Lower Extremity Amputation (LEA) is among the oldest surgically performed procedures using surgical principles that were initially described by Hippocrates and that are still valid nowadays. He designates amputation at the edge of tissue of ischemic, leaving the wound open, so that it will facilitate healing by ancillary intent. The amputation surgery involved several risks that include hemorrhage, shock, as well as sepsis. Besides, the procedure was quite challenging before anesthesia was discovered. In most cases, amputation is the only treatment of choice for severe tumors, trauma, and vascular diseases. However, most people in the society consider it as a failure in treatment. An individual undergoing the amputation surgery faces a challenge to overcome the psychological stigma that is associated with the loss of a limb. LEA is increasingly becoming a health problem, not only in the United States but also in a number of other countries in the world. This has triggered the efforts of Health Resources and Services Administration (HRSA) to develop a comprehensive program with the aim of preventing lower extremity amputation (LEAP) to increase its awareness among home health nurses. The discussion seeks to find an answer to whether an implementation of an educative program about LEAP would increase home health nurses’ awareness of the health problems.

Information About the Epidemiological/ Statistic Situation of the Lower Extremity Amputation

In the United States, more than 180 thousand amputations are performed every year, where approximately two million individuals live without a limb (Ertl, 2016). There is a number of reasons as to why a person will need his or her leg removed. The decision to allow amputation feels terrible to all parties involved, ranging from the individual himself/herself, to the family members and medical staffs. About 90% of all amputations are mainly associated with the lower limb (Lazzarini, Clark, & Derhy, 2011). The common causes of the amputations are Diabetes Mellitus (DM) and Peripheral Vascular Disease (PVD), making 54% of those individuals living with limb loss, about 45% of cases caused trauma and less than 2% caused by cancer (Uccioli, 2011). Amputations related to the DM and PVD are very common among the older adults. In addition, smoking cigarettes for a prolonged period of time increases the risks of amputation because it damages small blood vessels in the legs.

The diseases significantly decrease the supply of blood to the legs. In most cases, individuals develop infections, ulcers or wounds that do not heal, and other complications associated with pain. The above mentioned factors significantly affect the normal functioning of legs and people usually find it difficult to move and walk around freely. Inadequate flow of blood to the legs makes the body cells not get the necessary nutrients and oxygen from the bloodstream, making the affected body tissues die (McGuire, Longson, Adler, Farmer, & Lewin, 2016). Other factors that may lead to the LEA may include severe injuries, associated with severe burns or motor vehicle accident, thickening of nerve tissues or neuroma, chronic infections that are resistant to antibiotics and another form of treatment, and frostbite (Ruff, 2017). The world is facing the challenge of diabetes patients, risking amputation making the World Health Organization and the International Diabetes Federation to increase their efforts in preventing amputation by training health practitioners in both developed and developing countries (Moxey et al., 2011).

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Procedure of Amputation

A surgical removal of the limb usually calls for an individual to stay in the hospital from 5 to 14 days (Cold et al., 2017). However, the period may exceed two weeks depending on the possible complications and surgery. Factors, such as general health status of the patient and the extremity or limb being amputated, make the surgical procedure vary. It can be conducted under spinal anesthesia by numbing the body from the waist downward or with general anesthesia. Medical practitioners, performing an amputation, remove all of the tissues that are damaged, ensuring that they leave healthy tissues.

Doctors evaluate several methods that are helpful in determining how much tissues need to be removed and where to cut (Goodney, Tarulli, Faerber, Schanzer, and Zwolak, 2015). These may include comparing temperatures of skin between the affected limb and the healthy one, looking for parts with reddened skin, and checking for a pulse near the area that the surgeon intends to cut. Additionally, they ardently check to see whether the skin close to the site planned to cut is still sensitive when touched.

During the surgical procedure, the doctor keenly removes the dead tissues and, possibly, any crushed bones. After that, the doctor smoothens the rough areas of the bone and seals off all blood vessels and nerves. He also cuts and shapes limb muscles, such that an attachment of an artificial limb to the stump can be performed. Surgeons may opt to close the wound immediately by sewing the flaps of skin or leaving the area open for some days to make it easier, if additional removal of tissues arises (Jones & Marshall, 2008). The team performing the surgery then covers the wound with a sterile dressing and puts a stocking over the stump to ensure that bandages and drainage tubes are in place. A doctor uses a splint to hold the limb in a position or place it in a traction.

Recovery from Amputation

The type of anesthesia and procedure used determines the rate of patient’s recovery from amputation. On the one hand, staffs in the hospital regularly change dressings on the wound. On the other hand, they may teach the patients how to change them (Wise, 2006). Doctors monitor the healing process of the wound in order to ensure that they detect any conditions, such as hardening of the arteries or diabetes that may interfere with the process (Cold et al., 2017). They also prescribe medications that aid in preventing infection and easing the pain. Sometimes the patient may experience pain in the amputated area or even grief over the missing leg and, in such a case, the doctor recommends the needed counseling and further medication, as required (Barbosa, Santos, Rebelo, Leite, & Matos, 2014).

In order to facilitate a faster healing, physical therapy is necessary, starting with moderate stretching exercises that should start soon after the surgical procedure. From ten to fourteen days after the operation, the patient should start practicing with the artificial limb. The average period for the absolute healing of the wound ranges between four to eight weeks. However, emotional and physical adjustment, resulting from the lower extremity amputation, involves a long process (G?k, Selek, Selek, G?d?k, & G?ner, 2016). Rehabilitation, as well as the long-term recovery, include exercising with the aim of enhancing control and strength of muscles, use of artificial legs and devices that are assistive, and engaging in activities that are helpful in restoring the patient’s ability to execute daily accomplishments and alleviating the dependency from others.

In the healthcare organizations, the role of nurses is to provide healthcare services and actively participate in the prevention, as well as early detection of non-communicable diseases, among which is diabetes and complications that follow (Burdette-Taylor, 2015). Nurses are the biggest health group, globally working at different levels of healthcare institutions. The primary roles of nurses encompass offering education to the community, provision of care services to patients, participating in the administration of health system, and providing health care to the people with a risk of lower extremity amputation, thus, improving their quality of life (Rees & Williams, 2009). Since diabetes foot ulcers are the leading cause of LEA, American Diabetes Association (ADA) advocates for multidisciplinary team approach, as a way of preventing diabetes complications and reducing amputation rates that would conserve a lot of money for the nation (Chiu et al., 2011). The nursing intervention goals in the diabetic foot care are meant to enhance the overall wellbeing of patients and community. Nurses integrate art and science in their effort to provide health care services and try to eliminate emotional, physical, mental, spiritual, and social-cultural necessities of a patient (Schaper, Van Netten, Apelqvist, Lipsky, & Bakker, 2016).

Role of Nurses in Identifying Patients with Factors of Risk of Lower Limb Amputation

The major factors associated with diabetic foot ulcers that can lead to LEA are peripheral vascular disease, peripheral neuropathy, and infections. More than 80% of leg wounds in patients with diabetes mellitus are caused by peripheral neuropathy, making it imperative for neurological examination, as the initial step of screening patients who have risks for foot ulcers (Monteiro-Soares, Martins-Mendes, Vaz-Carneiro, and Dinis-Ribeiro, 2015). It is the role of nurses to perform diabetic foot tests with monofilament and collaborating with other members of the diabetic foot team. Some nurses are specialized in the foot care, and they actively participate in the initial stages of treatment and care (Hippisley-Cox & Coupland, 2015). Other than conducting foot examination, they dress wounds, as well as encourage families and patients to take care of the wounds appropriately and to adhere to the follow-up schedule of regular visits. The fundamental goal of screening is to detect foot problems that lead to amputation and identifying those at risk and eventually lay out the plans to alleviate the risk (HRSA, 2013).

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Role of Nurses in Educating Patients with Diabetes

Internationally, nurses play an effective role in the prevention of foot wounds, related to diabetic and LEA through educational interventions, offering health care and screening individuals who are at high risk (Jones & Harding, 2015). Nurses try to ensure that all diabetic patients, particularly those at risk for foot ulcers, are conversant with the basics of foot care (Unger, 2013). Nurses teach their patients and the community on ways to conduct a physical test and how to take care of their feet regularly (Quinn, 2004). Additionally, nurses develop a comprehensive program that significantly assists patients to control their blood sugar and teach them about the severity of diabetic foot ulcers (Dubey, Mishra, & Khare, 2014).

Nurses Collaboration with Other Healthcare Providers

Nurses collaborate with doctors and surgeons among other healthcare providers in offering services to patients (Havens, Vasey, Gittell, and Lin, 2010). Effective care for diabetic foot ulcers is ought to be a complementary care, where dressing of wounds is selected judiciously, according to the type of injuries. Before dressing them, nurses consider whether they are wet or dry because it requires covering them, while cleaning and maintaining their moisture aiding in the debridement, as well as decreasing the number of bacteria in the wounds (Larsen, 2010). They do that in accordance with the doctor’s prescription.

Nurses Role in Diabetic Foot Care At Home

Other than identifying patients with factors of risk of lower limb amputation and educating them, nurses make a follow-up to the homes, especially to the individuals with visual impairment caused by diabetes among other chronic diseases because they cannot conclusively evaluate their feet (Hovan-Somborac, 2002). Diseases like the peripheral vascular lower sensations of feet and delay the healing process of wounds, making it challenging to take care of their feet. Nurses evaluate such complications, both at clinics and home visits (Meaney, 2012). While examining the feet of patients, whether, at home or the hospital, nurses are ought to have completed first evaluation list of patients and their health, limb movement, temperature, sensation, and color, among others (Seaman, 2005).

Role of Nurses in Rehabilitation

Therapists play a vital role in supporting patients with diabetic foot wounds to make movement and, particularly, those who have undergone the lower limb amputation (Edelstein, 2005). They are taught to encourage the patients on how to use the assistive devices (Amirmohseni & Nasiri, 2014). Consequently, they identify various types of assistive devices and their applications and introduce them to the patients, depending on their conditions to enhance their mobility (Zhang & Lv, 2015). In addition, nurses offer counseling services to patients, whose limb has been removed with the aim of helping them to adjust quickly, both emotionally and physically.

In the United States, the Health Resources and Services Administration department has developed a comprehensive program, LEAP to prevent lower extremity amputation. The program significantly reduces the number of amputations in persons with Hansen’s disease and diabetic foot ulcers, among other diseases (LEAP, n.d.). The program involves five steps that include:

Annual Foot Screening

This is the foundation of the prevention program, and it helps in identifying individuals who have lost protective sensation. Initial wounds are a result of injury to a limb that has lost sensation. Without protective sensation, injuries can even arise from regular walking. The screening process uses a 5.07 monofilament that exerts a force of 10 grams to identify a person, whose feet are at a risk of developing problems (LEAP, n.d.). Those at risk should be examined at least four times annually to minimize the chances of a problem occurring.

Patient Education

This step actively involves nurses in teaching patients skills of self-management. After learning the simple techniques, patients adopt personal responsibility and fully partner with nurses and other health care providers to prevent problems.

Daily Self-Inspection

This is an essential part of the self-management program, where every person who has lost protective sensation is ought to regularly and more efficiently examine their feet every day (Abu-Qamar, 2014). This is the only way of protecting feet in the absence of a system that warns about pain. It helps in detecting foot injuries and toenail problems, thus preventing a possibility of more serious problems.

Footwear Selection

Shoes come in different shapes and designs. A patient without the protective sensation should be very careful in selecting shoes. Improperly fitting or poorly designed shoes can cause serious complications to feet (van Netten et al., 2016). Shoes are ought to fit the shape of the foot. It is unadvisable for patients who have lost protective sensation to walk barefooted even in the house.

Management of Simple Foot Problems

This step involves cleaning the legs regularly and reporting all types of injuries to the healthcare providers.

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Discussion

Guyana is a nation in South America with people from different ethnic groups. It is the third poorest village in the region. All citizens are at a risk of developing diabetes, which can lead to lower limb amputation. According to Lowe et al. (2015), diabetes was estimated as a fourth leading cause of deaths in that country in the year 2008. By 2011, diabetes prevalence among adults had escalated up to 15.5% (Lowe et al., 2015). The study found that intervention by offering adequate healthcare and education that would enhance self-management to individuals with diabetes and foot ulcers significantly reduces the chances of lower limb amputation.

A paper by Bonner, Foster, and Spears-Lanoix (2016), reviewed published studies on foot care practices and knowledge interventions, as means of foot care for diabetes patients and self-management interventions. They found that understanding risk factors that can lead to amputation of the lower limb and prevent complications, as well as manage them significantly reduce the level of amputation (Arag?n-S?nchez et al., 2010). They further established that self-management outside clinical, as an effective measure to reduce LEA.

Chronic wounds place a substantial economic burden to the system of healthcare in the world by reducing the state of life for the afflicted people. Further, chronic wounds might proceed to serious complications that lead to premature deaths or lower limb amputation (J?rbrink et al., 2017). As the proportion of people living with lifestyle diseases, like diabetes, and together with a number of elderly people, the economic burden also increases. J?rbrink et al. (2017) established that proper understanding of economic and humanistic burden caused chronic wound is important for the purposes of policy planning that would help in monitoring the trend of the burden and formulate real-world new therapies and treatment that are considered as cost effective.

Win Tin, Lee, and Colagiuri, (2015) conducted a study to examine the existing evidence about health, epidemiology, the economic, and social repercussions of diabetes in countries of Pacific island and territories around it. Diabetes prevalence was about 40%, and leading risk factors included obesity, physical inactivity, and excessive weight (Win Tin et al., 2015). The high rate of complications, related to diabetes and poor clinical outcomes, was reported. The author suggested for intervention to enhance the outcomes, as well as the quality of diabetes care.

Internationally, an estimation of about two million lower extremity amputations is performed annually by causing an alarm to the health organizations. With the current diabetes prevalence, the International Diabetes Federation (IDF) predicts an escalation from 285 million to 435 million by the year 2030. In turn, this will increase the economic and human cost of lower extremity amputations, related to diabetes, where in the United States, approximately US$ 20 billion is used annually (Amirmohseni & Nasiri, 2014). In the United Kingdom and other developed countries, about 3% of the total health care expenditures are directed to care and treatment of chronic wounds.

Impact of Implementation of LEA Prevention

The implementation of LEAP will significantly reduce the burden the nurses have in providing health care to diabetic patients. This is because patients learn how to inspect themselves on a daily basis and learn about the simple tactics to manage mild problems on their legs (Global Lower Extremity Amputation Study Group, 2000). Additionally, the program enhances the awareness of nurses about problems of amputation, and they manage to serve more patients and even have time to visit those with visual impairment at their homes.

Conclusion

Lower Extremity Amputation (LEA) is a global problem caused by complications related to Diabetes Mellitus (DM) and other diseases, like the Peripheral Vascular Disease (PVD). Amputations related to the DM and PVD are very common in older adults. Moreover, smoking cigarettes for a prolonged period increases the risks of amputation because it damages the small blood vessels in legs. Increased level of lower limb amputation creates an economic burden on the healthcare system and the healthcare providers. A considerable proportion of health funds, allocated by governments, is directed to amputations, rather than enhancing health facilities. World Health Organization and other health organizational developed programs like LEAP to minimize the load. Implementation of LEAP program is important, because it encourages patients to regular screening and daily self-inspection and teaches them about the simple self-management techniques of diabetes. In addition, world governments will be saving a lot of money that can be used in other key projects of improving economic status.

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