Rural Hospital – Mrs. C: Amputee Case Study

Title

Rural Hospital – Mrs C: Amputee Case Study

Abstract

Mrs. C is a recent below knee amputee who is currently hospitalized in Canada for palliative care. Her left lower leg was the posterior tibial dysplasia (PVD) amputation. His incision is healing well and he has recently progressed to residual limb shaping equipped with a shrinker. Traveling with a 2-wheeled walker and a few 1-person animals. Her goal with her family is to qualify for prosthetics and return home to live with her daughter.

Key Words

transtibial PVD dementia before rural contracture

Client Characteristics

Mrs C is an 81-year-old woman who had a recent knee amputation on June 15 2015. She is retired and lives in a one-story house with 1 of her 2 daughters.

His 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 upper right leg due to obstructed hearing loss former smoker of age 40 hypokalemia due to.

Prior to amputation Mrs C was independent in all activities of daily living and would receive assistance with local transportation from her daughter for appointments and social events. His family would receive respite care as needed. He did not use a walker.

Examination Findings

Subjective: At the first visit Mrs C reported no pain in the left residual limb. One of his daughters was present for this visit. Patient reports that she plans to return home with one of her daughters after discharge. Her daughter will make changes to the house in order to. the needs of the patient. The daughter there reported declining cognition in recent years and reports that the patient will need assistance in completing prescribed exercises due to memory impairment.

Purpose: Mrs C was admitted to bed upon arrival. She was able to answer appropriate questions about the home environment and arrange discharge as confirmed by the daughter who was present. He was unable to follow some simple and complex multi-step commands. Range of motion was full and the average strength was 3+/5 for both lower extremities.

Complications: Cognitive deficits were noted by following instructions during exercise and gait testing. Bed Mobility was independent and transfers were minimal assistance by 1 person.

Restrictions on Participation: As the patient relies on family members for community transportation, his/her participation is limited to family preferences and timing.

Environment: Patient’s home is within 3 feet of a single-door entrance. The patient will need to walk stairs prior to discharge or will need a wheelchair for home use with modifications to the home to build the ramp.

Clinical Hypothesis

The greatest challenge to Mrs C’s treatment is her cognitive impairment. Although his remaining limbs are healing well, the family’s goals seem unrealistic for his future development. The family will need a prosthetic to help him walk independently in order for him to return house under their care. It is discussed with the patient and family that the patient’s cognitive impairment will make it unlikely that he/she will be able to wear a prosthesis and use a prosthesis safely and also that he/she may be able to learn how to walk properly with the prosthesis or. Appropriate goal setting will continue to be a concern during this patient’s referral and further family and patient education will be required.

Intervention

Mrs. C’s treatments began with bed rest exercises to maintain range of motion and strength. Bed movements and pivot transfers using a 2-wheeled walker began immediately. Patient bed exercises also include lying down for 15 minutes and lying down for 15 minutes 3-5 times a day. Due to the patient’s cognitive deficits he was unable to understand how to lie prone on the floor facing the right so that the left hip remains neutral during extension.

The patient also disliked lying supine to maintain a neutral hip position. He was given a wheelchair with an amputee board but was frequently seen with the limb dangling sideways to grasp his waist and bend his knee. He was advised to avoid sitting in beds and chairs for long periods of time just in case prevent hip flexion and knee flexion contractures but due to his memory loss he would not remember these instructions every day. His family and nursing staff were also advised of the importance of these guidelines and would work with him but he would deny simple lies more than 5 minutes once a day.

As there was growing concern over the development of contractures passive stretching of the hip into extension was done in therapy but due to staff limitations could only be completed 2-3x/week. When appropriate, fabric shrinker was applied to the organ after tensor wrapping. Limb only recently began desensitization techniques.

Outcome

Unfortunately, Mrs C’s cognitive limitations result in exercise completion only during exercise because family and nursing staff do not engage in limiting preventive behaviors that foster alliance during visits in the 19th century. This places Mrs. C at high risk for hip flexion hip abduction the limits of a knee injury that would ultimately prevent him from considering a prosthetic that would allow him to return home with family.

Additionally her attending physician and family continue to push for an appointment with chiropractors to see if she wants to do so. Naturally physiotherapy will continue with limb desensitization and shaping as appropriate to his condition but this is not beneficial for him as he is non-compliant his bed exercises are extensive and will likely build more muscle before his prosthetics.

A family meeting has been completed but physiotherapy has not been called to this meeting to further discuss these issues with his medical team. This model of patient care will not benefit the patient in the long term and will lead to the continuation of unrealistic goal setting.

Mrs. C will continue to admit him for recovery until the prosthetic evaluation is completed. Following that, discharge planning will occur with patients likely being referred to a home care OT for equipment recommendations and environmental modifications.

Discussion

Mrs. C is a typical patient situation seen in a rural hospital. Her treatments were based on physical therapy experiences and in consultation with other downtown therapists. Another skill that was tested with Mrs C during various stages of her recovery was simple limbs when created wound drilling and gentle tapping techniques described by Amputee OT[1] and cloth shrinker with protocol for use as described in Donning and Doffing Gel Liners video in week 5[2]. . . . .

Her exercise prescription was also adjusted to incorporate the opposite limbs with therabands, as shown in the Amputee OT: Exercises for Amputee Beginners… video [3]. Unfortunately, this rural hospital does not include all members of the medical team in family meetings and processes Goal setting can sometimes influence the patient’s and family’s overall discharge planning [4]. Therefore, future education of families and staff seems to have to be incorporated into clinical practice.