Our Lady of Fatima University Our Lady of Fatima University
Antipolo Campus Antipolo Campus College of Nursing College of Nursing
A Case Study on: A Case Study on: Multiply Physical Injury; Multiply Physical Injury; Traumatic Amputation of the Traumatic Amputation of the
Left Upper Extremity Left Upper Extremity
In Partial Fu
In Partial Fulfillmentlfillment of the Requirements in the of the Requirements in the Related Learning Experience 104 Related Learning Experience 104
Orthopedic Ward Rotation Orthopedic Ward Rotation
Table of Contents
Introduction«««««««««««««««««««««««««««««««««3 I. Demographic Data
II. Medical Management a. Medicines
b. Laboratory Data III. Diagnostic Results IV. Surgical Management V. Nursing Management VI. Drug Study
Introduction
³I 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 to es 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 to remove tissue that no longer has an adequate blood supply y to remove malignant tumors
y 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
I. Demographic Data
Name : RMR
Age : 18 y/o
Address : SitioMacopa, BagongNayon 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
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
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
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
III. Diagnostic Results
Examination Result Purpose
1. Chest X-ray 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 r ib 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
To note if the lung has been affected and so as to answer questions of there is presence of DOB.
2. Complete Blood Count with Blood Typing WBC: 30 RBC: 3.96 Hbg: 12.2 Hct: 37.1 Platelet: 494 Blood Type: O
For baseline and monitoring of blood clotting factors and
infection and for possible blood transfusion.
Before an amputation is performed, extensive testing is do ne to determine the proper level o f 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, t he 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 y infrared measurements of skin temperature1
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
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PartV.Nursing Management
Nursing Care Plan
Assessment Diagnosis Plan Intervention Evaluation
Subjective:
³Masakitparinyungpinagputulanngkamayko, gusto konanganginuminlahatnggamotnapampatanggalngsakit´ as verbalized by the patient
Objective: >PR: 108 bpm >facial grimace >guarding behavior Acute pain related to surgical procedure: amputation as manifested by facial grimace
After 1 hour of nursing intervention, the patient will be able to feel relief regarding the pain he is experiencing. 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
After 1 hour of nursing
intervention, the patient was able
to feel relief regarding the pain he is
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to prevent fatigue
Assessment Diagnosis Plan Intervention Evaluation
Subjective:
³Siempremahihirapannaakongmagtrabaho,
ngayonnganahihirapanakongmaglakaddahilsabalisapaa ko´ as verbalized by the patient
Objective:
>limited range of motion >slowed movement
>movement-induced shortness of breath/tremor
Impaired physical mobility related to loss of extremity as manifeste d by slowed movement s
After 1 hour of nursing
intervention, the patient will be able
to demonstrate techniques/behavio rs that enable the resumption of activities.
1. Assess degree of pain, listening to client¶s 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.
After 1 hour of nursing
intervention, the patient was able to
demonstrate techniques/behavio rs that enable the resumption of activities.
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7.Administer medications prior to activity as needed for pain relief
8.Provide regular skin care to include pressure area management
Assessment Diagnosis Plan Intervention Evaluation
Subjective:
³Kapagnagbibihis, kelanganko pa si mama o si papa ko, kasinaninibago pa
akodahilwalanakamayko.´ as verbalized by the patient
Objective:
>amputated left upper extremity
Self-care deficit related to loss of extremity
After 1 hour of nursing intervention, the patient will be able to demonstrate techniques/lifestylechanges to meet self-care needs.
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 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
After 1 hour of nursing intervention, the patient was able to demonstrate techniques/lifestyle changes to meet self-care needs.
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concerns. Modify activities/environment to reduce risk for injury
Assessment Diagnosi
s
Plan Intervention Evaluatio
n Subjective:
³Ayawniyangmagpadalawsamgakaibiganniyagawangwalanasiyangisang kamay.´ as verbalized by the mother of the patient
Objective:
>amputated left upper extremity > over-exposing of body part
Disturbed body image related to amputatio n of body part as evidenced by over-exposure of body part After 1 hour of nursing interventio n, the patient will be able to verbalize acceptance of self in situation 1. Assess mental/physical influence of illness/condition to the client¶s 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 After 1 hour of nursing interventio n, the patient was able to verbalize acceptance of self in situation
12 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 Diagnosis Plan Intervention Evaluation
Subjective: ³Kahitwalanayungkamayko, nararamdamanko paring sumasakitsiya, minsanngakakamutinkosana, sakakomaaalalangwalanangapalasiya´ as verbalized by the patient
Risk for disturbed sensory perception: phantom limb pain
related to amputation
After 1 hour of nursing intervention, the patient will be able to verbalize awareness of sensory needs and presence of overload and/or deprivation
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
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.