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.