Building a successful support group for post-amputation patients.

The purpose of this article is to identify five steps to attain a successful amputee support group and share the process for establishing and maintaining a peer visitation program for in-patient amputees. Whatever the cause, losing a limb is a life-changing event that one should not go through alone. Support groups can assist patients and their families through this transition in a positive and healthy way.     

A family-centered critical care unit

Although care of the family has long been a focus of nursing, there has been an increased emphasis in recent years to provide opportunities for families to be an integral part of the hospitalization experience. This has been difficult for many nurses who perceive themselves as competent to care for a patient in "medical crisis" but feel unqualified to provide family care. This article will address issues related to implementing a family-centered philosophy of care in a critical care unit. Implementation strategies that will be discussed include: formulating a staff-led family support group and family committee, instituting a family visitation contract within open visitation parameters, and developing clinicians with expertise in family care. Tools such as a performance plan for a Clinical Nurse II specializing in family care and the family visitation contract will be shared.     

Visitation policies in the ICU: a time for change

The belief that visitation restrictions in the ICU are for the patient's good is not fully supported by research. However, there are no firm conclusions regarding how visitation decisions should be made. This paper suggests that decisional control over visitation be given to the patient and that, with the nurse functioning as a patient advocate, individualization of visitation be practiced. It is up to nursing to institute changes in visitation of the critical care patient.     

Implementation and sustainment strategies for open visitation in the intensive care unit: A multicentre qualitative study

ObjectiveOpen visitation in adult intensive care units has been associated with improved family and patient outcomes. However, worldwide adoption of this practice has been slow and reasons for this are unclear. This study documents barriers and strategies for implementing and sustaining open visitation in adult intensive care units in the United States experienced by nursing leadership.Research designQualitative approach using grounded theory.ParticipantsNurse leaders in adult intensive care units with open visitation.SettingMagnet® or Pathway to Excellence® designated hospitals in the United States.MethodsSemi structured interviews were conducted with 19 nurse leaders from 15 geographically dispersed hospitals. Interviews were recorded, transcribed and imported into Atlas.ti qualitative software for analysis. Grounded theory constant comparison analysis was used for coding and category development.FindingsThe analysis revealed three barriers; nursing attitudes and clinical and nonclinical barriers. Strategies to overcome these barriers were empathy, evidence-based practice, models of care, shared governance, nurse discretion, security and family spaces.ConclusionIntensive care nursing leadership experienced distinct barriers and strategies during pre-implementation, implementation and sustainment of open visitation. Other nursing leaders interested in open visitation can use these findings as they plan this transition in their intensive care units.     

Patient, visitor, and nurse evaluations of visitation for adult postanesthesia care unit patients

Although PACU visitation for children is sometimes encouraged, most families of adult postoperative patients continue to be excluded from PACUs in this country. At an academic medical center, an open visitation policy for adult postoperative patients was evaluated by eliciting patient, visitor, and nurse evaluations of visitation for adult patients from 181 families. Commonly cited reasons for restricting PACU visitation were not identified as problems by the vast majority of respondents. Even when some aspect of a PACU visit was disturbing, patients and families expressed a desire for visitation. The results of this evaluation of a change in practice led to permanent implementation of an open visitation policy in this PACU.     

An amputee visitor program as an adjunct to rehabilitation of the lower limb amputee.

Based on evaluation of the rehabilitative needs of patients who have had a leg amputated because of cancer, an amputee visitor program was developed. The visitor is a cancer amputee who has successfully completed rehabilitation. About 5 days after a patient's amputation, the visitor sees the patient, telling of personal experiences, answering the patient's questions, and showing the prosthesis. The visitor later evaluates the visit on a data collection sheet. From 1 to 6 months after the visit, the patient and, if possible, a relative are interviewed to determine their long-term reaction to the program. During a 30-month period, 65 new patients were seen and evaluated by two visitors. Sixty (92%) responded favorably to the visit. In follow-up interviews with 36 patients, 33 (92%) said the visit substantially improved their outlook. In summary, our data indicate that the amputee visitor contributes significantly to rehabilitation.     

Visitation in critical care: processes and outcomes of a performance improvement initiative

When family members became dissatisfied with a restrictive visiting policy in a combined coronary and medical intensive care unit, this situation was seen as an opportunity to better meet patient and family needs. A review of the literature indicated that open visitation policies enhance patient and family satisfaction, while a survey of patients, families, and health care team members revealed a desire for a more open visitation policy. Nursing staff, with input from other disciplines, developed and implemented a less restrictive visitation policy. Post-intervention surveys revealed higher patient and family satisfaction and a marked decrease in formal complaints.     

New perspectives on nursing lower limb amputees

New perspectives on nursing lower limb amputees arise from the author's researches into amputee rehabilitation and a summary of other recent research findings. These are dealt with in the context of basic amputee treatment and the nursing process. There is new material on the psychological and neurological sequelae of amputation, the practical problems of loss of a limb and the prosthetic dimension of treatment. The patients' reactions to lower limb amputation were found to vary from intense grief to intense relief, many noting it to be of minor or moderate consequence. The model of sudden and shocking loss is largely incorrect. Attention is drawn to an unrecognized ordinariness which should become part of amputee nursing. Patients have many practical problems. These are social and economic, personal and domestic. The ward environment is unsuited to these needs but, working closely with therapists, nurses can do much to facilitate amputee rehabilitation. The modern purpose of amputation surgery is prosthetic replacement. Nurses should be working with some urgency towards uniting patient and prosthesis. Pain and discomfort are underestimated and research shows them to be a major characteristic of amputation continually and for many years after surgery. A variety of pain syndromes are involved.     

Stubby prostheses: an alternative to conventional prosthetic devices

Stubby prostheses offer potential advantages over conventional prosthetic devices in terms of safety, stability, and energy efficiency. Although cosmesis is compromised in the process, these short nonarticulated pylon prostheses may be a viable option to consider in bilateral A-K or knee disarticulation amputee patients under the following circumstances: (1) as a training tool to determine whether progression to full-length articulated devices is feasible; (2) as permanent prostheses for the patient whose primary need for ambulation is within his own home; (3) for the elderly bilateral amputee in whom ambulation is feasible but safety and energy efficiency are of particular importance; and (4) as a definitive device in the patient who expresses a preference for them. Two patients who have become successful users of stubby prostheses are presented to illustrate these points.     

Rehabilitation of patients with end-stage renal failure after lower extremity amputation

Four patients with end-stage renal failure on maintenance hemodialysis and one patient with near end-stage renal failure received inpatient rehabilitation following lower extremity amputation. All were prosthetically restored. Three of the patients had bilateral below-knee amputations and were ambulatory at the time of discharge, including the patient with near end-stage renal failure who was on maintenance hemodialysis at follow-up. One unilateral below-knee amputee was also ambulatory at discharge. The other unilateral below-knee amputee had an ulcer on the other foot and used a pylon for transfers only. To assess the prevalence of patients on maintenance hemodialysis with lower extremity amputations, a survey of 310 patients at four dialysis units was performed. Of the 310 patients 2.9 percent had at least one amputated lower extremity and 1.0 percent had bilateral lower extremity amputations. Preliminary data and the potential for functional results following prosthetic restoration suggest the need for further research concerning prosthetic restoration in the lower extremity amputee with end-stage renal failure.     

Contracting for visitation with families

Visitation in adult critical care units is an important aspect of patient care, and thus should be incorporated into the patient's plan of care. There is no longer a question as to whether visitation should be liberalized or restricted; instead, visitation is individualized in each situation to best meet the patient's needs. One method of incorporating visitation into the care plan is by contracting with patients and family members.     

Visitation in the intensive care unit: impact on infection prevention and control

Evidence-based practice has shown that open visitation in the intensive care setting positively impacts patient outcomes. However, many intensive care units continue to strictly limit visitation hours. One concern for nurses is that open visitation will expose their vulnerable patients to an increased risk of infection. This fear is unfounded in professional literature as well as in the experience of a busy intensive care unit in San Antonio, Texas. Keeping our patients safe from hospital-acquired infections requires vigilant attention to infection prevention procedures. Meanwhile, what may actually be bugging our patients is a health care culture that is based on tradition and is blind to the many benefits provided by a more liberal visitation policy rooted in patient-centered care.     

Open visitation policies and practices in US ICUs: can we ever get there?

Open visitation has been highly recommended by critical care groups but is not prevalent in practice. Here we discuss the present study on current visitation practices in US ICUs and discuss several factors affecting open visitation. We conclude with suggestions on achieving more liberal visitation practices.In a previous issue of Critical Care, Liu and colleagues embark upon a timely and important topic: visitation practices in US ICUs [1].There are many benefits to open visitation. Patients feel supported [2] and safe [3]. Families are more satisfied with care and are less anxious [4]. Healthcare providers have increased opportunities for communication and teaching [2]. Because of these benefits, open and unrestricted visitation in ICUs has been recommended by critical care groups [5,6]. However, Liu and colleagues report that almost all US ICUs (90%) have restrictive visitation policies, and most (62%) have three or more restrictions. What is disconcerting is that these findings are not all that different from those reported in 2007, where only 32% of ICUs had open visitation [7]. Even this statistic is misleading, because ''open'' referred only to the hours of visitation, and most ICUs considered open had restrictions on age and the number of visitors [7]. Liu and colleagues'' findings are also consistent with those from other countries where very few, if any, ICUs have open visitation policies [8,9]. With all of the evidence guiding practice toward open visitation, why is it that most ICUs continue to have restrictions on visitation? There are several factors to be considered before ICUs truly embrace open visitation.One factor is the ICU patient. Open visitation has been studied from the perspective of the family and the healthcare provider, but very few studies have focused on the patient''s perspective. Because ICU patients are often unable to communicate their preferences about visitation, they are often excluded from research studies. However, Olsen and colleagues interviewed 11 ICU patients to gain their perspective on visitation [10]. These patients stated that they felt supported when their families were present and were in favor of flexible visitation. Yet most patients wanted some limitations, such as having only close family members visit. In addition, these patients felt stressed when trying to communicate with visitors and when thinking about how upsetting this experience was for their families [10]. Recently, Hardin and colleagues surveyed 122 ICU patients on their satisfaction with unrestricted visiting hours [11]. Their results support those of Olsen and colleagues, since most patients wanted some restrictions and control over visitation. These two studies on the patient''s perspective indicate that the patient''s voice needs to be heard when developing visitation policies.Another factor is the potential contributions of visiting ICU family members to the well-being of their loved ones. Interviews of 25 family members of 24 high risk of dying ICU patients showed that families took on certain roles while in the ICU and that they were physically and actively present in their loved ones'' care [12]. These families reported that they were physically and actively present in their loved ones'' care. Families'' contributions included protecting the patient, facilitating information, providing necessary patient history, comforting and motivating the patient, and performing caregiving activities. As a result, families believed the patient felt safer and more supported if they were present. Others have found that families can contribute to patient care by keeping ICU diaries for the patient [13]. In families that kept diaries, researchers reported significantly lower post-traumatic stress symptoms in both patients and family members 12 months after the ICU stay [13]. Families can also contribute to patient care by participating in patient rounds. Investigators assessing this approach reported improved family satisfaction with communication and decision-making, both of which are important needs for families [14]. Families have much to offer, and allowing them open visitation could help them fulfill their roles, contribute to patient care, and decrease patient and family symptoms.One more factor is the healthcare provider. In a study comparing healthcare providers'' beliefs and attitudes toward open visitation, researchers found that nurses were generally not in favor of it [15]. Nurses feared losing control of their ICU room and felt that visits did not offer more comfort and support to the family. They also felt that open visitation hindered patient rest, infringed on patient privacy, and was an impediment to the nurses doing their job [15]. In addition, there is a great deal of inconsistency among healthcare providers in the level of comfort they have in communicating with families. For example, those who feel more comfortable working with families may favor open visitation, whereas those who do not may want stricter visitation policies. Liu and colleagues found this lack of consistency to be the case, with more restrictions in the Northeast and fewer restrictions in the Midwest and smaller hospitals [1]. This lack of consistency, along with varying beliefs and attitudes toward visitation, can lead to confusion and resentment to all involved (patient, family and healthcare provider) and may be another factor as to why open visitation policies in ICUs continue to be elusive.So how do ICUs embrace open visitation? First, it should be understood that open visitation is not a one-size-fits-all philosophy. Second, it should be clarified that open visitation does not mean a free-for-all, with visitors being on the unit whenever they like. Third, it is important to understand that addressing visitation is a complex process that means patient interests are accounted for, clinicians have improved communication skills, and families are supported and prepared for their visits. Fourth, changing the terms ''open'' and ''unrestricted'' to ''flexible'' and ''liberal'' could help alleviate some of the barriers that healthcare providers have toward open visitation. Finally, perhaps each ICU will need to have an individualized approach to open visitation policies that meet the needs of the patient, the family, and the healthcare provider. However ICUs choose to embrace open visitation, it needs to happen.     

Videotape immediate playback: a tool in rehabilitation of persons with amputations

This study attempted to measure whether immediate videotape feedback would improve the degree of motor learning and ambulation performances of amputee patients. Twelve amputee patients were randomly assigned either to a control or to an experimental group. Subjects in the experimental group were videotaped during four sessions at weekly intervals and were permitted to view tapes to discuss their performances with the experimenter, to attempt to correct mistakes and to view the second effort again. Members of the control group were also videotaped at weekly intervals but they did not view the tapes or discuss their performances. Initial and final tapes of both groups were rated by a group of physicians and physical therapists on an Amputee Gait Rating Scale which consisted of objective behavioral measures of ambulation. Reliability of ratings was determined and difference scores between the groups were calculated. Results indicate that immediate television feedback is a valuable adjunct in the teaching process for the amputee patient.     

Open visiting in adult intensive care units – A structured literature review

BackgroundOpen visitation in adult intensive care units report benefits such as reduced frequency and duration of deliriums, improved patient and family satisfaction, and reduced anxiety and depression of family members. ‘Being close’ is one of the most basic and important needs of family members of critically ill patients. Open visitation provides an increased opportunity of being at the bedside with the patient, however, it is not universally embraced by adult intensive care units worldwide.AimTo critically appraise the literature concerning open visitation in adult intensive care units.DesignA structured literature review.MethodThis review was guided by the methodology by Kable et al. (2012). Sixteen articles are included in the review.ResultsDespite the documented benefits, several challenges exist which hinder broad application of open visitation in adult intensive care units.ConclusionThis review acknowledged challenges faced in adopting an open visiting policy in adult intensive care units such as negative staff perceptions and attitudes; patient protection; family and cultural consideration, as well as organisational challenges. The lack of a clear and consistent definition of open visitation is problematic, and strategies are urgently needed to support staff to provide holistic patient- and family-centred care.     

The post anesthesia care unit experience: a family-centered approach

The Post Anesthesia Care Unit (PACU) visitation program of Memorial Sloan-Kettering Cancer Center needed revision. The process was disorganized, visits were unescorted, and nurses and physicians were resistant. A committee was formed with the goal of developing a new unit philosophy and improving the overall process. Committee steps included reviewing the literature, educating staff about the benefits of visitation, empowering nurses to incorporate family visitation into patient care, and providing family education. As a result, staff attitudes changed, and nurses now contact the family within 90 minutes of the patient's arrival to the PACU to develop an individualized visitation plan. Morale is high, and nurses take pride in meeting the needs of patients and families.     

Patient education after amputation: Systematic review and experts’ opinions

ObjectiveTo perform a systematic review of the literature regarding amputee self-care, and analyze current experts’ opinions.MethodThe research in Medline and Cochrane Library databases was performed using the keywords “amputee self-care”, “amputee health care”, “amputee education”, and “amputee health management”. The methodological quality of the articles was assessed using four levels of evidence and three guideline grades (A: strong; B: moderate; C: poor).ResultOne prospective randomized controlled study confirm the level of evidence of self-care amputee persons with grade B, which is similar others chronic diseases self-care. Self-care of amputee persons contributes to improve functional status, depressive syndrome, and also health-related quality of life. A review of the patients’ needs and expectations in self-care amputee persons has been established thanks to the presence of qualitative focus group study.ConclusionA multidisciplinary self-care of amputee persons can be recommended. Regarding literature date, the level of evidence of self-care amputee persons is moderate (grade B). Experts groups are currently working on a self-care amputee persons guideline book in order to standardize practicing and programs in the physical medicine and rehabilitation departments.     

Alignment of lower-limb prostheses

Alignment of a prosthesis is defined as the position of the socket relative to the other prosthetic components of the limb. During dynamic alignment the prosthetist, using subjective judgment and feedback from the patient, aims to achieve the most suitable limb geometry for best function and comfort. Until recently it was generally believed that a patient could only be satisfied with a unique "optimum alignment." The purpose of this systematic study of lower-limb alignment parameters was to gain an understanding of the factors that make a limb configuration or optimum alignment, acceptable to the patient, and to obtain a measure of the variation of this alignment that would be acceptable to the amputee. In this paper, the acceptable range of alignments for 10 below- and 10 above-knee amputees are established. Three prosthetists were involved in the majority of the 183 below-knee and 100 above-knee fittings, although several other prosthetists were also involved. The effects of each different prosthetist on the established range of alignment for each patient are reported to be significant. It is now established that an amputee can tolerate several alignments ranging in some parameters by as much as 148 mm in shifts and 17 degrees in tilts. This paper describes the method of defining and measuring the alignment of lower-limb prostheses. It presents quantitatively established values for bench alignment position and the range of adjustment required for incorporation into the design of new alignment units.     

Le chaussage de la prothèse chez le sujet amputé âgé

Medical advancement over the last 20 years has deeply changed the epidemiological data concerning lower limb amputation: henceforth, it mainly affects elderly subjects suffering from arteritis. The aim of prosthetics, as well as reeducation is to restore the most complete functional independence for these patients, often impaired with multiple pathology. The dependency towards fitting the prosthesis should be considered in this context. Indeed, this is a common problem concerning two thirds of the patients aged over 70. The choice of an appropriate prosthesis and the involvement of the whole medical and paramedical team in the teaching process are the bases that will help the patient recover his or her autonomy. These concepts apply to both the transfemoral amputee, in which the use of a socket as an interface is clearly established, and the transtibilal amputee.