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Integument > Post-Operative and Pre-Prosthetic Assessment > Flashcards

Post-Operative and Pre-Prosthetic Assessment Flashcards

1
Q

The shorter the time between ____ and ____, the better the overall outcomes.

A
  • amputation
  • prosthetic
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2
Q

What complications can youanticipate could occur with delayed prosthetic fitting?

A
  • Infection
  • Uncontrolled edema
  • Uncontrolled pain
  • Delayed wound healing (suture)
  • Improper positioning results in contractures
  • Insurance (how many visits they will pay for)
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3
Q

IPOP and EPOP

A

IPOP: Immediate Post-op Prosthetic
* Applied in the OR
* Prosthetist present for application
* Focus on rehabilitation over simply recovery

EPOP: Early Post-op Prosthetic
* 5-7 days post-surgical
* Prosthetist performs at bedside
* Allows for wound management

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4
Q

Prosthetic Phase - Post Surgery

A
  • Part 1: time between surgeryand fitting with adefinitive prosthesis oruntil the decision ismade to not fit thepatient for a prosthesis
  • Part 2: Starts with the delivery of a “check (trial) socket” and progresses to the permanent prosthesis.
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5
Q

Limb volume, shaping and post-operative edema management
Why does it matter?

A
  • Pain control
  • Promote wound healing
  • Protect incision
  • Prepare for prosthesis and weight bearing
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6
Q

Limb volume, shaping and post-operative edema management
Options (Least to most constrictive)

A
  • Soft dressings (wrap, no compression)
  • Ace wraps/compressive coverings
  • Semi-rigid dressing (SRD)
  • Removable Rigid Dressing (RRDs)
    – Very popular
  • Rigid cast dressing (done in OR)
    – Cannot be taken off
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7
Q

Rigid - Plaster Cast

A
  • Must be cut off like a cast
  • Holds knee in extension
  • Removed when limb volume decreases or per surgeon protocol
  • May afforc limited WB with distal attachment
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8
Q

Rigid - Pre-fabricated polymer shell

A
  • Removable to be ableto inspect wound
  • Holds knee inextension
  • May ormay notaccommodate distal attachment
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9
Q

This is an example of

A
  • Rigid Dressing
  • Often used for transtibial amputations
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10
Q

Rigid Dressings: Pros and Cons

A

Pros
* Excellent post-op edemacontrol (Fluid can’t come in)
* Excellent residual limb (RL)protection (Hard shell keep shape)
* Better control of phantomand post op pain
* Allow for earlier WB andprosthesis fitting

Cons
* No access to incision if it isnot removable
* More expensive – requiresprosthetist in OR or at bedside
* Training is essential forproper application andmonitoring
* Close supervision required

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11
Q

Semi-Rigid Dressing (SRD)

A
  • Composed of paste compounds and are applied inOR
  • Dressing adheres to skin – no need for suspensionbelts
  • Allows slight jointmovement

Just like an Unna boot – same materials used for post-op amputation.

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12
Q

Semi-Rigid Dressing: Air Splint - Pros/Cons

A
  • Put on, pumped up; immobilizes and compresses
  • Similar to what would be used for fracture immobilization in an acute environment.
  • Can also be used as a temporary prosthesis.

Pros:
* Allows inspectionand protection
* Comfort

Cons:
* Pressure is notuniform
* Hot , humid
* Require frequentcleaning limb and air cast
* Require frequentcleaning

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13
Q

Semi-Rigid Dressings: Overall - Pros/Cons

A

Pros
* Better edema control than soft dressings
* Residual limb (RL) protection

Cons
* Needs frequent changing
* Must be applied by a professional
* No access to incision

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14
Q

Soft Dressing: Elastic Wrap

A
  • ACE Wrap

Pros
* Easy to apply
* Easy to incision
* Inexpensive

Cons:
* Needs frequent rewrapping (slippage)
* Risk of torniquet pressure
* May be tough to put on oneself

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15
Q

Soft Dressings: Shrinker

A
  • Sock-like garments of heavy rubberized cotton

Pros:
* Easy to apply
* Inexpensive
* Various sizes
* Easy to apply (slide on)

Cons:
* May or may not be used prior to suture removal
* Must change sizes as RL volume decreases

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16
Q

Early Prosthetic Fitting

A
  • Ideally fit RL when shrinkage is maximal
  • Reality is limb will shrink regardless
  • Literature strongly supports benefits of early fittingfor pain and edema control, RL protection andimproved activity levels. (8-12 weeks)
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17
Q

Pros and cons of remaining non-WB early on?

A
  • Pros: skin protection, incision protection, healing time, controlling RL volume, pain management, desensitization
  • Cons: delayed ambulation patterning/practice, possible delay in strengthening and balance training, pain management, edema control
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18
Q

Discharge Options - Post Surgical

A

Inpatient rehab: patient must be able to tolerate 3 hours of therapy/day (PT, OT, SLP combined)
Home health care: patient must be able to get into home, but be homebound
Outpatient: patient must be able to get into/out of home without significant burden
SNF/sub-acute stay: patient unable to return home but needs a slower therapy progression

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19
Q

Early Post-Operative Therapy (Pre-Prosthetic) Goals

A
  • Promote RL wound healing
  • Residual limb pain management and control
  • Phantom limb pain/sensation management
  • Optimize ROM of B LE and UE without impairing RL healing
  • Optimize strength of B LE and UE without impairing RL healing
  • Protect remaining limb
  • Demonstrate functional sitting and standing balance
  • Perform independent transfers and bed mobility
  • Ambulate with appropriate assistive device
  • Demonstrate proper sitting and bed positioning
  • Begin psychological adjustment
  • Understand the process of prosthetic rehabilitation
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20
Q

Variables Impacting Progress

A
  • Type of amputation
  • Etiology of amputation (Traumatic, PVD, etc.)
  • Co-morbidities
  • Pt’s ability tocontribute information
  • Pain
  • Infection
  • Post-surgicaldressing
  • Psychological status (Mental adjustment after loss of limb)
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21
Q

How to perform exam for someone with amputation?

A
  • Subjective
  • Systems Review
  • Objective
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22
Q

Priorities of the Acute Care Exam

A
  • Pain management (PCA button, oral medication, when last taken)
  • Grieving and psychological adjustment
  • Wound care /sutureline healing
  • Limb volume control
  • Mobility training
  • Readiness for singlelimb ambulation
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23
Q

Post-Surgical Exam Guide

A
  • Systems review/ Medical record review
  • Post-op status (medically how are they?)
  • Pain
  • Vascularity/ conditionof the wound
  • Functional status
    – bed mobility
    – transfers
    – Balance
  • Gross ROM
    – Sound extremity
    – Amputated extremity
    – UEs
  • Gross functional muscle performance (strength)
24
Q

Phantom Pain

A
  • 70-80% incidence (Normal anticipated outcome; pre-op education)
  • Pain experience varies
  • Etiology poorly understood
  • 33% extremely bothered by phantom pain post-amputation regardless of time
25
Q

What is the shape of a TTA and TFA?

A
  • Transtibial(TTA)tapered cylindricalshape
  • Transfemoral(TFA)conical shape
26
Q

Wound Integrity and Healing ofResidual Limb

A
  • Initial exam of incision
  • Drainage
  • Wound closure
    – Risk of dehiscence
    – Delayed prostheticfitting
    – Impact of co-morbidities?
27
Q

Considerations for Sound Limb

A
  • Biomechanical stress of sinlge limb mobility
  • Effect of co-morbidities (at risk for wounds?)
28
Q

How do you perform early strength testing?

A
  • Active, NON-resistive ROM at the joint proximal to amputation ONLY until wound is closed to protect myodesis
  • If they can perform full active ROM (3/5 MMT)
29
Q

Early Post-Operative POC: Goals

A
  • Healing of RL
  • Protection of uninvolved limb(i.e. dysvascular co-morbidities)
  • Independent in transfers, bed and W/Cmobility
  • Demonstrate properpositioning
  • Begin psychologicaladjustment
  • Education regardingprosthetic rehab
30
Q

Early Post-Operative POC: Interventions

A
  • Phantom pain control
  • Positioning
  • Residual limb care/ bandaging
  • Care of uninvolved limb
  • Functional training
  • Balance training
  • Mobility with assistive device (ambulation & gait training)
  • Postural control (core training)
  • Education on amputation andprosthetics
31
Q

____ related amputations are 1.5x more likely to have phantom limb pain

A
  • Trauma
  • 80% reported PLP regardless of time since amputation
  • UE most common
32
Q

Treatments for Phantom Limb Pain

A
  • Pharmalogical (Gabapentin; short term pain relief)
  • Non Pharmalogical
    – TENS
    – Dry Needling
    – Massage
    – Mirror Therapy/Virtual Reality
33
Q

How does mirror therapy/virtual reality help with PLP? How do they work?

A
  • Both: Target neuroplastic mechanisms to restore neural representation of the missing limb through motor imagery.
  • MT: Patient observes movements executed by their intact limb, viewed in a mirror or a virtual environment, and then couple the observed movement with movement of the phantom limb.
  • VR: Augmented virtual reality allowsimages to be created from myoelectric signals from the RL, and therefore can be used for patients with bilateral amputations.
34
Q

What motions are essential to:
Transtibial amputation?
Transfemoral amputation?
Partial foot amputation?

A

Depends on the functional task!

For walking degrees needed
Hip Extension: 10, F: 30
Knee Extension: 5-10 in flexion
Knee Flexion: 40
Plantarflexion:
Dorsiflexion: 10

Sit to stand
Knee flexion: 100

35
Q

What are the predictable contracture patterns for:
Transtibial amputation?
Transfemoral amputation
Partial foot amputation?

A

Transtibial:
* Knee flexion
* Hip Flexion

Transfemoral: (Due to how IR/Adductor muscles are cut)
* Hip flexion
* Hip ER
* Hip Abduction
– Need to teach neutral leg position when sitting

36
Q

Optimal Transitbial positions

A
37
Q

Optimal Transfemoral Positions

A
  • Same as transtibial positions for seated, supine and prone.
  • Emphasizeneutral LE positioning, especially in supine and seated positions.
  • Avoid position with hip flexion and abduction (cushion under the stump for example).
38
Q

Residual Limb Care

A
  • PROTECTION!
    – Sutures gradually and sequentially removed
    – Primary focus: Teach the patient how to protect the RL while moving in bed, coming to sitting and transferring.
    – Patients should not put pressure on the limb or drag it on the bed: AVOID STRESS ON INCISION!
  • Cleansing anddrying
  • Gentle AROM /noresistance!
  • Tissue and scar mobilization –only after sutures areremoved
  • Inspection & patient education!
39
Q

Residual Limb Care: Edema Control

A

If RL is in rigid dressing or removable rigid dressing, limb wrapping is not needed at that time.
– Educate on limb wrapping in a later phase of healing.

If RL is in a soft dressing, limb wrapping is necessary
– Educate on wrapping
– Educate on application of shrinker

40
Q

Things to remeber with limb wrapping

A
  • Nowrinkles!
  • No tourniquet! (Figure 8wrap).
  • No clips! (Use tape, Velcro orpins tofasten).
  • Proximal jointextension.
  • Special accommodations forelderly. (skin more fragile, circulation may be more compromised, may be more diffcult to apply)
41
Q

Limb wrapping should be performed…

A

every 4 hours!

  • All skin of the RL should be covered
  • The shape of the RL should be cylindrical
42
Q

How are shrinkers applied?

A
  • Transtibial: Rolled onto the RL to midthigh, designed to be self-suspending
  • Transfemoral: Utilize a hip spica (encircle the pelvis)
  • Proper suspension is key!
    – Any rolling of the edges or slipping can create a tourniquet
  • Easier to apply than ACE wraps
  • More expensive; need to be replaced as limb volume decreases
43
Q

How to treat contractures

A
  • Prevent prolonged positions (Except prone)
  • Place them in prolonged prone position
  • PNF
  • Soft Tissue
  • Joint Mobilizations
44
Q

Care of Uninvolved Limb

A

Examination should include:
* Skin
* Presence of pulses
* Sensation
* Temperature
* Edema
* Pain on exercise or at rest
* Presence of wounds/ulcerations/abnormalities

ROM & Strength status

Deformities or other orthopedic problems
I.e. arthritis, previous replacement (knee, hip, etc)

WB Status

Prevent contractures on the sound limb

45
Q

Functional Mobility: What is important and why?

A
  • COM redistributes upon amputation

Skills needed for preparation for prosthetic:
* Bed mobility (shift, scoot, roll, sit up, bridge)
* Transfers: (slide board, squat and stand pivot)
* Wheelchair mobility (through doorways, turning, getting back in, curbs)
* Balance skills (Seated, SL)
* Pre-gait training (adequate strength and motion to get them ready for gait)
* Gait training with appropriate AD (w/o and w/IPOP/EPOP)

46
Q

Adaptive equipment for bed mobility and transfers

A

Adaptive equipment:
Supine<>sit
* Leg lifter
* Sliding board
* Grab bars on bed

Sit<>stand; bed<>chair
* Walker vs. Crutches
* Slideboard

Transfer Options:
* Slideboard transfer
* Stand-pivot transfer
* Squat-pivot transfer
* Front sliding transfer (for bilateral amputation)

47
Q

Transfers should occur from ____ levels

A

different

48
Q

What is a precaution with bed mobility and transfers?

A
  • Hemodynamics (Need to ask for dizziness and take vitals pre/post)
  • Increased incidence of AAA and MI post-amputation
49
Q

Sitting Pressure Relief Training

A
  • Look to eliminate high pressure areas
  • Every 15 minutes need to pressure relief for 30 seconds
    – Lean to side, lift up and hold or lean back
50
Q

How do wheelchairs need to be adapted for amputees?

A
  • Clients with high or double amputations do not have the weight of their leg(s) to stop their wheelchair from tipping backwards
  • To improve the user’s balance in the wheelchair and reduce the risk of tipping, position the rear wheel axle in the ‘safe’ position (behind the patient’s shoulders).
  • For some users, as they gain confidence and experience, it may be possible to review the wheelchair set up and move the rear wheel axle position to a more active position.
51
Q

ALL levels of amputation, ____ is critical in assuming a balanced upright posture without compensations that may lead to gait asymmetries and back pain.

A

full hip extension (30 degrees)

52
Q

For TTA, full range of motion in ____, most noted into extension,is needed.

A

hip and knee

53
Q

Strengthening Exercises - TTA

A

Exercises should be given for involved limb, uninvolved limb, UE’s, and trunk/core.

Bed exercises for TTA:
* Quad set
* Hip extension with knee extended
* SLR
* Hip/knee extension with contralateral KTC
* Hip abduction against resistance
* Hip extension against towel roll (“bridging”)

54
Q

Strengthening Exercises - TFA

A

Consider the importance of hip extension and abduction strength for TTA and TFA in regard to ambulation.

Bed exercises for TFA:
* Glute sets
* Hip abduction supine against resistance
* Hip abduction side-lying active and against resistance
* Hip extension prone
* Hip extension against a towel roll (“bridging”)

55
Q

How does postural control change with amputation?

A
  • Shifts upward and toward the uninvolved (remaining) limb
  • The longer the limb, the less the shift
  • If bilateral, COM only shifts up
56
Q

Balance and Postural Control Exercises

A
  • Seated on Foam Pad
  • Seated balance on physioball
  • Seated balance on physioball with UE movement
  • Single limb balance w/UE support
  • Variable surfaces
  • UE challenge
  • Single limb balance w/o UE support
  • Variable surfaces
  • UE challenge

Weight bearing through RL
* TTA only
* Standing with chair
* Kneeling on mat
* Add weight shifting forward-backward

57
Q

Core Stabilization Training

A

Core stability training is critical in amputees where balance becomes compromised, resulting in diminished limb power outputs.

The higher the amputation, the more they need core stabilization.

Consider:
* Core training as a component of postural control
* Core training as a functional component
* Core training related to patient goals (I.e. return to sport)

Examples of core exercises:
* Crunch/sit-up-based activities (w/ or w/o resistance)
* Quadruped activities
* Use of compliant surface (in any position)
* Prolonged stabilization (i.e. plank)

Integument (7 decks)

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