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
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 / NAME OF THE CANDIDATE & ADDRESS / MS. ABDUL RAHMAN ALI1ST YEAR M.SC, NURSING STUDENT
A.E & C.S. PAVAN COLLEGE OF NURSING
BANGALORE-CHENNAI BYEPASS
ROAD, KOLAR - 563101
2 / NAME OF THE INSTITUTE / A.E & C.S. PAVAN COLLEGE OF NURSING
KOLAR - 563101
3 / COURSE OF THE STUDY AND SUBJECT / M.Sc. NURSING
MEDICAL AND SURGICAL IN NURSING
4 / DATE OF ADMISSION / 04 -06 -2008
5 / TITLE OF THE TOPIC / A STUDY TO EVALUATE THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON STUMP CARE AMONG AMPUTEES IN SELECTED HOSPITALS AT KOLAR DISTRICT, KARNATAKA.
6. BRIEF RESUME OF INTENDED WORK
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 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
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
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
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
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 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