Purpose: To describe the care coordination by the Limb Loss CNS (CWCN) to expediently support this patient through a lower extremity amputation – pre-operatively through rehabilitation.
Objective: To engage a team of healthcare professionals to support a patient with complex needs through life changing surgery.
Outcomes: The first admission failed; not fully prepared and declined surgery. For success, APRN’s collaborated to create a contract with explanations of the surgical consent and a simple, but inclusive timeline expected in the hospital, including discharge, future prosthetic fitting and gait training. The primary internal medicine physician confirmed this patient was mentally ready for the surgery. Stress management provided relaxation therapy in the pre operative holding area. Occupational therapy provided immediate lymph wrapping of the residual limb post operatively. His social worker created an agreeable discharge plan. Other services included daily physical therapy, compressive garment applied by his prosthetist, peer visit from an amputee and daily visits from the Limb Loss CNS to reinforce plan. Coordination by CNS likely reduced LOS, readmissions, clinic and emergency room visits. The Limb Loss CNS continues to assist with such challenges as redundant skin, prosthetic fitting and correcting four years of poor gait.