BKA Nursing Diagnosis: Addressing Impaired Physical Mobility After Below Knee Amputation

Impaired physical mobility is a significant nursing diagnosis, particularly relevant and often complex following a Below Knee Amputation (BKA). While the general nursing diagnosis of impaired physical mobility is frequently multifactorial, in the context of a BKA, it stems directly from the surgical removal of the lower leg. This condition can be temporary as patients rehabilitate and adapt, but without proper care and intervention, it can become a persistent issue, potentially leading to secondary complications such as skin breakdown, infections, falls, and social isolation.

Amputation, while sometimes necessary, profoundly impacts a patient’s mobility. Nurses play a crucial role in recognizing the unique challenges faced by individuals post-BKA. Effective nursing care requires a comprehensive, multidisciplinary approach, involving collaboration with physical therapists, occupational therapists, prosthetists, and rehabilitation specialists. This team works together to address the physical and emotional aspects of mobility impairment and support the patient’s journey towards regaining independence and improving their quality of life.

In this article, we will delve into the specific aspects of impaired physical mobility as a Bka Nursing Diagnosis, covering causes, signs and symptoms, expected outcomes, essential nursing assessments, and targeted interventions to optimize patient care.

Causes (Related to BKA)

While many factors can contribute to impaired physical mobility in general, for patients with a BKA, the causes are directly and indirectly related to the amputation itself and the subsequent recovery process:

• Surgical Amputation: The primary and most direct cause is the removal of the lower leg, fundamentally altering the patient’s biomechanics, balance, and ability to ambulate.
• Post-operative Pain: Pain at the surgical site, phantom limb pain, and residual limb pain are significant barriers to movement and participation in rehabilitation.
• Muscle Weakness and Deconditioning: Pre-existing conditions leading to amputation (like peripheral vascular disease or diabetes) often involve muscle weakness. Post-surgery, reduced mobility further contributes to deconditioning and muscle atrophy in the affected and unaffected limbs.
• Impaired Balance and Proprioception: Loss of the lower leg disrupts balance and proprioception (body awareness in space), making movements, especially weight-bearing and ambulation, challenging and increasing the risk of falls.
• Wound Healing and Stump Management: Concerns about wound healing, infection, and proper shaping and care of the residual limb (stump) can limit early mobility and weight-bearing activities.
• Edema and Swelling: Post-surgical edema in the residual limb can cause discomfort, restrict movement, and impede prosthetic fitting and training.
• Psychological Factors: Depression, anxiety, body image concerns, and fear of falling can significantly impact a patient’s motivation and willingness to engage in mobility-promoting activities and rehabilitation.
• Contractures: Prolonged immobility and improper positioning post-amputation can lead to joint contractures, particularly in the hip and knee, further hindering mobility and prosthetic use.
• Prosthetic Issues: Poorly fitting prostheses, discomfort, or difficulties with prosthetic management can create significant barriers to mobility and functional independence.
• Comorbidities: Pre-existing conditions like arthritis, cardiovascular disease, or neurological disorders can compound the mobility challenges post-BKA.

Signs and Symptoms (As Evidenced By Post-BKA)

Recognizing the signs and symptoms of impaired physical mobility in a patient post-BKA is crucial for effective nursing care planning. These can be categorized into subjective reports from the patient and objective assessments made by the nurse.

Subjective: (Patient Reports)

• Pain and Discomfort: Verbalization of pain in the residual limb, phantom limb pain, or discomfort with movement, weight-bearing, or prosthetic use.
• Fear of Falling: Expressing anxiety or apprehension about falling, especially when attempting to move or ambulate.
• Frustration and Discouragement: Statements of frustration, sadness, or discouragement related to mobility limitations and dependence on others.
• Perceived Limitations: Reporting an inability to perform previously easy movements or activities of daily living (ADLs).
• Reluctance to Move: Verbal or non-verbal cues indicating a hesitation or unwillingness to engage in movement or physical therapy.

Objective: (Nurse Assesses)

• Limited Range of Motion (ROM): Restricted movement in the joints of the affected and unaffected limbs, particularly the hip and knee of the amputated leg.
• Gait Deviations: Abnormal walking patterns, limping, or compensatory movements due to amputation and prosthetic use.
• Balance Deficits: Poor balance, instability when standing or walking, and increased sway.
• Weakness: Decreased muscle strength in both the residual limb and the unaffected leg, assessed through manual muscle testing.
• Difficulty with Transfers: Inability to independently transfer between bed, chair, and standing positions.
• Prosthetic Malalignment or Fit Issues: Observation of prosthetic issues like pistoning, rotation, or signs of skin irritation indicating poor fit.
• Edema in Residual Limb: Visible swelling in the residual limb, impacting prosthetic fit and comfort.
• Contractures: Physical examination revealing joint contractures, especially at the hip and knee.
• Use of Assistive Devices: Reliance on wheelchairs, walkers, crutches, or other devices for mobility.
• Slowed Movement: Demonstrating slow, hesitant, or uncoordinated movements.

Expected Outcomes (Post-BKA Mobility Goals)

Setting realistic and patient-centered expected outcomes is vital for guiding nursing care and rehabilitation efforts. For patients with impaired physical mobility post-BKA, common goals include:

• Patient Participation in Rehabilitation: The patient will actively participate in physical therapy, occupational therapy, and prosthetic training programs.
• Improved Mobility and Function: The patient will demonstrate measurable improvements in mobility, such as transferring independently, ambulating with or without a prosthesis and assistive devices, and performing ADLs.
• Pain Management: The patient will achieve adequate pain control, including residual limb pain and phantom limb pain, to facilitate participation in mobility activities.
• Wound Healing and Stump Health: The residual limb will heal without complications, maintaining skin integrity and a well-shaped stump suitable for prosthetic fitting.
• Prevention of Complications: The patient will remain free from secondary complications of immobility, such as contractures, pressure ulcers, and falls.
• Prosthetic Acceptance and Use: The patient will successfully adapt to and utilize their prosthesis effectively for functional mobility.
• Enhanced Quality of Life: The patient will report improved confidence, independence, and overall quality of life related to increased mobility.
• Psychological Adjustment: The patient will demonstrate positive coping mechanisms and emotional adjustment to limb loss and altered mobility.
• Community Reintegration: The patient will successfully reintegrate into their community and participate in social and recreational activities to their desired level.

Nursing Assessment (Post-BKA Mobility)

A thorough nursing assessment is the foundation for developing an individualized care plan for patients with impaired physical mobility post-BKA. Key assessment areas include:

1. Comprehensive Medical History Review: Understand the underlying condition that led to amputation, pre-existing comorbidities, and previous mobility levels. This provides context for the current mobility status and potential complicating factors.

2. Pain Assessment: Evaluate the location, intensity, quality, and aggravating/relieving factors of residual limb pain, phantom limb pain, and incisional pain. Effective pain management is crucial for mobility. Utilize pain scales and patient self-reports.

3. Residual Limb Assessment: Inspect the surgical site for signs of infection, delayed healing, edema, skin breakdown, and proper wound closure. Assess the shape and size of the residual limb for prosthetic readiness. Monitor for neuroma formation and tenderness.

4. Range of Motion and Strength Assessment: Evaluate ROM and muscle strength in both the residual limb and the unaffected leg. Pay particular attention to hip and knee flexion and extension, as these are critical for ambulation and prosthetic use.

5. Balance and Gait Assessment: Assess static and dynamic balance in sitting, standing, and during attempted ambulation (with or without assistive devices or prosthesis). Observe gait patterns for deviations, stability, and safety. Utilize standardized balance assessments if appropriate.

6. Functional Mobility Assessment: Evaluate the patient’s ability to perform functional tasks such as bed mobility (rolling, scooting), transfers (bed to chair, chair to commode), and ambulation distance and endurance. Use standardized functional assessments like the Timed Up and Go test or the Amputee Mobility Predictor.

7. Prosthetic Assessment (if applicable): If the patient has a prosthesis, assess its fit, alignment, suspension, and condition. Observe the patient donning and doffing the prosthesis and assess for any skin irritation or pressure points.

8. Psychological and Emotional Assessment: Screen for signs of depression, anxiety, body image disturbances, and fear of falling. Assess the patient’s motivation, coping mechanisms, and support system. Limb loss can have a significant psychological impact on mobility and rehabilitation.

9. Environmental Assessment: Evaluate the patient’s home environment for accessibility barriers, safety hazards, and the availability of necessary assistive devices or modifications. Consider the need for ramps, grab bars, and removal of trip hazards.

10. Nutritional Status Assessment: Assess nutritional intake and hydration status, as adequate nutrition is essential for wound healing, muscle strength, and overall recovery.

Nursing Interventions (Enhancing Mobility Post-BKA)

Nursing interventions are crucial for addressing impaired physical mobility and promoting recovery after a BKA. These interventions should be tailored to the individual patient’s needs and progress, and implemented in collaboration with the multidisciplinary team.

1. Pain Management: Administer prescribed analgesics as ordered and assess their effectiveness. Utilize non-pharmacological pain management techniques such as positioning, heat/cold therapy, massage, TENS units, and relaxation techniques. Address both residual limb pain and phantom limb pain.

2. Residual Limb Care: Provide meticulous wound care to promote healing and prevent infection. Educate the patient and family on proper stump hygiene, including daily washing, drying, and inspection. Teach techniques for residual limb shaping and edema control, such as compression wrapping with elastic bandages or shrinker socks.

3. Positioning and Contracture Prevention: Implement strategies to prevent hip and knee flexion contractures. Encourage prone positioning several times a day (if tolerated), avoid prolonged sitting with knee flexion, and educate on proper positioning in bed and chair.

4. Range of Motion Exercises: Initiate and encourage active and passive ROM exercises for all joints, including the residual limb and unaffected leg, to maintain joint flexibility, prevent stiffness, and improve muscle strength.

5. Strengthening Exercises: Implement a progressive strengthening program focusing on core, upper extremity, and lower extremity muscles, including the residual limb. This may include isometric, isotonic, and isokinetic exercises, gradually increasing resistance as tolerated.

6. Balance Training: Incorporate balance exercises to improve static and dynamic balance. Start with simple exercises in sitting and progress to standing and weight shifting activities. Utilize parallel bars and assistive devices as needed.

7. Transfer Training: Provide instruction and assistance with safe transfer techniques, including bed to chair, chair to commode, and car transfers. Utilize transfer boards, gait belts, and mechanical lifts as appropriate to ensure patient and nurse safety.

8. Prosthetic Training and Management: Collaborate with the prosthetist and physical therapist to facilitate prosthetic fitting, donning and doffing, and gait training. Educate the patient on proper prosthetic care, skin inspection, and wearing schedules.

9. Assistive Devices and Adaptive Equipment: Assess the need for and provide appropriate assistive devices such as walkers, crutches, wheelchairs, and adaptive equipment for ADLs. Ensure proper fit and instruction on safe use.

10. Psychological and Emotional Support: Provide emotional support and encouragement to address psychological challenges related to limb loss and impaired mobility. Facilitate access to counseling, support groups, and peer support networks. Promote a positive body image and self-esteem.

11. Education and Empowerment: Educate the patient and family about impaired physical mobility, amputation recovery, prosthetic use, home safety, and community resources. Empower the patient to actively participate in their care and rehabilitation.

12. Interdisciplinary Collaboration: Actively participate in the multidisciplinary team, including physical therapy, occupational therapy, prosthetics, social work, and case management, to ensure coordinated and comprehensive care.

13. Home Environment Modification: Collaborate with occupational therapy and social work to assess the home environment and recommend necessary modifications to improve accessibility and safety, such as ramps, grab bars, and widened doorways.

14. Fall Prevention Strategies: Implement fall prevention measures, including environmental safety modifications, assistive devices, balance training, medication review, and patient education on fall risks and prevention techniques.

Nursing Care Plans (Examples for BKA Patients)

Nursing care plans are essential tools for organizing and prioritizing care for patients with impaired physical mobility post-BKA. Here are brief examples of diagnostic statements and interventions:

Care Plan #1: Post-operative Mobility

Diagnostic Statement: Impaired physical mobility related to post-surgical pain and edema secondary to below knee amputation as evidenced by limited movement and verbal reports of pain.

Interventions:

• Administer pain medication as prescribed and assess effectiveness.
• Elevate residual limb to reduce edema.
• Apply compression dressings as ordered.
• Initiate gentle ROM exercises within pain tolerance.
• Educate patient on pain management techniques and importance of early mobilization.

Care Plan #2: Prosthetic Training Phase

Diagnostic Statement: Impaired physical mobility related to balance deficits and muscle weakness secondary to below knee amputation as evidenced by gait deviations and inability to ambulate without assistance with prosthesis.

Interventions:

• Collaborate with physical therapy for gait and balance training.
• Provide a safe environment for ambulation practice.
• Encourage use of assistive devices as needed for stability.
• Monitor skin integrity with prosthetic use.
• Provide positive reinforcement and encouragement during prosthetic training.

Care Plan #3: Long-Term Mobility Management

Diagnostic Statement: Risk for falls related to impaired balance and prosthetic use secondary to below knee amputation.

Interventions:

• Assess home environment for fall hazards and recommend modifications.
• Educate patient on fall prevention strategies.
• Reinforce proper prosthetic use and maintenance.
• Encourage ongoing exercise program to maintain strength and balance.
• Schedule regular follow-up appointments to monitor mobility and prosthetic fit.

References

1. Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
2. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
3. Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
4. Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
5. NANDA International. (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme Medical Publishers.
6. Esquenazi, A., & Meier, R. H., III. (2022). Amputation Rehabilitation and Prosthetic Restoration. PM&R knowledge NOW.
7. Dillingham, T. R., Pezzin, L. E., & MacKenzie, E. J. (2002). Limb amputation and limb deficiency: epidemiology and recent trends in the United States. Southern medical journal, 95(8), 875–883.

This revised article provides a comprehensive overview of impaired physical mobility as a BKA nursing diagnosis, offering valuable information for nurses caring for patients who have undergone below knee amputations. It emphasizes the unique challenges and needs of this patient population and highlights the essential role of nursing in promoting mobility, recovery, and improved quality of life.