PLP Nursing diagnosis

Since we have almost completed our journey through phantom limb pain, it is important to discuss the relevant nursing diagnosis relating to amputation and limb pain.  I found one of the best and most comprehensive examples from Nursing-Help.com.

Some relevant nursing diagnosis:

• Acute pain related to amputation
• Risk for disturbed sensory perception: phantom limb pain related to amputation
• Impaired skin integrity related to surgical amputation
• Disturbed body image related to amputation of body part
• Ineffective coping, related to failure to accept loss of body part
• Risk for anticipatory and/or dysfunctional grieving related to loss of body part
• Self-care deficit: feeding, bathing/hygiene, dressing/grooming, or toileting, related to loss of extremity
• Impaired physical mobility related to loss of extremity

Some of the most important goals:

• relief of pain
• absence of altered sensory perceptions
• wound healing
• acceptance of altered body image
• resolution of the grieving process
• independence in self-care
• restoration of physical mobility
• absence of complications

Interventions:

• Relieving pain
• Many different options for this
• Minimizing altered sensory perceptions
• Promote wound healing if recent amputation
• Enhancing body image
• Helping the patient achieve physical mobility

Expected outcomes:

• Experiences absence of pain
• appears relaxed
• verbalizes comfort
• uses measures to increase comfort
• Experiences absence of phantom limb pain
• reports diminished phantom sensations
• uses distraction techniques
• performs stump desensitization massage
• Achieves wound healing
• controls residual limb edema
• achieves healed, non-tender, non-adherent scar
• demonstrates residual limb care
• Demonstrates improved body image and effective coping
• acknowledges change in body image
• participates in self-care activities
• demonstrates increasing independence
• Exhibits resolution of grieving
• expresses grief
• works through feelings with family and friends
• focuses on future functioning
• participates in support group

Resource:

http://www.nursing-help.com/2011/03/amputation-and-nursing-care-plan.html

Nursing care of patients with PLP

How, as nurses, can we provide the best care for patients with phantom limb pain?

This is a difficult question.  One of the best ways a nurse can help a patient with PLP is by doing very thorough pain assessments.  Since nurses have the most contact time with a patient, we are better able to assess and provide updated treatment courses for patients in pain.

As nurses, we can help a patient with PLP, by finding other methods that could work to relieve their pain, other than pain medications (which don't work well for controlling PLP).  Some of these include distract, hot/cold packs, guided imagery, and exercise.  A lot of times, patients need moral support and encouragement to help them cope with the pain.  As nurses we can be there for patients to talk to and support.

According to one article, normalizing PLP and helping patients understand that it is a common occurrence can positively effect patients.  Furthermore, nurses dealing with patients who have PLP should keep up to date on treatment modalities involving imagery and imagining movement in the phantom limb, which have been shown to positively effect PLP.

(http://www.amputee-coalition.org/inmotion/jul_aug_04/massagetherapy.html)

References:

Fieldsen, D., & Wood, S. (2011). Dealing with phantom limb pain after amputation. Nursing Times, 107(1), 21-23.  

Richardson, C. (2008). Nursing aspects of phantom limb pain following amputation. Br J Nursing British Journal of Nursing, 17(7), 422-426.  

Treatments for PLP

Alright, so phantom limb pain hurts, and its common. So what do we do to treat phantom limb pain?

This is a very complicated task.  Since PLP is a chronic pain, neuropathic pain, normal pain medication such as opiates/opioids don't work.  Even though they are commonly prescribed, those types of pain medications poorly treat chronic types of pain.  There really are no great ways to treat neuropathic types of pain.

One randomized control trial looked at the effects of a combined approach to treat PLP that included training of progressive muscle relaxation, mental imagery, and phantom exercises 2 times/wk for 4 weeks.  The control group did the same exercises, but on the residual limb.  The participants were given a questionnaire on their pain repeatedly throughout the trial.  The results showed a significant decrease in all of the domains the researchers included in their questionnaire in the experimental group, but no change in the control group.  Another significant aspect of this study is that these patients were not receiving any pharmacological treatment for their pain.

(http://www.deltaholistics.com/holistictouch/tag/progressive-muscle-relaxation/)

(http://www.ireflex.co.uk/mirrorboxtherapy.com/how-its-used/)

References:

Brunelli, S., Morone, G., Iosa, M., Ciotti, C., De Giorgi, R., Foti, C., & Traballesi, M. (2015). Efficacy of Progressive Muscle Relaxation, Mental Imagery, and Phantom Exercise Training on Phantom Limb: A Randomized Controlled Trial. Archives Of Physical Medicine & Rehabilitation, 96(2), 181-187. doi:10.1016/j.apmr.2014.09.035

Signs and Symptoms of PLP

Since its, Star Wars day:

(http://onearmchick.blogspot.com/2013_08_01_archive.html)

We have briefly touched on the common symptoms of phantom limb pain.

In about 50-80% of all amputees, there will be some sort of pain present in the part of the body that no loner exists.  There are also some non-painful phantom sensations that may include a specific position, shape, or movement of the phantom, feelings of warmth or cold, itching, tingling, or electric sensations, and other paraesthesias.

The pain that is felt in the phantom limb seems to be more intense in the distal portions of the phantom limb and can have several different qualities, such as stabbing, throbbing, burning, or cramping.

Rates are variable, some clinical research studies have found that phantom pain decreases years after the surgery, but sometimes the phantom limb pain can actually get worse years after the surgery.

(http://www.scienceshorts.com/020208.htm)

References:

Flor, H. (2002). Phantom-limb Pain: Characteristics, Causes, And Treatment. The Lancet Neurology, 1(3), 182-189.

Diagnosis of PLP

Diagnosing phantom limb pain is a rather subjective endeavor.

There is no specific medical test to diagnose this disease, it is purely based on your medical history and the description of your pain (onset, pattern, location, etc).  Because of this, it is very important to document the characteristics of your pain and write them down.  Every time pain is felt, do your best to describe it in as much detail as possible.  Then, the next time you visit your PCP, give them or read them your pain log.  This will give them the best chance to diagnose your disease.

(http://www.bfe.org/protocol/pro05eng.htm)

Phantom Limp Pain Pathophysiology

While there are many theorized mechanisms for the existence of phantom limb pain (PLP), the exact 

mechanism is not known.  In this post, I will cover a few of the main theories and attempt to explain some possible origins of PLP.  However, as with most things in the human body, the mechanism that controls PLP is likely an amalgamation of mechanisms that work together to cause the symptoms of this disease.

(http://www.amazingsuperpowers.com/2012/08/en-garde/)

Three of the main theories are :

The peripheral theory, which assumes that PLP originates at the nerves around the injury.
When tissues are injured, chemicals and enzymes create an inflammatory process and sensitize the pain receptors.  Neurotransmitters are released around the site of damage, which then activates neighboring nerve endings.  This causes nerves not originally involved in the damage to become involved and expands the area of the body the pain perceives.  In normal tissue, this sensitization resolves spontaneously, but in damaged tissue it leads to neuropathic pain such as PLP.

The spinal theory, which attributes the cause to changes in the spinal cord.
Amputation damages the nerves which causes a hyperexcitability in the CNS, manifesting as an increase in neuronal firing, changes in the structure of the sensory neurons, and a reduction in the normal spinal cord inhibitory processes.
 
The central theory, which assumes that PLP is caused by some mechanism in the brain.
This theory is grounded in the idea of remapping of the somatosensory cortex of the brain.  Basically, when damage occurs and an area of the brain is no longer receiving impulses from a section (where the amputation was), the brain will "rewire" itself and interpret sensations from other parts of the body in the missing limb.  This is evident when a part of the body is touched, but the amputee feels it in their amputated limb.  


(http://kin450-neurophysiology.wikispaces.com/Phantom+Limbs+II)

References:

Chapman, S. (2011). Pain management in patients following limb amputation. Nursing Standard, 25(19), 35-40.

What do the numbers look like for Phantom Limb Pain?

In order to look at the prevalence of phantom limb pain, we obviously have to look through the numbers of amputations that occur.
Amputations that occur in the United States occur due to vascular disease, complications to diabetes, trauma and cancer.
According to a study conducted looking into the future projections of amputations, there were approximately 1.6 million in 2005 and a projected number of amputations greater that 3.6 million by 2050. The increase is attributable to the increasing numbers of older adults and the high number of older adults living with vascular disease.
In general, men are more likely than women to have a limb amputated for any reason.
Table 1 displays these values:

So why do these numbers matter and where do they fit with phantom limb pain?

According to one of the studies I researched, of the surgical amputations that occurred in the United States, approximately 70% of the patients experience phantom limb pain after the procedure.  Furthermore, and more significantly, 50% of the patients experience continued pain 5 years after the surgery.  

As we can see, the prevalence of phantom limb pain, and persistent limb pain, is a significant proportion of amputees, whose numbers are going to continue to grow into the future.  

References:
Bloomquist, T. (2001). Amputation and phantom limb pain: a pain-prevention model. AANA Journal, 69(3), 211-217.

Ziegler-Graham, K., MacKenzie, E., Ephraim, P., Travison, T., & Brookmeyer, R. (2008). Estimating the prevalence of limb loss in the United States: 2005 to 2050. Archives Of Physical Medicine & Rehabilitation, 89(3), 422-429.