6 · web viewphantom pain was reported most often (79.9%), with 67.7% reporting residual limb...
TRANSCRIPT
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
A STUDY TO EVALUATE THE EFFECTIVENESS
OF STRUCTURED TEACHING PROGRAMME
ON STUMP CARE AMONG AMPUTEES
IN SELECTED HOSPITALS
AT KOLAR DISTRICT,
KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
Mr. ABDUL RAHMAN ALI
A.E & C.S PAVAN COLLEGE OF NURSING
KOLAR
1
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECT FOR
DISSERTATION
1 NAME OF THE
CANDIDATE &
ADDRESS
MS. ABDUL RAHMAN ALI
1ST YEAR M.SC, NURSING STUDENT
A.E & C.S. PAVAN COLLEGE OF NURSING
BANGALORE-CHENNAI BYEPASS
ROAD, KOLAR - 563101
2 NAME OF THE
INSTITUTE
A.E & C.S. PAVAN COLLEGE OF NURSING
KOLAR - 563101
3 COURSE OF THE
STUDY AND
SUBJECT
M.Sc. NURSING
MEDICAL AND SURGICAL IN NURSING
4 DATE OF
ADMISSION
04 -06 -2008
5 TITLE OF THE
TOPIC
A STUDY TO EVALUATE THE
EFFECTIVENESS OF STRUCTURED
TEACHING PROGRAMME ON STUMP CARE
AMONG AMPUTEES IN SELECTED
HOSPITALS AT KOLAR DISTRICT,
KARNATAKA.
2
6. BRIEF RESUME OF INTENDED WORK
Introduction
“A Stitch in time saves nine”
Thomas Fuller
The word “Amputation” derived from the Latin Amputare “To cut away”, from
Ambi – (“about”, “Around”) and put are (“to prune”) the Latin word has never been
recorded in a surgical context, being reserved to indicate punishment for criminals.
Amputation is the removal of a body extremity by trauma or surgery. The English word
“Amputation “was first applied to surgery in the 17th century possibly First in peter
Lowe’s book named “A discourse of the whole art of chirurgerie” (Published in either
1597 or 1612) his work was derived from 16th century French text and early English
writers also used the words “extirpation”, “disarticulation”, and “dismemberment”, or
simply “cutting”, but by the end of the 17th century “Amputation” had come to dominate
as the accepted medical term.1
As a surgical measure, it is used to control pain or disease process in the affected
limb, such as malignancy or gangrene. In some cases, it is carried out on individuals as a
preventive surgery for such problems. In some countries, amputation of the hands or feet
is or was used as a form of punishment for people who committed crimes. Amputation
has also been used as a tactic in war and acts of terrorism. In some cultures and religions,
minor Amputation or mutilation are considered a ritual accomplishment 2
.
The history of human Amputation can be divided in to a number of periods.
Initially, limb loss was usually the result of trauma or “non surgical” removal. This was
followed by the hesitant beginnings of surgical intervention, mainly on gangrenous limbs
or those already terribly damaged, which developed through surgical amputations around
3
the 15th century. The distinction is marked by the choice of the patient and the aim of
saving a life and achieving a healed stump. Despite the difficulties with infection and
lack of effective control for pain or blood loss. Improvements in surgical techniques were
married with better hemorrhage control in the 19th century and in the 1840 s with
anesthesia and around 20 year later efficient infection control. The 20th century noted
marked improvements in surgical techniques and also a move to increasingly
sophisticated prosthetic limb. 3
Each year, the majority of new amputations occur due to complications of the
vascular system, especially from diabetes. These types of amputations are known as
dysvascular, although rates of cancer and trauma related amputations are decreasing, rates
for dysvascular amputations are on the rise. Incidence of congenital limb deficiency has
seen little or no change. 3
The vast majority of amputation is performed because the arteries of the legs have
become blocked due to hardening of the arteries (atheroselerosis). Blockages in the
arteries result in insufficient blood supply to the limb. Because diabetes can cause
hardening of the arteries, about 30-40% of amputation performed in patients with
diabetes. Patients with diabetes can develop foot/toe ulceration and about 7%of patients
will have an active ulcer or a healed ulcer. Ulcers are recurrent in many patients and
approximately 5-15% of diabetic patients with ulcers will ultimately require an
amputation. Because hardening of the arteries occurs most commonly in older men who
smoke, the majority of amputation for vascular disease occurs in these groups when
hardening of the arteries becomes so severe that gangrene develops or pain becomes
constant and severe, amputation may be the only option. If amputation is not performing
in these circumstances infection can develop and threaten the life of the patient. some
times bypass surgery can be performed to avoid amputation , but not all patients are
suitable for bypass surgery . Serious accident can lead to the loss of a limb, as can the
development of a tumor or cancer in a limb. These amputations occur in younger patients
4
before amputation, the limb can cause serious problem with infection and pain and may
even be a threat to the life of some patient. 4
Amputation can be divided into minor and major. Minor amputations are
amputation where only a toe or part of the foot is removed. A ray amputation is particular
form of minor amputation where a toe and part the corresponding metatarsal bone is
removed. A forefoot amputation can be helpful in patients with more than one toe
involved by gangrene. In this operation all toes and the ball of foot is removed. Major
amputations are amputation where part of the leg is removed. These are usually below the
knee or above the knee. An amputation of just the foot can be performed with a cut
through the ankle joint (symes amputation). This is not suitable for the majority of
patients, but can be an option in some patients in diabetes. Amputation through the knee
joint or just above the knee joint is Gritti-stokes amputation. If a major amputation is to
be performed then a below knee amputation will give the patients the best chance of
remaining mobile and walking postoperatively. 4
After minor amputation the wound is not always closed completely with stitches.
If the infection is present or too much skin has had to be removed then the surgeon may
leave the amputation wound open. When a ray amputation is performed the wound is left
open to heel. This is awful to the untrained eye the resulting wound can appear dreadful.
The conditions are right for heeling these wounds can heel well over a period of 1-3
months and leave a fully functioning leg and foot. It is possible to walk normally after
loosing toes and fore foot. 4
Major amputations is possible before the operation (although not always) for the
surgeon to decide at what level the amputation will be performed (above knee and bellow
knee). Sometimes gangrene or infection will only involve a toe or part of a foot and
limited or minor amputation can be performed. This is only worthwhile if the surgeon
thinks that wound that is created will heal. In some patients, it is better to try a limited
5
amputation if there is a chance of healing, but to be prepared to proceed to a major
amputation if healing doesn’t take place. 4
One of the most important factors in healing is the blood supply to the tissues. If
the blood supply is damaged or important it may not be possible for the tissue to heal
even after a minor amputation. If in the opinion of the surgeon the tissues will clearly not
heal because of a poor blood supply it would be reckless to precede with a minor
amputation when really a major amputation is required.4
In general the more limited the amputation the lower the risks and the better the
chances of walking. It is better to have a below knee amputation when compared with a
much knee amputation, because the chances of successfully walking after the operation
are much better. Everyone is not suitable for this operation and many people need to have
an above knee amputation. This may be because the blood supply to lower leg is too poor
and a below knee amputation would not heal properly. If the knee cannot straighten out
properly before the surgery, it will be impossible to walk with an artificial leg after the
operation. In these circumstances it may be better to undergo an above knee amputation.
Once an amputation stump is created it is a potentially vulnerable area that will require
life long care and attention. A major amputation wound is almost always closed with
stitches or staples. 4
Below knee amputation is performed using two major techniques (skew flap and
posterior flap). The bone in the lower leg (tibia) is divided 12-15cms below the knee
joint. This produces a good size stump to which prosthesis can be fitted. 4
Above knee amputation is the operation done on the bone in the thigh (femur) is
divided about 12-15cms above the knee joint and the muscle and skin closed over the end
of the bone. 4
6
NEED FOR THE STUDY
Most people who require an amputation have peripheral artery disease (PAD), a
traumatic injury, or cancer. Peripheral artery disease is the leading cause of amputation
in people age 50 and older, and accounts for up to 90 percent of amputations overall.
Normally, surgeons treat advanced Peripheral artery disease through other methods, like
controlling infection using antibiotics and draining or removing any infected tissue as
well as performing surgery or other procedures to increase the blood flow to the affected
area. However, if these treatments do not work, or if the tissue damage is too far
advanced initially, amputation will remove a source of major infection and may be
necessary to save your life. 5
A traumatic injury, such as a car accident or a severe burn, can also destroy blood
vessels and cause tissue death. As infection is not properly treated it can spread
throughout patient’s body and threaten his life. Medical team will make every effort to
save his limb by surgically replacing or repairing his damaged blood vessels or using
donor tissue. However, if these measures do not work, amputation can save patients life.
Traumatic injuries are the most common reason for amputations in people younger than
age 50. 5
The physician may recommend amputation if a person have a cancerous tumor of
the limb. The person may also receive chemotherapy, radiation, or other treatments to
destroy the cancer cells. Depending upon the particular circumstances, these treatments
can shrink the tumor and may increase the effectiveness of his amputation. 5
Dysvascular-Related Amputations: Amputations due to vascular disease -
problems associated with the blood vessels - accounted for the majority (82 percent) of
limb loss discharges and increased from 38.30 per 100,000 people in 1988 to 46.19 per
100,000 people in 1996. Lower-limb amputations accounted for 97 percent of all
dysvascular limb loss discharges.5
7
o 25.8 percent at above-knee level
o 27.6 percent at below-knee level
o 42.8 percent involving numerous other levels.
In all age groups, the risk of dysvascular amputation was highest among males
and individuals who are African, American. 6
Trauma-Related Amputations: Upper-limb amputations accounted for the vast
majority (68.6 percent) of all trauma-related amputations occurring during the study
period. Males were at a significantly higher risk for trauma-related amputations than
females. For both males and females, risk of traumatic amputations increased steadily
with age, reaching its highest level among people age 85 or older. 6
Cancer-Related Amputations: Limb amputations resulting from cancer most
commonly involved the lower limb; above-knee and below-knee amputations alone
accounted for more than a third (36 percent) of all cancer-related amputations. There
were no notable differences by sex or race in the age-specific risk of cancer-related
amputations, though rates of limb loss due to cancer were generally higher among
individuals other than African Americans. 6
Congenital-Related Incidences: Rates of congenital limb anomalies among
newborns were at 26 per 100,000 live births, relatively unchanged over the study period.
Upper-limb deficiencies accounted for 58.5 percent of newborn, congenital limb
anomalies. 6
After amputation, medication is prescribed for pain and patients are treated with
antibiotics to discourage infection. The stump is moved often to encourage good
circulation. Physical therapy and rehabilitation are started as soon as possible, with in
48hrs. Studies have shown that there is positive relation between early rehabilitation and
effective functioning of the stump and prosthesis. Length of stay in the hospital depends
8
on the severity of the amputation and general health of the amputee, ranges from several
days to weeks. 7
Rehabilitation is a long, arduous process, especially for above the knee amputees.
Twice daily physical therapy is given. Psychological counseling is an important part of
rehabilitation. Many people feel a sense of loss and grief when they loose a body part.
Others are bothered by phantom limb syndrome, where they feel as if the amputated part
is still in place. They may even feel pain in this limb that does not exist. Addressing the
emotional aspects of amputation are often speaks the physical rehabilitation process. 7
Complications of amputation after surgery are chest infection, angina heart
attacks and strokes. Because patient’s mobility is restricted after an amputation, pressure
sores can develop. The nursing staff particularly will make grate efforts to avoid this.
Special mattresses and beds are used to reduce pressure on areas at risk of sores.7
A study conducted in Canada on amputees experiencing stump pain, phantom
limb sensations, pain, and a general awareness of missing limb states that the
mechanisms underlying these perceptions could involve nervous system neuroplasticity
and be reflected in altered sensory function of residual limb. They concluded that
phantom limb pain described one to three years after an amputation is not related to
peripheral sensory function, stump pain, limb temperature and phantom limb phantom
limb pain is influenced by the frequent user of prosthesis. 8
A prospective observational study conducted in serbia on pain characteristics and
functional status of amputees two months after the amputation and to determine their
social function and the condition of their habitation states that elderly amputees with
unilateral lower limp amputations achieved significant functional improvement and
reduction of pain, in spite of their social dysfunction, absence of sociomedical support
and inadequacy. 9
9
A study conducted in United States of America on local administration of nor
epinephrine in the stump evokes dose dependent pain in amputees states that 20 patients
with post amputation stump pain participated in the study. In 15 patients, 0.2ml of
saline and nor epinephrine where administered in a single blinded fashion in the region of
maximal tenderness and tinel sign, a probable site of a neuronal. They concluded that
alpha adrenoceptor mechanisms contribute to stump pain, possibly associated with
neuromas in amputees. 10
A study conducted on surgical treatment of chronic phantom limb sensation and
limb pain after lower limb amputation in Germany 15 patients with lower limb
amputation were included in study . In all patients the sciatic nerve was spilt at a point
approximately 3cms proximal to the popliteal fossa, and the two parts were reconnected
in a sling fashion using an epiperineurial technique under microscopic vision. The
nerves were covered with a fibrin patch and anesthetics were applied by means of a local
plain catheter. Frequency, duration, intensity, and quality of phantom pain were
compared preoperatively and one week, three weeks, six months and one year
postoperatively they concluded that accurate treatment of the peripheral nerve can help to
reduce phantom limb pain. 11
A retrospective study conducted to characterize elderly lower limb amputees and
explore problems and requirements inherent in their case in Sweden states that patients
surviving after six months of amputation had permanent problems in the area of nutrition,
elimination, skin ulceration, sleep, pain and pain alleviation. The patients who died
during the hospital stay had problems in all these areas. 12
A population based study conducted in United States to know the incidence of limb
amputation and birth prevalence of limb deficiency. The studies varied in scope, quality,
and methodology, making comparisons between studies. Incidence rates of acquired
amputation varied greatly between and within nations. Rates of all-cause acquired
10
amputation ranged from 1.2 first major amputations per 10,000 women in Japan to 4.4
per 10,000 men in the Navajo Nation in the United States between 1992 and 1997.They
concluded that the Consistent among all nations, the risk of amputation was greatest
among persons with diabetes mellitus. 13
A prospective inception cohort study conducted to evaluate physical, mental, and
social characteristics as predictors of functional out come of elderly amputees in
Netherlands states that elderly patients with the leg amputation had a low functional level
for about one year. 14
A retrospective study conducted to document the functional natural history of
patients undergoing major amputations than academic vascular surgery and rehabilitation
medicine practice states that vascular patients in a contemporary setting who require
major lower extremity amputation and rehabilitation often remain independent despite. 15
A study conducted to establish and to enable a comparison of lower extremity
amputation incidence rates between different centers around the world. Ten centers, all
with populations greater than 200 000, in Japan, Taiwan, Spain, Italy, North America and
England collected data on all amputations done between July 1995 and June 1997. : The
highest amputation rates were in the Navajo population (43.9 per 100 000 population per
year for first major amputation in men) and the lowest in Madrid, Spain (2.8 per 100 000
per year). The incidence of amputation rose steeply with age; most amputations occurred
in patients over 60 years. In most centers the incidence was higher in men than women
and the incidence of major amputations was greater than that of minor amputations.
Diabetes was associated with between 25 and 90 per cent of amputations. 16
A study conducted on psycho physiological contributions to phantom limbs in
Ontario to evaluate evidence of peripheral, central and psychological processes that
trigger or modulate a variety of phantom limb experiences. Study concluded that the
11
experience of a phantom limb is determined by a complex interactions of inputs from
the periphery and wide spread regions of the brain subserving sensory, cognitive, and
emotional process. 17
India had about 3.3 crore diabetics and 15 per cent of them were likely to develop
foot complications. "Many of them will need amputations unless they have access to
good foot care programme." Around 80 per cent of these complications are preventable,
say experts. Of the 40,000 lower extremity amputations in India every year, 80 per cent
are performed on infected neuropathic feet, which are potentially preventable. 18
Based on the review of literature and personal experience of the investigator during
practice in the field of nursing, found that amputees who were admitted in ortho ward and
post operative ward had lack of knowledge on stump care and its complications. This gap
of knowledge necessitates the need for systematic education to prevent complications.
Thus the investigator felt that planned health education will facilitate the amputee to
know about stump care and complications and thereby reduce complications of
amputation.
12
6.2 REVIEW OF LITERATURE
Review of literature is a key step in research process. It refers to an extensive,
exhaustive and systemic examination of publication relevant to the research project.
According to polit and Beck (2000) “A Broad, comprehensive, in depth, systemic
and critical view of scholarly publications, unpublished materials, audio visual materials
and personal communication is called review of literature” 19.
The related literature is organized and presented under the following headings:-
Studies related to post operative stump care.
Studies related to Phantom limb pain.
Studies related to rehabilitation.
Studies related to post operative stump care:
A study conducted to investigate the validity of post-amputation application of
removable rigid dressings for trans-tibial amputees, regarding preparation for prosthetic
management and key rehabilitation timelines. A retrospective case-note audit was
conducted, in which consecutive trans-tibial amputees who underwent amputation in the
2 years before removable rigid dressings implementation (non- removable rigid dressings
group, n = 37) and in the 2 years after removable rigid dressings implementation
(removable rigid dressings group, n = 28) were eligible for inclusion. A significant
reduction in acute length of stay for the removable rigid dressings group was also
identified (15.9 days vs. 8.7 days, respectively, p < 0.001). There were no significant
differences in other rehabilitation timeframes, such as rehabilitation length of stay, total
length of stay, outpatient rehabilitation days, and total rehabilitation days between the
two groups. This study shows that the application of removable rigid dressings reduces
acute length of stay and time-to-first-prosthetic-casting, thereby providing substantial
13
benefits in preparing the trans-tibial amputee for early rehabilitation and prosthetic
intervention. 20.
A study conducted to evaluate the incidence of ipsilateral postoperative deep
venous thrombosis in the amputated lower extremity of patients with peripheral
obstructive arterial disease. The incidence of deep venous thrombosis during the early
postoperative period or the risk factors for the development of deep venous thrombosis in
the amputation stump. This prospective study evaluated the incidence of deep venous
thrombosis during the first 35 postoperative days in patients who had undergone
amputation of the lower extremity due to Peripheral artery disease and its relation to co
morbidities and death. Between September 2004 and March 2006, 56 patients (29 men),
with a mean age of 67.25 years, underwent 62 amputations, comprising 36 below knee
amputations and 26 above knee amputations. Deep venous thrombosis occurred in 25.8%
of extremities with amputations (10 above knee amputations and 6 below knee
amputations). The cumulative incidence in the 35-day postoperative period was 28%
(Kaplan-Meier). There was a significant difference (P = .04) in the incidence of deep
venous thrombosis between above knee amputations (37.5%) and below knee
amputations (21.2%). Age >/=70 years (48.9% vs. 16.8%, P = .021) was also a risk factor
for deep venous thrombosis in the univariate analysis. Of the 16 cases, 14 (87.5%) were
diagnosed during outpatient care. The time to discharge after amputation was averaged
6.11 days in-hospital stay (range, 1-56 days). One symptomatic nonfatal pulmonary
embolism occurred in a patient already diagnosed with deep venous thrombosis. The
incidence of deep venous thrombosis deep venous thrombosis in the early postoperative
period (</=35 days) was elevated principally in patients aged >/=70 years and for above
knee amputations. 21
A retrospective study conducted to analyze early fitting and elastic bandaging.
Study investigated the effects of early fitting in trans- tibial amputees. The assumption is
compared to elastic bandaging; the use of a rigid dressing in early fitting will result in
quicker wound healing and earlier ambulation. A retrospective file search was carried out
14
in three different hospitals; each of the hospitals used a different method of postoperative
care: elastic bandaging, immediate postoperative application of the plaster cast or delayed
application of the plaster cast within one week post amputation. In comparison to the
elastic bandaging method (N=52), the use of a rigid dressing in the early fitting method
(immediate and delayed, N=97) resulted in a statistically significant shorter period from
amputation to the delivery of a first regular prosthesis (110 days vs. 50 days) and a
decreased risk of knee flexion contracture. This study concludes that early fitting by use
of a rigid dressing after trans-tibial amputation is the treatment of choice. If it is possible
to apply a plaster cast in operating room immediate fitting method should be preferred. 22
A study conducted on Postoperative management of lower extremity amputation.
Postoperative management of lower extremity amputation continues to evolve with
advances in prosthetic technology, surgical technique, and rehabilitation considerations.
Almost 50 years ago, the first immediate postoperative prosthesis was conceived, and has
been used since with varying degrees of success. More recently, use of the removable
rigid dressing combined with aggressive physical therapy has been found to be a safe and
cost-effective method of treatment for the new amputee. 23
A study conducted on Unna and elastic postoperative dressings: comparison of
their effects on function of adults with amputation and vascular disease. A successive
series of adults with vascular disease who had lower limb amputation surgery. Subjects
were randomly assigned to the semi rigid dressing (12 patients with 12 recent
amputations) or the elastic bandage soft dressing(ED) (9 patients with 10 recent
amputations) group. Subjects in the semi rigid dressing group had Unna dressings applied
to the amputation limb by physical therapists trained in the technique. Those in the elastic
bandage soft dressing group had elastic bandaging by therapists, nurses, family, and
themselves, all of whom were trained in the technique. : Sixty-seven percent of the semi
rigid dressing group and 20% of those in the elastic bandage soft dressing group were
discharged from the rehabilitation unit ambulating with prostheses. Of those who
received prostheses, time from admission to the rehabilitation unit to readiness for fitting
15
averaged 20.8 days for the semi rigid dressing group and 28.7 days for the elastic
bandage soft dressing group. Comparison of survival curves shows that the time from
surgery to fitting in the semi rigid dressing almost half that of the group; 30% of the semi
rigid dressing group was fitted within 34 days, whereas it took 64 days for the same
percentage of the elastic bandage soft dressing group to be fitted with prosthesis. Unna
semi rigid dressings are more effective in fostering amputation limb wound healing and
preparing the amputation limb for prosthetic fitting. Subjects treated with semi rigid
dressings were more likely to be fitted with prostheses and to return home walking with
prosthesis. 24
An epidemiologic study conducted on Incidence, acute care length of stay, and
discharge to rehabilitation of traumatic amputee patients. To examine patterns of trauma-
related amputations over time by age and gender of the patient and by level and type of
amputation, and to explore factors affecting acute care length of stay and discharge to
inpatient rehabilitation. Patients (N = 6,069) discharged with either (1) a principal or
secondary diagnosis of a trauma-related amputation to the upper or lower extremity or (2)
a procedure code for a lower or upper limb amputation in combination with a principal
diagnosis of an extremity injury or injury-related complication. . Acute care length of
stay for trauma-related amputations declined 40% over the study period and was
significantly affected by the patient's income source, amputation level, and injury
characteristics. Of the patients with a major amputation, 15% were discharged to
inpatient rehabilitation; 60% were discharged directly home. The leading causes of
trauma-related amputation were injuries involving machinery (40.1%), powered tools and
appliances (27.8%), firearms (8.5%), and motor vehicle crashes (8%). Findings suggest a
substantial decline in incidence rates of both major and minor amputations over the 15-
year study period, a low rate of disposition to inpatient rehabilitation services of patients
sustaining major amputations, and an apparent role of firearms as a cause of trauma-
related amputations in patients younger than 25 years of age. 25
STUDIES RELATED TO PHANTOM PAIN:
16
A study conducted on painful and nonpainful phantom and stump sensations in
acute traumatic amputees. The formation, prevalence, intensity, course, and predisposing
factors of phantom limb pain were investigated to determine possible mechanisms of the
origin of phantom limb pain in traumatic upper limb amputees among Ninety-six upper
limb amputees participated in the study. A questionnaire assessed the following such as
side, date, extension, and cause of amputation, preamputation pain, and presence or
absence of phantom pain, phantom and stump sensations or stump pain or both. In 64
(98.5%) participants a traumatic injury led to amputation; the amputation was necessary
because of infection in one patient (1.5%). The median follow-up time (from amputation
to evaluation) was 3.2 years (range, 0.9-3.8 years) The prevalence of phantom pain was
44.6%, phantom sensation 53.8%, stump pain 61.5%, and stump sensation 78.5%. After
its first appearance, phantom pain had a decreasing course in 14 (48.2%) of 29 amputees,
was stable in 11 (37.9%) amputees, and worsened in 2 (6.9%) of 29 amputees. Stump
pain had a decreasing course in 19 (47.5%) of 40 amputees but was stable in 12 (30%)
amputees. Phantom pain occurred immediately after amputation in 8 (28%) of 29
amputees between 1 month and 12 months in 3 (10%) amputees and after 12 or more
months in 12 (41%) amputees. Stump pain and stump sensation predominate traumatic
amputees' somatosensory experience immediately after amputation; phantom pain and
phantom sensations are often long-term consequences of amputation. Amputees
experience phantom sensations and phantom pain within 1 month after amputation, a
second peak occurs 12 months after amputation. Revised diagnostic criteria for phantom
pain are proposed on the basis of these data. 26
A national survey conducted on Phantom pain, residual limb pain, and back pain
in amputees. To describe the prevalence of amputation-related pain, to ascertain the
intensity and affective quality of phantom pain, residual limb pain, back pain, and
nonamputated limb pain, and to identify the role that demographics, amputation-related
factors, and depressed mood may contribute to the experience of pain in the amputee. A
stratified sample by etiology of 914 persons with limb loss. Prevalence, intensity, and
17
bothersomeness of residual, phantom, and back pain, depressed mood as measured by the
Center for Epidemiologic Study Depression Scale, characteristics of the amputation,
prosthetic use, and sociodemographic characteristics of the amputee. Nearly all (95%)
amputees surveyed reported experiencing 1 or more types of amputation-related pain in
the previous 4 weeks. Phantom pain was reported most often (79.9%), with 67.7%
reporting residual limb pain and 62.3% back pain. A large proportion of persons with
phantom pain and stump pain reported experiencing severe pain (rating 7-10). Across all
pain types, a quarter of those with pain reported their pain to be extremely bothersome
chronic pain is highly prevalent among persons with limb loss, regardless of time since
amputation. A common predictor of an increased level of intensity and bothersomeness
among all pain sites was the presence of depressive symptoms. 27
A study conducted on Pain site and impairment in individuals with amputation
pain. To determine the association between pain site and pain interference with activities
of daily living among persons with acquired amputation. : Six or more months after
lower-limb amputation, participants completed an amputation pain questionnaire that
included several standardized pain measures. Phantom limb, residual limb, and back pain
intensity ratings, as a group, accounted for 20% of the variance in pain interference. The
pain intensity ratings associated with each individual pain site made a statistically
significant contribution to the prediction of pain interference with activities of daily
living even after controlling for the pain intensity of the other. Pain in each of 3 sites
(phantom limb, residual limb, back) appears to be important to pain-related impairment
and function. Measurement of the intensity of pain at each site appears to be required for
a thorough assessment of amputation pain-related impairment. 28
A study conducted on chronic phantom sensations, phantom pain, residual limb
pain, and other regional pain after lower limb amputation. To determine the characteristics
of phantom limb sensation, phantom limb pain, and residual limb pain and to evaluate
pain-related disability associated with phantom limb pain. A Retrospective, cross-sectional
survey was carried out Six or more months after lower limb amputation, participants (n =
18
255) completed an amputation pain questionnaire that included several standardized pain
measures. Of the respondents, 79% reported phantom limb sensations, 72% reported
phantom limb pain, and 74% reported residual limb pain. They concluded that many
described their phantom limb and residual limb pain as episodic and not particularly
bothersome. Most participants with phantom limb pain were classified into the two low
pain-related disability categories: grade I, low disability/low pain intensity (47%) or grade
II, low disability/high pain intensity (28%). Many participants reported having pain in
other anatomic locations, including the back (52%). Phantom limb and residual limb pain
are common after a lower limb amputation, most of the pain is episodic and not particularly
disabling but for a notable subset, the pain was quite disabling. Pain after amputation
should be viewed from a broad perspective that considers other anatomic sites as well as
the impact of pain on functioning. 29
A study conducted on Phantom limb, residual limb, and back pain after lower
extremity amputations. This study describes the sensations and pain reported by persons
with unilateral lower extremity amputations. Participants (n = 92) were recruited from two
hospitals to complete the Prosthesis Evaluation Questionnaire which included questions
about amputation related sensations and pain. Participants reported the frequency, intensity,
and bothersomeness of phantom limb, residual limb, and back pain and nonpainful
phantom limb sensations. A survey of medication use for each category of sensations also
was included. Statistical analyses revealed that nonpainful phantom limb sensations were
common and more frequent than phantom limb pain. Residual limb pain and back pain
were also common after amputation. Back pain surprisingly was rated as more bothersome
than phantom limb pain or residual limb pain. Back pain was significantly more common
in persons with above knee amputations. These results supported the importance of looking
at pain as a multidimensional rather than a unidimensional construct. 30
STUDIES RELATED TO REHABILITATION
19
A study conducted on why traumatic leg amputees are at increased risk for
cardiovascular diseases. Post-traumatic lower limb amputees have an increased morbidity
and mortality from cardiovascular disease. Risk factors for this amplified morbidity and
the involved pathophysiologic mechanisms have not been comprehensively studied.
Insulin resistance, psychological stress and patients' deviant behaviors are prevalent in
traumatic lower limb amputees. Each of these factors may have systemic consequences
on the arterial system and may contribute to the increased cardiovascular morbidity in
traumatic amputees. Abnormalities of arterial flow proximal to the amputation site may
hold the explanation for the linkage between the extent of leg amputation and the
magnitude of the cardiovascular risk: proximal leg amputation is associated with greater
risk than distal amputation and bilateral amputation with greater risk than unilateral
amputation. This review focuses on hemodynamic culprits (shear stress, circumferential
strain, reflected waves), hemodynamic consequences in proximity to the occluded
femoral artery and hemodynamic consequences Coronary risk in lower limb amputees
may be substantially greater than predicted by available algorithms, given that neither
hemodynamic nor psychological factors concern the current prediction models. It seems
reasonable to take early prophylactic measures in lower limb amputees by discouraging
smoking, excessive alcohol consumption and adherence to a low fat diet. 31
A study conducted on Rehabilitation setting and associated mortality and medical
stability among persons with amputations. To estimate the differences in outcomes across
post acute care settings-inpatient rehabilitation, skilled nursing facility, or home-for
dysvascular lower-limb amputees. : Dysvascular lower-limb elderly amputees (N=2468).
The 1-year mortality for the elderly amputees was 41%. Multivariate probit models
controlling for patient characteristics indicated that patients discharged to inpatient
rehabilitation were significantly (P<.001) more likely to have survived 12 months post
amputation (75%) than those discharged to an skilled nursing facility. (63%) or those sent
home (51%). Acquisition of a prosthesis was significantly (P<.001) more frequent for
persons going to inpatient rehabilitation (73%) compared with skilled nursing facility
20
(58%) and home (49%) disposition Receiving inpatient rehabilitation care immediately
after acute care was associated with reduced mortality, fewer subsequent amputations,
greater acquisition of prosthetic devices, and greater medical stability than for patients
who were sent home or to an skilled nursing facility. 32
A study conducted on Patient rehabilitation following lower limb amputation.
Patient rehabilitation following lower limb amputation is essential to provide optimum
patient outcomes and to improve the amputee's quality of life. The age of the patient and
the stump length or level of amputation emerge as dominant factors affecting the
outcome of rehabilitation. A variety of outcome measures are available to assess the
patient's rehabilitative potential to maximize functional ability. 33
A study conducted on the effectiveness of inpatient rehabilitation in the acute
postoperative phase of care after transtibial or transfemoral amputation: study of an
integrated health care delivery system. To compare outcomes between lower-extremity
amputees who receive and do not receive acute postoperative inpatient rehabilitation
within a large integrated health care delivery system. A national cohort of veterans
(N=2673) who underwent transtibial or transfemoral amputation between October 1,
2002, and September 30, 2004. After reducing selection bias, patients who received acute
postoperative inpatient rehabilitation compared to those with no evidence of inpatient
rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95%
confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06).
Prosthetic limb procurement did not differ significantly between groups. The receipt of
rehabilitation in the acute postoperative inpatient period was associated with a greater
likelihood of 1-year survival and home discharge from the hospital. 34
A study conducted on Prosthetic rehabilitation for older dysvascular people
following a unilateral transfemoral amputation.Dysvascularity accounts for 75% of all
lower limb amputations in the United Kingdom. Around 37% of these are at transfemoral
level (mid-thigh), with the majority of people being over the age of 60 and having
21
existing co-morbidities. A significant number of these amputees will be prescribed lower
limb prosthesis for walking. However, many amputees do not achieve a high level of
function following prosthetic rehabilitation. Random of 38 full reports obtained for
consideration, one trial was included and four were excluded. The sole included trial was
a short-term crossover randomized trial which tested the effects of adding three
seemingly identical prosthetic weights (150 g versus 770 g versus 1625 g) to the
prostheses of 10 participants with unilateral dysvascular transfemoral amputation. Eight
participants were over 60 years of age. The trial found that four participants preferred the
lightest weight (150 g), five preferred the middle weight (770 g) and one preferred the
addition of the heaviest weight (1625 g).there is lack of evidence from randomized
controlled trials testing prosthetic rehabilitation interventions following a unilateral
transfemoral or transgenicular amputation in older (aged 60 years or above) dysvascular
people. The study concluded that there is a lack of evidence from randomized controlled
trials to inform the choice of prosthetic rehabilitation, including the optimum weight of
prosthesis, after unilateral transfemoral amputation in older dysvascular people. 35
A study conducted on Health related quality of life and related factors in 539
persons with amputation of upper and lower limb. Limb amputation is followed by an
important rehabilitation process, especially when prosthesis is involved. The objective of
this study is to assess the nature of factors related to health related quality of life (HRQL)
of persons with limb amputation. The Nottingham Health Profile (NHP) treated 1011
subjects with major amputation of one or several limbs. Response rate was 53.3%. Health
related quality of life measured by the Nottingham Health Profile was mostly impaired in
the categories of physical disability, pain and energy level. Controlling for sex and age,
young age at the time of amputation, traumatic origin and upper limb amputation were
independently associated with better health related quality of life. The study concluded
that health related quality of life is largely related to factors which are inherent to the
patient and the amputation. 36
STATEMENT OF THE PROBLEM:
22
“A study to evaluate the effectiveness of structured teaching program on stump
care among amputees in selected hospitals at Kolar district, Karnataka”
6.3 OJECTIVES:-
To assess the existing Knowledge regarding stump care among amputes.
To evaluate the effectiveness of structured teaching Program on stump care
among amputees.
To find the association between posttest knowledge level with their selected
demographic variables.
6.4 OPERATIONAL DEFINITIONS:
Evaluate: -
Refers to judgment made based on knowledge gained by structured
teaching program on stump care.
Effectiveness: -
Refers to the desired changes brought by the structured teaching program
on stump care.
Structured teaching program: -
Refers to a system of planned instructional design to impart information
in order to bring the changes in knowledge regarding stump care among
amputees.
Stump care: -
Refers to the care given to part of a limb left after the rest had been cut off.
Amputees:
23
Refers to the person who had undergone amputation of one or more limbs
and above 15 years of age.
6.5 Hypothesis:-
Ho – There will be no significant difference between pre test and postest scores of
stump care among amputees.
6.6 Variables:-
6.6-1 Dependent variable: -
Knowledge of amputees regarding stump care.
6.6-2 Independent variable: -
Structured teaching program on stump care.
7 Material and methods:-
7.1 Source of data: -
Amputees admitted in the selected hospitals at kolar.
7.2 Methods of data collection:
7.2.1 Research design-
Pre experimental design (one group pre test and Post test)
7.2.2 Setting –
The study will be conducted in two hospitals namely sri Narasimha raja
hospital (SNR), Kolar which is situated 2 kms away from Pavan college nursing, having
500 bed strength and RL Jalappa hospital and research center, Tamaka, Kolar district
situated 5 Kms away from Pavan college nursing having 850 bed strength.
7.2.3 Population:
24
The population for the present study comprises of patients who underwent
amputation.
7.2.4 Sample:
Patient who underwent amputation with the age group above 15 years.
7.2.5 Sample size:
60 amputees.
7.2.6 Sampling technique:
Convenient sampling technique.
7.2.7 Sampling Criteria:
Inclusion criteria:-
o Who underwent amputation in SNR and RL Jalappa hospitals.
o Amputee’s age group above 15 years.
o Who can communicate in Kannada or English.
o Who are willing to participate in the study.
Exclusion criteria:-
o Amputees who are below 15 years of age.
o Who are not willing to participate in the study.
o Who cannot communicate in Kannada or English
25
7.2.8 Tool of data collection:
Structured interview schedule will be used for data collection.
The tools consist of two sections.
Section A: - consist of demographic data of subject.
Section B: - consist of knowledge question regarding stump care.
7.2.9 Methods t of data collections:
Structured interview schedule will be used to collect the data from
amputees.
The purpose of the study will be explained and consent from the participant
will obtained to involve in the study.
The tentative period of data collection will be 6 weeks, before that tool will
be developed and after validation by the experts, further refinement of the
tool will be done. After that the pilot study will be conducted.
7.2.10 Data analysis and interpretation:
Data will be analyzed on the basis of objective and hypothesis by using descriptive
and inferential statistics. Frequency percentage mean and standard deviation will be used
for descriptive statistics. In inferential statistics the chi -square test will be used to find
the association between posttest knowledge level with their selected demographic
variables and paired‘t’ test will be used to know the effectiveness of structured teaching
program on stump care. The result will be presented in the form of tables, graphs and
diagrams.
26
7.3 Does the studies require any investigation or intervention to be conducted on
patient/ Sample populations or other humans or animals?
Yes. The study will be conducted on the amputees. Since it is pre experimental
study, it requires intervention on stump care structured teaching programme will be given
to the amputees. It will not have any harm to the patient (Amputee).
7.4 Has Ethical clearance been obtained from your institute?
Yes. Prior permission will be obtained from the concerned authorities of SNR
hospital and RL Jalappa hospital in kolar to conduct a Study and also from research
committee of Pavan College of nursing kolar. The purpose of study will be explained to
the amputee of the selected hospitals. Scientific objectivity of the study will be
maintained with honesty.
27
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32
9 SIGNATURE OF THE CANDIDATE:
10 REMARKS OF THE GUIDE:
11 NAME AND DESIGNATION :
11.1 GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF THE DEPARTMENT
11.6 SIGNATURE
12 REMARK OF CHAIRMAN AND PRINCIPAL
12.1 SIGNATURE:
33