A Case Study of

Below the Knee Amputation

on CKD V Sec to DM Neph
Patient

To

discuss the pathophysiology of the

disease
To understand the risk factors that may
lead to BKA on DM Patients
To discuss the clinical management of
post operative status of patient

Objectives

BKA

stands for below-the-knee

amputation.

Transtibial

amputation is the preferred

term for BKA, as the tibia is the larger
bone below the knee.

What is BKA?

Risk

Factors that may lead to Amputation

on DM Patients:

Decreased perfusion (Diabetic Neuropathy)

Injury or Trauma
Severe infection on affected limb
Uncontrolled Hyperglycemia

What are the risk factors?

Signs and Symptoms:

Decreased sensation on extremeties
Non healing wound
Immobility
Increased Pre HD and Post HD RBS
Increased WBC count on CBC

Clinical Manefestations

Foot

care, including regular follow-up,

patient education, and referral as
appropriate
Tight, stable glycemic control (most
important for slowing progression of
neuropathy)
Pain management

Management

Below the Knee Amputation

on CKD V Sec to DM Neph
Patient
Patient Case

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Frequency: 2x/wk
Duration: 4 hours
Dialyzer: LOPS 18
BFR: 300ml/min
DFR: 500ml/min
Bicarbonate Bath
PNSS Flushing
UF based on DW

HD PRESCRIPTION

RV, 56yo, male patient with diagnosis of

CKD V secondary to DM Nephropathy is
undergoing hemodialysis treatment for 2x a
week.
General Information:
Weight: 68kg
Height: 5 6
BMI: 24.56kg/m2

PATIENT BACKGROUND

History

of Present Illness:

Patient complained of severe headache for 3days

and episodes of increased blood pressure at
home, pain medications were ordered and
adjustment on anti-hypertensive medications
was done. Also to alleviate the pain, the patient
opted to use warm compress and placed it on
the soles of his feet causing 2nd degree burn.

PATIENT HISTORY

Past

Medical History

Hepatitis B infection
Type 2 Diabetes Mellitus (Routine Dialysis)
Social

History

(-) tobacco use, alcohol and elicit drugs

Surgical

History

Debridement of Right Foot (diabetic ulcer)

December, 2010

PATIENT HISTORY

Complete

Blood Count
FBS Monitoring
Xray of both foot APO

Diagnostic Tests

JUNE 8, 2015

JUNE 10, 2015

Hgb: 7
Hct: .0.21
RBC:4.03
WBC: 32.9
PLT: 215
Neutrophil: 71
Lymphocyte: 0.20
Monocyte: 0.03

Hgb: 6.3
Hct: .0.19
RBC:3.05
WBC: 31.2
PLT: 269
Neutrophil: 72
Lymphocyte: 0.25
Monocyte: 0.03

On Feso4 + FA 1tab tid

On 2x/wk EPO
Cefuroxime 500mg BIDx7d

BT Of 3u PRBC
Meropenem 1g q 12hrs
Levofloxacin 500mg OD
x7d

JUNE 27, 2015

Hgb: 7.8
Hct: .0.23
RBC:2.53
WBC: 8.0
PLT: 289
Neutrophil: 64
Lymphocyte: 0.21
Monocyte: 0.04

COMPLETE BLOOD COUNT

June 03, 2015

The visualized bony structure appear
intact.
There are no lytic changes seen
Calcified blood vessels are seen in the soft
tissue of the distal L and R Foot.

Xray of both foot APO

Precipitating

Factors:

Trauma caused by the warm compress

Uncontrolled Hyperglycemia
Predisposing

Factors:

DM Patient
Diabetic Neuropathy

Kidney Failure

PATHOPHYSIOLOGY

TISSUE INJURY
ACUTE
INFLAMMATION
RELEASE OF CHEMICAL
MEDIATORS
VASODILATION

INC. CAPILLARY
PERMEABILITY

CHEMOTAXIS

Clot and fibrin

mesh walls off
area

Phagocytosis

IRRITATION OF
NERVE ENDINGS

PREPARATION FOR
HEALING
CHRONIC
INFLAMMATION

HEALING

PROCESS OF WOUND HEALING

SURGICAL

MANAGEMENT

DEBRIDEMENT
BELOW KNEE AMPUTATION
PHARMACOLOGICAL

MANAGEMENT

HEMODIALYSIS
NURSING

MANAGEMENT

MEDICAL MANAGEMENT

ANTI-DM

MEDS
ANTI- HPN MEDS
ANTIBIOTICS
ANEMIA MANAGEMENT
PAIN MEDICATIONS

PHARMACOLOGIC MANAGEMENT

ASSESSMENT

Subjective:
Verbal report of pain and discomfort
Pain scale of 5 out of 10 (10 being the highest)

Objective:
(+) post op BKA; mild pain
(+) weakness
Behavioral change

NURSING CARE PLAN

DIAGNOSIS

Impaired physical mobility due to surgical

interruption and musculoskeletal impairment

NURSING MANAGEMENT

PLANNING

LONG TERM:
After 1-2 weeks of nursing intervention, the client will be able
to participate in ADL and desired activities.
SHORT TERM:
After 15-20 minutes of nursing intervention, the client will be
able to:
Verbalize understanding about the methods that provide relief
Demonstrate use of relaxation skills and diversional
activities appropriate to situation.
State the importance of compliance to ff. check up and
medication compliance

NURSING MANAGEMENT

INTERVENTION

1. Assess signs of pain, verbal and non-verbal, location and

intensity should be noted to be able

Rationale: to determine appropriate therapeutic
intervention.
2. Support affected body parts/joints using pillows/rolls
Rationale: to maintain position of function and reduce risk
of pressure ulcers.
3. Encourage participation in self-care,
occupational/diversional/recreational activities.
Rationale: This enhances self-concept and sense of
independence.
4. Give analgesics prescribed and evaluation of effectiveness.
Rationale: analgesics in severe pain may need to block
pain

NURSING MANAGEMENT

EVALUTAION

LONG TERM:
After 1-2 weeks of nursing intervention, the client was able to
participate in ADL and desired activities.
SHORT TERM:
After 15-20 minutes of nursing intervention, the client was able
to:
Verbalized understanding about the methods that provide
relief
Demonstrated use of relaxation skills and diversional activities
appropriate to situation.
Stated the importance of compliance to ff. check up and
medication compliance

NURSING MANAGEMENT