Rural Hospital - Mrs. C: Amputee Case Study

Title

Rural Hospital - Mrs. C: Amputee Case Study

Abstract

Mrs. C is a recent below knee amputee that is presently admitted to hospital in Canada for convalescent treatment. Her amputation was a result of peripheral vascular disease (PVD) of her left lower foot and toes. Her incision is healing well and she has recently progressed to residual limb shaping with a shrinker. She is ambulating with a 2-wheeled walker and minimal assistance of 1 person. Her and her family's goal is to be eligible for a prosthesis and return home to live with her daughter.

Key Words

transtibial, PVD, dementia, pre-prosthetic, rural, contracture

Client Characteristics

Mrs. C is an 81-year-old female with a recent transtibial knee amputation on June 15, 2015. She is retired, and lives with 1 of 2 daughters in a single level home.

Her past medical history is as follows: Hypertension, PVD, chronic anemia, dementia, hiatal hernia, cholelithiasis, superior femoral artery angio 2013 left leg, LEEP procedure 2009, stent in right upper leg due to blockage, hard of hearing, ex-smoker of 40 years, hypokalemia.

Prior to her amputation, Mrs. C was independent with all activities of daily living, and would have assistance for community ambulation from her daughter for appointments and social outings. Her family would have respite care as needed. She did not use a gait aid.

Examination Findings

Subjective: On the initial visit, Mrs. C reported no pain in the left residual limb. One of her daughters was present for this visit. Patient reports that she plans to return home with one of her daughters following discharge. Her daughter will be making changes to the home to accommodate the patient's needs. The daughter present reported cognitive decline in recent years and reports the patient will need assistance in completing prescribed exercises due to memory deficits.

Objective: Mrs. C was received sitting reclined in bed upon arrival. She was able to answer questions appropriately regarding home environment and plan for discharge, as was confirmed by the daughter present. She was unable to follow some simple, and many complex multi-step commands. Range of motion was full and strength was averaged 3+/5 for both lower extremities.

Impairments: Cognitive deficits were noted with following instructions during exercise trial and ambulation. Bed Mobility was independent and transfers were a minimal assistance of 1 person.

Participation Restrictions: As patient is dependent on family members for community ambulation, her participation is limited to family's preference and time.

Environmental Factors: Patient's home has 3 steps at entrance with single railing. Patient will need to ambulate stairs prior to discharge, or will need a wheelchair for home use with modification to the home for ramp construction.

Clinical Hypothesis

A large challenge for Mrs. C's treatment is her cognitive impairment. Although her residual limb is healing well, the family's goals appear to be unrealistic regarding her future progress. The family will need her to have a prosthesis so that she can ambulate independently in order to return home under their care. It was discussed with the patient and her family that the patient's cognitive impairments will make it unlikely that she will be able to don and doff a prosthesis safely, and furthermore whether she will be able to learn to ambulate well with the prosthesis. Appropriate goal setting will continue to be a concern during this patient's admission and further family and patient education will be necessary.

Intervention

Mrs. C's treatments began with bed exercises for maintaining range of motion and strength. Bed mobility and pivot transfers with use of a 2-wheeled walker began immediately. Patient's bed exercises also included prone lying of 15 minutes, and supine lying 15 minutes, 3-5 times per day. Due to the patient's cognitive limitations, she was unable to understand how to lie in prone facing toward the right so that her left hip would remain in neutral during the stretch.

Patient also did not enjoy lying supine to maintain a neutral hip position. She was given a wheelchair with an amputee board, but would often be found hanging the limb over the side into hip abduction and knee flexion. She was advised to avoid prolonged sitting postures in bed and in the chair to prevent hip flexion and knee flexion contractures, however due to her memory deficits she would not remember these instructions from day to day. Her family and the nursing staff were also advised of the significance of these instructions and would work with her, however she would refuse prone lie for more than 5 minutes once daily.

As there was increasing concern for development of contractures, passive stretching of the hip into extension was done in therapy, however due to staffing limitations, it could only be completed 2-3x/week. When appropriate, a fabric shrinker was applied to the limb following tensor wrapping. Limb desensitization techniques were recently begun.

Outcome

Unfortunately, Mrs. C's cognitive limitations result in exercises being completed only during physiotherapy sessions, as family and nursing staff are not involved in restricting contracture-developing behaviors during visits. This makes Mrs. C a high risk for developing hip flexion, hip abduction and knee flexion contractures that will ultimately result in her inability to be considered for a prosthesis which will limit her ability to return home with family.

Furthermore, her attending doctor and family continue to push for a consult with prosthetics to determine her candidacy for it. As such, physiotherapy will continue with limb desensitization and shaping as appropriate for her situation, but this is unlikely to benefit her as she is not compliant with her bed exercises and stretches and will likely result in having multiple contractures prior to getting a prosthetic.

A family meeting has been completed but physiotherapy was not invited to attend this meeting to further express these concerns to her medical team. This model of patient care will not benefit the patient in the long run and will result in unrealistic goal setting continuing to occur.

Mrs. C will remain admitted for convalescent care until a consult to prosthetics is completed. Following that, patient discharge planning will occur with likely referral to home care OT for equipment recommendations and environment adaptations.

Discussion

Mrs. C is a typical patient scenario seen in a rural hospital. Her treatments were based on generalist physiotherapy experiences and consult with other therapists in the larger city center. New skills trialed with Mrs. C through her stages of the recovery were limb desensitization with the tapping, scar mobility, and gentle slapping techniques described by the Amputee OT[1], and application of a fabric shrinker with protocol for use as described in the "Donning and Doffing Gel Liners" video in week 5[2].

Her exercise prescription was also adapted to incorporate opposite limb strengthening with therabands as shown in the "Amputee OT: Beginner Exercises for Amputees..." video[3]. Unfortunately, this rural hospital does not incorporate all members of the healthcare team in family meetings and the process of goal setting, and at times can be a deficit to the patient's and family's overall plans for discharge[4]. As such, it appears that future education of family and staff will have to be incorporated into clinical practice.

References

  1. Retrieved from "http://www.physio-pedia.com/Pre-fitting_management_of_the_a mputee#Desensitisation_of_the_stump_and_scar_massage"
  2. Retrieved from "http://www.physio-pedia.com/PP06_-_Week_Five"
  3. Retrieved from "http://www.physio-pedia.com/Pre-fitting_management_of_the_a mputee#Desensitisation_of_the_stump_and_scar_massage"
  4. Retrieved from "http://www.physio-pedia.com/Multidisciplinary/interdisciplinary_ management_of_the_amputee"