P&O Flashcards
(44 cards)
Medicare covers what for patients with Diabetes?
Medicare covers
– DM with DM neuropathy –> yearly Podiatry evaluation
– DM –> one pair of DM specific shoes a year
Every Physical exam of a amputee, make sure to…
Check the other limb! (For wounds, For decreased sensation, For subtle findings like hair loss)
9-17% of patients undergoing transtibial amputation will require contralateral amputation within 12 months
% of patients that undergo transtibial amputation within 12 months of the contralateral amputation…
9-17% of patients undergoing transtibial amputation will require contralateral amputation within 12 months
Screening tool for limb health =
ABI (ABI = SBP at ankle / SBP at arm)
ABI > 0.9 is good
ABI < 0.9 mild PVD,
< 0.7 mod PVD,
< 0.4 severe PVD
If not yet done, referral for vascular evaluation – arterial angiography +/- angioplasty +/- stenting
Timeline and Goals (4) for PREPROSTHETIC phase of amputation:
Post-op after acute amputation
Inpatient rehabilitation admission
About 3 weeks admission
- Key concepts:
– Surgical wound healing
– Conditioning & strengthening for later prosthetic ambulation
– Prevention of contractures
– Medical care
Common post-op wound care orders for new amputation:
“clean & dry, cover incision line with ABD pad to protect it, wrap with soft gauze wrap, wrap over everything with figure of 8 ACE wrap, no tape on skin.” (last part is VERY important)
When can you use shrinkers on the new residual limb?
Only after sutures/staples out
General conditioning in therapy during PREPROSTHETIC phase: (% demand)
Atherosclerosis likely already in place, and increased risk after amputation. Increased metabolic demand per step (1 TT, 30%, 2 TT 40%, 1 TF 70%, 2 TF 200%)
Does energy rate change for amputees?
amputees walk at own self selected
slower speed, so rate of energy expenditure is same as non-amputee
– Rate = energy used / time to walk a distance
Strengthening goals in preprosthetic phase therapy:
-UE
-LE
w/ examples
– Shoulder complex & triceps for UE assist with transfer & ambulation with walker. Ex) Rickshaw, resistance bands, weighted bars.
– Core, Hip girdle, gluteal muscles – all the movement of the prosthetic limb will be initiated by the remaining intact proximal muscles. Ex) Supine leg lifts, Prone leg extensions, Side lying hip abduction
Transtibial BKA prosthesis contracture limit?
Transtibal BKA Prosthesis usually can only accommodate 15deg of knee flexion contracture
Lower extremity contracture risks for AKA and BKAs:
w/ exercises to prevent them!
– Transtibial BKAs prone to hip flexion & knee flexion contractures
– Transfemoral AKAs prone to hip flexion & hip abduction contractures
– Ex) Prone stretching of iliopsoas & hip flexors; knee immobilizer/Flotech for passive stretching of hamstrings & keeping knee extended
List common Amputee DME orders:
– Long handled mirror for self-inspection of amputation site
– Wheelchair adjustments:
* Rear axle more posterior to increase base of support to prevent tipping backwards (accounts for less anterior weight from loss of limb)
* For transtibial BKAs, knee extension board added to elevating leg rest
Describe post-amputation (type, duration, prognosis)
What modalities work best to treat phantom limb pain? (4)
– General somatic pain related to surgical incision
* Usually subsides over 1-3 weeks post-op
* Analgesic medications as medically appropriate & tolerated
– Phantom limb pain
* Desensitization
* Analgesic medications
* Neuropathic pain medications
* Mirror therapy (central processing and possible cortical reorganization)
Based on National Surgical QPI database: Perioperative morality for lower ext. amputations? What about the likelihood they had a complication within one month? (what type of comp?)
National Surgical Quality Improvement Program database:
- 30 day perioperative mortality
–13%, for transfemoral AKA
– 6.5% for transtibial BKA - 34% of of transtibial BKAs had a 30 day perioperative complication
– Most commonly = return to operating room for revision (15%) – Amputation site wound infection (9%)
Likelihood of thromboembolic disease in those with LE amputations NOT on anticoagulation?
- 38% incidence of DVT after transfemoral AKA
- 21% incidence of DVT after transtibial BKA
You begin a prosthetic evaluation after when?
What is the time course of this process beginning/duration itself?
Patient completes inpatient recovery phase + already done their post-op discharge follow up with their surgeon.
– every patient will take their own time for wound healing &
limb shaping
– every insurance will take their own time to approve/deny
prosthesis
– every patient & prosthetist will take their own time to fabricate & adjust prosthesis prior to prosthetic training
After surgeon has taken sutures and staples out, what do you continually do at each visit before even considering a prosthetic/during the process?
Skin eval! (don’t forget the other side)
– Scabs associated with surgical incision
– Day-to-day cuts & scratches
Shrinker garments worn more or less all day & night to address residual limb edema & promote ideal limb shaping
Ideal limb shape for UE and LE amputations:
A conical shape is preferred for the transhumeral amputation and a screwdriver shape for the transradial amputation. The latter preserves maximum use of residual rotation
– Transtibial BKA = cylindrical shape
– Transfemoral AKA = conical shape
(Shrinker garments worn more or less all day & night to address residual limb edema & promote ideal limb shaping)
Fabrication of the prosthetic involves:
What are common post-production modifications/adjustments?
Fabrication of socket & combining of components into a prosthesis
– Plaster casting of residual limb to use as a mold for socket creation (most common and cheaper, but dependent on the skills of the prosthetist)
– New technology: 3D scanning of residual limb ($$$)
Even after fabrication, still probably going to need some adjustments
– Ex) Cut out some pressure relief of socket; Resize endoskeleton pylon for proper height
Prosthetic training begins when and how is it organized?
After outpatient re-evaluations & “final” fitting of initial temporary prosthesis
- Therapy course specifically to practice and become independent with prosthetic management
- Inpatient rehabilitation admission (if authorized), about 2 weeks
- Or if inpatient admission not authorized, formal outpatient therapy
During this process, make sure to Reinforce all the amputee health maintenance concepts:
-thorough residual limb skin evaluations
-prevention of contracture, etc.
Initial prosthetic wear/use time instructions:
Red flags to look out for:
– Start low & build up gradually
– Can start as little as 15 min wear time intervals
– EVERYTIME prosthesis is taken off, skin must be inspected
- BAD: erythema that does not go away even after a few minutes of the prosthesis being off; ecchymosis; skin breakdown/abrasions; etc
Two major skin complications that can be a result of poorly fitting prosthesis
CHOKE SYNDROME
* Venous obstruction from socket that is too tight proximally
* Red, indurated skin that does not improve long after prosthesis is removed
VERRUCOUS HYPERPLASIA
* Wart-like overgrowth of thickened skin
* Fissuring & ulceration adds to infection risk
* Chronic proximal constriction
Examples of independence of prosthetic management when used: Donning, Doffing, Maintenance, and Managing socks
Donning:
-Enough clicks for pin & shuttle lock suspension (at least 5) without struggling to get them all (too tight)?
-At the same time, not too many clicks (too fast or too loose)
Doffing:
-Finding the release button for shuttle lock suspension to release it
Maintenance:
-Higher end components need this (charging microprocessor)
Socks:
-Adding or subtracting # of ply of socks over course of day to ensure fit.
