the spine is most vulnerable to fracture.

Fractures generally result from indirect trauma caused by excessive loading, sudden mus- cle contraction, or excessive motion beyond physiologic limits. Osteoporosis contributes to vertebral body collapse (compression fracture). Stable spinal fractures are caused by exion, extension, lateral bending, or vertical loading. The anterior structural column (ver- tebral bodies and dis s) or the posterior structural column (neural arch, articular processes, ligaments) has been disrupted. !nstable fractures occur "ith fracture-dislocations and exhibit disruption of both anterior and posterior structural columns. The potential for neural damage exists. The patient "ith a spinal fracture presents "ith acute tender- ness, s"elling, paravertebral muscle spasm, and change in the normal curves or in the gap bet"een spinous processes. #ain is greater "ith moving, coughing, or "eight bearing. $mmobili%a- tion is essential until initial assessments have determined "hether there is any spinal cord in&ury and "hether the fracture is stable or unstable. Fe" spinal fractures are associated "ith neurologic decits. $f spinal cord in&ury "ith neurologic decit does occur, it usually re'uires immediate surgery (laminectomy "ith spinal fusion) to decompress the spinal cord.

L e Amputation is the removal of a body part, v usually an extremity. *mputation of a lo"er extremity is often madee necessary by pro- gressive peripheral vascularl disease (often a se'uela of diabetes mellitus),s

*mputation

fulminating gas gangrene, trauma (crushing in&uries, burns, frostbite, electrical burns), congenital deformities, chronic osteomyelitis, oro malignant tumor. Of all these causes, peripheral vascular disease accounts for most amputationsf of lo"er extrem- ities. (See /hapter (1 for more information.) A *mputation is used to relieve symptoms, m improve function, and save or improve the patients 'uality of life. $f the health care team p communicates a positive attitude, the patient u ad&usts to the amputation more readily and actively participates in the rehabili- tative plan, t learning ho" to modify activities and ho" to use a as- sistive devices for *23s and mobility.

t i o n

Medical Management
Stable spinal fractures are treated conservatively "ith limited bed rest. The head of the bed is elevated less than () degrees until the acute pain subsides (several days). *nalgesics are prescribed for pain relief. The patient is monitored for a transient paralytic ileus caused by associated retroperitoneal hemorrhage. Sitting is avoided until the pain subsides. * spinal brace or plastic thoracolumbar orthosis may be applied for support during progressive ambulation and resumption of activities. The patient "ith an unstable fracture is treated "ith bed rest, possibly "ith the use of a special turning device (eg, Stry er frame) to maintain spinal alignment. +eurologic status is monitored closely during the preoperative and postoperative periods. ,ithin -. hours after fracture, open reduction, decompression, and xation "ith spinal fusion and instrument stabili%ation are usually accomplished. #ostoperatively, the patient may be cared for on the turning device or in a bed "ith a rm mattress. #rogressive ambulation is begun a fe" days after surgery, "ith the patient using a body brace orthosis. #atient teaching emphasi%es good posture, good body mechanics, and, after healing is sufcient, bac -strengthening exercises. (Spinal cord in&ury is discussed in /hapter 0(.)

2.

diagnostic a *ngiograph

* st a g e d a m p ut at io n m a y b e us e d " h e n g a n gr e n

e and infection exist. $nitially, a guillotine amputation is performed to remove the necrotic and infected tissue. The "ound is d4brided and al- lo"ed to drain. Sepsis is treated "ith systemic antibiotics. $n a fe" days, after the infection has been controlled and the patients con- dition has stabili%ed, a denitive amputation "ith s in closure is performed.

Complications
/omplications that may occur "ith amputation include hemorrhage, infection, skin breakdown, phantom limb pain, and joint contracture. 5ecause ma&or blood vessels have been severed, massive bleeding may occur. $nfection is a ris "ith all surgical procedures. The ris for infection increases "ith contaminated "ounds after traumatic amputation. S in irritation caused by the prosthesis may result in s in brea do"n. Phantom limb pain is caused by the severing of peripheral nerves. 6oint contracture is caused by positioning and a protective exion "ithdra"al pattern associated "ith pain and muscle imbalance.

Medical Management
The ob&ective of treatment is to achieve healing of the amputa- tion "ound, the result being a nontender residual limb (stump) "ith healthy s in for prosthesis use. 7ealing is enhanced by gentle handling of the residual limb, control of residual limb edema through rigid or soft compression dressings, and use of aseptic techni'ue in "ound care to avoid infection.

2104

Unit 15

8!S/!3OS9:3:T*3 F!+/T$O+

Above knee (AK)

Above elbow (AE) Below elbow (BE)

Knee disarticulation Below knee (BK)

Syme

F !U"# $%&1$

3evels of amputation are determined by circulatory ade'uacy, type of prosthesis,

function of the part, and muscle balance. (A) 3evels of amputation of upper extremity. ( ') 3evels of amputation of lo"er extremity.

* closed rigid cast dressing used to provide uniform

is fre'uently

porated in the dressing. Stump ("ound) hematomas are controlled

compression, to support soft tissues, to control pain, and to pre- vent &oint contractures. $mmediately after surgery, a sterili%ed residual limb soc is applied to the residual limb. Felt pads are placed over pressure-sensitive areas. The residual limb is "rapped "ith elastic plaster-ofparis bandages "hile rm, even pressure is maintained. /are is ta en not to constrict circulation. For the patient "ith a lo"er extremity amputation, the plaster cast may be e'uipped to attach a temporary prosthetic extension (pylon) and an articial foot. This rigid dressing techni'ue is used as a means of creating a soc et for immediate postoperative pros- thetic tting. The length of the prosthesis is tailored to the indi- vidual patient. :arly minimal "eight bearing on the residual limb "ith a rigid cast dressing and a pylon attached produces little dis- comfort. The cast is changed in about 1) to 1. days. :levated body temperature, severe pain, or a loose-tting cast may neces- sitate earlier replacement. * removable rigid dressingmay be placed over a soft dressing to control edema, to prevent &oint exion contracture, and to pro- tect the residual limb from unintentional trauma during transfer activities. This rigid dressing is removed several days after surgery for "ound inspection and is then replaced to control edema. The dressing facilitates residual limb shaping. * soft dressing"ith or "ithout compression may be used if there is signicant "ound drainage and fre'uent inspection of the resid- ual limb (stump) is desired. *n immobili%ing splint may be incor-

"ith "ound drainage devices to minimi%e infection.

"ehabilitation
#atients "ho re'uire amputation because of severe trauma are usu- ally, but not al"ays, young and healthy, heal rapidly, and partici- pate in a vigorous rehabilitation program. 5ecause the amputation is the result of an in&ury, the patient needs psychological support in accepting the sudden change in body image and in dealing "ith the stresses of hospitali%ation, long-term rehabilitation, and mod- ication of lifestyle. #atients "ho undergo amputation need sup- port as they grieve the loss, and they need time to "or through their feelings about their permanent loss and change in body image. Their reactions are unpredictable and can include anger, bitterness, and hostility. The multidisciplinary rehabilitation team (patient, nurse, phy- sician, social "or er, psychologist, prosthetist, vocational rehabil- itation "or er) helps the patient achieve the highest possible level of function and participation in life activities (Fig. 0;-1<). #ros- thetic clinics and amputee support groups facilitate this rehabi- litation process. =ocational counseling and &ob retraining may be necessary to help patients return to "or . #sychological problems (eg, denial, "ithdra"al) may be in- uenced by the type of support the patient receives from the re- habilitation team and by ho" 'uic ly *23s and use of the

5ased on the assessment data, the patients ma&or nursing diag- noses may include the follo"ing> ? *cute pain related to amputation ? ?is for disturbed sensory perception> phantom limb pain related to amputation ? $mpaired s in integrity related to surgical amputation ? 2isturbed body image related to amputation of body part ? $neffective coping, related to failure to accept loss of body part ? ?is for anticipatory and@or dysfunctional grieving related to loss of body part ? Self-care decit> feeding, bathing@hygiene, dressing@grooming, or toileting, related to loss of extremity ? $mpaired physical mobility related to loss of extremity /O33*5O?*T$=: #?O53:8S@ #OT:+T$*3 /O8#3$/*T$O+S 5ased on the assessment data, potential complications that may develop include the follo"ing>

F !U"# $%&1(

8any amputees receive prostheses

soon after surgery and begin learning ho" to use them "ith the help and support of the rehabilita- tion team, "hich includes nurses, physicians, physical therapists, and others.

? ? ?

#ostoperative hemorrhage $nfection S in brea do"n

Planning and !oals

The ma&or goals of the patient may include relief of pain, absence of altered sensory perceptions, "ound healing, acceptance of al- tered body image, resolution of the grieving process, independence in self-care, restoration of physical mobility, and absence of complications.

prosthesis are learned. 9no"ing the full options and capabilities available "ith the various prosthetic devices can give the patient a sense of control over the disability.

)U"* )! P"+C#**, -.# PA- #)- U)/#"!+ )! A) AMPU-A- +)

Assessment
5efore surgery, the nurse must evaluate the neurovascular and func- tional status of the extremity through history and physical assessment. $f the patient has experienced a traumatic amputation, the nurse assesses the function and condition of the residual limb. The nurse also assesses the circulatory status and function of the unaf- fected extremity. $f infection or gangrene develops, the patient may have associated enlarged lymph nodes, fever, and purulent drainage. * culture is ta en to determine the appropriate antibiotic therapy. The nurse evaluates the patients nutritional status and creates a plan for nutritional care, if indicated. For "ound healing, a bal- anced diet "ith ade'uate protein and vitamins is essential. *ny concurrent health problems (eg, dehydration, anemia, car- diac insufciency, chronic respiratory problems, diabetes mellitus) need to be identied and treated so that the patient is in the best possible condition to "ithstand the trauma of surgery. The use of corticosteroids, anticoagulants, vasoconstrictors, or vasodilators may inuence management and "ound healing. The nurse assesses the patients psychological status. 2eter- mination of the patients emotional reaction to amputation is es- sential for nursing care. Arief response to a permanent alteration in body image is normal. *n ade'uate support system and pro- fessional counseling can help the patient cope in the aftermath of amputation surgery.

)u0sing nte0ventions
?:3$:=$+A #*$+ Surgical pain can be effectively controlled "ith opioid analgesics, nonpharmaceutical interventions, or evacuation of the hematoma or accumulated fluid. #ain may be incisional or may be caused by inammation, infection, pressure on a bony prominence, or hematoma. 8uscle spasms may add to the patients discomfort. /hanging the patients position or placing a light sandbag on the residual limb to counteract the muscle spasm may improve the pa- tients level of comfort. :valuation of the patients pain and re- sponses to interventions is an important part of the nurses role in pain management. The pain may be an expression of grief and alteration of body image. 8$+$8$B$+A *3T:?:2 S:+SO?C #:?/:#T$O+S *mputees may experience phantom limb pain soon after surgery or - to ( months after amputation. $t occurs more fre'uently may in above- nee amputations. The patient describes pain or unusual sensations, such as numbness, tingling, or muscle cramps, as "ell as a feeling that the extremity is present, crushed, cramped, or t"isted in an abnormal position. ,hen a patient describes phantom pains or sensations, the nurse ac no"ledges these feel- ings and helps the patient modify these perceptions. #hantom sensations diminish over time. The pathogenesis of the phantom limb phenomenon is un no"n. 9eeping the patient active helps decrease the occurrence of phantom limb pain. :arly