Postoperative care

Some patients return from theatre thinking that they still have their leg as they can still 'feel' it. Without reminders they may get out of bed and try to 'stand on two feet' resulting in a fall and possible injury to the stump or the other foot.

Phantom sensation gradually decreases and may telescope so that the patient feels his foot at his thigh.

During the postoperative period patients who have lost a limb often describe similar feelings to those described by people who have just had a chronic disease such as diabetes diagnosed, or people who have undergone a bereavement.

There may be physical sensations including:

• Helplessness, muscle weakness, lack of energy

• Feeling of hollowness in stomach

• Tightness in chest and throat, and breathlessness

• Oversensitivity to noises

Common emotional reactions include:

• Sense of unreality and light-headedness

• Feeling of observing oneself from outside

• Disbelief, confusion, hallucinations, sleep disturbance, dreams

• Preoccupation

• Sense of the presence of the lost limb

• Absent mindedness

Other feelings may include:

• Anger and frustration

• Guilt and self-reproach

The initial phase involves shock and disbelief, which is often followed by feelings of sadness, despair, anxiety and sometimes anger or pining. Although these feelings usually decrease as patients start to recover or adapt, individual reactions vary. It is important for patients and their families to be aware of these effects.

In the early phase, patients may feel emotionally numb, and may need help with making the simplest decisions. Common social reactions include:

• Social withdrawal

• Avoiding reminders of the amputation.

Gradually the patient enters the recovery phase. In order to optimize recovery it is necessary for all healthcare professionals to:

• Listen and give the patient time

• Acknowledge their special loss

• Acknowledge any feeling, especially negative ones such as anger, and offer reassurance that these are normal and to be expected

• Be prepared to handle the stump and encourage spouse or family to do likewise

• Be aware that some patients hate the word 'stump'

• Be aware that the first dressing change is particularly frightening. Comments about the state of the wound should be true and tactfully presented, avoiding negative facial disgust or inappropriate belittling comments

• Reassure the patient that any stump pain should settle gradually as oedema and inflammation settle and should be reduced by regularly prescribed analgesia. The relatives of patients also need attention and sympathy. The psychological effect of amputation on the patient's relatives maybe profound. We remember the wife of a major amputee who refused to have a ramp fitted to the house because she said it would spoil the look of her home. We are not sure whether she meant that ramps were unaesthetically pleasing, whether she felt there was a stigma attached to a house with a ramp, or whether she simply enjoyed being able to control their exits and their entrances. We were also unclear about the motives of another patient's wife who refused to allow him to be fitted with a prosthesis after his below-knee amputation. She said the reason was that she was afraid that he would fall over and hurt himself, but the patient himself believed that she enjoyed being in control.

Amputation wounds are often slow to heal in neurois-chaemic patients. Infection should be treated aggressively and the vacuum-assisted closure (VAC) pump may be useful. However, if there is poor arterial perfusion to the below-knee wound it may be necessary to convert it into an above-knee amputation.

Shortly after the amputation has been performed, oedema of the stump can be a problem, and JUZO socks, which are compression stump shrinkers, provide good oedema control both in the acute stages, and long term. They are only provided after the stitches have been removed as they can otherwise drag on the wound edges and cause dehiscence. The stump is measured and the sock supplied between days 5 and 10 postamputation.

Initially, the sock is applied for 10 min only and the stump is then inspected for problems including colour change and breaks in the skin.

Once healed, the stump should be inspected daily for skin breakdown, which should be cleaned, dressed and off-loaded until complete healing is achieved.

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