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Home health nurses can help smooth transition
Helping an amputee with the physical effects of surgery is only part of the challenge for home health workers. Being alert to the emotional needs of patients who have lost one or more limbs can speed recovery and smooth the transition to a new life.
Deanna Lieving, RN, CNS, director of mental health for Olsten Health Services in Virginia Beach, VA, says home health nurses can be a vital link in the chain of support for amputees, because so many of the emotional issues patients face arise after they have left the hospital.
"The impact doesn’t really hit home until they go home," Lieving says. "So the home health nurse going in on a case is going to get the whole range of emotions, more so than I would in a hospital. As soon as they go home, they face a familiar place where they can’t function like they functioned before. It may be temporary, but they don’t know that. All they know is they’re a one-legged person in a two-legged world, and that hurts."
Lieving, a psychotherapist, has been involved with amputation patients in hospital and home settings for 15 years and teaches a course at Old Dominion University on the psychosocial issues following amputation. She says many of her patients are older and have lost limbs due to diseases such as diabetes, although some suffered traumatic losses through accidents.
In every case, she says, the patient goes through a grieving process similar to that of losing a loved one, and medical professionals should understand that such a response is normal and even healthy.
"A doctor will call me and say, Go see Frank Smith. He’s depressed.’ This is post-op, three days. I go see Frank Smith; he’s not depressed — he’s tearful over the loss. That is a normal response to any amputation. That’s not depression. When I see a patient crying, I see that as a good thing."
She points to a second coping mechanism, denial, which also can be confusing to home health workers. "Denial is not a bad thing," Lieving says. "It’s a natural defense mechanism built into our brains to protect us from harm that our mind cannot tolerate at the time. I never ever try to tear someone’s defense mechanisms down. They’ll come around; some people take longer than others."
However, she says it is important to keep a watch for signs of true clinical depression — weight changes, sleep disturbances, agitation, loss of interest or pleasure, decreased sex drive, fatigue, feelings of worthlessness and guilt, or a prolonged sadness that persists for more than a month.
A home health nurse attending an amputee should perform these functions to bolster the patient’s emotional health, Lieving says:
• Encourage communication. Patients should feel free to verbalize feelings of anger, frustration, and fear as they deal with new problems and limitations. "When women feel loss, most women get depressed. When men feel loss, most men get angry," Lieving says. "So it’s important. The woman needs to feel anger, and the man needs to feel that sadness."
• See the situation through the patients’ eyes.
• Identify support systems. Those systems can be many and diverse — friends and family certainly are among them. Lieving also includes religious belief, "which actually gets a lot of my patients through this."
• Try to involve family in the process. She says family members often tell her things the patient won’t. "A patient might say, Yeah, I’m getting up once a day. Yeah, I’m walking around the house,’ and [family members] will say, Oh no, he’s not. He’s not getting out of bed.’"
Family members also have emotional needs, as they try to be strong for the patient and deny their own feelings of anger and loss, Lieving says.
At Olsten, home health nurses are often the ones to notice that a patient is having difficulty coping during the difficult process of healing and learning to use a prosthetic limb, and they will suggest referrals to mental health professionals.
Other tips for home health workers include the following:
• Answer questions honestly. Some questions can be odd — many amputees, for instance, want to know what happened to their amputated limb. Others can be hard to answer, such as a realistic assessment of the patient’s new limitations. Lieving says answering such a question over-optimistically — saying, "You’ll do everything you did before you lost your leg," for instance — isn’t telling a patient the whole story.
"They may be able to do the things they did before, but they’re going to do it a little slower," she says. "It’s a little bit like the aging process, I tell them."
• Empower patients to participate in his care. Medical professionals must try to get patients to reclaim their independence, Lieving says. "You have to give that sense of control back to the patient. A lot of times, that is just done with empathetic caring."
• Prepare patients for setbacks. Lieving says she teaches coping skills for continual failures, which inevitably occur during the course of recovery. She praises any progress and sets realistic goals. "I tell them that they need to set their goals in tiny steps. I think that’s important. I try to always reflect on their progress."
• Have patients discuss their self-image. The loss of a limb can be a devastating blow to a person’s body image, Lieving says. They worry about being seen in public, about how they can be intimate with their spouses, and other important considerations. Sexual issues often are compounded by the patient’s underlying illness, such as diabetes, which can cause impotence problems.
"Ask them, What do you think of the prosthesis?’" she says. "What do you think when people stare at you?’"
Home health nurses also can help prepare patients for the inevitable embarrassing moments that come with dealing with a prosthetic limb. As an example, she points out that an above-the-knee prosthetic leg can make a small burping sound when slid into place. "That’s embarrassing enough, but if the fit isn’t good, when you walk, it’s going to sound like you’re expelling gas. That’s so embarrassing. If you warn a patient that’s going to happen, then they’re a little less embarrassed about it."
• Invite patients to meet with other amputees. Often the best time for this is after a patient has gone home and already is beginning to see other amputees in physical therapy and at the prosthetist. Lieving encourages her patients to join support groups, while pointing out that such groups can include people with very different outcomes and problems. She says emotional support from home health workers can make the difference between a lingering period of coping problems and a shorter one. "The emotional part is not touched on. If you don’t treat the emotional aspects of amputation, it will take two years for your body to recoup. If you treat it, it may take three months. It’s the part that a lot of physicians do not even want to come to terms with."
• Deanna Lieving, RN, CNS, Director of Mental Health, Olsten Health Services, 5700 Cleveland St., Suite 408, Virginia Beach, VA 23462. Phone: (757) 499-9401.