Introduction to Medical-Surgical Nursing, 6th ed.
45
Lesson Plans for
Amputations
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 45.1:
2. Describe the different types of amputations.
3. Discuss the medical and surgical management of the amputation patient.
Lesson 45.2:
4. Identify appropriate nursing interventions during the preoperative and postoperative phases of care.
5. Assist in developing a nursing care plan for the amputation patient.
CHAPTER TEACHING FOCUS
• In this chapter, students will be introduced to the clinical indications for amputations, including the
different types of amputations, and the medical and surgical management of the patient who has had
an amputation.
• Furthermore, students will have the opportunity to learn about appropriate nursing interventions during
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Protection and Movement
• Concept: Pain
2 Chapter 45Amputations ____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) An amputation that occurs through a joint is called a__________.
a) joint amputation
b) replantation c) disarticulation
d) staged amputation
2) The most common cause of upper extremity amputations is (are) __________.
a) vascular disease
b) trauma c) congenital defects
d) tumors
3) A patient who is undergoing an amputation due to a severe infection will likely have which type of
amputation?
a) Closed amputation
b) Total amputation c) Congenital amputation
d) Guillotine amputation
4) Which health care professional will fit the patient for an artificial limb following an amputation?
a) prosthetist
b) physician c) occupational therapist
d) physical therapist
5) A patient who has had an above–the-knee amputation complains of severe pain in his ankle. This is
an example of which complication associated with amputations?
a) Phantom limb sensation
b) Contractures c) Posttraumatic stress
d) Phantom limb pain
6) The grief that a patient experiences before amputation is known as __________.
a) disturbed body image
b) anger c) anticipatory grief
d) denial
7) The nurse assesses the dressing of a patient who has just undergone an amputation to monitor for
which complication?
a) Infection
b) Hemorrhage c) Pain
d) Necrosis
8) The purpose of a compression wrap on the residual limb of an amputation patient is to __________.
a) control bleeding
b) prevent contractures
c) reduce phantom limb sensations
d) prepare the residual limb for a prosthetic
9) A child’s finger has been traumatically amputated in a car door. What should be done with the
amputated finger?
a) Put it in a bag and place the bag in ice water.
b) Put it in a container of salt water.
c) Throw it out, since it can’t be reattached.
d) Wrap it in a towel.
10) The room temperature of a patient who has undergone replantation should be kept above 80° F to
prevent __________.
a) infection
b) rejection c) compensatory vasoconstriction
d) increased pain
___________________________________________________________________ Chapter 45Amputations 3
Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: What are the four most common incidences that lead to amputation? Explain your answers.
Question: What are the two common types of amputations performed? Explain the indications and basic
procedure.
Answer: There are two common types of amputations that surgeons perform. The first type is a closed
4 Chapter 45Amputations ____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.1
• Assemble materials and supplies needed for each lesson as indicated below.
Textbook Objectives Covered
2. Describe the different types of amputations.
3. Discuss the medical and surgical management of the amputation patient.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying amputations, including:
• Clinical indications for amputation
Materials and Supplies
Key Terms
• gangrene (p. 991)
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 990-991)
REVIEW
• Figure 45-1: Common sites of amputation in the upper and lower extremities (p. 991)
ANSWER – Study Guide
• Part IA: 4-6, 10, 11 (p. 297)
• Part IB: 1 (p. 297)
• Part IIE: 17 (p. 299)
• Part IIIF: 2, 3 (p. 301)
2
• Part IA: 1-3, 8, 9 (p. 297)
READ – Textbook (pp. 992-993)
ANSWER – Study Guide
___________________________________________________________________ Chapter 45Amputations 5
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.1
3
READ – Textbook (pp. 991-994)
REVIEW
• Table 45-1: Diagnostic Tests and Procedures Associated with Indications for Amputation (p.
992)
ANSWER – Text
• Review Questions for the NCLEX Examination: 5, 6 (p. 1004)
ANSWER – Study Guide
Lecture Outline 20 minutes
Slide 1
Chapter 45
Amputations
1
Slide 2
Amputation
• Can occur through a joint (between the bones) or through a bone itself
• Disarticulation: term used for an amputation through the joint
• The general site of the amputation is described by the joint nearest to it
TALKING POINTS:
• In the past two decades, many advances have been made in surgical amputation and
Slide 3
Indications and Incidence
• Trauma
• Common types of accidents and injuries leading to amputation include those involving
motorcycles and automobiles, farm machinery, firearms and explosives, electrical
TALKING POINTS:
• What is the most common reason for upper extremity amputations?
• Vascular diseases account for the majority of the estimated 30,000 lower-extremity
amputations performed in the United States each year.
6 Chapter 45Amputations ____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.1
Slide 4
Indications and Incidence (cont.)
• Tumors
• Bone tumors that are very large and invasive
• Congenital defects
• Convert a deformed limb into a more functional one that can be fitted with a prosthetic
device
TALKING POINTS:
• What is the most common age for primary bone tumors?
3
Slide 5
Diagnostic Tests and Procedures
• Vascular studies
• Pulse volume recording
• Thermography
• Doppler ultrasound
• Biopsy
2
Medical Treatment
• Must include appropriate treatment and control of underlying diseases or injuries
Slide 7
Surgical Treatment
• Amputation at the lowest level that will preserve healthy tissue and favor wound healing
• Surgeon chooses one of two procedures, depending on condition of the extremity and the
reason for the surgery
• Closed amputations
TALKING POINTS:
• Amputation is recommended only when other options are not possible or have failed.
• What procedure may be performed in an effort to avoid amputation?
Slide 8
• With lower-extremity amputations, older or debilitated patients, and infection, prosthesis
• Can usually bear full weight on permanent prosthesis about 3 months after amputation
Prostheses
• Artificial substitutes for missing body parts
• Prosthetist creates and supervises use of prosthesis
___________________________________________________________________ Chapter 45Amputations 7
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.1
Slide 9
Complications
• Hemorrhage and hematoma
• Necrosis
• Wound dehiscence
• Gangrene
• Edema
Slide 10
Question 1
• Which of the following diseases is not known to cause impaired circulation, therefore
potential amputation?
A. Arteriosclerosis
B. Diabetes mellitus
C. Peripheral vascular disease
D. Peyronie’s disease
TALKING POINTS:
Slide 11
Question 2
• Which of the following is not considered a complication of an amputation?
A. Edema
B. Infection
C. Heart failure
D. Wound dehiscence
TALKING POINTS:
8 Chapter 45Amputations ____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.1
Activities
Classroom Choose from below to make 30 minutes
Online
1
each group one of the following clinical
indications for amputations: trauma, disease,
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss which diseases and injuries indicate
amputation.
PRACTICE
• Divide the class into four groups. Assign
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Conduct an
online image search of pictures from the
U.S. Civil War and the use of amputations.
2
DISCUSS
• As a class, discuss the different types of
amputations, including closed amputations
and open amputations (staged or guillotine).
Ask the students to give explanations as to
why each type of amputation might be
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss why
different types of amputations are
performed. Which type of amputation would
be most difficult to rehabilitate? Ask students
3
DISCUSS
• Discuss options that might be considered
before amputation, such as angioplasty and
surgical bypass of obstructed vessels.
• Facilitate a class discussion regarding
surgical management of the amputation
patient. Have students answer the questions
about when an amputation is performed.
What is considered when determining the
level of amputation? What are some
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss the
determination of the level of amputation and
provide examples of when each type of
amputation would be used. Ask students to
provide constructive comments on each
other’s posts.
___________________________________________________________________ Chapter 45Amputations 9
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.1
Critical Thinking Question
A 19-year-old patient presents to the emergency department with a severe crushing injury to
his right forearm following an automobile accident. The patient will require amputation due
to the severity of the injury. What diagnostic tests will likely be performed before the
surgery, and what type of surgery would most likely be indicated for this patient?
Discussion Guidelines: The patient will undergo diagnostic tests to determine the extent of
Instructor Notes/Student Feedback
10 Chapter 45Amputations ____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.2
Textbook Objectives Covered
5. Assist in developing a nursing care plan for the amputation patient.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying amputations, including:
• Clinical indications for amputation
• Types of amputations
Materials and Supplies
Key Terms
• gangrene (p. 991)
• guillotine amputation (p. 993)
Assignments 2 hours
4
READ – Textbook (pp. 993-1003)
REVIEW
• Box 45-1: Assessment of the Patient Undergoing an Amputation (p. 996)
• Figure 45-4: Proper techniques for wrapping a lower-extremity residual limb (p. 998)
ANSWER – Text
• Review Questions for the NCLEX Examination: 2, 4, 7, 9, 10 (pp. 1003-1004)
ANSWER – Study Guide
___________________________________________________________________ Chapter 45Amputations 11
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.2
5
READ – Textbook (pp. 993-1003)
REVIEW
• Nursing Care Plan 45-1: Patient with an Upper Extremity Amputation (pp. 994-995)
ANSWER – Text
• Review Questions for the NCLEX Examination: 8 (p. 1004)
ANSWER – Study Guide
• Part IIE: 1, 5, 7, 8 (pp. 298-299)
50-Minute Lesson Plan
Lecture Outline 20 minutes
4
&
5
Slide 12
Assessment
• Record conditions that resulted in need for amputation
• Preexisting cardiovascular problems
• Family history of diabetes, hypertension, and vascular diseases
• Signs and symptoms that relate to the vascular condition or other chronic and acute
problems
• Diet and fluid intake, intake of salt and alcohol, and use of tobacco
TALKING POINTS:
• Identify the patient’s occupation and responsibilities to determine how amputation will
affect that aspect of his or her life.
• What types of fears may the patient about to undergo an amputation have?
Slide 13
Physical Examination
• Height, weight, and vital signs
• Assess neurovascular status
• Skin color, texture, temperature, and turgor
• Palpate peripheral pulses for quality, symmetry
TALKING POINTS:
• How can pulses be assessed when they are not palpable?
• Wounds to the extremities are common when blood supply is inadequate.
Slide 14
Interventions
• Anxiety
• Grieving
12 Chapter 45Amputations ____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.2
Slide 15
Postoperative Nursing Care
• Assessment
• Monitor vital signs frequently in the first 48 hours
• Inspect the dressing frequently for bleeding
• If drain receptacle, note color and amount of drainage
• Monitor patient’s temperature for elevations that may indicate infection
• Note any foul odor from the dressing
• After the dressing is removed, inspect the residual limb for edema
• Document patient’s pain, including type, location, severity, and response to treatment
Slide 16
• Risk for injury
• Impaired physical mobility
• Readiness for enhanced self-care
• Anxiety, Fear, and Ineffective coping
• Disturbed body image
Postoperative Nursing Care (cont.)
• Interventions
• Decreased cardiac output
• Pain
• Risk for infection
• Impaired skin integrity and Risk for impaired skin integrity
• Disturbed sensory perception
Slide 17
The Older Adult Amputee
• May have needs that should be taken into consideration when planning and providing
care
• Completely capable of learning, but often requires smaller units of information, more
repetition, more time
• During teaching process patients with glasses or hearing aids should have them in place
• Remind that phantom sensations are not uncommon or bizarre; this can reduce fear or
anxiety of these sensations
• Many have one or more chronic health problems
• The loss of a limb can be especially difficult; it is important to provide psychological
support
TALKING POINTS:
• What is phantom limb pain?
Slide 18
Nutrition Considerations
• Nutritional assessment
• Patient should be well-hydrated; IV fluids may be given
• Increased need for calories and protein for healing
___________________________________________________________________ Chapter 45Amputations 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.2
Slide 19
Replantation
• Involves the use of a microscope and highly specialized instruments to reanastomose
(reconnect) blood vessels and nerve fibers in a severed limb
• Limb sutured into its correct anatomic position
• Advances in microsurgical techniques and preservation of severed limbs have made this
technique increasingly successful
Slide 20
for replantation.
Indications
• For amputations through the hand or wrist
• Amputated thumbs are reattached whenever possible because of their importance in
hand function
• In severely injured hand in which two or more fingers are detached, surgeon restores
as many fingers as possible
• In general, the greater the muscle mass injury, the less likely replantation is possible
TALKING POINTS:
• What factors are taken into consideration by the surgeon before performing replantation
surgery?
• Severely traumatized tissue can become ischemic, leading to death of the tissues and
Slide 21
• Patient may require treatment for shock due to blood loss
Emergency Care
• Wrap amputated parts in a clean cloth saturated with normal saline or Ringer’s lactate
• Put in a sealed plastic bag that is placed in ice water
• Direct contact between the amputated part and the ice can lead to further tissue damage
and cell death
• Partially amputated parts should remain attached to the patient and be kept cool if
possible
TALKING POINTS:
• How can blood loss from the residual limb be minimized?
Slide 22
• Note patient’s emotional status, and assess understanding of the preoperative activities
Assessment
• Assess circulatory status
• Closely monitor vital signs
• Inspect the residual limb (or dressing) for bleeding
• Assess pain at the site of the injury and at other locations
14 Chapter 45Amputations ____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.2
Slide 23
• Provide brief, simple explanations
Preoperative Nursing Care
• Interventions
• Administer intravenous fluids and blood as ordered
• If the dressing becomes saturated with blood, reinforce the dressing
• Report continued or excessive bleeding to the provider
Slide 24
Preoperative Nursing Care(cont.)
• Interventions
• Decreased cardiac output
• Fear and Anxiety
• Acute pain
Postoperative Nursing Care: Assessment
• Monitor vital signs, intake and output, and level of consciousness
• Hourly neurovascular assessment of limb
TALKING POINTS:
• What are the signs of arterial occlusion? Venous congestion?
Slide 26
Postoperative Nursing Care: Interventions
• Elevate the limb
• Abstain from nicotine– and caffeine-containing products for 7 to 10 days postoperatively
• Enforce a strict ban on cigarette smoking
• Room at 80° F to prevent compensatory vasoconstriction of peripheral tissues
TALKING POINTS:
• How should the replanted limb be elevated?
Slide 27
Postoperative Nursing Care: Interventions (cont.)
• Ineffective peripheral tissue perfusion
• Acute pain
• Disturbed body image
___________________________________________________________________ Chapter 45Amputations 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 45.2
Activities
Classroom Choose from below to make 30 minutes
Online
4
DISCUSS
• Discuss nursing interventions for treating
preoperative anticipatory grief of the
amputation patient and his or her family
members.
PRACTICE
• Divide the class into groups. Have each
group develop a list of preoperative and
postoperative nursing interventions that
would be appropriate for a patient who will
be undergoing an above-the-knee
amputation after a traumatic injury. Nursing
diagnoses might include the following:
• Anxiety (pre- and post-)
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss this
situation: You have had a serious
automobile accident. When you recover
consciousness, you are in the intensive care
unit. You notice your right lower leg is
missing.
• What is your immediate reaction?
• Which concerns are the priority for you:
your physical health or your emotional
concerns?
• What would you like to be told about
your situation?
• How will you be able to continue in
16 Chapter 45Amputations ____________________________________________________________________
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LESSON 45.2
5
DISCUSS
• Discuss teaching for the preamputation and
postamputation patient.
• Discuss the types of complications that can
affect the preoperative and postoperative
care plans of the amputation patient.
• Discuss and define replantation.
PRACTICE
• Divide the class into small groups and
present the following scenario:
• A 55-year-old man is scheduled to
undergo a below-the-knee amputation
tomorrow morning for complications
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to prepare and post a video of a nurse
providing patient/family education for an
individual who has undergone a lower leg
amputation. What aspects of care will need
to be emphasized? In this instance, the
person portraying the patient should be
reluctant to learn to care for the stump, due
to fear and anxiety.
Critical Thinking Question
A 68-year-old patient has been brought back to the surgical unit following a below–the-knee
amputation for complications associated with peripheral vascular disease. What are the
most common postoperative complications in a patient with an amputation? What nursing
interventions would be indicated in the immediate postoperative period?
Discussion Guidelines: The most common complications associated with amputation are
Instructor Notes/Student Feedback
___________________________________________________________________ Chapter 45Amputations 17
Introduction to Medical-Surgical Nursing, 6th ed.
45
Assessments for
Amputations
CHAPTER OBJECTIVES
Lesson 45.1:
1. Identify the clinical indications for amputations.
3. Discuss the medical and surgical management of the amputation patient.
Lesson 45.2:
5. Assist in developing a nursing care plan for the amputation patient.
Assessments by Lesson & Objective
Lesson 45.1
1
Study Guide
• Part IA: 4-6, 10, 11 (p. 297)
• Part IB: 1 (p. 297)
Evolve Instructor Resources
• Test Bank: 3, 26
• Open book Quiz 1
2
Study Guide
• Part IA: 1-3, 8, 9 (p. 297)
• Part IC: 1-4 (p. 298)
Evolve Instructor Resources
• Test Bank: 6, 7, 9, 27, 30
• Open Book Quiz: 2
Evolve Student Resources
• NCLEX Review: 8
3
Study Guide
Evolve Instructor Resources
• Test Bank: 1, 5, 31
Evolve Student Resources
• Test Bank: 4
• Prioritization 4, 5
18 Chapter 45Amputations ____________________________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
4
Study Guide
• Part IIE: 2-4, 6, 9-13, 15, 16 (pp. 298-299)
• Part IIIF: 2, 5, 6 (p. 300)
• Part IIIG: 4 (p. 301)
Evolve Instructor Resources
Evolve Student Resources
• Test Bank: 1-3, 5-7
• Open Book Quiz: 1, 2
5
• Prioritization: 3
Study Guide
• Part IIE: 1, 5, 7, 8 (pp. 298-299)
• Part IIIF: 1, 3, 4 (p. 300)
• Part IIIG: 1, 5 (p. 301)
Evolve Instructor Resources
Instructor’s Notes/Student Feedback