient mental/physical intervention, the patient
magpadalaw sa mga body part as evidenced will be able to verbalize influence of was able to verbalize
kaibigan niya gawa ng by over-exposure of acceptance of self in illness/condition to the acceptance of self in
wala na siyang isang body part situation client’s emotional state situation
kamay.” as verbalized 2. Recognize behavior
by the mother of the indicative of
patient overconcern with body
and its processes
Objective: 3.Have client describe
>amputated left upper self, noting what is
extremity positive and what is
> over-exposing of negative
body part 4. Discuss meaning of
loss/change to client
5. Discuss the
availability of
prosthetics,
reconstructive surgery
and
physical/occupational
therapy or other referrals
as dictated by individual
situation
6.Help client to select
and use clothing
7.Offer positive
reinforcement for efforts
made

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 Assessment Diagnosis Plan Intervention Evaluation
Subjective: Risk for disturbed After 1 hour of nursing 1. Identify underlying After 1 hour of nursing
“Kahit wala na yung sensory perception: intervention, the patient reason for alterations in intervention, the patient
kamay ko, phantom limb pain will be able to verbalize sensory perception was able to verbalize
nararamdaman ko related to amputation awareness of sensory 2. Note degree of awareness of sensory
paring sumasakit siya, needs and presence of alteration/involvement needs and presence of
minsan nga kakamutin overload and/or 3. Explain overload and/or
ko sana, saka ko deprivation procedures/activities, deprivation
maaalalang wala na nga expected sensations and
pala siya” as verbalized outcomes
by the patient 4. Provide undisturbed
sleep/rest periods
5. Provide diversional
activities as able
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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