Rajiv Gandhi University of Health Sciences s102

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON STUMP CARE AMONG AMPUTEES IN SELECTED HOSPITALS AT KOLAR DISTRICT, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

Mr. ABDUL RAHMAN ALI A.E & C.S PAVAN COLLEGE OF NURSING KOLAR

1 RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA. PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 NAME OF THE MS. ABDUL RAHMAN ALI CANDIDATE & 1ST YEAR M.SC, NURSING STUDENT ADDRESS A.E & C.S. PAVAN COLLEGE OF NURSING BANGALORE-CHENNAI BYEPASS ROAD, KOLAR - 563101

2 NAME OF THE A.E & C.S. PAVAN COLLEGE OF NURSING INSTITUTE KOLAR - 563101

3 COURSE OF M.Sc. NURSING THE STUDY MEDICAL AND SURGICAL IN NURSING AND SUBJECT

4 DATE OF 04 -06 -2008 ADMISSION

5 TITLE OF THE A STUDY TO EVALUATE THE TOPIC EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON STUMP CARE AMONG AMPUTEES IN SELECTED HOSPITALS AT KOLAR DISTRICT, KARNATAKA.

6. BRIEF RESUME OF INTENDED WORK

2 Introduction “A Stitch in time saves nine” Thomas Fuller

The word “Amputation” derived from the Latin Amputare “To cut away”, from Ambi – (“about”, “Around”) and put are (“to prune”) the Latin word has never been recorded in a surgical context, being reserved to indicate punishment for criminals. Amputation is the removal of a body extremity by trauma or surgery. The English word “Amputation “was first applied to surgery in the 17th century possibly First in peter Lowe’s book named “A discourse of the whole art of chirurgerie” (Published in either 1597 or 1612) his work was derived from 16th century French text and early English writers also used the words “extirpation”, “disarticulation”, and “dismemberment”, or simply “cutting”, but by the end of the 17th century “Amputation” had come to dominate as the accepted medical term.1

As a surgical measure, it is used to control pain or disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a preventive surgery for such problems. In some countries, amputation of the hands or feet is or was used as a form of punishment for people who committed crimes. Amputation has also been used as a tactic in war and acts of terrorism. In some cultures and religions, minor Amputation or mutilation are considered a ritual accomplishment 2 . The history of human Amputation can be divided in to a number of periods. Initially, limb loss was usually the result of trauma or “non surgical” removal. This was followed by the hesitant beginnings of surgical intervention, mainly on gangrenous limbs or those already terribly damaged, which developed through surgical amputations around the 15th century. The distinction is marked by the choice of the patient and the aim of saving a life and achieving a healed stump. Despite the difficulties with infection and

3 lack of effective control for pain or blood loss. Improvements in surgical techniques were married with better hemorrhage control in the 19th century and in the 1840 s with anesthesia and around 20 year later efficient infection control. The 20th century noted marked improvements in surgical techniques and also a move to increasingly sophisticated prosthetic limb. 3

Each year, the majority of new amputations occur due to complications of the vascular system, especially from diabetes. These types of amputations are known as dysvascular, although rates of cancer and trauma related amputations are decreasing, rates for dysvascular amputations are on the rise. Incidence of congenital limb deficiency has seen little or no change. 3

The vast majority of amputation is performed because the arteries of the legs have become blocked due to hardening of the arteries (atheroselerosis). Blockages in the arteries result in insufficient blood supply to the limb. Because diabetes can cause hardening of the arteries, about 30-40% of amputation performed in patients with diabetes. Patients with diabetes can develop foot/toe ulceration and about 7%of patients will have an active ulcer or a healed ulcer. Ulcers are recurrent in many patients and approximately 5-15% of diabetic patients with ulcers will ultimately require an amputation. Because hardening of the arteries occurs most commonly in older men who smoke, the majority of amputation for vascular disease occurs in these groups when hardening of the arteries becomes so severe that gangrene develops or pain becomes constant and severe, amputation may be the only option. If amputation is not performing in these circumstances infection can develop and threaten the life of the patient. some times bypass surgery can be performed to avoid amputation , but not all patients are suitable for bypass surgery . Serious accident can lead to the loss of a limb, as can the development of a tumor or cancer in a limb. These amputations occur in younger patients before amputation, the limb can cause serious problem with infection and pain and may even be a threat to the life of some patient. 4

4 Amputation can be divided into minor and major. Minor amputations are amputation where only a toe or part of the foot is removed. A ray amputation is particular form of minor amputation where a toe and part the corresponding metatarsal bone is removed. A forefoot amputation can be helpful in patients with more than one toe involved by gangrene. In this operation all toes and the ball of foot is removed. Major amputations are amputation where part of the leg is removed. These are usually below the knee or above the knee. An amputation of just the foot can be performed with a cut through the ankle joint (symes amputation). This is not suitable for the majority of patients, but can be an option in some patients in diabetes. Amputation through the knee joint or just above the knee joint is Gritti-stokes amputation. If a major amputation is to be performed then a below knee amputation will give the patients the best chance of remaining mobile and walking postoperatively. 4

After minor amputation the wound is not always closed completely with stitches. If the infection is present or too much skin has had to be removed then the surgeon may leave the amputation wound open. When a ray amputation is performed the wound is left open to heel. This is awful to the untrained eye the resulting wound can appear dreadful. The conditions are right for heeling these wounds can heel well over a period of 1-3 months and leave a fully functioning leg and foot. It is possible to walk normally after loosing toes and fore foot. 4

Major amputations is possible before the operation (although not always) for the surgeon to decide at what level the amputation will be performed (above knee and bellow knee). Sometimes gangrene or infection will only involve a toe or part of a foot and limited or minor amputation can be performed. This is only worthwhile if the surgeon thinks that wound that is created will heal. In some patients, it is better to try a limited amputation if there is a chance of healing, but to be prepared to proceed to a major amputation if healing doesn’t take place. 4

5 One of the most important factors in healing is the blood supply to the tissues. If the blood supply is damaged or important it may not be possible for the tissue to heal even after a minor amputation. If in the opinion of the surgeon the tissues will clearly not heal because of a poor blood supply it would be reckless to precede with a minor amputation when really a major amputation is required.4

In general the more limited the amputation the lower the risks and the better the chances of walking. It is better to have a below knee amputation when compared with a much knee amputation, because the chances of successfully walking after the operation are much better. Everyone is not suitable for this operation and many people need to have an above knee amputation. This may be because the blood supply to lower leg is too poor and a below knee amputation would not heal properly. If the knee cannot straighten out properly before the surgery, it will be impossible to walk with an artificial leg after the operation. In these circumstances it may be better to undergo an above knee amputation. Once an amputation stump is created it is a potentially vulnerable area that will require life long care and attention. A major amputation wound is almost always closed with stitches or staples. 4

Below knee amputation is performed using two major techniques (skew flap and posterior flap). The bone in the lower leg (tibia) is divided 12-15cms below the knee joint. This produces a good size stump to which prosthesis can be fitted. 4

Above knee amputation is the operation done on the bone in the thigh (femur) is divided about 12-15cms above the knee joint and the muscle and skin closed over the end of the bone. 4

NEED FOR THE STUDY

6 Most people who require an amputation have peripheral artery disease (PAD), a traumatic injury, or cancer. Peripheral artery disease is the leading cause of amputation in people age 50 and older, and accounts for up to 90 percent of amputations overall. Normally, surgeons treat advanced Peripheral artery disease through other methods, like controlling infection using antibiotics and draining or removing any infected tissue as well as performing surgery or other procedures to increase the blood flow to the affected area. However, if these treatments do not work, or if the tissue damage is too far advanced initially, amputation will remove a source of major infection and may be necessary to save your life. 5

A traumatic injury, such as a car accident or a severe burn, can also destroy blood vessels and cause tissue death. As infection is not properly treated it can spread throughout patient’s body and threaten his life. Medical team will make every effort to save his limb by surgically replacing or repairing his damaged blood vessels or using donor tissue. However, if these measures do not work, amputation can save patients life. Traumatic injuries are the most common reason for amputations in people younger than age 50. 5

The physician may recommend amputation if a person have a cancerous tumor of the limb. The person may also receive chemotherapy, radiation, or other treatments to destroy the cancer cells. Depending upon the particular circumstances, these treatments can shrink the tumor and may increase the effectiveness of his amputation. 5

Dysvascular-Related Amputations: Amputations due to vascular disease - problems associated with the blood vessels - accounted for the majority (82 percent) of limb loss discharges and increased from 38.30 per 100,000 people in 1988 to 46.19 per 100,000 people in 1996. Lower-limb amputations accounted for 97 percent of all dysvascular limb loss discharges.5

o 25.8 percent at above-knee level

7 o 27.6 percent at below-knee level

o 42.8 percent involving numerous other levels.

In all age groups, the risk of dysvascular amputation was highest among males and individuals who are African, American. 6

Trauma-Related Amputations: Upper-limb amputations accounted for the vast majority (68.6 percent) of all trauma-related amputations occurring during the study period. Males were at a significantly higher risk for trauma-related amputations than females. For both males and females, risk of traumatic amputations increased steadily with age, reaching its highest level among people age 85 or older. 6

Cancer-Related Amputations: Limb amputations resulting from cancer most commonly involved the lower limb; above-knee and below-knee amputations alone accounted for more than a third (36 percent) of all cancer-related amputations. There were no notable differences by sex or race in the age-specific risk of cancer-related amputations, though rates of limb loss due to cancer were generally higher among individuals other than African Americans. 6

Congenital-Related Incidences: Rates of congenital limb anomalies among newborns were at 26 per 100,000 live births, relatively unchanged over the study period. Upper-limb deficiencies accounted for 58.5 percent of newborn, congenital limb anomalies. 6

After amputation, medication is prescribed for pain and patients are treated with antibiotics to discourage infection. The stump is moved often to encourage good circulation. Physical therapy and rehabilitation are started as soon as possible, with in 48hrs. Studies have shown that there is positive relation between early rehabilitation and effective functioning of the stump and prosthesis. Length of stay in the hospital depends

8 on the severity of the amputation and general health of the amputee, ranges from several days to weeks. 7

Rehabilitation is a long, arduous process, especially for above the knee amputees. Twice daily physical therapy is given. Psychological counseling is an important part of rehabilitation. Many people feel a sense of loss and grief when they loose a body part. Others are bothered by phantom limb syndrome, where they feel as if the amputated part is still in place. They may even feel pain in this limb that does not exist. Addressing the emotional aspects of amputation are often speaks the physical rehabilitation process. 7

Complications of amputation after surgery are chest infection, angina heart attacks and strokes. Because patient’s mobility is restricted after an amputation, pressure sores can develop. The nursing staff particularly will make grate efforts to avoid this. Special mattresses and beds are used to reduce pressure on areas at risk of sores.7

A study conducted in Canada on amputees experiencing stump pain, phantom limb sensations, pain, and a general awareness of missing limb states that the mechanisms underlying these perceptions could involve nervous system neuroplasticity and be reflected in altered sensory function of residual limb. They concluded that phantom limb pain described one to three years after an amputation is not related to peripheral sensory function, stump pain, limb temperature and phantom limb phantom limb pain is influenced by the frequent user of prosthesis. 8

A prospective observational study conducted in serbia on pain characteristics and functional status of amputees two months after the amputation and to determine their social function and the condition of their habitation states that elderly amputees with unilateral lower limp amputations achieved significant functional improvement and reduction of pain, in spite of their social dysfunction, absence of sociomedical support and inadequacy. 9

9 A study conducted in United States of America on local administration of nor epinephrine in the stump evokes dose dependent pain in amputees states that 20 patients with post amputation stump pain participated in the study. In 15 patients, 0.2ml of saline and nor epinephrine where administered in a single blinded fashion in the region of maximal tenderness and tinel sign, a probable site of a neuronal. They concluded that alpha adrenoceptor mechanisms contribute to stump pain, possibly associated with neuromas in amputees. 10

A study conducted on surgical treatment of chronic phantom limb sensation and limb pain after lower limb amputation in Germany 15 patients with lower limb amputation were included in study . In all patients the sciatic nerve was spilt at a point approximately 3cms proximal to the popliteal fossa, and the two parts were reconnected in a sling fashion using an epiperineurial technique under microscopic vision. The nerves were covered with a fibrin patch and anesthetics were applied by means of a local plain catheter. Frequency, duration, intensity, and quality of phantom pain were compared preoperatively and one week, three weeks, six months and one year postoperatively they concluded that accurate treatment of the peripheral nerve can help to reduce phantom limb pain. 11

A retrospective study conducted to characterize elderly lower limb amputees and explore problems and requirements inherent in their case in Sweden states that patients surviving after six months of amputation had permanent problems in the area of nutrition, elimination, skin ulceration, sleep, pain and pain alleviation. The patients who died during the hospital stay had problems in all these areas. 12

A population based study conducted in United States to know the incidence of limb amputation and birth prevalence of limb deficiency. The studies varied in scope, quality, and methodology, making comparisons between studies. Incidence rates of acquired amputation varied greatly between and within nations. Rates of all-cause acquired

10 amputation ranged from 1.2 first major amputations per 10,000 women in Japan to 4.4 per 10,000 men in the Navajo Nation in the United States between 1992 and 1997.They concluded that the Consistent among all nations, the risk of amputation was greatest among persons with diabetes mellitus. 13

A prospective inception cohort study conducted to evaluate physical, mental, and social characteristics as predictors of functional out come of elderly amputees in Netherlands states that elderly patients with the leg amputation had a low functional level for about one year. 14

A retrospective study conducted to document the functional natural history of patients undergoing major amputations than academic vascular surgery and rehabilitation medicine practice states that vascular patients in a contemporary setting who require major lower extremity amputation and rehabilitation often remain independent despite. 15

A study conducted to establish and to enable a comparison of lower extremity amputation incidence rates between different centers around the world. Ten centers, all with populations greater than 200 000, in Japan, Taiwan, Spain, Italy, North America and England collected data on all amputations done between July 1995 and June 1997. : The highest amputation rates were in the Navajo population (43.9 per 100 000 population per year for first major amputation in men) and the lowest in Madrid, Spain (2.8 per 100 000 per year). The incidence of amputation rose steeply with age; most amputations occurred in patients over 60 years. In most centers the incidence was higher in men than women and the incidence of major amputations was greater than that of minor amputations. Diabetes was associated with between 25 and 90 per cent of amputations. 16

A study conducted on psycho physiological contributions to phantom limbs in Ontario to evaluate evidence of peripheral, central and psychological processes that trigger or modulate a variety of phantom limb experiences. Study concluded that the

11 experience of a phantom limb is determined by a complex interactions of inputs from the periphery and wide spread regions of the brain subserving sensory, cognitive, and emotional process. 17

India had about 3.3 crore diabetics and 15 per cent of them were likely to develop foot complications. "Many of them will need amputations unless they have access to good foot care programme." Around 80 per cent of these complications are preventable, say experts. Of the 40,000 lower extremity amputations in India every year, 80 per cent are performed on infected neuropathic feet, which are potentially preventable. 18

Based on the review of literature and personal experience of the investigator during practice in the field of nursing, found that amputees who were admitted in ortho ward and post operative ward had lack of knowledge on stump care and its complications. This gap of knowledge necessitates the need for systematic education to prevent complications. Thus the investigator felt that planned health education will facilitate the amputee to know about stump care and complications and thereby reduce complications of amputation.

12 6.2 REVIEW OF LITERATURE

Review of literature is a key step in research process. It refers to an extensive, exhaustive and systemic examination of publication relevant to the research project. According to polit and Beck (2000) “A Broad, comprehensive, in depth, systemic and critical view of scholarly publications, unpublished materials, audio visual materials and personal communication is called review of literature” 19. The related literature is organized and presented under the following headings:-  Studies related to post operative stump care.  Studies related to Phantom limb pain.  Studies related to rehabilitation.

Studies related to post operative stump care:

A study conducted to investigate the validity of post-amputation application of removable rigid dressings for trans-tibial amputees, regarding preparation for prosthetic management and key rehabilitation timelines. A retrospective case-note audit was conducted, in which consecutive trans-tibial amputees who underwent amputation in the 2 years before removable rigid dressings implementation (non- removable rigid dressings group, n = 37) and in the 2 years after removable rigid dressings implementation (removable rigid dressings group, n = 28) were eligible for inclusion. A significant reduction in acute length of stay for the removable rigid dressings group was also identified (15.9 days vs. 8.7 days, respectively, p < 0.001). There were no significant differences in other rehabilitation timeframes, such as rehabilitation length of stay, total length of stay, outpatient rehabilitation days, and total rehabilitation days between the two groups. This study shows that the application of removable rigid dressings reduces acute length of stay and time-to-first-prosthetic-casting, thereby providing substantial

13 benefits in preparing the trans-tibial amputee for early rehabilitation and prosthetic intervention. 20.

A study conducted to evaluate the incidence of ipsilateral postoperative deep venous thrombosis in the amputated lower extremity of patients with peripheral obstructive arterial disease. The incidence of deep venous thrombosis during the early postoperative period or the risk factors for the development of deep venous thrombosis in the amputation stump. This prospective study evaluated the incidence of deep venous thrombosis during the first 35 postoperative days in patients who had undergone amputation of the lower extremity due to Peripheral artery disease and its relation to co morbidities and death. Between September 2004 and March 2006, 56 patients (29 men), with a mean age of 67.25 years, underwent 62 amputations, comprising 36 below knee amputations and 26 above knee amputations. Deep venous thrombosis occurred in 25.8% of extremities with amputations (10 above knee amputations and 6 below knee amputations). The cumulative incidence in the 35-day postoperative period was 28% (Kaplan-Meier). There was a significant difference (P = .04) in the incidence of deep venous thrombosis between above knee amputations (37.5%) and below knee amputations (21.2%). Age >/=70 years (48.9% vs. 16.8%, P = .021) was also a risk factor for deep venous thrombosis in the univariate analysis. Of the 16 cases, 14 (87.5%) were diagnosed during outpatient care. The time to discharge after amputation was averaged 6.11 days in-hospital stay (range, 1-56 days). One symptomatic nonfatal pulmonary embolism occurred in a patient already diagnosed with deep venous thrombosis. The incidence of deep venous thrombosis deep venous thrombosis in the early postoperative period (/=70 years and for above knee amputations. 21

A retrospective study conducted to analyze early fitting and elastic bandaging. Study investigated the effects of early fitting in trans- tibial amputees. The assumption is compared to elastic bandaging; the use of a rigid dressing in early fitting will result in quicker wound healing and earlier ambulation. A retrospective file search was carried out

14 in three different hospitals; each of the hospitals used a different method of postoperative care: elastic bandaging, immediate postoperative application of the plaster cast or delayed application of the plaster cast within one week post amputation. In comparison to the elastic bandaging method (N=52), the use of a rigid dressing in the early fitting method (immediate and delayed, N=97) resulted in a statistically significant shorter period from amputation to the delivery of a first regular prosthesis (110 days vs. 50 days) and a decreased risk of knee flexion contracture. This study concludes that early fitting by use of a rigid dressing after trans-tibial amputation is the treatment of choice. If it is possible to apply a plaster cast in operating room immediate fitting method should be preferred. 22

A study conducted on Postoperative management of lower extremity amputation. Postoperative management of lower extremity amputation continues to evolve with advances in prosthetic technology, surgical technique, and rehabilitation considerations. Almost 50 years ago, the first immediate postoperative prosthesis was conceived, and has been used since with varying degrees of success. More recently, use of the removable rigid dressing combined with aggressive physical therapy has been found to be a safe and cost-effective method of treatment for the new amputee. 23

A study conducted on Unna and elastic postoperative dressings: comparison of their effects on function of adults with amputation and vascular disease. A successive series of adults with vascular disease who had lower limb amputation surgery. Subjects were randomly assigned to the semi rigid dressing (12 patients with 12 recent amputations) or the elastic bandage soft dressing(ED) (9 patients with 10 recent amputations) group. Subjects in the semi rigid dressing group had Unna dressings applied to the amputation limb by physical therapists trained in the technique. Those in the elastic bandage soft dressing group had elastic bandaging by therapists, nurses, family, and themselves, all of whom were trained in the technique. : Sixty-seven percent of the semi rigid dressing group and 20% of those in the elastic bandage soft dressing group were discharged from the rehabilitation unit ambulating with prostheses. Of those who received prostheses, time from admission to the rehabilitation unit to readiness for fitting

15 averaged 20.8 days for the semi rigid dressing group and 28.7 days for the elastic bandage soft dressing group. Comparison of survival curves shows that the time from surgery to fitting in the semi rigid dressing almost half that of the group; 30% of the semi rigid dressing group was fitted within 34 days, whereas it took 64 days for the same percentage of the elastic bandage soft dressing group to be fitted with prosthesis. Unna semi rigid dressings are more effective in fostering amputation limb wound healing and preparing the amputation limb for prosthetic fitting. Subjects treated with semi rigid dressings were more likely to be fitted with prostheses and to return home walking with prosthesis. 24

An epidemiologic study conducted on Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients. To examine patterns of trauma- related amputations over time by age and gender of the patient and by level and type of amputation, and to explore factors affecting acute care length of stay and discharge to inpatient rehabilitation. Patients (N = 6,069) discharged with either (1) a principal or secondary diagnosis of a trauma-related amputation to the upper or lower extremity or (2) a procedure code for a lower or upper limb amputation in combination with a principal diagnosis of an extremity injury or injury-related complication. . Acute care length of stay for trauma-related amputations declined 40% over the study period and was significantly affected by the patient's income source, amputation level, and injury characteristics. Of the patients with a major amputation, 15% were discharged to inpatient rehabilitation; 60% were discharged directly home. The leading causes of trauma-related amputation were injuries involving machinery (40.1%), powered tools and appliances (27.8%), firearms (8.5%), and motor vehicle crashes (8%). Findings suggest a substantial decline in incidence rates of both major and minor amputations over the 15- year study period, a low rate of disposition to inpatient rehabilitation services of patients sustaining major amputations, and an apparent role of firearms as a cause of trauma- related amputations in patients younger than 25 years of age. 25

STUDIES RELATED TO PHANTOM PAIN:

16 A study conducted on painful and nonpainful phantom and stump sensations in acute traumatic amputees. The formation, prevalence, intensity, course, and predisposing factors of phantom limb pain were investigated to determine possible mechanisms of the origin of phantom limb pain in traumatic upper limb amputees among Ninety-six upper limb amputees participated in the study. A questionnaire assessed the following such as side, date, extension, and cause of amputation, preamputation pain, and presence or absence of phantom pain, phantom and stump sensations or stump pain or both. In 64 (98.5%) participants a traumatic injury led to amputation; the amputation was necessary because of infection in one patient (1.5%). The median follow-up time (from amputation to evaluation) was 3.2 years (range, 0.9-3.8 years) The prevalence of phantom pain was 44.6%, phantom sensation 53.8%, stump pain 61.5%, and stump sensation 78.5%. After its first appearance, phantom pain had a decreasing course in 14 (48.2%) of 29 amputees, was stable in 11 (37.9%) amputees, and worsened in 2 (6.9%) of 29 amputees. Stump pain had a decreasing course in 19 (47.5%) of 40 amputees but was stable in 12 (30%) amputees. Phantom pain occurred immediately after amputation in 8 (28%) of 29 amputees between 1 month and 12 months in 3 (10%) amputees and after 12 or more months in 12 (41%) amputees. Stump pain and stump sensation predominate traumatic amputees' somatosensory experience immediately after amputation; phantom pain and phantom sensations are often long-term consequences of amputation. Amputees experience phantom sensations and phantom pain within 1 month after amputation, a second peak occurs 12 months after amputation. Revised diagnostic criteria for phantom pain are proposed on the basis of these data. 26

A national survey conducted on Phantom pain, residual limb pain, and back pain in amputees. To describe the prevalence of amputation-related pain, to ascertain the intensity and affective quality of phantom pain, residual limb pain, back pain, and nonamputated limb pain, and to identify the role that demographics, amputation-related factors, and depressed mood may contribute to the experience of pain in the amputee. A stratified sample by etiology of 914 persons with limb loss. Prevalence, intensity, and

17 bothersomeness of residual, phantom, and back pain, depressed mood as measured by the Center for Epidemiologic Study Depression Scale, characteristics of the amputation, prosthetic use, and sociodemographic characteristics of the amputee. Nearly all (95%) amputees surveyed reported experiencing 1 or more types of amputation-related pain in the previous 4 weeks. Phantom pain was reported most often (79.9%), with 67.7% reporting residual limb pain and 62.3% back pain. A large proportion of persons with phantom pain and stump pain reported experiencing severe pain (rating 7-10). Across all pain types, a quarter of those with pain reported their pain to be extremely bothersome chronic pain is highly prevalent among persons with limb loss, regardless of time since amputation. A common predictor of an increased level of intensity and bothersomeness among all pain sites was the presence of depressive symptoms. 27

A study conducted on Pain site and impairment in individuals with amputation pain. To determine the association between pain site and pain interference with activities of daily living among persons with acquired amputation. : Six or more months after lower-limb amputation, participants completed an amputation pain questionnaire that included several standardized pain measures. Phantom limb, residual limb, and back pain intensity ratings, as a group, accounted for 20% of the variance in pain interference. The pain intensity ratings associated with each individual pain site made a statistically significant contribution to the prediction of pain interference with activities of daily living even after controlling for the pain intensity of the other. Pain in each of 3 sites (phantom limb, residual limb, back) appears to be important to pain-related impairment and function. Measurement of the intensity of pain at each site appears to be required for a thorough assessment of amputation pain-related impairment. 28

A study conducted on chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. To determine the characteristics of phantom limb sensation, phantom limb pain, and residual limb pain and to evaluate pain-related disability associated with phantom limb pain. A Retrospective, cross-sectional survey was carried out Six or more months after lower limb amputation, participants (n =

18 255) completed an amputation pain questionnaire that included several standardized pain measures. Of the respondents, 79% reported phantom limb sensations, 72% reported phantom limb pain, and 74% reported residual limb pain. They concluded that many described their phantom limb and residual limb pain as episodic and not particularly bothersome. Most participants with phantom limb pain were classified into the two low pain-related disability categories: grade I, low disability/low pain intensity (47%) or grade II, low disability/high pain intensity (28%). Many participants reported having pain in other anatomic locations, including the back (52%). Phantom limb and residual limb pain are common after a lower limb amputation, most of the pain is episodic and not particularly disabling but for a notable subset, the pain was quite disabling. Pain after amputation should be viewed from a broad perspective that considers other anatomic sites as well as the impact of pain on functioning. 29

A study conducted on Phantom limb, residual limb, and back pain after lower extremity amputations. This study describes the sensations and pain reported by persons with unilateral lower extremity amputations. Participants (n = 92) were recruited from two hospitals to complete the Prosthesis Evaluation Questionnaire which included questions about amputation related sensations and pain. Participants reported the frequency, intensity, and bothersomeness of phantom limb, residual limb, and back pain and nonpainful phantom limb sensations. A survey of medication use for each category of sensations also was included. Statistical analyses revealed that nonpainful phantom limb sensations were common and more frequent than phantom limb pain. Residual limb pain and back pain were also common after amputation. Back pain surprisingly was rated as more bothersome than phantom limb pain or residual limb pain. Back pain was significantly more common in persons with above knee amputations. These results supported the importance of looking at pain as a multidimensional rather than a unidimensional construct. 30

STUDIES RELATED TO REHABILITATION

19 A study conducted on why traumatic leg amputees are at increased risk for cardiovascular diseases. Post-traumatic lower limb amputees have an increased morbidity and mortality from cardiovascular disease. Risk factors for this amplified morbidity and the involved pathophysiologic mechanisms have not been comprehensively studied. Insulin resistance, psychological stress and patients' deviant behaviors are prevalent in traumatic lower limb amputees. Each of these factors may have systemic consequences on the arterial system and may contribute to the increased cardiovascular morbidity in traumatic amputees. Abnormalities of arterial flow proximal to the amputation site may hold the explanation for the linkage between the extent of leg amputation and the magnitude of the cardiovascular risk: proximal leg amputation is associated with greater risk than distal amputation and bilateral amputation with greater risk than unilateral amputation. This review focuses on hemodynamic culprits (shear stress, circumferential strain, reflected waves), hemodynamic consequences in proximity to the occluded femoral artery and hemodynamic consequences Coronary risk in lower limb amputees may be substantially greater than predicted by available algorithms, given that neither hemodynamic nor psychological factors concern the current prediction models. It seems reasonable to take early prophylactic measures in lower limb amputees by discouraging smoking, excessive alcohol consumption and adherence to a low fat diet. 31

A study conducted on Rehabilitation setting and associated mortality and medical stability among persons with amputations. To estimate the differences in outcomes across post acute care settings-inpatient rehabilitation, skilled nursing facility, or home-for dysvascular lower-limb amputees. : Dysvascular lower-limb elderly amputees (N=2468). The 1-year mortality for the elderly amputees was 41%. Multivariate probit models controlling for patient characteristics indicated that patients discharged to inpatient rehabilitation were significantly (P<.001) more likely to have survived 12 months post amputation (75%) than those discharged to an skilled nursing facility. (63%) or those sent home (51%). Acquisition of a prosthesis was significantly (P<.001) more frequent for persons going to inpatient rehabilitation (73%) compared with skilled nursing facility

20 (58%) and home (49%) disposition Receiving inpatient rehabilitation care immediately after acute care was associated with reduced mortality, fewer subsequent amputations, greater acquisition of prosthetic devices, and greater medical stability than for patients who were sent home or to an skilled nursing facility. 32

A study conducted on Patient rehabilitation following lower limb amputation. Patient rehabilitation following lower limb amputation is essential to provide optimum patient outcomes and to improve the amputee's quality of life. The age of the patient and the stump length or level of amputation emerge as dominant factors affecting the outcome of rehabilitation. A variety of outcome measures are available to assess the patient's rehabilitative potential to maximize functional ability. 33

A study conducted on the effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system. To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system. A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004. After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups. The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. 34

A study conducted on Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation.Dysvascularity accounts for 75% of all lower limb amputations in the United Kingdom. Around 37% of these are at transfemoral level (mid-thigh), with the majority of people being over the age of 60 and having

21 existing co-morbidities. A significant number of these amputees will be prescribed lower limb prosthesis for walking. However, many amputees do not achieve a high level of function following prosthetic rehabilitation. Random of 38 full reports obtained for consideration, one trial was included and four were excluded. The sole included trial was a short-term crossover randomized trial which tested the effects of adding three seemingly identical prosthetic weights (150 g versus 770 g versus 1625 g) to the prostheses of 10 participants with unilateral dysvascular transfemoral amputation. Eight participants were over 60 years of age. The trial found that four participants preferred the lightest weight (150 g), five preferred the middle weight (770 g) and one preferred the addition of the heaviest weight (1625 g).there is lack of evidence from randomized controlled trials testing prosthetic rehabilitation interventions following a unilateral transfemoral or transgenicular amputation in older (aged 60 years or above) dysvascular people. The study concluded that there is a lack of evidence from randomized controlled trials to inform the choice of prosthetic rehabilitation, including the optimum weight of prosthesis, after unilateral transfemoral amputation in older dysvascular people. 35

A study conducted on Health related quality of life and related factors in 539 persons with amputation of upper and lower limb. Limb amputation is followed by an important rehabilitation process, especially when prosthesis is involved. The objective of this study is to assess the nature of factors related to health related quality of life (HRQL) of persons with limb amputation. The Nottingham Health Profile (NHP) treated 1011 subjects with major amputation of one or several limbs. Response rate was 53.3%. Health related quality of life measured by the Nottingham Health Profile was mostly impaired in the categories of physical disability, pain and energy level. Controlling for sex and age, young age at the time of amputation, traumatic origin and upper limb amputation were independently associated with better health related quality of life. The study concluded that health related quality of life is largely related to factors which are inherent to the patient and the amputation. 36 STATEMENT OF THE PROBLEM:

22 “A study to evaluate the effectiveness of structured teaching program on stump care among amputees in selected hospitals at Kolar district, Karnataka”

6.3 OJECTIVES:-  To assess the existing Knowledge regarding stump care among amputes.  To evaluate the effectiveness of structured teaching Program on stump care among amputees.  To find the association between posttest knowledge level with their selected demographic variables.

6.4 OPERATIONAL DEFINITIONS:

Evaluate: - Refers to judgment made based on knowledge gained by structured teaching program on stump care.

Effectiveness: - Refers to the desired changes brought by the structured teaching program on stump care.

Structured teaching program: - Refers to a system of planned instructional design to impart information in order to bring the changes in knowledge regarding stump care among amputees.

Stump care: - Refers to the care given to part of a limb left after the rest had been cut off.

Amputees:

23 Refers to the person who had undergone amputation of one or more limbs and above 15 years of age.

6.5 Hypothesis:-

Ho – There will be no significant difference between pre test and postest scores of stump care among amputees.

6.6 Variables:- 6.6-1 Dependent variable: - Knowledge of amputees regarding stump care.

6.6-2 Independent variable: - Structured teaching program on stump care.

7 Material and methods:- 7.1 Source of data: - Amputees admitted in the selected hospitals at kolar.

7.2 Methods of data collection: 7.2.1 Research design- Pre experimental design (one group pre test and Post test)

7.2.2 Setting – The study will be conducted in two hospitals namely sri Narasimha raja hospital (SNR), Kolar which is situated 2 kms away from Pavan college nursing, having 500 bed strength and RL Jalappa hospital and research center, Tamaka, Kolar district situated 5 Kms away from Pavan college nursing having 850 bed strength. 7.2.3 Population:

24 The population for the present study comprises of patients who underwent amputation.

7.2.4 Sample: Patient who underwent amputation with the age group above 15 years.

7.2.5 Sample size: 60 amputees.

7.2.6 Sampling technique: Convenient sampling technique.

7.2.7 Sampling Criteria:

Inclusion criteria:- o Who underwent amputation in SNR and RL Jalappa hospitals. o Amputee’s age group above 15 years. o Who can communicate in Kannada or English. o Who are willing to participate in the study.

Exclusion criteria:- o Amputees who are below 15 years of age. o Who are not willing to participate in the study. o Who cannot communicate in Kannada or English

25 7.2.8 Tool of data collection: Structured interview schedule will be used for data collection. The tools consist of two sections.

Section A: - consist of demographic data of subject.

Section B: - consist of knowledge question regarding stump care.

7.2.9 Methods t of data collections: Structured interview schedule will be used to collect the data from amputees. The purpose of the study will be explained and consent from the participant will obtained to involve in the study. The tentative period of data collection will be 6 weeks, before that tool will be developed and after validation by the experts, further refinement of the tool will be done. After that the pilot study will be conducted.

7.2.10 Data analysis and interpretation:

Data will be analyzed on the basis of objective and hypothesis by using descriptive and inferential statistics. Frequency percentage mean and standard deviation will be used for descriptive statistics. In inferential statistics the chi -square test will be used to find the association between posttest knowledge level with their selected demographic variables and paired‘t’ test will be used to know the effectiveness of structured teaching program on stump care. The result will be presented in the form of tables, graphs and diagrams.

26 7.3 Does the studies require any investigation or intervention to be conducted on patient/ Sample populations or other humans or animals?

Yes. The study will be conducted on the amputees. Since it is pre experimental study, it requires intervention on stump care structured teaching programme will be given to the amputees. It will not have any harm to the patient (Amputee).

7.4 Has Ethical clearance been obtained from your institute?

Yes. Prior permission will be obtained from the concerned authorities of SNR hospital and RL Jalappa hospital in kolar to conduct a Study and also from research committee of Pavan College of nursing kolar. The purpose of study will be explained to the amputee of the selected hospitals. Scientific objectivity of the study will be maintained with honesty.

27 BIBLIOGRAPHY

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31 related factors in 539 persons with amputation of upper and lower limb.Disabil Rehabil.2003 May 6:25(9):480-6

32 9 SIGNATURE OF THE CANDIDATE:

10 REMARKS OF THE GUIDE:

11 NAME AND DESIGNATION :

11.1 GUIDE

11.2 SIGNATURE

11.3 CO-GUIDE

11.4 SIGNATURE

11.5 HEAD OF THE DEPARTMENT

11.6 SIGNATURE

12 REMARK OF CHAIRMAN AND PRINCIPAL

12.1 SIGNATURE: