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Amputation
Background
Amputation is an acquired condition that results in the loss of a limb, typically from disease, injury, and/or surgery. There are approximately 278,000 new amputees each year in the United States (Amputation statistics, 2012). Seventy-seven percent of these cases are from circulatory problems, particularly peripheral vascular disease (PVD) related to diabetes, while most of the rest are due to trauma.
Warning Signs
Most amputations involve the lower limbs, above or below the knee. The greatest risk factor for amputation is diabetes with peripheral vascular disease, with African American men having a 2.3 times greater rate of amputation than Whites with diabetes. Advanced age and the incidence of diabetes in the elderly make this a potential problem in the older age group. Additionally, a recent study showed that HgbA1c level was a significant predictor of foot amputation (Palmer, et al,et al., 2011).
Diagnosis
In the acute phase of recovery after surgery, it is important to prevent contractures of the knee joint and maintain normal muscle power and range of motion in remaining joints. The limb should not be hung over the bedside or placed in a dependent position. Both in acute care and rehabilitation, the stump should be conditioned to prepare for the wearing of a prosthesis (an artificial limb). In certain cases, an older person may choose, after speaking with the doctor, not to wear a prosthesis. But, this is usually only when there are other health problems, such as poor balance from another disease or disorder that would make falling and injury more likely with the use of an artificial limb.
Treatment
Initially, there may be drainage from the surgical site, and a sterile dressing will be kept in place and changed at least daily. Eventually, the staples or sutures will be removed and a thick, black eschar (like a hard, dark scab) will form at the amputation site and gradually come off. An Ace wrap or stump shrinker sock (elastic) is used to help prepare the stump for wearing a prosthesis. Several factors should be considered when preparing the stump to wear this artificial limb. These include a movable scar, lack of tenderness/sensitivity, a cone shape, firm skin, and minimizing any swelling. All of these can be achieved by proper wrapping of the stump. The prone position (laying on the stomach), if tolerable, is an excellent way to promote full extension of the residual limb.
It is also important for the person to begin therapy right away. Persons wearing a prosthesis use more energy to walk. An older person with an artificial leg generally has a 40% decrease in speed but uses 80% more energy to walk than the average healthy adult (Chinn et al, 2005).
When using the prosthesis at first, an older adult may tire easily. Be sure to take into account any coexisting problems, such as heart of lung disease, when considering energy expenditure. However, the newest technologies allow prosthetics to be light, durable, and more comfortable.
Patients and families will need to learn about stump care, mobility, adaptation, coping, and self-care. Home maintenance, dealing with complications and/or additional health problems, wear and tear on non-weight-bearing joints, adapting to the environment, accessibility, stigma, depression, role changes, decreased energy, and chronic pain are all issues to be aware of related to amputation. It is likely that the person with a leg amputation will experience some shoulder problems over time due to the additional stress on the non-weight-bearing joints. Phantom limb pain, or pain sensations in the nonexistent limb, is more common after traumatic amputations and may last for weeks after amputation. Massage and medications may help with this type of pain control (Beers, 2005). Additionally, proper wrapping of the stump (in a figure-eight wrap) may help decrease the chance of phantom limb pain later (Kalapatapu, 2012). Also, people with an amputation may struggle with difficult feelings about the changed appearance of their body. They might worry if their spouse or loved ones will see them differently. They might fear what others will think and worry about getting their life back to what feels normal.
In general, older persons with amputation may return to a normal quality of life with some adaptations. The care provided by nurses and physicians in rehabilitation after amputation may make the difference in the person’s ability to cope with the changes that result after surgery. Nurses can help with the transition back into the community after amputation by educating patients and families about resources to assist with adaptation.
Adapted from Mauk, K. L., Hanson, P., & Hain, D. (2014). Review of the management of common illnesses, diseases, or health conditions. In K. L. Mauk’s (Ed.) Gerontological Nursing: Competencies for Care. Sudbury, MA: Jones and Bartlett Publishers. Used with permission.
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How to Find the Best Healthcare for Assisted Living
In the world of healthcare, the quality of assisted living can vary in any given location. That’s why it’s critical you do the correct homework while implementing strategies to find out the situation. There will be some potentially shocking things discovered along the way when you notice the differences between facilities. Many do not offer you the optimal care you deserve, but the price tag is also a variable. Generally, more expensive locations will have more accommodations and higher-level care.
Choosing Based on a Good Location
You might be wondering, “where can I find an assisted living near me?” Well, there are many viable locations to start exploring right now. It’s better to view this as an important journey rather than an arduous chore. Things can get challenging when it comes to making the final decision. Location is incredibly important because you want them to feel safe. According to Diamond Willow, they have a service that “covers a wide range of communities as Minnesota’s premier senior care provider, specializing in unmatched memory care and assisted living services.” They are giving you a wider range of options to make effective assisted living healthcare more convenient and accessible.
Use a Comprehensive Assisted Living Directory
One of the ways to get acquainted with the options in your area is through consulting with a directory. Here, you will discover some interesting options and can view the important details without even visiting. From there, you can compare and contrast which ones would be more suitable for your loved one. These directories have valuable information about living conditions and perks that come with each facility. You may also learn about the history of any given building and details like the age and qualifications. These are especially important if you have someone who needs intensive care and constant monitoring. Assisted living directories make the process of finding stable and safe healthcare opportunities more manageable.
Consult with Your Healthcare Provider
There are many tips to find assisted living facilities that will serve as a guide towards a successful decision. If you’re worried about regretting any given decision, then it would be a wise idea to consult with your healthcare practitioner to shed light on the subject. They will be well-acquainted with the dynamics of many local facilities because of their job working with people. This can be a significant advantage for discovering certain realities that you wouldn’t have discovered otherwise. For instance, if a facility has behavioral issues or problems with crime in a bad area then the doctor will know this. They will also be able to tailor your decision based on your personal medical history with better results!
Ask Friends and Family about their Experience
Another great way to gain insight into any assisted living facility is to speak with others who have gone through the experience themselves. One of the advantages of this is you’ll get transparent honesty from a friend or family member who experienced the current staff. This can be a variable that people often overlook when searching for good spots, and patient satisfaction is important. Reviews can also be found online which may enlighten you as to whether or not a care facility treats their elderly folks well. They can give you critical details about their experience and you can decide if certain elements are deal-breakers. Taking notes when they describe their experience is good for comparing spots later. Also, when someone speaks about their assisted living stories you’ll be able to get the general vibe which is better than reading reviews. Simply reach out and ask people about their time and see how you feel later when you deliberate.
Doing the Right Research Will Pay Off
It is possible to establish a good middle-ground without emptying your wallet in search of an assisted living location. When conducting your own research you must keep your budget in mind along with the smaller details of each location. It’s imperative you communicate effectively with the individual to ensure their needs are fully met across different atmospheres. The new spot should feel like home in a safe location that is accessible to the family. This helps because it’s easier to visit!
Total Knee Replacement
Background
Similar to hip replacement, knee replacement is done when a person is experiencing decreased range of motion, trouble walking or climbing stairs, and increased degeneration of the joint so as to impair quality of life. This most often occurs as a result of arthritis.
Treatment
Total knee replacement (TKR) surgery involves resurfacing or removing the distal portion of the femur that articulates with the end of the shin bone. The prosthesis consists of metal and plastic or similar materials that are cemented onto the newly resurfaced areas of the articulating bones. Although often done under general anesthetic, this surgery can also be performed under spinal anesthesia. Sometimes blood loss is significant, so patients may be asked to donate their own blood ahead of time to be given back to them in the event it is needed. In addition, a growing trend is toward bilateral knee replacement in those persons requiring both knees to be surgically repaired. The benefits of this are the one-time operative anesthetic and room costs, and many physicians feel recovery from bilateral replacement is similar to single replacement. However, the pain and lack of mobility, as well as the significant increase in the assistance needed after surgery when a bilateral replacement is done, may make this less than ideal for older patients. Surgical procedures for TKR have not evolved quite as rapidly as total hip arthroplasty.
Discomfort after knee surgery is generally severe in the first few days. Complications after surgery may occur, including pain, infection, and blood clots. Patients may use cold packs on the operative area and take pain and sleeping medications as ordered. In addition, alternative therapies such as guided imagery have been shown to help with pain management (Posadzi & Ernst, 2011). Many joint replacement patients feel a loss of control and independence.
Therapy will begin immediately in the acute care hospital. Although weight bearing does not usually occur until 24 hours after surgery, sitting in a chair and using a continuous passive motion machine (CPM) (if ordered), will ease recovery. The use of a CPM is generally based on the surgeon’s preference. There is research to support it, as well as studies indicating that walking soon after surgery has an equal effect and makes the CPM unnecessary. However, in cases of an older person who may not have the mobility skills initially after surgery that a younger person would, a CPM may be beneficial to keep the joint flexible and decrease pain.
Dr. Zann (2005) indicated that “patients undergoing total knee replacement do not achieve their maximum improvement until 2–4 years” (p. 1). This is attributed to the lack of muscular structures that surround and protect the knee and the need for the ligaments and tendons to adapt to the indwelling prosthesis. Recovery times vary and depend upon a number of variables, including the patient’s overall health, age, other preexisting health issues, and motivation. Patients report that the new knee joint never feels normal even years after the surgery, but that they experience an increase in function and generally much less pain than before.
Patients should be educated about signs and symptoms of infection, care of the surgical site (if staples are still present), pain management, and expectations for recovery. A range of motion from 0–90 degrees is the very minimum needed for normal functioning. Normal knee flexion is 140 degrees, but few older persons would get this amount of flexion after surgery, and may not have had full flexion even prior to the operation. After discharge, a walker is usually used in the first few weeks, followed by light activities 6 weeks after surgery. In addition, the patient’s spouse may experience feelings of being overwhelmed due to role transitions that occur after surgery and during the recovery period (Walker, 2012 ). Newer knee prosthetics are still going strong for the majority of patients 15 years after surgery.
Guest Blog: Common Skin Conditions Affecting the Elderly
No matter how well we take care of ourselves, advancing age eventually takes its toll – especially on our skin. Over time, the various components that make up our bodies gradually become less able to resist the onset of decay. The epidermis, which is the body’s largest organ, is no exception. As we age, it dries out, grows thinner, and becomes more vulnerable to disease. These naturally-occurring difficulties are compounded when an elderly patient is confined to a long-term care facility.
In some cases, a skin problem may indicate an underlying condition that has gone undetected. Skin conditions can also arise from problems in positioning for patients who are confined to a bed or a wheelchair for an extended period. Once the wound has been healed, the caregiver should make sure that its cause is determined and addressed, and nothing else is being overlooked.
While there are many possible skin disorders that can affect the epidermis of an elderly patient, not all of them will require treatment. Some do, however, and the following are a few of the more common conditions and their possible treatments.
Allergic Reactions
It has been estimated that approximately 5-10% of people 65 or older suffer from an allergic disease. In addition to those who suffer from allergies throughout their lives, some individuals only develop allergies once they reach an advanced age. Underlying medical conditions, memory issues, the use of several medications simultaneously, and overall poor health, can also contribute to the late appearance of an allergy problem in an elderly patient.
Prescription medications are often the culprit when a geriatric patient develops a systemic allergic reaction. Because of this, anyone who does have allergies should be asked about any recent new medications he or she may have begun taking. However, there are other potential causes, including exposure to detergents or mites. Allergic reactions can present in a wide array of symptoms, making it difficult to sometimes narrow down a specific cause.
Allergic reactions should always be treated with topical steroids for one to two weeks. The caregiver should also make sure that the cause of the reaction has been addressed.
Fungal Infections
The most common fungal infection, regardless of a patient’s age, is candidiasis, which is a yeast infection that tends to appear on occluded regions of the epidermis, such as in the folds of the skin or under dressings. It’s most dangerous to older patients and most transmittable to patients who are confined to bed or a wheelchair. In geriatric patients, candidiasis presents with chills, fever, pustular skin lesions, and in some cases, symptoms indicating sepsis.
Fortunately, candidiasis can be prevented by applying miconazole powder to at-risk patches of skin. When it does appear, it should be treated by applying clotrimazole or nystatin cream to the affected areas. If it becomes a recurring problem for patients, bowel eradication using nystatin pastilles should be considered. The provider should also be sure to check the patient for signs of retinal lesions, as many elderly patients suffer from cataracts.
Another common fungal problem is seborrheic dermatitis, which is caused by infection from a different type of yeast, malassezia furfur. It presents as red and scaly patches of skin typically found in areas where hair is present; particularly the head, neck, and chest. It can be treated with ketoconazole (nizoral) 2% shampoo or selenium sulfide 2.5% (Selsun Blue).
Staph and Strep infections
Staph and strep infections are also among the most common problems health professionals will face in patients at a long-term care facility. Studies have estimated that, at any given time, 30-40% of long-term care residents are experiencing a fungal infection.
A staph infection typically results when bacteria enter the epidermis through a sore or a cut (including in areas where a patient may be attached to a catheter or other medical device). The infection presents painfully as a red, swollen patch on the skin. This may be accompanied by pus drainage, a skin abscess, warmth in the area, and a fever as well. In more severe cases, patients may even experience shortness of breath, chills, chest pain, fatigue, muscle aches, headaches, and rashes.
When a geriatric patient is suffering from a staph or strep infection, it should first be treated with a topical antibiotic such as mupirocin (bactroban). If this does not cure the infection and it enters the surrounding tissue, a tissue culture should then be taken to determine what organism is causing the problem. Depending on the results, a systemic antibiotic – usually augmentin, bactrim, ciprofloxacin, or tetracycline – should be given to the patient.