Providing Residual Limb Care Following Amputation

Nursing Procedure 9.10

Providing Residual Limb Care Following Amputation

Reduces edema
Promotes stump shrinkage and healing in a manner conducive for prosthetic fitting and application
Prevents contractures

Compression dressings
Double-length elastic bandages of appropriate size (usually 4-in. wrap for an amputation below the knee or 6-in. wrap for an amputation above the knee in an adult)
Stump shrinker socks (compression dressing)
OR
Rigid residual limb dressing (casting material usually applied at time of surgery; see Nursing Procedure 9.5)
Pen

Assessment should focus on the following:

Incision (appearance, size, healing status)
Skin integrity (redness, abrasion, or irritation)
Range of motion of all limbs
Phantom limb sensation/pain
Ability of client to comprehend instructions regarding care of residual limb
Additional learning needs of client
Psychosocial impact of loss of limb; coping skills

Nursing diagnoses may include the following:

Acute pain related to physical injury (surgery)
Impaired physical mobility related to musculoskeletal impairment
Disturbed body image related to surgery (below-the-knee amputation)
Deficient knowledge regarding stump care related to lack of exposure
Risk for injury related to altered mobility

Outcome Identification and Planning

Desired Outcomes

Sample desired outcomes include the following:

The client will demonstrate proper residual limb care.
The client's residual limb will heal in a timely manner without contracture formation.
The residual limb will shrink in such a manner as to allow fitting and application of a prosthesis.

Special Considerations in Planning and Implementation

Pediatric

Since children tend to heal rapidly, they often have an immediate postoperative prosthesis (IPOP) applied. This decreases pain and facilitates early ambulation. Demonstrate the appropriate shrinkage device/procedure using a doll or a stuffed toy with an "amputation." Allow the child to express concerns and understanding through play.

Geriatric

Elderly clients are particularly prone to skin breakdown because they have less subcutaneous fat and their skin is less elastic, thinner, drier, and more fragile than that of a younger person. They also often have decreased range of motion. The caregiver must be vigilant in caring for and positioning the residual limb to prevent skin breakdown and contractures.

Home Health

Approximately 3 weeks after surgery (clarify timing with doctor), client should be instructed to massage residual limb with a rough terry-type cloth to prevent adhesions and desensitize the skin in preparation for prosthesis fitting. If needed, family caregivers should be taught to care for residual limb and techniques to prevent contractures. Have them show competency by return demonstration.

Delegation

Instruct assistive personnel on positioning techniques to prevent formation of contractures. Routine monitoring of neurovascular, incision, and skin status remains the responsibility of licensed personnel.

[Outline]

Desired Outcomes
Special Considerations in Planning and Implementation

Action		Rationale
1	Perform hand hygiene.	Reduces microorganism transfer
2	Organize equipment.	Promotes efficiency
3	Reassure client that phantom limb sensation is normal and usually diminishes over time.	Reduces anxiety
4	If client had a lower limb amputation, avoid elevating residual limb unless directed to do so by doctor’s order (if elevated at all, usually only during the first 24 hr).	Prevents formation of flexion contractures
	Avoid positioning client in Fowler’s or semi-Fowler’s position for extended lengths of time.	Prevents contractures of hips
	After the first 24 hr, position client in prone position for 20 min at least twice a day.	Promotes hip/knee extension; prevents flexion contractures
5	Instruct client on need to maintain extension of the joints in the residual limb.	Prevents flexion contractures; facilitates function of residual limb
6	Maintain application of device to shrink stump.	Reduces edema; promotes shrinkage of residual limb
	Inspect incision each shift until healed.	Allows early intervention if complications occur
	Wash healed incision/residual limb daily with mild soap and water.	Reduces microorganisms; promotes good hygiene
7	Instruct client on correct method to apply shrinkage dressings.	Promotes appropriate healing
7	Apply elastic bandages in a figure-eight configuration with increased constriction at distal end of residual limb and less constriction at proximal end of dressing, taking care not to interrupt perfusion of the distal end of the residual limb. Example: Below the knee (Fig. 9.22A) Example: Above the knee (Fig. 9.22B)	Promotes shrinkage in a manner to allow prosthetic fitting; promotes tissue integrity
8	Instruct client on how to maintain dressings:
	Client should remove shrinkage dressing daily to inspect residual limb.	Allows early intervention if complications occur
	Client should clean shrinkage dressings daily, allowing them to dry completely before reapplication.	Reduces microorganisms; prevents skin irritation due to moisture
	Client should air out any open areas of skin on residual limb for 1 hr four times a day.	Promotes healing
	Client should have at least two complete changes of shrinkage dressings.	Avoids long periods of time without the device in place
9	Demonstrate range-of-motion and isometric exercises of all extremities, including the residual limb.	Promotes understanding; maintains strength and function
10	Inform client that the prosthesis is usually fit by a specialist, called a prosthetist, 6–8 weeks after surgery.	Allows client to anticipate timeline of continued treatment
11	Perform hand hygiene.	Reduces microorganism transfer

Were desired outcomes achieved? Examples of evaluation include:

Desired outcome met: Client demonstrated proper residual limb care.
Desired outcome met: Client's residual limb healed in a timely manner without contracture formation.
Desired outcome met: Client's residual limb shrunk and allows for fitting and application of a prosthesis.

The following should be noted on the client's record:

Residual limb incision, skin, and dressing appearance
Positioning of residual limb
Range of motion of residual limb and other limbs
Client instruction and return demonstration; additional learning needs of client

section name header

Purpose ⬇

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Nursing Diagnoses ⬆ ⬇

Outcome Id ⬆ ⬇

Implementation ⬆ ⬇

Evaluation ⬆ ⬇

Documentation ⬆