ADAMSON UNIVERSITY

Manila, Philippines

College of Nursing

A Case Presentation:
Above Knee Amputation (AKA) and
Below Knee Amputation (BKA)

Submitted by:
Tapnio, Crizzel Ann C.

BSN IV

Submitted to:

Dr. Almira A. Tenorio RN, MAN, MAED

I. Objectives of the case study

A. Nurse-centered

At the end of the study, the student nurses will be able to:

General Objective:

To better understand the disease process, how the disease is acquired and how it
progresses, the signs and symptoms that are manifested, the treatment for the condition,
and the nursing responsibilities.

Specific Objectives:

 Define what Above Knee Amputation (AKA) and Below Knee Amputation
(BKA) are
 Trace the pathophysiology of Mangled Extremity
 Enumerate the different signs and symptoms of Mangled Extremity
 Formulate and apply nursing care plans utilizing the nursing process
 Learn new clinical skills as well as sharpen current clinical skills required in
the management of Mangled Extremity

B. Patient-centered
At the end of the study, the client will be able to:
General Objective:
Gain knowledge on how the client developed the disease, the different kinds of
treatments involved, and comply to instructions prescribed to treat the disease.

Specific Objectives:
 Gain better understanding of the treatment involved for AKA and BKA.
 Identify different alternative treatment methods
 Demonstrate compliance to the treatment management
 Determine the effectiveness and the appropriateness of the treatment
given.
II. Introduction
“I have two hands, the left and the right” is a song which cannot be sung by an
amputated patient. A patient who has been amputated because of one of the following
reasons: (1) accident (2) in born or (3) sickness.

According to the freedictionary.com, amputation is defined as the intentional

surgical removal of a limb or body part. It is performed to remove diseased tissue or
relieve pain. Arms, legs, hands, feet, fingers, and toes can be amputated. Most
amputations involve small body parts such as a finger, rather than an entire limb.

Amputation is performed for the following reasons:

 to remove tissue that no longer has an adequate blood supply

 to remove malignant tumors
 because of severe trauma to the body part

Amputation is performed to relieve pain to stop blood loss and prevent infection
after the limb undergoes severe damage to prevent the spread of bone cancer and to
prevent the spread of gangrene as a complication to injuries, frostbite, diabetes, or any
other sickness that causes impairment to blood circulation. (Brunner & Suddarth’s,
Medical Surgical Nursing, Volume 1, 13th edition.)

Above-Knee Amputation (AKA) is a surgical procedure performed to remove the

lower limb at or above the knee joint when that limb has been severely damaged via
trauma, disease, or congenital defect. Most transfemoral amputations are performed due
to peripheral vascular disease (a complication of diabetes), or severe disease of the
circulation in the lower limb. Poor circulation limits healing and immune responses to
injury.

Below-Knee Amputation (BKA) is an amputation often performed for foot and

ankle problems. The BKA often leads to the use of an artificial leg that can allow a patient
to walk. A BKA is performed roughly in the area between the ankle and knee. This
amputation provides good results for a wide range of patients with many different
diseases and injuries.

Amputations require a complete health assessment to check for infections, blood

sugar abnormalities, and use of blood thinning medications, allergies to anesthesia, pain
medications, or antibiotics to prevent any complications after the procedure. Amputations
cannot be performed on patients with infection, heart failure, uncontrolled diabetes
mellitus, or those with blood clotting disorders. (Retrieved:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3535134/)

More than 90% of amputations performed in the United States are due to circulatory
complications of diabetes. Sixty to eighty percent of these operations involve the legs or
feet. Although attempts have been made in the United States to better manage diabetes
and the foot ulcers that can be complications of the disease, the number of resulting
amputations has not decreased.
In Philippines, DOH states that amputation commonly happens to only three types
of patients, a patient who has complications regarding his/her sickness (i.e. diabetes),
congenital defects or a patient who has been in severe trauma causing the need to
remove the affected limb.

This case study that will be discuss is about amputation due to a motor vehicle
accident as evidenced by the patient who is the primary focus of this research. According
to the World Health Organization, Motor vehicle accidents are among the top 5 risk factors
of death and one of the top two reasons of amputation. In the Philippines however,
vehicular accidents, which is also included in the general category of Physical Accidents,
ranks as the second in causing the death of millions of Filipinos for the year 2018.

According to the National Limb Loss Information Center, almost two million people
are living with a limb amputation in the United States as of September 6, 2018. The loss
of a limb can create a lifetime of complications, decrease functioning, and cause
emotional distress. In some cases, it may permanently change certain aspects of a
person’s life. But the loss of a limb does not just affect the individual who suffered the
amputation; it also affects the entire family. (https://www.ahcmedia.com/articles/140552-
traumatic-amputations)

Some current statistics (as of 2018) about Mangled extremity are the following; it is
estimated that there are 2.1 million people living with limb loss in the USA, and that
number is expected to double by 2050.185,000 people have an amputation each year.
This means that 300 to 500 amputations are performed every day. Around 30% of
people with limb loss experience depression and/or anxiety. 85% of lower limb
amputations are proceeded by a foot ulcer. (https://www.ahcmedia.com/articles/140552-
traumatic-amputations).
III. Patient’s Data

Name : Mr. JMR

Age : 43 y/o
Address : San. Nicolas II Magalang, Pampanga
Religion : Roman Catholic
Occupation :None
Height :5’ 6”
Weight :160 lbs.
Time and date of Admission: 4AM 01-18-19
Admitting Diagnosis : Mangled Left lower extremity, fracture closed complete left
femur secondary to vehicular accident.

Present Health History

Few minutes prior to confinement, patient got into a vehicular accident. The patient
was riding a motorcycle when he was hit by a truck.

Past Health History

He never experience chickenpox, mumps, measles during his childhood. There is
no known allergy to any food and drugs. As common illness, he suffers from colds, coughs
and fever. In times when he feels any aforementioned illness: he will just increase her
oral fluid intake and he would usually take over the counter drugs such as paracetamol
for fever and Ambroxol for severe coughs until her condition minimizes.

Developmental History

Age Development Patient’s Behavior

Infancy Trust vs. Mistrust Reported that he grew up normally as a
young kid, demonstrated a normal steady
(birth to 18
growth. Nourished with breast milk for a
months)
year and a half.

Toddler Autonomy vs. Can fully walk alone without holding onto
Shame and Doubt support bars at the age of 1 year and 8
(18 months to 3
months. Was claimed to be very anxious
years)
about many things and enjoys playing
alone. Very negativistic about many things.

Preschooler Initiative vs. Guilt Play was the most important activity of the
day. Started to go along with peers and
(4 to 5 years old)
look for adventures. At this age, he can
manage to wash himself alone and toilet
training was established.

School Age Industry vs. Started grade 1 at the age of 6 years old.
Inferiority He enjoyed the company of his friends and
(6 to 12 years old)
also loves to study. Shows interest in
studying and playing.

Adolescent Self-Identity vs. This was marked as the most memorable

Role confusion time of the patient’s life especially that at
(12 to 18 years
this stage, he had already experienced boy
old)
to girl relationship.

Early adult Intimacy vs. Already got married at the age of 22 years
Isolation old. And he had 3 children; some were
(20 to 40 years
already professional and some got married
old)
and have children too.
At Present Now, it’s his concern to have more
grandchildren and his children would raise
them properly. He is ever glad that his
family has been very supportive in these
times.

Physical Examination History

General Appearance
Patient is not having fever, conscious, coherent, responsive w h e n
being asked. He has a slender body type; voice is clear when he talks
a n d a p p e a r s relaxed and comfortable.
Skin. Patient has cool and has good skin turgor. There is absence of rashes and itchiness
and no change in skin color.
Head. Patient is normocephalic, proportion to the body. Sometimes he
experienced headache but was relieved by taking OTC medications. There is even
distribution of hair and has slightly dry hair but has no presence of flakes.
Eyes. He has pinkish, palpable conjunctiva, does not wear glasses and has clear vision
with absence of eye infection.
Ears. Symmetrical, non-tender and smooth texture.
Nose. The nose is at the midline of the face, palpable, with no presence of swelling. He
also experienced colds due to weather conditions.
Mouth. He does not wear any dentures but experiences toothaches sometimes
due to lack of oral care.
Neck .There was no presence of neck stiffness or pain. It can move regularly and there is
no sign of swelling.
Upper Extremities. Warm and has good skin turgor, smooth texture, and non-tender.
Breast. There was absence of lumps, nipple discharge, scales or cracks around
the nipples.
Lungs. He has no cough, his not wheezing or having any lung disease.
Abdomen. Flabby, soft and non-tender
Lower Extremities. He has impaired mobility thus he really needs assistance upon
movement.
GENITOURINARY SYSTEM. No presence of sexually transmitted disease. Fore skin
retracts easily. Testicles are sensitive to pressure firm, smooth and equal in size. No
swelling, lesions, itching noted in the reproductive area.
NEUROLOGIC SYSTEM. Has clear thinking and has slight changes in emotional
state such as changes in mood and sometimes being irritable because of his health
condition. Has a good sense of memory and shows no signs of speech problems.
ENDOCRINE SYSTEM. He is able to tolerate cold and hot temperature; he is above the
normal appropriate body mass index.

IV. ANATOMY AND PHYSIOLOGY

Bones of the Foot

The human foot is a very complex and highly developed structure. The bones of
the foot provide mechanical support for the soft tissues, helping the foot withstand the
weight of the body.

The bones of the foot can be divided into three categories:

Tarsals – A set of seven

irregularly shaped bones.
They are situated proximally
in the foot, in the ankle area.

Metatarsals – These bones connect the phalanges to the tarsals. There are five in
number – one for each digit.

Phalanges – The bones of the toes. Each toe has three phalanges – a proximal,
intermediate and distal (except the big toe, which only has two phalanges).
 The Femur

The femur is the only bone in the thigh. It is classed as a long

bone, and is the longest bone in the body. The main function of the
femur is to transmit forces from the tibia to the hip joint.

It acts as the site of origin and attachment of many muscles

and ligaments, and can be divided into three areas; proximal, shaft
and distal.

Patella

The patella (knee-cap) is

located at the front of the knee joint,
within the patellofemoral groove of the
femur. Its superior aspect is attached
to the quadriceps tendon, and inferior
aspect to the patellar ligament.

It is classified as a sesamoid type bone due to its position within the quadriceps
tendon, and is the largest sesamoid bone in the body.
 Tibia

The tibia is the main bone of the leg, forming

what is more commonly known as the shin. It
expands at the proximal and distal ends, articulating
at the knee and ankle joints respectively.

It is the second largest bone in the body, this

is due to its function as a weight bearing structure.

Fibula

The fibula is a bone located within the lateral aspect of the leg. Its main function is
to act as an attachment for muscles, and not as a weight-bearer.

It has three main articulations:

Proximal tibiofibular joint – articulates with the

lateral condyle of the tibia.

Distal tibiofibular joint – articulates with the

fibular notch of the tibia.

Ankle joint – articulates with the talus bone of the

foot.
MUSCLES

Fascia Lata

Fascia is defined as a sheet or band of fibrous tissue lying deep to the skin that
lines, invests and separates structures within the body. There are three general
classifications of fascia:

Superficial fascia: blends with the

reticular layer beneath the dermis.

Deep fascia: envelopes muscles, bones

and neurovascular structures.

Visceral fascia: provides membranous

investments that suspend organs within
their cavities.

Muscles of the Gluteal Region

The gluteal region is an anatomical area located posteriorly to the pelvic girdle, at
the proximal end of the femur. The muscles in this region move the lower limb at the hip
joint.

The muscles of the gluteal region can be broadly divided into two groups:

Superficial abductors and extenders – A group of large muscles that abduct and
extend the femur. Includes the gluteus maximus, gluteus medius, gluteus minimus and
tensor fascia lata.

Deep lateral rotators – A group of smaller muscles that mainly act to laterally rotate the
femur. Includes the quadratus femoris, piriformis, gemellus superior, gemellus inferior
and obturator internus.
 Muscles in the Anterior Compartment of the Thigh

The musculature of the thigh can be split into three

sections; anterior, medial and posterior. Each compartment has
a distinct innervation and function.

The muscles in the anterior compartment of the thigh are

innervated by the femoral nerve (L2-L4), and as a general rule,
act to extend the leg at the knee joint.

There are three major muscles in the anterior thigh – the

pectineus, Sartorius and quadriceps femoris. In addition to these, the end of the iliopsoas
muscle passes into the anterior compartment.
 Muscles of the Medial Compartment of the Thigh

The muscles in the medial compartment of the thigh

are collectively known as the hip adductors. There are five
muscles in this group; gracilis, obturator externus, adductor
brevis, adductor longus and adductor magnus.

All the medial thigh muscles are innervated by

the obturator nerve, which arises from the lumbar plexus.
Arterial supply is via the obturator artery.

Muscles of the Posterior Compartment of the Thigh

The muscles in the posterior compartment of

the thigh are collectively known as
the hamstrings. They consist of the biceps femoris,
semitendinosus and semimembranosus,
which form prominent tendons medially and
laterally at the back of the knee.

As group, these muscles act to extend at the

hip, and flex at the knee. They are innervated by
the sciatic nerve (L4-S3).

Muscles of the Anterior Compartment of the Leg

There are four muscles in the anterior

compartment of the leg; tibialis anterior, extensor
digitorum longus, extensor hallucis longus and fibularis
tertius.

Collectively, they act to dorsiflex and invert the

foot at the ankle joint. The extensor digitorum longus
and extensor hallucis longus also extend the toes. The
muscles in this compartment are innervated by the deep fibular nerve (L4-L5), and blood
is supplied via the anterior tibial artery.

Muscles in the Lateral Compartment of the Leg

There are two muscles in the lateral compartment of the

leg; the fibularis longus and brevis (also known as peroneal
longus and brevis).

The common function of the muscles is eversion – turning

the sole of the foot outwards. They are both innervated by the
superficial fibular nerve.

Muscles in the Posterior Compartment of the Leg

The posterior compartment of the leg contains

seven muscles, organized into two layers
– superficial and deep. The two layers are separated
by a band of fascia.

The posterior leg is the largest of the three

compartments. Collectively, the muscles in this
area plantarflex and invert the foot. They are innervated by the tibial nerve, a terminal
branch of the sciatic nerve.

Muscles of the Foot

The muscles acting on the foot can be divided into two distinct groups; extrinsic
and intrinsic muscles
 The extrinsic muscles arise from the anterior, posterior and lateral compartments
of the leg. They are mainly responsible for actions such as eversion, inversion, plantar
flexion and dorsiflexion of the foot.

The intrinsic muscles are located within the foot and are responsible for the fine
motor actions of the foot, for example movement of individual digits.

NERVES

The Lumbar Plexus

The lumbar plexus is a network of nerve fibers that

supplies the skin and musculature of the lower limb. It is
located in the lumbar region, within the substance of
the psoas major muscle and anterior to the transverse
processes of the lumbar vertebrae.The plexus is formed by
the anterior rami (divisions) of the lumbar spinal nerves L1,
L2, L3 and L4. It also receives contributions from thoracic
spinal nerve 12.
The Sacral Plexus

The sacral plexus is a network of nerve fibers that

supplies the skin and muscles of the pelvis and lower
limb. It is located on the surface of the posterior pelvic
wall, anterior to the piriformis muscle.

The plexus is formed by the anterior

rami (divisions) of the sacral spinal nerves S1, S2, S3 and
S4. It also receives contributions from the lumbar spinal
nerves L4 and L5.

The spinal nerves S1 – S4 form the basis of the

sacral plexus.

Femoral Nerve The femoral nerve is

one of the major peripheral nerves of the lower
limb.

Nerve Roots: L2-L4

Motor: Innervates the anterior thigh muscles that

flex the hip joint (pectineus, iliacus, sartorius)
and extend the knee (quadriceps femoris: rectus
femoris, vastus lateralis, vastus medialis and
vastus intermedius),

Sensory: Supplies cutaneous branches to the

anteromedial thigh (anterior cutaneous
branches of the femoral nerve) and the medial side of the leg and foot (saphenous nerve).
 The Obturator Nerve

The obturator nerve is a

major peripheral nerve of the lower limb.

Nerve roots: L2-L4

Motor: Innervates the medial (adductor)

compartment of the thigh.

Sensory: Cutaneous branch innervates the skin of

the medial thigh.

The Sciatic Nerve

The sciatic nerve is a major nerve of the lower limb. It is a thick flat band,
approximately 2cm wide – the largest nerve in the body. In this article, we shall look at
the anatomy of the sciatic nerve – its anatomical course, motor and sensory functions,
and its clinical correlations.

Nerve Roots: L4-S3.

Motor: Innervates the muscles of the posterior thigh

and the hamstring portion of the adductor magnus.
Indirectly innervates (via its terminal branches) the
muscles of the leg and foot.

Sensory: No direct sensory functions. Indirectly

innervates (via its terminal branches) the skin of the
lateral leg, heel, and both the dorsal and plantar
surfaces of the foot.
The Common Fibular Nerve

Nerve roots: L4 – S2

Motor: Innervates the short head of the biceps femoris

directly. Also supplies (via branches) the muscles in the
lateral and anterior compartments of the leg.

Sensory: Innervates the skin over the upper lateral and lower
posterolateral leg. Also supplies (via branches) cutaneous
innervation to the skin of the anterolateral leg, and the
dorsum of the foot.

The Superficial Fibular Nerve

Nerve roots: L4-S1

Motor: Innervates the muscles in the lateral compartment of the leg.\

Sensory: Supplies the vast majority of the skin over the dorsum of the foot, apart from the
webbing between the hallux and the second digit. It also supplies the anterior and lateral
aspect of the inferior third of the leg.

The Deep Fibular Nerve. The deep

fibular nerve (also referred to as the
deep peroneal nerve) is a nerve of
the leg. It is one of the terminal
branches of the common fibular
nerve.

Nerve roots: L4 and L5.

Motor function: Innervates the

muscles in the anterior compartment
of the leg, as well as some of the
intrinsic muscles of the foot.
Sensory function: Supplies the triangular region of skin between the 1st and 2nd toes.

BLOOD VESSELS AND LYMPHATICS

ARTERIES OF THE LOWER LIMB

In the Thigh and Gluteal Region

Femoral Artery

The main artery of the lower

limb is the femoral artery. It is a
continuation of the external iliac
artery (terminal branch of the
abdominal aorta). The external
iliac becomes the femoral artery
when it crosses under the inguinal
ligament and enters the femoral
triangle.

In the femoral triangle, the profunda femoris artery arises from the posterolateral aspect
of the femoral artery. It travels posteriorly and distally, giving off three main branches:

Perforating branches – Consists of three or four arteries that perforate the adductor
magnus, contributing to the supply of the muscles in the medial and posterior thigh.

Lateral femoral circumflex artery – Wraps round the anterior, lateral side of the femur,
supplying some of the muscles on the lateral aspect of the thigh.

Medial femoral circumflex artery – Wraps round the posterior side of the femur,
supplying its neck and head. In a fracture of the femoral neck this artery can easily be
damaged, and avascular necrosis of the femur head can occur.

After exiting the femoral triangle, the femoral artery continues down the anterior
surface of the thigh, via a tunnel known as the adductor canal. During its descent the
artery supplies the anterior thigh muscles.
 The adductor canal ends at an opening in the adductor magnus, called
the adductor hiatus. The femoral artery moves through this opening, and enters the
posterior compartment of the thigh, proximal to the knee. The femoral artery now known
as the popliteal artery.

In the Leg

The popliteal artery descends down the posterior

thigh, giving off genicular branches that supply the knee
joint. It moves through the popliteal fossa, exiting
sandwiched between the gastrocnemius and popliteus
muscles. At the lower border of the popliteus, the popliteal
artery terminates by dividing into the anterior tibial artery
and the tibioperoneal trunk. The tibioperoneal trunk then
divides into the posterior tibial and fibular arteries.

The posterior tibial artery continues inferiorly, along

the surface of the deep muscles (such as tibialis posterior).
It accompanies the tibial nerve in entering the sole of the
foot via thetarsal tunnel. The fibular artery moves laterally
from its point of origin, penetrating the lateral compartment
of the leg. It supplies muscles in the lateral compartment,
and adjacent muscles in the posterior compartment.

The other division of the popliteal artery, the

anterior tibial artery, passes anteriorly between the tibia
and fibula, through a gap in the interosseous membrane.
It then moves inferiorly down the leg. It runs down the
entire length of the leg, and into the foot, where it becomes
the dorsalis pedis artery.
In the Foot

Arterial supply to the foot is delivered via two arteries:

Dorsalis pedis (a continuation of the anterior tibial artery)

The dorsalis pedis artery begins as the anterior tibial artery enters the foot. It
passes over the dorsal aspect of the tarsal bones, then moves inferiorly, towards the sole
of the foot. It then anastomoses with the lateral plantar artery to form the deep plantar
arch. The dorsalis pedis artery supplies the tarsal bones and the dorsal aspect of the
metatarsals. Via the deep plantar arch, it also contributes to the supply of the toes.

Posterior tibial

The posterior tibial artery enters the sole of the foot through the tarsal tunnel. It
then splits into the lateral and medial plantar arteries. These arteries supply the plantar
side of the foot, and contributes to the supply of the toes via the deep plantar arch.

The Foot and Leg

The main venous structure of the foot is

the dorsal venous arch, which mostly drains
into the superficial veins. Some veins from the
arch penetrate deep into the leg, forming
the anterior tibial vein.

On the plantar aspect of the

foot, medial and lateral plantar veins arise.
These veins combine to form the posterior
tibial and fibular veins. The posterior tibial vein
accompanies the posterior tibial artery, entering
the leg posteriorly to the medial malleolus.

On the posterior surface of the knee, the anterior tibial, posterior tibial and fibular
veins unite to form the popliteal vein. The popliteal vein enters the thigh via the adductor
canal.
The Thigh

Once the popliteal vein has entered the thigh, it is known as the femoral vein. It is
situated anteriorly, accompanying the femoral artery.

The deep vein of the thigh (profunda femoris vein) is the other main venous
structure in the thigh. Via perforating veins, it drains blood from the thigh muscles. It then
empties into the distal section of the femoral vein.

The femoral vein leaves the thigh by running underneath the inguinal ligament, at
which point it is known as the external iliac vein.

The Gluteal Region

The gluteal region is drained by inferior and superior gluteal veins. These empty
into the internal iliac vein.

THE SUPERFICIAL VEINS OF THE LOWER LIMB

The superficial veins of the lower limb run in the subcutaneous tissue. There are
two major superficial veins – the great saphenous vein, and the small saphenous vein.

The Great Saphenous Vein.

The great saphenous vein is formed by the dorsal

venous arch of the foot, and the dorsal vein of the great
toe. It ascends up the medial side of the leg, passing
anteriorly to the medial malleolus at the ankle, and
posteriorly to the medial condyle at the knee.

As the vein moves up the leg, it receives

tributaries from other small superficial veins. The great
saphenous vein terminates by draining into the femoral
vein immediately inferior to the inguinal ligament.

Surgically, the great saphenous vein can be harvested and used as a vessel in
coronary artery bypasses.
The Small Saphenous Vein

The small saphenous vein is formed by the dorsal venous arch of the foot, and the
dorsal vein of the little toe. It moves up the posterior side of the leg, passing posteriorly
to the lateral malleolus, along the lateral border of the calcaneal tendon. It moves between
the two heads of the gastrocnemius muscle and empties into the popliteal vein in
the popliteal fossa.

LYMPHATIC DRAINAGE OF THE LOWER LIMB

The lymphatic system functions to drain tissue fluid, plasma proteins and other
cellular debris back into the blood stream, and is also involved in immune defence. Once
this collection of substances enters the lymphatic vessels it is known as lymph; lymph is
subsequently filtered by lymph nodes and directed into the venous system.

The lymphatic vessels of the lower limb can be divided into two major groups;
superficial vessels and deep vessels. Their distribution is similar to the veins of the lower
limb.

SUPERFICIAL LYMPHATIC VESSELS

The superficial vessels can be divided into two major subsets; (i) medial vessels,
which closely follow the course of the great saphenous vein and; (ii) lateral vessels which
are more closely associated with the small saphenous vein.

Medial Vessels

The medial group originate on the dorsal surface of the foot. They travel up the
anterior and posterior aspects of the medial lower leg, with the great saphenous vein,
passing with it behind the medial condyle of the femur. This group of vessels ends in the
groin, draining into the sub inguinal group of the inguinal lymph nodes.

Lateral Vessels. The lateral vessels arise from the lateral surface of the foot and either
accompany the small saphenous vein to enter the popliteal nodes, or ascend in front of
the leg and cross just below the knee joint to join the medial group.
DEEP LYMPHATIC VESSELS

These are far fewer in number than their superficial counterparts and accompany
the deep arteries of the lower leg. They are found in 3 main groups: anterior tibial,
posterior tibial and peroneal following the corresponding artery respectively, and entering
the popliteal lymph nodes.

Superficial Inguinal Nodes

These form a line directly below the inguinal ligament and

receive lymph from the penis, scrotum, perineum, buttock and
abdominal wall.

Superficial Sub-Inguinal Nodes

These are located on each side of the proximal section of

the great saphenous vein. They receive afferent input primarily
from the superficial lymphatic vessels of the lower leg.

Deep Sub-Inguinal Nodes

These are often found in one to three in number and are

most commonly found on the medial aspect of the femoral
vein. The afferent supply to these nodes is from the deep
lymphatic trunks of the thigh which accompany the femoral
vessels.

POPLITEAL NODES

The popliteal lymphatic nodes are small in size, usually

between five and seven in number, and are often found imbedded in fat reserves in
the popliteal fossa. They receive lymph from the lateral superficial vessels.
 V. THE PATIENT AND HIS ILLNESS
a. Pathophysiology
a.1 Schematic Diagram (Book-Based)
Non-modifiable
factors:
 Age (adolescents)
 Sex (male)
1. Restore anatomic
alignment of extremity NO
2. Neurovascular
assessment
Evidence of
YES
vascular injury?
Modifiable factors:
Vehicular  Inexperienced driver
Accident (first licensed)
 Secondary tasks
(texting, dialing,
Mangled reaching for an object,
Extremity looking at a roadside
object, eating)
 Night time/driving
 Presence of teenage
Initial
passengers
Evaluation
 High speed driving
 Alcohol
Control active
hemorrhage
To OR for emergent
Persistent hemorrhage or YES
operative exploration
hemodynamic instability
and vascular control
CTA to exclude Intraluminal NO Criteria for immediate
or define shunt as amputation present?
vascular injury needed
Synthesis of the disease

Mangled Extremity

The term “mangled extremity” refers to an injury to an extremity so severe that the
viability of the limb is often questionable and loss of the limb a likely outcome. The
mangled extremity has been previously defined as a complex fracture with additional
involvement of at least two of the following: artery, tendon, nerve, or soft tissue (skin, fat,
and muscle). This injury is always a result of high-energy trauma caused by some
combination of crush, shear, and/or blast.

The skin is often degloved with large areas of loss secondary to avulsion or
ischemia and the fascial compartments are typically incompletely opened by explosion or
tear. Muscles are typically damaged at both local and regional levels by direct as well as
indirect injury. Furthermore, soft tissue planes are usually extensively disrupted and,
when present, contaminants generally infiltrate all of these tissue planes. Not only are the
injury patterns themselves complex, but the medical, psychological, and socioeconomic
impacts that these injuries have on the patient make their management a difficult task,
even in the most experienced of hands.

Although most of the advances that have taken place in the management of the
mangled extremity have occurred during times of war, the majority of limb-threatening
injuries seen in practice today are the result of high-speed motor vehicle collisions.
Injuries to the lower and upper extremities occur more frequently than head injuries in
motorcycle crashes.59 Modification of passenger restraints, vehicle safety engineering,
and the legislation of seatbelt and air bag protection appear to be decreasing the mortality
rate associated with motor vehicle crashes. As a result, the incidence of severe lower
extremity trauma may be increasing.

Severe mangled foot injuries are rare in civilian patients and these injuries have
not been widely studied. Both civilian and military clinicians have determined that the
extent of the soft tissue injury is the major deciding factor for salvage versus amputation
of the mangled foot. Keeling et al. suggested that an assessment by at least two surgeons
with limb salvage experience is the most consistent way to decide whether a limb has the
potential to be saved.

Ellington et al. reported on 174 open severe hind foot or ankle injuries that were
part of the prospective LEAP study, of which 116 were salvaged and 58 had a below-
knee amputation (BKA). Using the SIP as the major outcome measure at 2 years, patients
with foot injuries that required flaps or ankle fusions did significantly worse than the BKA
patients. Shawen et al. also noted that foot injuries requiring free flaps and patients whose
pain management require large doses of narcotics or nerve blocks had the worst clinical
outcomes.

There is insufficient literature to determine what is salvageable in the foot and at

what level the amputation should be performed. In our hands, most patients with mangled
feet with severe soft tissue injuries rarely undergo free flap coverage. The most common
reason for this is the low success rates of microvascular anastomosis in the distal lower
extremity. Because of the high rates of infection in the setting of a severe
unreconstructable soft tissue envelope of the foot many patients end up with BKAs.

(Predisposing/Precipitating factors)

Predisposing (Non-modifiable) factors:

According to the World Health Organization, people aged between 15 and 44 years
account for 48% of global road traffic deaths. From a young age, males are more likely to
be involved in road traffic crashes than females. About three quarters (73%) of all road
traffic deaths occur among young males under the age of 25 years who are almost 3
times as likely to be killed in a road traffic crash as young females.

Motor vehicle (MV) crashes are the leading cause of death among US adolescents
aged 16 to 19 (Olsen et al., 2017).

Teenage drivers have higher crash rates than older drivers (National Highway
Traffic Safety Administration, 2016), making motor vehicle crashes the leading cause of
mortality and a major cause of injury for U.S. teenagers. (as cited by Simons-Morton et
al., 2016).

Precipitating (Modifiable) factors:

The high crash rates of novice teenage drivers are thought to be due to early age
at licensing, inexperience, and youthful risk taking, exacerbated by complex driving
conditions. Both age at licensure and inexperience seem to make independent
contributions to the high rate of crashes among novice drivers. Newly licensed drivers of
any age experience high rates of crashes that decline rapidly for a period of months, and
then more slowly for a period of years. However, the older the age at licensure, the lower
the initial crash rate and the faster the decline. Despite a decline over time among
novices, crash rates, particularly among teenagers, remain elevated relative to
experienced adults throughout the early years of driving (Simons-Morton et al., 2011).

In addition to young age and inexperience, crash rates are also higher under
certain driving conditions, such as passengers and driving at night. Speeding and other
risky driving behaviors are commonly associated with crashes among young drivers.
Similarly, crash risk is higher in the presence of teenage passengers, particularly teenage
male passengers, and is lower in the presence of adult passengers. Through their actions
or manner, passengers can increase or decrease attention to the driving task and exert
direct pressure to drive in a more or less risky or safe way. (Simons-Morton et al., 2011).

According to a study by Klauer et al. (2018), their analysis showed that the
performance of secondary tasks, including dialing or reaching for a cell phone, texting,
reaching for an object other than a cell phone, looking at a roadside object, and eating,
was associated with a significantly increased risk of a crash or near-crash among novice
drivers. Among experienced drivers, only dialing a cell phone was associated with an
increased risk. The secondary tasks associated with the risk of a crash or near-crash all
required the driver to look away from the road ahead.

Alcohol is a depressant of the CNS, meaning it slows activity down. Does this
surprise you? Many people think that alcohol is a “pick-me-up” experience because,
initially, when people begin to drink, it causes them to become more animated and less
reserved. But the opposite occurs as they continue to drink and more alcohol enters the
brain.

Signs and symptoms with rationale

The mangled extremity has been previously defined as a complex fracture with
additional involvement of at least two of the following: artery, tendon, nerve, or soft tissue
(skin, fat, and muscle). This injury is always a result of high-energy trauma caused by
some combination of crush, shear, and/or blast.

Associated fractures usually verify the high-energy forces of the mechanism of

injury by exhibiting extensive comminution patterns frequently a result of a combination
of three point bending, axial load, and torsional forces imparted to the extremity.

The skin is often degloved with large areas of loss secondary to avulsion or
ischemia and the fascial compartments are typically incompletely opened by explosion or
tear.

Muscles are typically damaged at both local and regional levels by direct as well
as indirect injury. Furthermore, soft tissue planes are usually extensively disrupted and,
when present, contaminants generally infiltrate all of these tissue planes.

Limb-threatening injuries are often associated with vascular insult. Arterial injuries
usually present with either hard or soft signs suggestive of injury. Examples of hard signs
that should be documented and investigated include pulsatile bleeding, the presence of
a rapidly expanding hematoma, a palpable thrill, or audible bruit, as well as the presence
of any of the classic signs of obvious arterial occlusion (pulselessness, pallor,
paresthesia, pain, paralysis, poikilothermia).

A compartment syndrome is not uncommon after restoration of arterial inflow to an

ischemic and traumatized limb. The diminished arterial inflow during the ischemic period
combined with the “reperfusion injury” that occurs after arterial repair can result in
interstitial fluid leakage and elevated compartment pressures.
(CLINICAL INTERVENTION)

Description of prescribed surgical treatment performed

Amputation is the surgical removal of all

or part of a limb or extremity such as an arm,
leg, foot, hand, toe, or finger. The goal of
amputation is to remove unhealthy tissue and
create a remaining leg that is less painful and
more useful. Amputation can improve quality
of life for many patients. A below-knee
amputation (BKA) is an amputation often
performed for foot and ankle problems. The
BKA often leads to the use of an artificial leg
that can allow a patient to walk. A BKA is
performed roughly in the area between the ankle and knee. This amputation provides
good results for a wide range of patients with many different diseases and injuries. A BKA
is performed when a patient is severely injured or has a severe infection. Other reasons
for amputation can include non-healing ulcers, chronic pain, birth defects and tumor. The
decision to amputate involves many factors and is done after a thorough discussion
between patient and orthopaedic surgeon.

Indication of prescribed surgical treatment

There are many reasons an amputation may be necessary. The most common is
poor circulation because of damage or narrowing of the arteries, called peripheral arterial
disease. Without adequate blood flow, the body's cells cannot get oxygen
and nutrients they need from the bloodstream. As a result, the affected tissue begins to
die and infection may set in. The reason for amputation in this study is a severe injury
from a vehicle accident.

Amputation is the treatment of choice for diseased limbs and devastating lower-
extremity injuries for which attempts at salvage and reconstruction may be lengthy,
emotionally and financially costly, and have a less-than-satisfactory result. Lower-
extremity amputations may be performed for the following reasons:

 Peripheral vascular disease (PVD)

 Trauma
 Tumors
 Infections

Whatever the indication for amputation, the goal remains length preservation and
surgical reconstruction that maintains the most functional limb possible.

Trauma

Although safer equipment exists and improvements in limb salvage surgery have
been made, traumatic limb loss continues to occur because of industrial and motor vehicle
accidents. These accidents involve high-grade open fractures with associated nerve
injury, soft-tissue loss, and ischemia and unreconstructable neurovascular injury. In this
setting, limb salvage may initially be successful, only to end in an infected painful
extremity that affects the patient's activities of daily living and work. Attempts at limb
salvage are often made with less-than-favorable results, leaving the patient with an
extremity that is less functional than a prosthesis would be and resulting in workdays lost
and expense in treatment.
Severe open (IIIc) fractures with popliteal artery and posterior tibial nerve injuries
can be treated with current techniques; however, treatment is at a high cost, and multiple
surgeries are required. The result is often a leg that is painful, nonfunctional, and less
efficient than a prosthesis.

There are many medical reasons why a patient may not be a good candidate for a
BKA. Below is a list of some of the more common reasons.

 Poor blood flow: Patients with poor blood flow should not undergo an operation
without proper evaluation before surgery. Adequate blood flow is necessary for
wound healing. This may mean a referral to a vascular specialist before surgery is
 considered. Medical problems: Severe heart or lung disease, a poor immune
system or bleeding problems may be reasons to not have surgery.
 Infections or tumors that extend above the knee: In cases where an infection or
tumor goes above the knee joint, a higher level of amputation may be required.
 Scar tissue or skin and muscle loss: Patients with scarring, tissue grafting or tissue
loss may not be candidates for a BKA. Such patients may not have adequate skin
or muscle to heal a wound or to use an artificial leg.
 Limited knee function or knee pain: Patients who cannot straighten their knee or
have pain and giving way at the knee may find it difficult to use an artificial leg.
 Patients who already do not walk or stand due to other reasons may not benefit
from a BKA.

Risk Complication

 Pain
 Infection
 Blood clot
 Necrosis
 Joint contracture

Required instruments, devices, supplies, equipment, and facilities

a. Scalpel – used to cut on skin and muscle tissue to create a surgical incision.

b. Needle holder – A needle holder, also called needle driver, is a surgical instrument,
similar to a hemostat, used by doctors and surgeons to hold a suturing needle for
closing wounds during suturing and surgical procedures.
c. Needle – is a medical device used to hold body tissues together after an injury or
surgery. Application generally involves using a needle with an attached length of
thread.

d. Thumb forceps – are commonly held between the thumb and two or three fingers
of one hand, with the top end resting on the first dorsal interosseous muscle at the
base of the thumb and index finger. Spring tension at one end holds the grasping
ends apart until pressure is applied. This allows one to quickly and easily grasp small
objects or tissue to move and release it or to grasp and hold tissue with easily
variable pressure. Thumb forceps are used to hold tissue in place when applying
sutures, to gently move tissues out of the way during exploratory surgery and to
move dressings or draping without using the hands or fingers.
e. Tissue forceps – are used in surgical procedures for grasping tissue. Often, the tips
have "teeth" to securely hold a tissue. Typically tissue forceps are designed to
minimize damage to biological tissue.

f. Metzenbaum – are surgical scissors designed for cutting delicate tissue and blunt
dissection.

g. Army navy – is a surgical instrument with which a surgeon can either actively
separate the edges of a surgical incision or wound, or can hold back underlying
organs and tissues, so that body parts under the incision may be accessed.
h. Mayo curve – are a type of surgical scissor, often used in the cutting of fascia.

i. Curve clamp – used by surgeons and medical professionals to cut off blood flow or
other fluids during surgery.

j. Mesh – There are many types of mesh products available, but surgeons typically
use a sterile, woven material made from a synthetic plastic-like material, such as
polypropylene. The mesh can be in the form of a patch that goes under or over the
weakness, or it can be in the form of a plug that goes inside the hole..
 k. Suction tubes – is an instrument used to remove large quantities of fluid from
surgical sites during procedures.

l. Drill/Bone saw – is a surgical instrument used to cut or remove bones.

Perioperative tasks and responsibilities of the Nurse

Pre-operative Responsibilities:

 Evaluate the neurovascular and functional status of the extremity through history
and physical assessment.
 Assess the circulatory status and function of the unaffected extremity
 Any concurrent health problems (e.g., dehydration, anemia, cardiac insufficiency,
chronic respiratory problems, and diabetes mellitus) need to be identified and
treated so that the patient is in the best possible condition to withstand the trauma
of surgery.
 The nurse assesses the patient’s psychological status. Determination of the
patient’s emotional reaction to amputation is essential for nursing care.
Intra-operative Responsibilities:

 Identify the patient.

 Position the patient.
 Ensure safety of the patient.
 Maintain surgical asepsis. Proper handling of equipment.

Post-operative Responsibilities:

 Changing the patient’s position or placing a light sandbag on the residual limb to
counteract the muscle spasm may improve the patient’s level of comfort
 Keeping the patient active helps decrease the occurrence of phantom limb pain.
Early intensive rehabilitation and stump desensitization with kneading massage
brings relief. Distraction techniques and activity are helpful.
 The residual limb must be handled gently. Whenever the dressing is changed,
aseptic technique is required to prevent wound infection and possible
osteomyelitis.
 The nurse who has established a trusting relationship with the patient is better able
to communicate acceptance of the patient who has experienced an amputation.
 The nurse encourages the patient to look at, feel, and then care for the residual
limb.
 The nurse acknowledges the loss by listening and providing support.
 The patient is encouraged to be an active participant in self-care.
 Positioning assists in preventing the development of hip or knee joint contracture
in the patient with a lower extremity amputation. Abduction, external rotation, and
flexion of the lower extremity are avoided.
 The nurse assesses body systems (e.g., respiratory, gastrointestinal,
genitourinary) for problems associated with immobility (e.g., pneumonia, anorexia,
constipation, urinary stasis) and institutes corrective management. Avoiding
problems associated with immobility and restoring physical activity are necessary
for maintenance of health.
Expected outcomes of surgical treatment performed

As a new amputee it is normal to experience a variety of emotions following

surgery. You may feel sad and even depressed. If you have suffered intense pain for a
long time before surgery you may feel relieved despite the loss of your limb. All of these
emotions are normal. Regardless of the nature of your limb loss, feelings of depression
will soon be replaced by the will to once again resume an active lifestyle.

Depression is not the same for everybody. Some people describe depression as
a feeling of emptiness and despair. Others experience an overwhelming sense of
helplessness, hopelessness or anger. Some people don’t act out emotionally, but may
feel apathetic or even restless.

If you are struggling with the loss of your limb you may benefit from counseling to
help you work through the 5 stages of grief. Below are the 5 stages of grief. Reading
through these stages may help you understand where you are at in the acceptance of
your loss.

 Denial and Isolation

 Anger
 Bargaining
 Depression
 Acceptance

If you are having trouble working through the acceptance of losing a limb and you
would like help from a social worker, counselor or psychologist, please ask your physician
or therapist to refer you to someone who can help. How well you do during the limb loss
rehabilitation process can depend a lot on your ability to accept your loss.

Medical management of physiologic outcomes

Wound Management

After the amputation there will be a post-operative dressing on your amputated

limb (residual limb). The purpose of the dressing is to help control swelling, protect your
incision and promote wound healing. You may also have a drainage tube in place to
remove fluids and help with healing. Your health care team will take care of these
dressings for you.

Your role in wound management includes the following:

 Notify your nurse if your dressing becomes soiled or you notice any leakage of
 Drainage.
 Wash your hands well with soap and water or hand sanitizer if you come in
 Contact with drainage.
 Make sure everyone who comes in contact with your wound wears gloves and
 Washes his/her hands before and after a dressing change.
 Be careful when moving in bed, getting in and out of bed to avoid dislodging
 Dressings or drainage tubes.
 Notify the nursing staff if dressings become loose or dislodged.
 Eat a good diet. Tissues cannot heal without good nutrition.
 Tell your health care team if you experience pain during the care of your wound.

By working together, you and your rehab team can establish a medication
schedule that will minimize your discomfort during dressing changes.

Pain Management

It is normal to feel some pain following an amputation. This is the result of the
surgical trauma to bone, nerve, and soft tissue. As with any major surgery postoperative
pain can be expected to resolve in the first few weeks. This pain is often described as
sharp, is localized to the surgical site. It resolves as the edema decreases and wound
heals. In the immediate postoperative period the primary method of pain control is
medication.

Your health care team will help you with other activities to manage pain. This may
include the use of compression garments, exercises and other therapeutic activities. It is
not unusual following an amputation to experience sensations in the limb that is gone.
This is normal. If these sensations are painful, let your health care team know. There are
specific medications and therapeutic activities that may help with this kind of pain.

Managing pain is important. If you are in pain you will be less willing to do the
things you need to do to maximize your recovery.

Nursing management of physiologic, physical, and psychosocial outcomes

Lower extremity amputations are most commonly performed because of advanced

chronic peripheral arterial disease. Amputation can relieve signs and symptoms, improve
function, and maintain or improve the patient's quality of life. Most postoperative nursing
care priorities are the same as for any surgical patient: assessing and maintaining the
patient's airway, breathing, and circulation; monitoring vital signs; managing pain; taking
steps to prevent respiratory complications and venous thromboembolism; and watching
for signs and symptoms of hemorrhage.

After surgery, the patient will have a soft dressing or a rigid dressing made of
fiberglass or plaster. Assess the surgical dressing for integrity and drainage. Elevate the
stump for the first 24 to 48 hours.

Move and turn the patient gently and slowly to prevent severe muscle spasms.
Reposition the patient every 2 hours, turning the patient from side to side and prone, if
possible. Lying prone helps reduce hip flexion contractures. Avoid placing pillows
between the patient's legs or under the back.

Unwrap the stump dressing every 4 to 6 hours for the first 2 days postoperatively
as prescribed and then at least once daily. Assess the stump for signs and symptoms of
infection and skin irritation or breakdown. Assess the color, temperature, and most
proximal pulse on the stump before rewrapping it, comparing findings to the contralateral
extremity.

Before rewrapping the stump, provide periwound skin care as ordered, but avoid
lotion. Wrap the stump when it's elevated to prevent edema and vascular stasis. Follow
your facility's policy for replacing the bandage, such as every 2 to 4 days or sooner if it
becomes soiled.
 Help the patient perform range-of-motion and muscle-strengthening exercises.
Encourage the patient to push the residual limb into a soft pillow, then into a firmer pillow,
and finally against a hard surface to prepare for prosthesis fitting and to reduce the
incidence of phantom limb pain and sensation.

Encourage the patient to eat a well-balanced diet. Provide emotional support and
patient teaching to help your patient deal with altered body image and lifestyle changes.
Help with the grieving process.

VI. Diagnostics and Laboratory Examinations

Result Normal Findings Interpretation

WBC: 3.9 3.7-10.6 White blood cell (WBC)
count. White blood cells
protect the body against
infection. If an infection
develops, white blood cells
attack and destroy the
bacteria, virus, or other
organism causing it. White
blood cells are bigger than
red blood cells and normally
fewer in number. When a
person has a bacterial
infection, the number of
white cells can increase
dramatically.
RBC: 5.18 4.19-5.21 Red blood cell (RBC) count.
Red blood cells carry
oxygen from the lungs to
the rest of the body. They
also carry carbon dioxide
 back to the lungs so it can
be exhaled. If the RBC
count is low (anemia), the
body may not be getting the
oxygen it needs. If the count
is too high (a condition
called polycythemia vera),
there is a risk that the red
blood cells will clump
together and block tiny
blood vessels (capillaries).
Hbg: 15.5 12.5-16.0 Hemoglobin (Hgb).
Hemoglobin is the major
substance in a red blood
cells. It carries oxygen and
gives the blood cell its red
color. The hemoglobin test
measures the amount of
hemoglobin in blood and is
a good indication of the
blood's ability to carry
oxygen throughout the
body.
Hct: 39.1 38.8-49.7 Hematocrit (HCT, packed
cell volume, PCV). This test
measures the amount of
space (volume) red blood
cells occupy in the blood.
The value is given as a
percentage of red blood
cells in a volume of blood.
 For example, a hematocrit
of 38 means that 38% of the
blood's volume is
composed of red cells
Platelet: 494 1.5-4.5 Platelet (thrombocyte)
count. Platelets
(thrombocytes) are the
smallest type of blood cell.
They play a major role in
blood clotting. When
bleeding occurs, the
platelets swell, clump
together, and form a sticky
plug that helps stop the
bleeding. If there are too
few platelets, uncontrolled
bleeding may be a problem.
If there are too many
platelets, there is a risk of a
blood clot forming in a blood
vessel. Also, platelets may
be involved in hardening of
the arteries
(atherosclerosis).

Examination Result Purpose

1. Chest X-ray Normal chest X-ray shows To note if the lung has been
normal size and shape of affected and so as to
the chest wall and the main answer questions of there
structures in the chest. is presence of DOB.
 White shadows on the
chest X-ray signify solid
structures and fluids such
as, bone of the rib
cage,vertebrae, heart,
aorta, and bones of the
shoulders. The dark
background on the chest X-
rays represents air filled
lungs. These lung fields are
seen on either side of the
heart and the vertebrae
located in the center of the
film
2. Complete Blood Count WBC: 3.9 For baseline and
with Blood Typing RBC: 5.18 monitoring of blood clotting
Hbg: 15.5 factors and infection and
Hct: 39.1 for possible blood
Platelet: 494 transfusion.
Blood Type: O
X. Implications of the Case Study

A. Nursing Education

The care study provides the academe of nursing education the opportunity to
focus on how to engage in care management of Above Knee Amputation (AKA) and
Below Knee Amputation (BKA). And to renew the idea of dealing patients easily, instead
we must set much more effort in dealing with them because this is the times when they
need more support.

B. Nursing Practice

The care study provides a wider venue for nursing students to develop and enrich
their skills and knowledge in rendering efficient and effective care. It sharpens our abilities
in performing nursing measures to be rendered to our respective clients. Thus, provides
us satisfactory exposure that can’t be paid by any means.

C. Nursing Research

The care study helps in further investigation and research to optimize nursing care
and expand the scope of nursing practice. Thus, continued investigation is further
encouraged on the ultimate predisposing factor of having Above Knee Amputation (AKA)
and Below Knee Amputation (BKA).

XI. References/ Bibliography

Insurance Institute for Highway Safety (IIHS). (2012). Fatality facts 2010:
Teenagers. Retrieved September 19, 2013,
from http://www.iihs.org/iihs/topics/t/teenagers/topicoverview

Simons-Morton, B. G., Lerner, N., & Singer, J. (2005). The observed effects of teenage
passengers on the risky driving behavior of teenage drivers. Accident Analysis and
Prevention, 37(6), 973–982.
Klauer, S. G., Guo, F., Simons-Morton, B. G., Ouimet, M. C., Lee, S. E., & Dingus, T. A.
(in press). Distracted driving and crash risk among novice and experienced drivers. New
England Journal of Medicine.

Simons-Morton, B. G., Quimet, M. C., Zhang, Z., Klauer, S. E., Lee, S. E., Wang, J., et
al. (2011). The effect of passengers and risk-taking friends on risky driving and
crashes/near crashes among novice drivers. Journal of Adolescent Health, 49, 587–593.

National Highway Traffic Safety Administration. (2012). Alcohol-impaired driving. Traffic

Safety Facts: 2010 Data. (NHTSA Publication No. DOT HS 811 606). Retrieved
September 18, 2013, from http://www-nrd.nhtsa.dot.gov/Pubs/811606.pdf (PDF - 792K)

Klauer, S. G., Simons-Morton, B., Lee, S. E., Quimet, M. C., Howard, E. H., & Dingus, T.
A. (2011). Novice drivers' exposure to known risk factors during the first 18 months of
licensure: The effect of vehicle ownership. Traffic Injury Prevention, 12, 159–168.

Simons-Morton, B. G., Bingham, C. R., Ouimet, M. C., Pradhan, A., Falk, E., Li, K. -G., et
al. (in press). The effect of teenage passengers on simulated risky driving among
teenagers: A randomized trial. Health Psychology.

O'Malley Olsen, E., Shults, R. A., & Eaton, D. K. (2013). Texting while driving and other
risky motor vehicle behaviors among US high school students. Pediatrics, 131, e1708–
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https://www.ahcmedia.com/articles/140552-traumatic-amputations

Brunner & Suddarth’s, Medical Surgical Nursing, Volume 1, 13th edition.

https://nurseslabs.com/4-amputation-nursing-care-plans/

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