NURSING 4764 Care Man 4 Exam 2 Antibiotics Burns Shock and Musculoskeletal trauma,100% CORRECT

NURSING 4764 Care Man 4 Exam 2 Antibiotics Burns Shock and Musculoskeletal trauma Understanding Antibiotic Therapy • Bacteriostatic (inhibits) o inhibits growth of Bacteria by preventing bacteria from multiplying and then hosts defences deal with the small number of bacteria left • Bactericidal (kills) o kills Bacteria, so eliminates bacteria • Principles of Antibiotic Guidelines o Specimens for microbiology should be taken prior to the start of empiric Abx treatment. o In an emergency, at a minimum a set of blood cultures should be taken (meningitis). o Ensure any history of allergy is documented on the cover of notes and drug kardex prior to commencing antibiotics o 2 lab specimens should be collected o In case something happens to the first one (contamination) o 2 different sticks from 2 different locations o 12 hours before the results come back o Patient is started on a broad antibiotic while awaiting test results ▪ Switched to a culture specific antibody when test results return o Use chlorohexidine to prep site • Principles of Antibiotic Guidelines o Empiric antibiotics should be reviewed once labs have resulted. o Empiric therapy should be changed to directed therapy as soon as possible. o Directed therapy should be the narrowest spectrum antibiotic to adequately cover the pathogens • Definitions o Pharmacokinetics: Mathematical study of the rate process involved in absorption, distribution, metabolism and excretion o Pharmacodynamics: Time course of drug effects and other interactions between antimicrobials and the bacterium • Principles of Antibiotic Guidelines o Pharmacokinetics&Pharmacodynamics issues may necessitate dose adjustments o Consider compatibility of prescribed Abx interacting with other drugs o Doses of antibiotics should take into account certain labs and be reviewed regularly. ▪ BUN/ Creatinine; ALT/ AST (Kidneys and Liver respectively) ▪ Renal impairment = give a smaller dose • Body will hold on to the drug longer o Hang the antibiotic above the saline • Principles of Antibiotic Guidelines o All antibiotic prescriptions should be reviewed after 48 hours ▪ Determines if the medication is working o Consideration should be made when appropriate to switch from IV to oral ▪ Fever settled (96-100.4) ▪ WBC returning to normal () ▪ Patient clinically stable (stable vitals) ▪ No gastrointestinal upset o Patient can go home when they are switched to PO • General Principles of Therapy o If no improvement within 36-48 hours check adequate dose and /or level of drug should be checked • Therapeutic Drug Monitoring (TDM) o TDM necessary to ensure therapeutic effectiveness of a drug while ensuring toxic and sub therapeutic doses are avoided. o TDM is performed on drugs with narrow therapeutic indices such as glycopeptides (vancomycin) and aminoglycosides (gentamicin) o These drugs may be associated with toxicity so levels should be regularly monitored • General advice on taking levels o It is important to ensure the levels are taken at the correct time. o When: ▪ Trough: must be taken immediately before the next due dose. ▪ Peak: one hour after administration of dose. o Frequency: Levels will be taken more frequently with impaired renal or liver functions • General advice on taking levels o Action to be taken once levels resulted from lab ▪ If level is within therapeutic range, MD likely to continue current dosing ▪ If level below or above MD will make med dosage changes accordingly • Peak & Trough Values o Reference ranges ▪ Vancomycin trough: 10-20 mcg/mL ▪ Vancomycin peak: 25-50 mcg/mL ▪ Gentamycin trough: 0.5-2 mcg/mL ▪ Gentamycin peak: 5-10 mcg/mL o Toxic: Any value above normal range level • Concentration Dependent Killing o Increasing or decreasing the concentration of the drug • Time Dependent Killing o Increasing or decreasing the time period between each dose • Interpretation of Levels o High trough: increase time between intervals o Low trough: (subtherpeutic): decreases time between doses; increase dose o Highpeak: decrease dose o Low peak: increase dose • Antibiotic Mechanism of Action o Inhibition of bacterial protein synthesis o Inhibition of cell membrane synthesis o Inhibition of cell wall synthesis o Inhibition of nucleic acid synthesis • Properties of bacterial toxin o Exotoxin: heat labile (except – enterotoxin of S. aureus) o Endotoxin: heat stable (up to 250 C) • Structure of Bacteria o Gram – / + ▪ Gram-positive bacteria: can be compared to a heavy wooden fence, with thick and wide planks, surrounding a yard. Or, perhaps visualize gram-positive bacteria as a room in a house, which is reinforced by dry walled barriers, complete with 2x4 wooden studs and foam/fiberglass insulation between the layers of drywall. • Less to manage ▪ Gram-negative bacteria:can be likened to a thin bulletproof Kevlar vest surrounding a security guard. Or, perhaps the gram-negative bacteria can be compared to a very thin metal armored breastplate, surrounding a Roman warrior or medieval English knight during battle. It could also be envisaged as a thin chain mail shirt being worn by an ancient militant. • More time management and higher drug concentrations Chapter 26: Care of Patients with Burns • Hand Hygiene o Remember Hand Hygiene every time for you and others • Hand Hygiene Guidelines Fact Sheet o Frequent hand washing is the single best thing people can do to avoid getting sick, from colds and the flu due to germs lurking on surfaces and in food. o Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms (e.g. MRSA: methicillin resistant staphylococcus aureus) and reduce overall infection rates. o Handwashing with soap and water remains a sensible strategy for hand hygiene in non-health care settings and is recommended by CDC and other experts. o The use of gloves does not eliminate the need for hand hygiene. Always wash your hands after removing gloves. Likewise, the use of hand hygiene does not eliminate the need for gloves. Gloves reduce hand contamination by 70 percent to 80 percent, prevent cross- contamination and protect patients and health care personnel from infection. o Handrubs should be used before and after each client just as gloves should be changed before and after each client. When using an alcohol-based handrub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product. • Pathophysiology of Burn Injury o Skin changes resulting from burn injury ▪ Leads to local & systemic problems ▪ Fluid & Electrolyte Imbalances ▪ Protein losses ▪ Sepsis ▪ Metabolic changes o Anatomic changes ▪ Skin changes ▪ Prep the family to see how the patient looks now o Functional changes ▪ Protective barrier against injury and microbial invasion ▪ Helps maintain fluid & electrolyte balance ▪ All burn injuries are painful o Temperature (Thermoregulation) ▪ They will always be cold and shivering • Skin Assessment o Size and depth of injury o Percentage of total BSA affected o “Rule of nines" using multiples of 9% of total BSA ▪ Groin = 1% • Pathophysiology of Burn Injury o Anatomic changes ▪ Skin is the largest organ of the body ▪ Pt remain at risk for infection until all burns have healed o 2 Major layers: Epidermis & Dermis ▪ Epidermis • Outer layer of skin • It can grow back after a burn due to epidermal cells • Has no blood vessels ▪ Dermis • Has blood vessels • Sensory nerves • Sweat & Sebaceous glands • Classification of Burn Depth Characteristi c Superficial Superficial partial- thickness Deep partial- thickness Full thickness Deep full- thickness Color Pink to red Pink to red Red to white Black, brown, yellow, white, red Black Edema Mild Mild to moderate Moderate Severe Absent Pain Yes Yes Yes Yes and no Absent Blisters No Yes Rare No No Eschar no no Yes, soft and dry Yes, hard and inelastic Yes, hard and inelastic Healing time 3-6 days About 2 weeks 2-6 weeks Weeks to months Weeks to months Grafts required No No Can be used if healing is prolonged yes Yes Example Sunburn, flash burns Brief contact with hot objects Prolonged contact with hot objects, tar grease chemicals Electricity Electricity, tar o Severity is determined by how much body surface is involved, as well as depth o Differences in skin thickness in various parts of the body also a factor • Superficial Thickness o Least damage; epidermis is only part of skin that is injured o Desquamation (peeling of dead skin) occurs 2 to 3 days after burn o • Partial Thickness o Involves entire epidermis and dermis (Varying depths) o Categorized as: ▪ Superficial ▪ Superficial partial-thickness ▪ Partial-thickness ▪ Deep partial-thickness injuries o • Full Thickness o Destruction of entire epidermis and dermis o Skin does NOT regrow o The eschar is dead tissue and must slough off or be removed from the wound before healing can occur o Echarotomies or fasciatomies may be needed if blood flow compromised o • Deep Full-Thickness Burn o Extends beyond the skin o Damage done to muscle, bone, and tendons o • Resuscitation/Early Phase of Burn Injury o Continues for about 24 to 48 hours – until diuresis occurs o Assessment of body systems o Goals of management: ▪ Administer analgesics ▪ Secure airway ▪ Support circulation – fluid replacement ▪ Prevent infection ▪ Maintain body temperature ▪ Provide emotional support o See Best Practice for Patient Safety & Quality Care ▪ Charts: 26-1 on p.473 (General Management for all Burns) ▪ 26-3 on p.477 (Significance of Findings) ▪ 26-4 on p.479 (Best Practices) • Surgical Management of Burns o Escharotomy: incision through the eschar o Fasciotomy: incision through the eschar and fascia • Injuries to the Respiratory System o Direct airway injury o Carbon monoxide poisoning o Thermal injury o Smoke poisoning o Pulmonary fluid overload o Facial edema • Carbon monoxide poisoning o Normal: 1- 10% ▪ Increased threshold to visual stimuli ▪ Increased blood flow to vital organs o Mild Poisoning: 11- 20% ▪ Headache ▪ Decreased cerebral function ▪ Decreased visual acuity ▪ Slight blindness o Moderate Poisoning: 21-40% ▪ Decreased blood pressure, increased irregular heart rate ▪ Depressed ST segment on ECG and dysrhythmias ▪ Pale to reddish purple skin o Severe Poisoning: 41-60% ▪ Coma ▪ Convulsions ▪ Cardiopulmonary instability o Fatal Poisoning: 61- 80% ▪ Death o CO2 bind tighter to hemoglobin in place of oxygen to form carboxy-hemoglobin, which impairs oxygen unloading at the tissue level o Vasodilation occurs to cherry red color • Vascular Changes resulting from Burn Injuries o Fluid shift: Third spacing or capillary leak syndrome, usually occurs in first 12 hr, can continue 24 to 36 hr o Profound imbalances in fluids, electrolytes, & acid-bases; hyperkalemia and hyponatremia levels; hemoconcentration o Fluid remobilization after 24 hr, diuretic stage begins 48 to 72 hr after injury, hyponatremia and hypokalemia o Parkland Formula / Fluid Resuscitation p. 494 • Pulmonary Fluid Edema o Occurs even when lung tissues have not been damaged directly o Inflammatory response can occur causing capillaries to leak fluid into pulmonary tissue space o The fluids that diffuses into the lung tissue spaces contains proteins that can lead to respiratory distress ▪ Always try repositioning pt first with breathing difficulty followed by medication management • Cardiovascular Assessment o Cardiac rhythm, especially in cases of electrical burn injuries o Look for increased HR & decreased Cardiac Output o Hypovolemic shock – Common cause of death in early phase in patients with serious injuries • Hypovolemic Shock o Low circulating blood volume ▪ Mean arterial pressure (MAP) decrease; inadequate total body oxygenation o Commonly caused by hemorrhage (external or internal), dehydration o • Kidney/Urinary Assessment o Decreased kidney blood flow o Myoglobin released from damaged muscle, circulates to kidney o Kidney function, BUN, serum creatinine, serum sodium levels o Urine color & odor changes o Increased specific gravity (1.005-1.030) o Urine Output of at least 30ml/ hr • Gastrointestinal Assessment o Changes in GI function expected (Stomach ulcers) ▪ Could receive acid reducer meds o Decreased blood flow and sympathetic stimulation during early phase cause reduced GI motility, paralytic ileus o GI bleeding o Curling’s ulcer- Acute ulcer with stress of severe injury • Metabolic Assessment o Increased secretions of catecholamines, antidiuretic hormone, aldosterone, cortisol ▪ Catecholamines: can serve as neurotransmitters, transferring signals from neuron to neuron, as well as hormones, which regulate physiological functions such as your heartbeat and breathing rate • Epinephrine (adrenaline), norepinephrine, and dopamine ▪ ADH: regulates and balances the amount of water in your blood ▪ Aldosterone: increases sodium absorption from the urine, sweat, and the gut. This causes increased osmolarity in the extracellular fluid, which eventually turn blood pressure back to normal ▪ Cortisol: can help control blood sugar levels, regulate metabolism, help reduce inflammation, and assist with memory formulation. It has a controlling effect on salt and water balance and helps control blood pressure o Increased core body temperature as response to temperature regulation by hypothalamus • Nonsurgical Management of Burns o IV fluids o Monitoring patient response to fluid therapy o Drug therapy includes Abx& pain meds • Acute Phase of Burn Injury o Begins about 36 to 48 hr after injury; last until wound closure is completed o Care directed toward: ▪ Continued assessment and maintenance of CV, respiratory systems ▪ Continued assessment and maintenance of GI and nutritional status ▪ Burn wound care ▪ Pain control ▪ Psychosocial interventions • Nonsurgical Management: Acute Phase o Mechanical debridement: ▪ Hydrotherapy (Water treatment) o Enzymatic debridement: ▪ Autolysis (Not used often; slow) ▪ Collagenase (Rapid enzyme digestion of necrotic tissue) o Standard wound dressings o Biologic dressings ▪ Homograft – Human skin ▪ Heterograft – Skin from other species ▪ Cultured skin- Own unburned skin used ▪ Artificial skin- two layers (Beef/ Shark) o Biosynthetic/ Synthetic dressings • Interventions o Minimize Infection See Chart 26-5 p. 501 ▪ Clostridium tetani o Minimize weight loss (Nutrition): prealbumin / albumin o Maintaining Mobility ▪ Positioning ▪ Range of Motion ▪ Ambulation ▪ Compression dressings- Applied after grafts healed o Self Image consideration • Nonsurgical Management o Drug therapy o Opioid analgesics o Non-opioid analgesics o Complementary and alternative medicine (CAM) therapies o Environmental changes • Surgical Management o Surgical excision o Wound covering ▪ Skin graft (mesh autograph pictured) • Rehabilitative Phase of Burn Injury o Begins with wound closure, ends when patient returns to highest possible level of functioning o Emphasis on psychosocial adjustment, prevention of scars and contractures, resumption of preburn activity o This phase may last years or even a lifetime if patient needs to adjust to permanent limitations Chapter 37: Care of Patients with Shock • Shock o Any problem impairing oxygen delivery to tissues and organs can precipitate shock o Widespread abnormal cellular metabolism o Oxygenation and tissue perfusion needs not met o “Whole-body” response; “syndrome” o High glucoses are common in shock pts even if they are not a diabetic o High lactate values often exist o Lead to life-threatening emergency • Understanding the Basics o Ventilation: occurs through the process of inhalation and exhalation o Oxygenation: adding oxygen to the body system through gas exchange o Perfusion: the circulation of blood through the vascular bed of tissue • Types of Shock o Hypovolemic o Cardiogenic o Distributive o Obstructive • Cardiovascular Manifestations o Decreased cardiac output (4-8L is normal) o Increased pulse o Decreased blood pressure o Narrowed pulse pressure ▪ Systolic and diastolic number get closer to each other o Postural hypotension o Low central venous pressure o Flat neck and hand veins in dependent positions ▪ No JVD (low venous pressure) o Slow capillary refill o Diminished peripheral pulses • Cardiovascular Manifestations o Decreased cardiac output o Increased pulse o Decreased blood pressure o Narrowed pulse pressure o Postural hypotension o Low central venous pressure o Flat neck and hand veins in dependent positions o Slow capillary refill o Diminished peripheral pulses • Respiratory Manifestations o Increased respiratory rate o Shallow depth of respirations o Decreased Paco2 o Decreased Pao2 • Hypovolemic Shock o Low circulating blood volume ▪ Causes mean arterial pressure (MAP) decrease; inadequate total body oxygenation o Commonly caused by hemorrhage (external or internal), dehydration • Cardiogenic Shock o Actual heart muscle is unhealthy ▪ Pumping is directly impaired o Myocardial infarction most common cause • Distributive Shock o Blood volume distributed to interstitial tissues where it cannot circulate to perfuse organs o Caused by loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, capillary leak o Neural-induced distributive shock ▪ Sympathetic nerve impulses decrease smooth muscles relax o Chemical-induced distributive shock • Chemical-Induced Distributive Shock o Anaphylaxis o Sepsis o Capillary leak syndrome- the response of capillaries to the presence of body chemicals to allow fluid to shift from capillaries to interstitial tissue ▪ Examples: Severe burns, ascites, large wounds, trauma • Obstructive Shock o Impaired ability of normal heart muscle to pump effectively o Conditions outside heart prevent either adequate filling of heart or adequate contraction of healthy heart muscle o Pericarditis most common cause o Cardiac tamponade ▪ A serious medical condition in which blood or fluids fill the space between the sac that encases the heart and the heart muscle. This places extreme pressure on your heart ▪ The pressure prevents the hearts ventricles from expanding fully and keeps your heart from functioning properly ▪ Your heart cant pump enough blood to the rest of your body when this happens. This scan lead to organ failure, shock, and even death. • Stages of Shock o Initial o Nonprogressive o Progressive o Refractory • Initial Stage o Baseline MAP decreased by 10 mm Hg o Heart and respiratory rate increased from baseline, or slight increase in diastolic blood pressure o Adaptive responses of vascular constriction, increased heart rate • Nonprogressive Stage o MAP decreases by 10 to 15 mm Hg o Kidney and hormonal adaptive mechanisms activated o Tissue hypoxia in nonvital organs Skin, GI Tract, etc.. o Acidosis and hyperkalemia o Stopping conditions that started shock and supportive interventions can prevent shock from progressing • Progressive Stage o Sustained decrease in MAP of 20 mm Hg from baseline o Vital organs develop hypoxia o Life-threatening emergency o Conditions causing shock must be corrected within 1 hour of progressive stage onset • Refractory Stage o Too little oxygen reaches tissues; cell death and tissue damage result o Body cannot respond effectively to interventions; shock continues o Rapid loss of consciousness, nonpalpable pulse, cold, dusky extremities; slow, shallow respirations; unmeasurable oxygen saturation • Multiple Organ Dysfunction Syndrome (MODS) o Sequence of cell damage caused by massive release of toxic metabolites and enzymes o Dead and dying cells release metabolites o Microthrombi form o Tissue perfusion blockage o Ongoing cycle o Organs impacted first: ▪ Liver ▪ Heart ▪ Brain ▪ Kidneys • Nonsurgical Management o Maintain tissue oxygenation: ▪ Oxygen therapy o Increase vascular volume to normal range ▪ IV therapy • Normal saline (NS) or Ringer’s lactate (RL) o Drug therapy: table 37-4 • Drug Therapy o Please Review Chart 37-4 on pg 759 o Dopamine: vasopressor and inotrope o Norepinephrine: last resort drug o Phenylephrine: constriction properties o Dobutamine: ▪ It will burn and necrosis the injection site o Milrinone: contractility o Sodium nitroprusside (nipride): it will cause cyanide toxicity (it needs to be covered in the bag: light causes it to break down): decreases the blood pressure • Sepsis & Systemic Inflammatory Response Syndrome o Sepsis- Presence of infection in bloodstream o SIRS-Infection is spreading beyond bloodstream ▪ Infection spreads to the organs o Major types of Sepsis is bacterial infection that escapes local control • Severe Sepsis o Progression of sepsis with amplified inflammatory response o All tissues are involved and are hypoxic to some degree o This process uses up or consumes many platelets and clotting factors called Disseminated intravascular coagulation (DIC) o Continued stress response triggers impact liver leading to increased glucoses o Low O2 sats o Increased RR o Decrease or no UOP o Changes in LOC • Septic Shock o Sepsis induced hypotension persisting despite adequate fluid resuscitation o Stage of sepsis and SIRS – Multiple organ failure evident; uncontrolled bleeding occurs o Death rate for patients in this stage exceeds 60% • Interventions o Oxygen therapy o Drug therapy o Blood transfusion o IV Fluids • Community-Based Care o Home care management ▪ prevent infection ▪ Emphasize hydration o Teaching for self-management Chapter 51 Care of Patients with Musculoskeletal Trauma • Fractures o The most common manifestation of fractures is moderate to severe pain. o Remove rings, watches, jewelry, bracelets, etc.. that could impede circulation o If a grating sound is heard with ROM the nurse should immobilize the extremity. This does not mean circulation impairment or infection. o Assessment of shoulder and upper arms can be done best by having the patient sit or stand o Place pt in supine position to assess legs and pelvis • Common Types of Fractures o Fracture – Break or disruption in continuity of a bone o Types: ▪ Complete- Bone divided into 2 sections ▪ Incomplete- Fracture through part of bone ▪ Open or compound ▪ Closed or simple- Maybe Ecchymotic/ subcutaneous emphysema ▪ Pathologic (spontaneous) • Already weakened ▪ Fatigue or stress- Excessive amounts ▪ Compression- Loading force applied • Bone Healing o Stage 1: 24-72 hours o Stage 2: 3 days – 2 weeks o Stage 3: 3-6 weeks ▪ Callus: beginning of nonbony healing o Stage 4: 4-8 weeks ▪ Callus reabsorbed and transformed into bone o Stage 5: can start 4-6 weeks but lasts up to a year ▪ Consolidation and remodeling of bone continues o Bone infection = osteomyelitis • Give Heparin pt with fracture while in hospital, monitor pt inr ptt? lab values, or give lovenox or Coumadin or eliquis when about to go home • Complications of Fractures o Shock (Bone are very vascular) o Acute Compartment Syndrome o Fat embolism syndrome o Venous thromboembolism o Infection o Chronic complications – Avascular necrosis (AVN) ▪ Death of bone tissue due to the lack of blood o Peripheral neurovascular dysfunction ▪ Pallor, tingling and burning o Pain o Impaired physical mobility o Inadequate nutrition ▪ Pre-albumin and albumin important to monitor • Acute Compartment Syndrome (ACS) o Occurs most often in extremities o Serious condition in which increased pressure within one or more compartments reduces circulation to the area o Can result in: ▪ Ischemia ▪ Edema from plasma proteins leaking into interstitial fluid space ▪ Sensory deficits ▪ Pain o Fasciotomy • Early signs of Acute Compartment Syndrome o Six Ps ▪ Pain ▪ Pressure ▪ Paralysis ▪ Pulselessness ▪ Parasethesia ▪ Pallor • Fat Embolism Syndrome o Fat globules are released into the bloodstream within 12- 48 hours after injury/ illness o Early signs: ▪ SOB: earliest sign ▪ Tachypnea ▪ Low O2sats: latest sign • Venous Thromboembolism o Deep vein thrombosis- Usually in lower extremity o Pulmonary embolism- In lungs o Risk factors for Venous Thrombosis: ▪ CA or chemotherapy ▪ Surgery longer than 30 min ▪ History of smoking ▪ Obesity ▪ Heart disease ▪ Prolonged immobility ▪ Oral contraceptives or hormones ▪ History of VTE complications ▪ Older adults esp. with hip fractures • Assessment of Neurovascular Status o Skin Color o Skin Temp o Movement o Sensation o Pulses o Cap Refill o Pain • Fracture Activity o What should the nurse be most concerned about regarding a patient with a fracture? ▪ pulse o How does this fracture affect mobility? o What complications could this fracture cause? ▪ Femur: fat embolism, could cause MI, or stroke o How does this type of fracture affect the healing process? ▪ 5 stages of healing, can take up to a year in the last stage o What medical-surgical treatment should the nurse expect to occur? ▪ Casting, splinting • Immobilization Device o Fiberglass Synthetic Cast (material) ▪ The most common and preferred for immobilization ▪ Infection under cast sometimes occur, a fever may develop ▪ Circulation impairment can occur • Inform patient to assess for circulation, color, numbness and pain o Traction ▪ Application of a pulling force to body part to provide reduction, alignment, and rest ▪ Running traction: pulling force in 1 direction ▪ Balanced suspension: countertraction ▪ Skeletal traction: screws inserted surgically into bone; used to realign fractured bone ▪ Never allow weights to rest on the floor • Operative procedures o Open reduction- allows surgeon to directly view fracture o Internal fixation- pins, screws, rods, plates, prostheses to immobilize fracture o External fixation- pins and wires inserted through the skin and affected bone, then connected to rigid frame (ortho specialist needs to carefully clean around) • Amputations o Surgical o Traumatic o Levels of amputation o Complications – Hemorrhage, infection, phantom limb pain, neuroma, flexion contracture • Stump Care • Complications of Amputation o Hemorrhage o Infection o Phantom limb pain o Neuroma: painful condition ▪ Pinched nerve, a nerve tumor o Flexion contractures