Traumatic Amputation and Corrective Surgery: Rehabilitation and Person Centered Care

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This essay is about Marc, a 28 year old rugby player and a postman, who had an amputation to his right leg due to a road traffic collision. The health needs and services that will be available to Marc and his family to access, in order for them to be supported through the ordeal will be discussed. Also, the role of the multidisciplinary team (MDT) that will be involved in supporting Marc whilst in hospital will be integrated in this essay. In addition, the model of nursing care to be applied in Marc’s case, which should encourage effective communication, holistic care and person-centered care will be discussed. Consideration will be made to Marc’s depressive state due to changes in his life, which was caused by the road traffic collision.

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Amputation can be defined as the surgery that is done to remove the untreatable part of the upper or lower limb of the body. There are about 5000 lower limb amputations every year in the UK and it causes physical and psychological impact on the patient. Emergency amputation is carried out due to serious traumatic limb and for infection or malignancy. In addition, serious damage to some of the tissues such as bone, muscle, skin, nerve and artery can be a sign to amputate early. Based on this, emergency and traumatic amputation was performed on Marc’s left leg immediately after the collision.

The nursing model of care that can be applied to Marc’s case is the Roper, Logan and Tierney’s activities of living. Activities of daily living (ADL) could be defined as activities which people carry out daily without help from others. The twelve ADLs are; maintaining a safe, eliminating, breathing, controlling body temperature, personal cleansing and dressing, expressing sexuality, dying, working and playing, eating and drinking, mobilizing, sleeping and communicating. Additionally, ADLs is decided by environmental, sociocultural, biological, and psychological factors. Marc would be assessed by the nurse to know the ADLs he is able to carry out independently and the ones he will need support with. Following an ADL assessment, care plan for Marc would be put in place, documented and realistic goals set. The goals will be agreed with Marc. Other professionals would be consulted by the nurse, who would be acting as an advocate for Marc. For example, the physiotherapist will support Marc to learn to mobilize again. On the other hand, goals set with Marc should be evaluated to establish whether it has been accomplished. Consequently, ADL promotes effective communication and partnership approach to person-centered care.

Traumatic amputation and corrective surgery would result in Marc being in pain and he will benefit from aggressive pain management process. McCaffery statez that “pain is what the patient says it is and exists whenever he says it does”. Post amputation pain is challenging to treat due to the different types of pain such as somatic pain and neuropathic pain. Additionally, there is a risk of developing chronic pain if postoperative pain is badly managed. Assessment of pain, which is the initial stage of pain management should be done regularly and the service user’s interpretation of pain must be documented.

In Marc’s case, the type of pain that he may have been experienced after operation is phantom limb pain (PLP). PLP is described as a neuropathic pain condition which occurs after a limb amputation, caused by an accident. It is experienced by 80-90 percent of patients who underwent an amputation. PLP features are; subjective pain descriptors such as burning or sharp sensation; intensity such as increased pain; telescoping such as shrinking in size of the phantom limb. Other PLP features are; Pattern such as constant pain; and location such as pain in the digits or entire limb pain. Marc’s pain should be frequently assessed by the pain consultant or nurse to determine the type of pain and the consultant will prescribe the right analgesia for Marc to relieve his pain. The National Early Warning Score (NEWS) chart should be used to monitor Marc regularly. According to the Royal College of Physicians (2015), the parameters in the NEWS chart are; oxygen saturations, temperature, respiratory rate, blood pressure, heart rate, level of consciousness and pain (1=mild, 2=moderate and 3=severe). The nurse should refer Marc to the pain team if he is in severe pain.

Marc may be at a risk of developing a surgical site infection (SSI) as a result of the traumatic amputation and the corrective surgery. SSI is described as infection caused by superficial incision, which happens within 4 weeks of surgical procedure. Micro-organisms such as bacteria gets into the incision via the skin, resulting in infection. The symptoms of SSI are; redness, heat, fever, raised white blood cell count, pain and swelling.

Marc’s wound should be monitored regularly by the nurse for symptoms of SSI and communication with Marc is paramount, as he can confirm the way he is feeling. Also, Marc’s vital signs should be done and recorded on the NEWS chart. A referral should be made by the nurse to the tissue viability nurse (TVN) and the surgeon if the signs of SSI are observed. Healing of the wound will not happen if the surgical wound is infected. The nurse should take a sample from Marc’s wound if infection is suspected and send it to the laboratory for investigation by the microbiologist. The microbiologist will inform the doctor of the causative organism and the doctor will prescribe antibiotics for the treatment of Marc’s infection.

Because of the amputation of his knee, restricted activities and his new body image Marc is feeling depressed. The lack of activities of daily living makes a person to feel lonely, thereby becoming socially isolated and this may lead to depression. Also, body image worries of amputees can lead to depression, anxiety, low self-esteem and restriction of activities. Depression is described as a feeling of losing control of a situation. Screening tools such as the Patient Health Questionnaire (PHQ) should be used to identify depression and referrals should be sent to mental health professionals. The doctor should confirm Marc’s depression by using the PHQ. According to Spiess et al. (2014), questions asked by using the PHQ are; how frequently does feeling down bother patient and how frequently does having interest in carrying out activities bother them? Involving Marc in amputation support groups and increasing the control Marc feels in his life with family meetings all could help to improve his depressive state. Goals that cannot be achieved should be disengaged to combat depression and to encourage re-engagement in other goals. This applies to Marc as he will no longer be able to play rugby and he should be encouraged to take up alternative sport. Antidepressant may be prescribed by the doctor for Marc to manage his depression.

The multidisciplinary team (MDT) is defined as the involvement of people from different professions to give the best possible care to patients by using their knowledge, best practice and skills to reach a solution of complicated patients’ need. The team approach is the best way to care for amputees and the team meets on a regular basis for the discussion of the improvement and the problems experienced by the amputee. The benefits of multidisciplinary working are; it enhances sharing of knowledge, better health results for patients, effective use of resources, promotes person-centered care and increases satisfaction for patients and their families.

The MDT that will be involved in giving holistic care to Marc are: doctors, surgeons, physiotherapist, occupational therapists, counselors, nurses and prosthetists. The MDT can talk to Marc’s family if Marc consents to it. Advice and support can be given by the nurse to Marc and his family about his wound. Nurses can make referrals to other members of the MDT as outlined in section 8.1 of the Nursing and Midwifery Council (2015), that nurses should respect the skills and their colleagues’ contribution by making referrals to them when matters arises. For instance, Marc will be referred by the nurse to the surgeon or tissue viability nurse if his wound is not healing. The prosthetists measures, assesses, casts and designs the service user’s prosthesis. Prosthesis will be made for Marc once his wound has healed completely to help with his mobility.

The occupational therapist supports service users to recover from injury and to perform the activities of daily living such as mobilizing and maintaining a safe environment. The occupational therapist will carry out the assessment of Marc’s physical, social, psychological and environmental needs to know where he needs support. The psychologist helps patients with coping skills in order to adjust to life. Marc will be supported by the psychologist to manage his psychological wellbeing by using coping skills and counseling. The pharmacist will provide Marc and the MDT with vital information about the medication prescribed for him and will give advice on alternative medication if Marc experiences adverse reaction to his medication. Furthermore, Marc should be supported by the clinical support worker with tasks such as transferring from bed to chair, using the toilet, reassurance and encouragement.

Marc’s partner and parents will be concerned and anxious about what he had been through. Family support is vital in helping amputees to cope with their amputation and amputees tend to spend much of their time with their families. Although, Marc may be traumatized, his partner and parents are prone to social, mental and health injuries as a result of several stress intolerance. Valizadeh et al. (2014) suggest that families of amputee may encounter multiple stresses due to problems caused by their amputee’s disability. Marc and his family should be given information by the MDT about how to get access to the Limbless Association and to apply for benefits from social service. The Limbless Association offer support and information to amputees, their family and friends if they need it.

Marc may be eligible for some benefits from social services due to his disability. Marc can apply for a needs assessment by social service such as for disability equipment and adaptation to his home. Personal Independence Payment (PIP) is a benefit for about 16 and 64 year old people who needs help with daily activities or moving about due to disability. Marc will be eligible for PIP and Employment and Support Allowance (ESA). ESA is a benefit for individuals who cannot work due to a disability. Marc could find it difficult getting back to work due to pain, depression and physical appearance. Also Marc may not be able to go back to work as a postman due to the nature of his job when he recovers from his injury. Marc should inform his employer about his hospital stay so that he can be granted a sick leave and paid by his employer whilst he recovers.

Person centered care can be described as to focus care on the needs of the individual instead of the needs of the service. Marc has his own views on what is best for him. His priorities in life that are important to him would be respected to aid recovery. The MDT should be flexible to meet Marc’s needs and to take his needs into consideration when delivering his care. The MDT should negotiate with Marc to agree a plan which is suitable for him and the MDT. When planning care for the individual, a holistic approach should be considered. Holistic approach is described as focusing care Marc’s physical, psychological, spiritual and social needs. Marc’s comfort, safety and wellbeing should be paramount when delivering his care.

Effective communication is important in care and when there is difficulty in the communication process, the service user will be at risk. The skills required for effective communication to happen are; listening, comprehending communication from another’s point, emotional intelligence and management of conflict. The staff team should communicate effectively with Marc by giving Marc all the information about his care and consider Marc’s views and priorities. The staff team must be open and transparent with Marc and use clear and simple communication terms which Marc can understand. This will make Marc gain trust in the staff team. Communication barriers can lead Marc to frustration, demoralization, resentment and misunderstanding. Effective communication promotes person-centered care and wellbeing of Marc.

Living on the third-floor flat with his parents would make it problematic for Marc due to disability, it will be better for Marc to move to the ground floor when he is discharged from hospital. Social service may make adaptations to Marc’s parent’s home if his parents’ consents, in order for Marc to move about easily. They may receive financial help from the social service in carrying out the adaptations.

To conclude, traumatic amputation of Marc’s right leg has had a significant impact on his life. Marc became dependent in some of his ADLs as a result of the amputation and should be supported by the staff team after carrying out his assessment of ADLs. Marc may be in pain and his pain should be managed effectively by performing pain assessment to know the type of pain he experiences such as sharp pain, regular pain and location of pain. The assessment of Marc’s pain will determine the analgesia which will be prescribed for him by the doctor. The NEWS chart should be used to perform observations on Marc which may determine his pain and infection. Since Marc is at a risk of infection in his wound due to the traumatic amputation and surgery, the doctor should prescribe antibiotics for him and a sample should be taken from his wound to determine the causative organism. Due to Marc’s depression, he should be encouraged to increase the control he feels in his life and he should join the amputation support groups. Marc should start thinking about taking up an alternative sport as he will not be able to play rugby due to his amputated leg. The MDT should support Marc holistically to achieve his realistic goals set by them and Marc. The MDT should work with Marc and involve Marc’s family if Marc consents. The Limbless Association can offer support to Mark and his family to deal with their anxieties. Marc should apply for social benefits to help him with his disability. Marc may be discharged early from hospital if the MDT works collaboratively and effectively.

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