Above knee amputation

Table of Contents
i.
Acknowledgement
...........................................................................................................................
1
I.
Introduction
.....................................................................................................................
2
II.
Objectives (General & Specific)
.....................................................................................................................
III.
Patients Data
.....................................................................................................................
IV. Family Background and Health History
.....................................................................................................................
V. Developmental Data
.....................................................................................................................
VI.
Definition of Complete Diagnosis
.....................................................................................................................
23
VII.
Physical Assessment
.....................................................................................................................
24
VIII.
Anatomy and Physiology
.....................................................................................................................
29
IX.
Pathophysiology
.....................................................................................................................
41
X.
Doctors Order
.....................................................................................................................
46
XI.
Diagnostic Exams
.....................................................................................................................
55

XII.
Drug Study
.....................................................................................................................
67
XIII.
Surgical Procedure
.....................................................................................................................
94
XIV.

Nursing
Care
Plan
.....................................................................................................................
104
XV. Discharge Plan (M. E. T. H. O. D.) &
.....................................................................................................................
131

XVI.

Prognosis..............
134
XVII.
Recommendation
.....................................................................................................................
138

XVIII.

Conclusion...
141
XIX.
References
.....................................................................................................................
143

ACKNOWLEDGEMENT

The proponents of this case study would like to extend their warmest gratitude to all the
people who made the success of this undertaking a reality.
First and foremost, to the Almighty Father, for His unceasing love and blessings; for
giving us enough power and fortitude to face all the hardships in the making of this work. To
Him be all glory and praise!

To our Clinical Instructors, Mrs Norilyn limchanco RN MAN , for their invaluable time,
knowledge and effort rendered to us.
To the staff and personnel of Armed Forces of the Philippines Medical
Center - V. Luna General Hospital , especially in the Surgical Intensive Care Unit for
giving us the opportunity to complete this endeavor. Thank you ma`am and sir.

INTRODUCTION
The first group of section 2D were given the opportunity to have a hospital exposure last
February 2,3 and 4 20145 at AFP medical center SICU.
The patient, to be mentioned in this paper as JC tolentino, was one of the patients
admitted to the SICU. She was admitted due to diagnosed above knee amputation related to
comminuted left leg fracture. She has undergone Left leg amputation last February 4, 2015.
Above the knee amputation :Unless time is a factor, as in emergency cases demanding
immediate surgery, the preoperative care of the potential amputee should include emotional and
vocational aspects as well as the physical. If patients are fully involved inplans for their
rehabilitation, understand what is expected of them, and know the regimen of exercise and skills
they will need to develop, their chances of full recovery and achievement of independence will
be greatly enhanced. Much emotional support and encouragement can be offered by other
amputees who are successfully mastering their prosthesis and making progress toward their goal
of total rehabilitation. Patients undergoing amputation will need help in dealing with the changes
in body image as they adjust to the loss of a limb. They should be encouraged and given the
opportunity to express feelings of anxiety, grief, anger, and depression, and given guidance in
working toward a healthy acceptance of their handicap.
In general, physical preparation of the patient undergoing surgical amputation includes
measures to promote optimum health and well-being, to establish nutritional and fluid balances,
and to increase muscular strength and endurance levels. A program of exercises may be started to
help the patient develop skill in using an overhead trapeze, crutches, and a walker and
transferring from wheelchair to bed.

The I chose JC tolentino as my subject primarily because her case posed as a very intricate case
requiring due understanding and knowledge. thus making this case a good avenue to broaden the
proponents knowledge about the disease and the surgical procedures involved.

OBJECTIVES

General Objective:
My main goal of is to be able to present the case study of our chosen client that would
provide a comprehensive discussion of the pathological mechanism of the disease to yield
significant information for the case study.

Specific Objectives:
In order to meet the general objective, the group aims to:

establish rapport to the patient and the patients significant others,

interpret the pertinent data gathered from the patient and her significant others,

state past and present health history of the patient,

define the complete diagnosis of the patient,

discuss the anatomy and physiology of the organ involved in the patients disease,

trace the pathophysiology of the patients disease,

obtain and rationalize the doctors order,

interpret the laboratory test results of the patient,

discuss the nature of the drugs given to the patient,

discuss the surgical procedure performed to the patient

present a specific, measurable, attainable, realistic and time-bounded nursing care plans
for the client,

justify the clients prognosis according to the different criteria,

outline recommendations based on the case studys findings.

PATIENTS DATA

Personal Data:
Patients Name:
Age:
Gender:
Birth date:

J.C tolentino
35 years old
Male
August 19, 1979

Birth Place

Batangas city

Civil Status

Married

Husband

N/A

Age

33 years old

Occupation
City Address:

Police officer
Batangas city

Family Income:

Php 50,000/month

Socioeconomic class:
Nationality:
Religion [Denomination]:
Educational Attainment:
Number of Siblings:

Middle class
Filipino
INC (iglesia ni cristo)
College graduate BS in criminology
1

Ordinal Rank:

N/A

Clinical/ Admitting Data:

Date of admission:
Time of admission:
Hospital & Hospital Number:
Ward [Room & Bed Numbers]:
Attending Physician:
Admitting Diagnosis:
Pre-Op Diagnosis:

January 26 2015
9:30 am
N/A
SICU [room # 5]
N/A
Comminuted ,distal frac femur left , left foot fracture
Comminuted ,distal fracture femur left , left foot fracture

Vital signs on admission:

Temperature:

38.2 Degrees Celsius

Pulse Rate:

120 Beats per Minute

Respiratory Rate:

28 Cycles per Minute

Blood pressure:

100/80 mmHg

Source of Information:

Patient, Patients Husband and Patients Chart

FAMILY BACKGROUND AND HEALTH HISTORY

HEALTH BACKGROUND
A. Family Background
JC tolentino is a 35 years old male. He got 1 sibling. His father is still alive and
his mother is still living and is hypertensive. Among her 7 siblings, one is also
hypertensive.
Out patient is married for 10 years. He is police officer. Her wife is a teacher. .
They have a 6 years old son and is currently in Grade 1 at Batangas elementary School.
The family lives in their owned house at Km. 7, Batangas
The familys source of income his salary in her work as being a police officer. He
has a daily salary of P 7000/ day or about P 21000/month. From this, the family can
afford eating three times a day. Their usual diet is composed of fish and vegetables since
their son likes to eat vegetables. They only cook meat once or twice a week. Sometimes,
they also go to mall to have family bonding and time for fun.
This is the first time in their family that an above knee amputation. However,
B. Past Health History
The patient was born via normal spontaneous vaginal delivery. There were no
complications or abnormalities when he was delivered. he does not have any information
about her immunization status.
According to his, he had a chicken pox when he was 9 years old. he does not
usually get cough or colds but experiences fever at times due to weather conditions.

B. Effects/ Expectations of Illness to Self/ Family

This condition of the patient has really affected the family. This loss saddened the
family, most notably the patient. Though it was only during this time that he knew he was
getting amputated, it could have been a lot better if this didnt happen. However, as the
patient verbalized, he couldnt do anything about it since its Gods will.
His wife has been very y supportive and provided all the support the patient
needed. He even skipped his work just to be with her wife. Emotionally, the family
support has been overwhelming. They really gave their effort to help the patient cope up
with this situation. Moreover, they didnt have problem in relation to finances since other
family members and relative contributed in paying the bill.

DEFINITION OF COMPLETE DIAGNOSIS

Fractured open N/C communited distal femur left ,

fractured closed completed displaced inferior and
superior pubic rami lef. R/O bund abdominal and chest
injury 2 degree.

PHYSICAL ASSESSMENT
I. Personal Data
Name: JC tolentino
Age: 35 years old

Sex: male
Diagnosis: AKA

II. General Survey

The patient was assessed lying on bed in supine position, awake, conscious and coherent
and in respiratory distress. he was oriented to person, place and time and talks coherently.
Thoughts were coherent and with logical sequencing. IVF was attached to him. he was on DAT
diet.he had a dressing in the hypogastric area covered with binder.he was properly groomed but
slight body odor was noted. The patient has an endomorphic body structure and looked according
to her age. he was cooperative and responsive during the entire assessment.
III. Vital Signs
The patient has a body temperature of 38C e. Respiration was assessed to be 28 cycles in
one full minute; her breathing was deep and in normal pace. Her pulse rate was 100 beats per
minute with a regular rhythm. Her cardiac rate is 103 beats per minute. Her blood pressure was
110/80 mmHg taking while he was lying supine on bed.
IV. The Integument
A. Skin
The patients skin is dry with poor skin turgor. Skin color is brown , the legs and
soles of the feet. Skin is warm to touch, which is uniform on both extremities. A surgical wound
covered by a sterile dressing is noted on the hypogastric area of the patients abdomen. Both the
right and left hands have scratches as it served as IV insertion sites.
B. Hair
Hair is evenly distributed over scalp. It is oily and black in color. Dandruffs are
present. Fine hairs are evenly distributed on both extremities.
C. Nails

Nails were unclean and not well trimmed with whitish to light pink nail beds, with
normal angle curvature, and with a capillary refill of 3 seconds. Fingernails and toenails were
pale. Surrounding tissues were intact; no lesions nor lacerations were observed.
V. The Head
A. Skull and Face
The patients head is normocephalic and proportional to body size. Presences of nodules
or masses are not noted. Facial features and movements are symmetrical. The patient is able to
raise her eyebrows, close her eyes, frown, and smile. Her face manifests a feeling of slight
tiredness.
B. The Eyes
The hair in the patients eyebrows is evenly distributed; skin is intact and
symmetrically aligned with equal movement and there was no noted scaling and flakiness of
skin. The eyelashes are equally distributed and curled slightly outward. Her eyelids close
symmetrically; discharges and discolorations were not noted. Her pupil size in both eyes are
equal, with a diameter of 3mm when dilated and 2mm when constricted; with brisk reaction to
light accomodation. According to her, when looking straight ahead, she can see objects in
periphery. There was no edema or tenderness noted over her lacrimal glands.
C. Nose and Sinuses
The external nose is symmetrical, straight and uniform in color. Nasal
flaring was not noted. Color is the same with the entire face; there was no tenderness noted upon
palpation. Lesions and tenderness were both absent. Nasal mucosa was pinkish. Both left and
right nares were patent, with no discharges; air could freely move in and out when the patient
breathes. The nasal septum is intact and in the midline without deviations. The frontal and
maxillary sinuses were non-tender upon palpation. Sense of smell was good. Patient was able to
differentiate water from that of alcohol, through scent.
D. Ears
Auricles are smooth, symmetrical and no discoloration noted. Her external pinna is
normoset; deformities, lesions or inflammations were not present. Pinna recoils after it is being

folded; it is firm and non tender. The ears were physically symmetrical in size and normoset
since boh are located in line with the outer canthus of his eyes. Normal voice tones are audible.
She was able to repeat whispered words and was able to hear ticking sound from the watch in
both ears.
E. Mouth and Oropharynx
There were no lesions and masses noted on the lips and they appear moist and
pinkish. Oral mucosa was pinkish and the tongue was located at the midline, pink in color,
slightly dry and furry with whitish coating. She was able to move her tongue freely. The gums
was pinkish, with no signs of bleeding. The uvula is in the midline and the mucosa surrounding it
is slightly pink. His tonsils were free from inflammation. Dental carries were present
VI. Neck
The muscles in her neck were equal in size. His neck movement was coordinated and
difficulty in moving was not noted. He was able to flex, hyperextend, laterally flex and rotate his
neck without distress. He can also turn his head on one side against the resistance of our hand
with the similar strength and shrug his shoulders up against the resistance of our hand with equal
strength. The trachea is in the midline. No lymph nodes were palpable.
VII. Chest and Lungs
The patient has a regular and normal breathing pattern; quiet and rhythmic respirations,
with respiratory rate of 28 cyles in one full minute. No tenderness and masses upon palpation.
No adventitious breath sounds on both left and right lung fields were heard during auscultation.
Tactile fremitus on both lungs are symmetrical. Posterior chest was not assessed.
VIII. Heart
A. Heart and Central Vessels
Point of maximum impulse and beat is auscultated at the 5 th intercoastal space left
midclavicular line. The patient has a cardiacrate of 103 beats per minute. Presence of abnormal
heart sounds were not noted upon auscultation.

B. Peripheral pulses
Peripheral pulses have regular rhythm strong. Her pulse rate is 100 beats
per minute. The skin is warm upon palpation and capillary refill time is 3 seconds.
IX. Abdomen
The patients abdomen has same color with his chest. The umbilicus is medially located
and shows no signs of inflammation. Bowel sounds are present upon auscultation. .
X. Genito-Urinary
The patient reported that there were no lesion, tenderness and masses in her perineum and
anus.
XI. Musculoskeletal
A. Upper Extremities
The patients radial and brachial pulses were regular but strong. Good range of
motion was noted. Palm is able to stay in both prone and supine in a good manner without
difficulty. He was able to exhibit strong hand grip on both arms. Client was able to extend
both arms. Reflex on the upper extremity was good.
B. Lower Extremities
The patient left leg is amputated while his right leg is normal.

ANATOMY AND PHYSIOLOGY

Muscle of the leg and foot.

Supporting, balancing, and propelling the body is the work of the muscular system of
the legs and feet. From the large, strong muscles of the buttocks and legs to the tiny,
fine muscles of the feet and toes, these muscles can exert tremendous power while
constantly making small adjustments for balance whether the body is at rest or in
motion.

Popliteal artery:
A branch of the femoral artery, the popliteal artery branches further to supply blood to the knee,
thigh, and calf. It ends at the anterior and posterior tibial arteries.
Posterior tibial artery: This branch of the popliteal artery supplies oxygenated blood to the leg
and sole of the foot. It runs on the inside of the leg and is accompanied by the posterior tibial
vein.
Anterior tibial artery:
The other branch of the popliteal artery from the back of the knee, it supplies blood to the
muscles of the leg and foot.
Peroneal artery:
This is the largest branch of the posterior tibial artery. It supplies blood to the outside and back of
the ankle and calf muscles. It ends at the lateral calcaneal artery.
Plantar arteries: The plantar arterieslateral, medial, and deepform a looping web across the
foot and down through each toe and unite with the dorsalis pedis artery.
Dorsalis pedis artery:
This artery supplies blood to the surface of the foot as a continuation of the anterior tibial artery.
The dorsalis pedis vein accompanies this artery.

PATHOPYSIOLOGY
vehicular accident

comminuted fracture

Poor blood flow

cannot be fixed

that

January 2 1600 H
Altered bleeding

1700 DOB

Febraury 3
Course in the ward

Pale skin , fatigue , low body temperature

Doctors order with on going luparin drip D5W
240 cc 10000 with teparin 13 cc/hr , continue
PT, APIT every 6 ours
>continuity patient accordingly
RR : 28
Administer oxygen
Place the patient semi fowler position
>relief DOB