CASE STUDY: ABOVE KNEE AMPUTATION

CASE STUDY: ABOVE KNEE AMPUTATION

CASE STUDY: ABOVE KNEE AMPUTATION. GROUP #1:

CASE STUDY: ABOVE KNEE AMPUTATION

 

Scenario:

E.B., a 69-year-old man with type 1 diabetes mellitus (DM), is admitted to a large regional medical center complaining of severe pain in his right foot and lower leg. The right foot and lower leg are cool and with-out pulses (absent by Doppler). Arteriogram demonstrates severe atherosclerosis of the right popliteal artery with complete obstruction of blood flow. Despite attempts at endarterectomy and administration of intravascular alteplase (tissue plasminogen activator [TPA]) over several days, the foot and lower leg become necrotic. Finally, the decision is made to perform an above-the-knee amputation (AKA) on E.B.’s right leg.

E.B. is recently widowed and has a son and daughter who live nearby. In preparation for E.B.’s surgery, the surgeons wish to spare as much viable tissue as possible. Hence, an order is written for E.B. to undergo 5 days of hyperbaric therapy for 20 minutes bid.

 

  1. What is the purpose of hyperbaric therapy?

 

 

Is it better to amputate above or below the knee?

CASE STUDY: ABOVE KNEE AMPUTATION

 

CASE STUDY PROGRESS

As you prepare E.B. for surgery, he is quiet and withdrawn. He follows instructions quietly and slowly

without asking questions. His son and daughter are at his bedside, and they also are very quiet. Finally,

E.B. tells his family, “I don’t want to go like your mother did. She lingered on and had so much pain. I

don’t want them to bring me back.”

  1. You look at his chart and find no advance directives. What is your responsibility?

 

  1. What is your assessment of E.B.’s behavior at this time? What characteristics of anticipatory grieving is E.B. exhibiting and what phase of anticipatory grieving is E.B. in?

 

  1. What are some appropriate interventions and responses to E.B.’s anticipatory grief?

 

 

 

 

CASE STUDY PROGRESS

E.B. returns from surgery with the right stump dressed with gauze and an elastic wrap. The dressing is dry and intact, without drainage. He is drowsy with the following vital signs (VS): 142/80, 96, 14, 97.9 ° F (36.6 ° C), Sp O2= 92%. He has a maintenance IV of D5NS infusing at 125 mL/hr in his right forearm.

 

  1. The surgeon has written to keep E.B.’s stump elevated on pillows for 48 hours; after that, have

him lie in a prone position for 15 minutes, four times a day. In teaching E.B. about his care,

how will you explain the rationale for these orders?

 

  1. In reviewing E.B.’s medical history, what factors do you notice that might affect the condition

of his stump and ultimate rehabilitation potential?

 

CASE STUDY PROGRESS

You have just returned from a 2-day workshop on guidelines for the care of surgical patients with type 1-DM. You notice that E.B.’s daily fasting blood glucose has been running between 130 and 180 mg/dL. The sliding-scale insulin intervention does not begin until blood glucose values equal to or greater than 200 mg/dL are reported. You recognize that patients with blood glucose values even slightly above normal suffer from impaired wound healing.

  1. Identify four interventions that would facilitate timely healing of E.B.’s stump.

 

  1. What should the postoperative assessment of E.B.’s stump dressing include?

 

  1. You are reviewing the plan of care for E.B. Which of these care activities can be safely

delegated to the nursing assistive personnel (NAP)? (Select all that apply.)

  1. Rewrapping the stump bandage
  2. Checking E.B.’s vital signs
  3. Assessing E.B.’s IV insertion site
  4. Assisting E.B. with repositioning in the bed
  5. Asking E.B. to report his level of pain on a 1-to-10 scale

 

 

  1. On the evening of the first postoperative day, E.B. becomes more awake and begins to

complaining of pain. He states, “My right leg is really hurting; how can it hurt so bad if

it’s gone?” What is your best response?

  1. “That is a side effect of the medication.”
  2. “You can’t be feeling that because your leg was amputated.”
  3. “Don’t worry, that sensation will go away in a few days.”
  4. “Are you able to rate that pain on a scale of 1 to 10?”

 

  1. What kind of pain is E.B. experiencing where his right leg used to be and what interventions can be employed to help E.B. with this type of pain?

 

11(a). What is causing this type of pain for E.B.?

 

How long is recovery from above-knee amputation?

CASE STUDY: ABOVE KNEE AMPUTATION

 

CASE STUDY PROGRESS

The case manager is contacted for discharge planning. E.B. will be discharged to an extended care

facility for strength training. Once the patient receives his prosthesis, he will receive balance training.

After that, he will be discharged to his daughter’s home. A physical therapy and occupational therapy

Home evaluation should be ordered.

 

  1. What instructions should be given to E.B.’s daughter concerning safety around

the home?

  1. The signs and symptoms of neurovascular compromise leading to compartment syndrome include: (Select all that apply)
  2. Increased pulse
  3. Paleness
  4. Poikilothermia
  5. Paresthesia
  6. Paralysis or paresthesia

 

  1. A nurse is performing an assessment on a client admitted to the hospital with a musculoskeletal injury. The nurse assesses for manifestations associated with neurovascular compromise when the nurse:
  2. Counts the client’s apical pulse for 1-full minute
  3. Observes for drainage on the dressing of the affected extremity
  4. Takes the client’s blood pressure on the unaffected side
  5. Determines if the pain is experienced with passive motion of the affected extremity

 

  1. A client with a fractured femur experiences sudden dyspnea, tachypnea and tachycardia. An ABG is ordered. The nurse suspects the client probably experienced a fat embolism based on the results of which factor in the ABG?
  2. pH
  3. PaCO2
  4. HCO3
  5. PaO2

 

CASE STUDY OUTCOME

E.B. makes a smooth transition from the hospital to the rehab facility and then to the daughter’s home.

He was never able to adapt to independent living, so he eventually moved into his daughter’s home.