A Case Presentation:

Above Knee Amputation

(AKA) and Below Knee
Amputation (BKA)
I. Objectives
• A. Nurse Centered
To better understand the disease process, how the disease is
acquired, how it progresses, the signs and symptoms, the treatment
needed at the nursing responsibilities.

• B. Patient Centered
To gain knowledge on how the client developed the disease,
the different kinds of treatment involved and to comply to
instructions prescribed to treat the disease.
 “AMPUTATION”
is defined as the intentional surgical removal of
a limb or body part.
 Above Knee Amputation (AKA)

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.
 Below Knee amputation (BKA)

a surgical procedure
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 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.
 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.
 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.
 III. Patient’s Data
Name : Mr. JMR
Age : 43 y/o
Address : San. Nicolas II 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
• 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.
IX. Physical Examination History
General Appearance

Patient is not having fever, conscious, coherent, responsive when

being asked. He has a slender body type; voice is clear when he
talks and appears 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.
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
• 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).
 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.
 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.
 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.
 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.
 “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.
Signs and symptoms:

Examples of hard signs that should be

documented and investigated include pulsatile
bleeding, the presence of a rapidly expanding
hematoma, a palpable thrill as well as the
presence of any of the classic signs of obvious
arterial occlusion (pulselessness, pallor,
paresthesia, pain, paralysis, poikilothermia)t.
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.
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.

The nurse acknowledges the loss by listening and

providing support.
 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 patient is encouraged to be an active participant in

self-care.
Medical reasons why a patient may not be a good
candidate for a BKA:
• Poor blood flow

• Infections or tumors that extend above the knee

• Scar tissue or skin and muscle loss

• Limited knee function or knee pain

• Patients who already do not walk or stand

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
 “5 STAGES OF GRIEF”

Denial and Isolation

Anger

Bargaining

Depression

Acceptance
Medical management of physiologic outcomes:

• Wound Management
The purpose of the dressing is to help control swelling,
protect your incision and promote wound healing.

• 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
VI. Diagnostics and Laboratory Examinations

Complete Blood Count with Blood Typing:

• WBC: 3.9
• RBC: 5.18
• Hbg: 15.5
• Hct: 39.1
• Platelet: 494
• Blood Type: O
Drug Study:

• Tramadol 50mg T.I.V q12

Opiod analgesic

• Ceftriaxone 1g, 1 vial T.I.V q12

(anti-infectives) Cephalosporin
Nursing Care Plan:
• Acute pain

• Impaired physical mobility related to loss of extremity as

manifested by slowed movements

• Self-care deficit related to loss of extremity

• Disturbed body image related to amputation of body part

• Risk for disturbed sensory perception

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/topicovervi
ew
• 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.
THANK YOU!!