MUSCULOSKELETAL SYSTEM NURSING

1. MISS. KINJAL RATHOD
NURSING TUTOR
AHMEDABAD SCHOOL OF
NURSING
Amputation

2. INTRODUCTION:
The word amputation is derived from
the Latin amputare, "to cut away". The English word
"amputation" was first applied to surgery in the 17th
century. By the end of the 17th century "amputation"
had come to dominate as the accepted medical term.
As a surgical measure, it is used to control pain or a
disease process in the affected limb, such
as malignancy or gangrene. In some cases, it is
carried out on individuals as a preventative surgery for
such problems.
Amputation is an acquired condition that result in the
loss of limb unusually from injury, diseases or surgery.

3. DEFINITION
 “Amputation is a surgical
procedure that involves removal of an
extremity or limb (leg or arm) or a part of
a limb (such as a toe, finger, foot, or
hand), usually as a result of injury, disease,
infection, or surgery.”
 Amputation is complete
Removal of injured or deformed
Part.

4. TYPES:
Leg amputations
 amputation of digits
 partial foot amputation
 ankle disarticulation
 below-knee amputation.
 knee disarticulation
 above-knee amputation
 hip disarticulation
Arm amputations
 amputation of digits
 Metacarpal amputation
 wrist disarticulation
 forearm amputation
 elbow disarticulation
 above-elbow amputation
 shoulder disarticulation

5. Surgical amputation:
 The first step is ligating the
supplying artery and vein, to
prevent hemorrhage (bleeding).
 Sharp and rough edges of the
bone(s) are filed down, skin and
muscle flaps are then
transposed over the stump.
Traumatic Amputation:
 Traumatic amputation is the
partial or total avulsion of a
part of a body during a
serious accident, like traffic.
 Traumatic amputation of a
human limb, either partial or
total, creates the immediate
danger of death from blood
loss.

6. CAUSES:
 Circulatory disorders
 Diabetic foot infection or gangrene (the most
frequent reason for infection-related amputations)
 Sepsis with peripheral necrosis
 Neoplasm
 Cancerous bone or soft tissue tumours
(e.g. osteosarcoma, osteochondroma, fibrosarcoma
, epithelioid sarcoma, Ewing's sarcoma, synovial
sarcoma, sacrococcygeal teratoma, liposarcoma)
 Melanoma

7.  Trauma
 Severe limb injuries in which the limb cannot be saved or efforts to save
the limb fail.
 Amputations in traffic accidents (cars, motorcycles, bicycles, trains, etc.)
 Amputations in labor accidents (equipments, instruments, cylinders,
chain saws, press machines, meat machines, wood machines, etc.)
 Amputations in agricultural accidents, with machines and mower
equipments.
 Amputations from electric shock hazard
 Amputations from guns, weapons, and explosives, dynamite, bombs,
fireworks, etc.
 Amputations from building doors and car doors.
 Amputations from other rare accidents.
 Congenital Deformities
 Extra digits and/or limbs (e.g., polydactyly- Baby is born with one or more
extra fingers.)

8.  Infection
 Bone infection (osteomyelitis)
 diabetes
 Frostbite (injury to body tissues caused by exposure
to extreme cold)
 Electric injury, frost bite, electrical burns
 SURGERY – to remove tumors from bones &
muscles.
 Legal punishment
 Amputation is used as a legal punishment in a
number of countries, among
them Iran, Yemen, Saudi Arabia and Islamic regions
of Nigeria.

9. SITE OF AMPUTATION:
a. The exact location for the amputation of
a limb is based on Several factors.
(1)Circulation in the part &
The blood supply available to the remaining limb.
(2 )The functional ability of the remaining limb
(3)The fitting of a functional prosthesis.
(4)The patient's age and overall physical condition.
(5)The patient's muscle strength.
(6)The patient's ability to learn.

10. b. The usual sites for amputation of a lower extremity.
 The foot, the ankle,below the knee (BKA), above the knee
(AKA) , at the hip (hip disarticulation), or at the
pelvis (hemipelvectomy).

11. c. The Usual sites involved in amputation of part of
an upper extremity.
The fingers, at the wrist, below the elbow (BEA), above
the elbow(AEA), and at the shoulder (shoulder disartic
ulation).
 The shoulder disarticulation, hipdisarticulation, and
hemipelvectomy are normally done only in cases of
extensive injuries, malignancy, or gangrene.

12. d. Two basic types of amputation procedures
On the basis of type of surgery
 They are referred to as open and closed, or flap amputation.
(1) Open amputation ( guillotine)
 is performed when infection is present or likely to
develop due to the circumstances of the injury or amputation.
 Tissue and bone are
severed at the same level, and the wound is not closed, but left op
en to drain. Bulky dressings cover the stump end.

13. (2) closed amputation (flap amputation)
 is the preferred method as it usually heals faster
and allows the patient to
be fitted for and begin using a prosthetic device much
sooner.
 When the tissue and bone are severed, skin flaps are
left to cover the stump end.
 Drains are placed in the wound and the skin flaps are
sutured.

14. The circulatory status of the extremities is evaluated by
following diagnostic studies & to determine the appropriate
level for amputation.
 X-rays: Identify skeletal abnormalities.
 CT scan: Identifies soft-tissue and bone destruction, neoplastic
lesions, osteomyelitis, hematoma formation.
 Angiography and blood flow studies: Evaluate circulation/tissue
perfusion problems and help predict potential for tissue healing
after amputation.
 Doppler ultrasound, : Performed to assess and measure blood
flow.

15.  Thermography: Measures temperature differences in an
ischemic limb at two sites: at the skin and centre of the
bone. The lower the difference between the two
readings, the greater the chance for healing.
 ESR: Elevation indicates inflammatory response.
 Wound cultures: Identify presence of infection and
causative organism.
 WBC count/differential: Elevation suggest infectious
process.
 Biopsy: Confirms diagnosis of benign/malignant mass.

16. COMPLICATIONS:
 Haemorrhage
 Infection
 Skin breakdown
 Phantom limb pain
 Joint contracture

17. MEDICAL MANAGEMENT:
 Gentle handling of the residual limb
 Control dressing and use of aseptic technique
 A closed Rigid cast dressing is frequently used :-
 to provide uniform compression ,
 to support soft tissues ,
 to control pain and
 to prevent joint contractures.
 The residual limb is wrapped with elastic plaster of paris
bandages while firm, even pressure is maintained.

18.  A Soft dressing with or without compression : if there is
significant wound drainage
 Frequent inspection of the residual limb
 An immobilizing splint may be incorporated in the
dressing.
 Stump (wound) hematomas are controlled with wound
drainage device to minimize infection.

19. prepration
 Before an amputation is performed,extensive
testing is done to determine the proper level of
amputation.
 The goal of the surgeon is to find the place where
healing is most likely to be complete, 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.

20. NURSING MANAGEMENT

21. Preoperative nursing care :-
 Explain the amputation procedure to the patient.
 Take written consent form the patient for to gives
permission to do the procedure.
 In addition to take a complete medical history,
complete physical examination to ensure good health
& perform blood tests or other diagnostic tests.
 to remove any jewellery or other objects that may
interfere with the procedure.

22. Cont……
 Nil by mouth before the procedure.
 Preparation of Skin as per hospital procedure.
 Give sedative to the patient for relaxation before surgery.
 Build the patient's strength by implementing muscular exercises for the
unaffected limbs & encourage for deep breathing & coughing exercise.
 Improve the patient's nutritional status by encouraging a balanced diet
high in vitamins and minerals and with adequate
protein to enhance wound healing & Maintain adequate hydration.
 Follow the physician's orders for therapeutic measures used to stabilize
any chronic medical conditions such as diabetes, hypertension, or
any other condition that may interfere with surgery or rehabilitation.

23.  If ordered, arrange preoperative counselling with the physical the
rapist.
 If a mobilization aid such as a walker or crutches is to
be used postoperatively, it is
easier to provide instruction in the preoperative period.
 The physical therapist will also
inform the patient about his postoperative rehabilitation
program.
 If authorized by the physician, schedule a visit from the prosthetic
specialist. This may help to alleviate some of the patient's anxieti
es about the fitting and wear of prosthetic devices.

24. Postoperative nursing care
• Immediate care:-
 Prepare an amputation bed.
 Collect emergency equipment near bed and check their working condition.
 Place a tourniquet at bedside to use if haemorrhage from the wound is life
threatening.
 Receive the patient gently.
 Pain medications and antibiotics administered.
 Monitor the patient's vital signs closely for changes in pulse or blood
pressure that may indicate haemorrhage under the Bulky dressing.
 A temperature elevation may indicate the presence of infection.
 Elevate stump for 12-24 hours to decrease edema, and then place it flat to
prevent contractures.

25.  General care :-
 Provide Good Stump care:-
 Keep the stump bandaged to shrink and to shape in preparation for
a prosthesis & mould the stump to smooth, conical shape.
 Keep the stump in proper alignment by using sand bags on both
ends.
 Apply daily dressing to provide some
compression of the stump, but a dressing that is too tight may cause
ischemia at the stump end. Check the stump dressing regularly.
 Evidence of bloody drainage should be marked with date and time,
and excessive bleeding reported to the physician.
 Check the proximal end of the stump dressing for swelling.

27. • Teach the patient about Phantom limb sensation
 Phantom limb is a physiologic reaction of the nerves in the
stump causing an unpleasant feeling that the limb is still
there.
 Phantom limb pain occurs when the unpleasant feelings
become painful or disagreeable; it is called phantom limb
pain because the limb is not there.
 Explain that this sensation may be constant intermittent
and of varying severity.

28.  Distract the patient to relieve phantom limb sensation;
have him look at the stump or close the eyes and put the
stump in range of motion as if the full limb were still there.
If there is still complaints of pain it needs to be reported.
• Shaping of stump for fitting of prosthesis:-
 Remove and reapply the bandage. When the wound is
healed, the stump must be conditioned and shaped for the
proper fitting of a prosthesis.
 During the shaping process, the bandage is worn day and ni
ght. It is customarily removed and reapplied twice daily or
as ordered by the physician.

29.  Rehabilitative care :- encourage prescribed exercises to
preserve the range of motion in the
affected limb and to strengthen the remaining limbs.
 Encourage the family to participate in the total care.
 Allow the patient to express his emotional reactions.

30. NURSING DIAGNOSIS:
1.Impaired Physical Mobility Related to Loss of a limb
(particularly a lower extremity) pain/discomfort as evidenced
by decreased muscle strength.
2.Risk for Infection related to Invasive procedures as evidenced
by fever & redness on amputation site.
3. Risk for Ineffective Tissue Perfusion related to surgical
amputation as evidenced by Reduced arterial/venous blood
flow; tissue edema, hematoma formation & Hypovolemia.
4.Situational Low Self-Esteem related to Loss of body
part/change in functional abilities

31. PROSTHESIS

32. INTRODUCTION:
 When an arm or other extremity is amputated or lost,
a prosthetic device, or prosthesis, can play an important
role in rehabilitation.
 For many people, an artificial limb can improve mobility
and the ability to manage daily activities, as well as
provide the means to stay independent.

33. DEFINITION
 “a prosthesis, (from Ancient
Greek prosthesis, "addition, application,
attachment") is an artificial device that replaces
a missing body part lost through trauma,
disease, or congenital conditions.”

34. Prostheses Parts:
 A socket into which the stump of the
amputated limb fits
 The suspension, which holds the prosthesis
onto the stump
 The shaft
 The foot, hand, or hook
 A covering for cosmetic appearances
 The socket is often lined with foam or
silicone to protect the stump. Special socks
are also worn over the stump to ensure a
proper fit and improve comfort

36. Types of prostheses:
 Arm and hand.
 The oldest and most commonly used prosthetic
arm is operated with the body's own
movements and a harness that extends in a
figure eight across the back and under the
opposite arm.
 Foot or partial foot prosthesis: This replaces
the part of the foot that was removed. The
ankle part may be bendable to help patient to
move easier. The foot may also have rubber
grips to decrease the risk of slipping.

37.  Below-the-knee prosthesis: This has a shin made of a
metal tube with a socket on top to connect to your
stump. It connects to the artificial foot and ankle at
the bottom.

38.  Above-the-knee prosthesis: This type of prosthesis is
made with a thigh, knee, shin, foot, and ankle. It is
made of a metal tube with a socket on top to connect
to the stump. The knee part of the prosthesis is
bendable for walking, sitting, and kneeling.

39. Choosing and Using a Prosthesis:
 A number of factors are involved in choosing a
prosthesis. They include:
The location and level of the amputation
The condition of the remaining limb
 Activity level, particularly for a prosthetic leg
or foot
 Specific goals and needs

40.  Prostheses are designed and fitted by a specialist
called a prosthetist. The fitting process typically
begins in the hospital shortly after amputation. It
involves:
Measuring the stump and the healthy opposite
limb
Making a plaster mould
Attaching the shaft
Aligning the prosthesis

41. Patient Assessment
 Perform a comprehensive assessment of the patient to
obtain an understanding of the patient's prosthetic
needs:
 Review patient’s prescription/referral.
 Take a comprehensive patient history, including
demographic characteristics, family dynamics, previous
use of an prosthesis, diagnosis, work history, a vocational
activities, signs and symptoms, medical history (including
allergies to materials, current medications),
reimbursement status, patient expectations, patient
compliance with ancillary care, results of diagnostic
evaluations.

42.  Perform a diagnosis-specific functional clinical and
cognitive ability examination that includes manual
muscle testing, gait analysis, and evaluation of sensory
function, range of motion, joint stability, and skin integrity.
 Consult with other health care providers and caregivers,
when appropriate, about patient’s condition in order to
formulate a treatment plan.
 Verify patient care by documenting history, ongoing care,
and follow-up, using established record-keeping
techniques.
 Refer patient, if appropriate, to other health care
providers for intervention beyond prosthetic scope of
practice.

43. Formulation & Implementation of the
Treatment Plan
 Create a comprehensive prosthetic treatment plan to
meet the needs and goals of the patient:
 Evaluate the findings to determine an prosthetic
treatment plan.
 Formulate treatment goals and expected outcomes
 to reduce pain,
 increase comfort,
 provide stability,
 prevent deformity,
 address aesthetic factors, and/or
 promote healing to enhance function and independence.

44.  Identify design, materials, and components to support
treatment plan.
 Assess device for structural safety and ensure
manufacturers’ guidelines have been followed prior to
patient fitting/delivery (e.g., torque values, patient weight
limits)
 Communicate to patient and/or caregiver about the
recommended treatment plan and any optional plans,
including disclosure of potential risks/benefits in prosthetic
care.
 Document treatment plan using established record-keeping
techniques.

45.  Ensure patient or responsible parties are informed of their
financial responsibilities (for example, insurance
verification/authorization) as they pertain to proposed
treatment plan.
 Educate patient and/or caregiver about the use and
maintenance of the prosthesis (e.g., wearing schedules,
other instructions)

46. Follow-up Treatment Plan
 Obtain feedback from patient and/or caregiver to evaluate
outcome (e.g., wear schedule/ tolerance, comfort, perceived
benefits, perceived detriments, ability to don and doff, proper
usage and function, overall patient satisfaction)
 Assess patient’s function and note any changes
 Assess patient’s skin condition (e.g., integrity, color, temperature,
volume) and note any changes
 Assess patient’s general health, height, and weight, and note any
changes
 Assess patient’s psychosocial status (e.g., family status, job, or
caregiver), and note any changes

47.  Assess fit of prosthesis with regard to strategic contact
(e.g., multiple force systems, total contact) to
determine need for changes relative to initial
treatment goals
 Assess fit of prosthesis with regard to anatomical
relationships to prosthesis to determine need for
changes relative to initial treatment goals
 Assess patient’s achievement of planned treatment
outcomes
 Formulate plan to modify prosthesis based on
assessment of outcomes and inform patient and/or
caregiver of plan to modify prosthesis as necessary

48.  Make or supervise modifications to prosthesis (e.g., relieve
pressure, change range of motion, change alignment, change
components, add pressure-sensitive pad)
 Assess modified device for structural safety
 Document all findings and actions and communicate with
physicians, referral sources, and appropriately licensed health
care providers to ensure patient status is updated
 Develop long-term follow-up plan

49. Prosthetic Comfort and Care
 To gain the greatest benefits of the new limb and help prevent
problems, it is important to take care of the device, the
amputation site, and general health by doing the following
every day:
 Remove the prosthesis before going to bed.
 Examine the device for loose parts or damage. Examine the
stump for blisters or other signs of irritation.
 Clean and put a small amount of lotion on the stump
and massage the skin .
 Place a bandage on the stump to decrease swelling when
patients is not wearing the prosthesis.

50.  Regularly inspect the skin of the stump to look for sores or
wounds.
 Practice exercises recommended by physical therapist. These
will include exercises for stretching, range of motion, body
positioning etc.
 For leg prostheses, wear proper fitting shoes and never change
the height of your heels. The prosthesis is designed for one
heel height only.
 Clean the prosthesis' socket with soap and water.
 Wear clean dry socks with the prosthesis.


51.  It is also important to maintain a stable body weight.
This will help to keep the prosthesis fitting properly.
 the prosthesis examined and serviced once a year to
make sure it is in proper working order.