Regain independence - The diabetic Veteran: Amputee Case Study

Title

Regain independence - The diabetic Veteran: Amputee Case Study

Abstract

Diabetes is a devastating disease, with one of the most feared complication being amputation[1]. Diabetes affects multiple organ systems and the complications of diabetes, including diabetic neuropathy, retinopathy, circulatory complications (PAD,CAD), Nephropathies kidney and other complications, including mental health issues, particularly in the Veteran population[2]. In the Veteran hospitalized population there is a high incidence of sibetes and diabetic complication including dialysis dependence and amputation as well as pre-operative infection and complication[3].

Key Words

Diabetes, co-morbidities, Veteran, dialysis, amputation, wounds

Client Characteristics

Veteran is a 60 y/o male with long history of diabetes not related to his service. He is also significant for end stage renal disease and on dialysis 3 x per week, retinopathy, PVD, CAD and depression. He reports his first amputations were in the fingers of R hand, then several toes on the R and L, and finally a BKA on the R. He also present with ongoing ulcerations and wounds on intact (minus lateral toes) limb. He is in early prostheses wearing phase after 6 month healing and good healing of stump, without wound healing complication.

He has a good relationship with his mental health provider to address depression and frustration due to multiple amputations and loss of independence. He is very focused on being less of a man, which is also difficult given his military experience. During this final phase of learning to be a prosthetic wearer, he is in very good spirits and reports that his depression is more manageable and enjoys his PT.

Examination Findings

SUBJECTIVE:

  • Veteran reports that he is depressed about his multiple amputations and his loss of independence.
  • He is positive about getting his new leg however and feels that walking should assist with his outlook.
  • Veteran has had multiple skin integrity issues since time of amputation (s/p BKA 6 months prior).
  • He reports that he frequently bumps ans scrapes his intact limb, however does not seem concerned about the healing sores.

OBJECTIVE:

  • sit to stand with crutches Independent

  • AROM: involved knee -10 to 95
 intact leg 2 + pitting edema with open area at digit 4 amputation site, scapes healing and scabed on shin
  • balance good - with level pelvis with his supportive footwear (diabetic high top)

  • Gait short distances with some difficulty secondary to amputation of fingers on dominant side.
independent at w/c level, uses b UE and intact limb for propulsion

Clinical Hypothesis

This Veterans primary clinic problem is his PAD and multiple amputation history resulting in further difficulty with functional mobility. His other greatest barrier is his dependence on dialysis and the heamodynamic changes associated with dialysis, resulting in high risk for further skin breakdown in intact extremity. He is managing his depression now that he has begun with gait training with prosthetic limb, but is in early stage of prosthetic wearing. This veteran is independent at w/c level, which is beneficial for his transport to and from dialysis. I feel with the new prosthetist, this veteran will be able to improve his over all health and have the emotional benefit of feeling 'whole' again.

Intervention

Diabetic education and management with his PCP and diabetic nurse
wound care though wound care specialist t
he amodialysis ongoing with renal specialist and team physical therapy with ongoing care x 2 years for gait training after amputaions (foot) and last 6 months ther exercises to prepare residue limb for prosthetic wearing including working with prosthetist with shrinker socks and gel liner. 

Gait training pre- prosthetic and early prosthetic wearing
, emotional and MH support by MH providers 
Orthotist ongoing for BKA prosthesis
. OT to address UE amputations and adaptive equipment for self care and safety

Outcome

This Veteran is at high risk for complications with his diabetes secondary to status of dependence on heamo-dialysis[3] and multiple amputations. He was having marked difficulty with depression with feelings of helplessness and hopelessness, however as he has progressed to wearing a prosthetic limb he has become more involved in his healthcare and has worked to regain his walking independence.

Discussion

This case involves a veteran with multiple complications form his diabetes. It seemed that once he began to have issues with his PVD, several amputations of toes and fingers occurred in a short period of time. The loss of the leg below the knee was the most difficult, physically and emotionally for this Veteran and he became very depressed. Now that he has begun with the early phase with his prosthetic leg wearing, he has much better spirits and is working hard to regain independence.

Despite his present return to ambulatory independence, he is at high risk for further loss of limb and care is being taken to reduce edema and promote wound healing on the intact limb. The multiple wounds on teh shin at the last appointment are worrisome as well. He will require careful skin monitoring during the next six months until he is a safe ambulatory.

References


  1. Reducing lower leg amputations in diabetes: a challenge for patients, healthcare providers and healthcare system. Schaper,NC Diabetologia 2012 jul: Vol 55 (7) pp 1869-72
  2. Amputations and foot ulcers in patients newly diagnosed with type 2 diabetes mellitus and and observed for 19 years. The role of age,gender and co-morbidity. Bruun C. Diabetic Medicine: A journal Of The British Diabetic Association 2013 Aug; Vol 30(3) pp964-72
  3. 3.0 3.1 major lower-extremity amputation: contemporary experience in a single Veterans Affairs institution. Toursarkissian B,Shireman PK, HarrisonA, D'Ayala, Schhoolfield j, Sykes MT, the American Surgeon, 0003-1348, 2002 Jul, Vol 68 issue 7