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Another Perspective on Finger Replantation Surgery: Nursing Support for the Psychological Levels of Recovery

O'Baire-Kark, Marika MS, RN, CMSRN, BC-psy; Klevay, Anne MSN, PMHCNS-BC

doi: 10.1097/JTN.0b013e3181ff26c9
CLINICAL CARE
Free

The psychological effects after traumatic hand injury, long hours of microsurgery, and an uncertain future can be hidden under the demands of technical care. Psychological changes affect many of these patients, the outcome of their surgery, length of hospital stay, time off from work, and costs. Nursing support about biopsychosocial aspects of finger replantation microsurgery extrapolated from 30 years of medical and nursing articles, and from the authors' current experience, resulted in new perspectives on what the patients are experiencing and how nurses can promote healing at each recovery level.

Stanford Hospital and Clinics, Stanford, California.

Correspondence: Marika O'Baire-Kark, MS, RN, CMSRN, BC-psy, 1600 Villa St, 303, Mountain View, CA 94041 (mobairekark@stanfordmed.org).

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CASE HISTORY

When her half-ton flatbed truck started to roll off a crumbling, ocean cliff on California highway 1, a tree branch came through the windshield and degloved her right hand, taking two fingers with it. The paramedics and life flight nurses found one of those fingers, and she had now had multiple surgeries for all the involved parts and their complications.

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NURSE'S PERSPECTIVE

“I know I shouldn't be doing this,” she said as I walked into her room.

This was the first time she had been assigned to me, although she had been our patient on the intermediate intensive care unit (IICU) for several weeks. That was an unusually long length of stay for a patient with a finger replant.

“What are you doing?” I said.

She was poking at her fingers' dressing, trying to lift the edges. She had just returned from her third debridement for infection in her wound.

“It feels so unreal,” she said.

“It takes time,” I said, remembering how it takes time to integrate something new in one's consciousness—a very recent, learned experience. “It takes time to integrate how your fingers have changed, so it may be a little strange for a while. That's normal.”

She stopped playing with the dressing. She had been anxious and irritable for weeks, calling her nurses frequently for pain medication and attention throughout every day, evening, and night shift. Now suddenly she just said, “Oh! Okay.”

We chatted about other things and worked as a team. She continued to make many small requests. Eventually, she learned that we would satisfy those requests. She began to trust us, so there was no need to keep testing.

She had the emotional support she needed. Our team arranged for a psychiatric consult because of bouts of recurring nightmares and inability to fall asleep. After the consult, she became quieter. Within a short time, she was discharged.

This is not the first time, as a trauma nurse, that I notice something different happening with patients recovering from redigitation surgery compared with patients recovering from other surgeries. I observe that people with replanted fingers seem to disregard their surgical hand as if it were not there or treat it as an annoyance or as a pet, ignored most of the time. I notice this happening on many occasions. It seems that there was much more happening with these patients than just the technical details with which IICU nurses are usually involved.

What is unreal for these patients? How can we help these patients more fully heal? Can we help them feel more confident and participatory?

When a finger trauma patient arrives to our trauma 1 center, with a finger that can be replanted, plastic surgeons are called in. This emergency microsurgery demands a specialized team to reattach veins, arteries, and align a nerve with its nerve sheath in the remaining stump of the detached finger. The IICU nurses receive patients just after the 4- to 12-hour surgeries to replant a finger or fingers that they have cut off—usually accidentally. Before patients arrive from the recovery room, nurses warm their private room to about 75°F and set up the pulse oximeter, sometimes more than 1 to check the patient's normal oxygenation with an operative finger's oxygen supply, and the intravenous equipment for a line of dextran, 1 for a maintenance or replacement fluid and 1 for patient-controlled analgesia.

Such a surgery seems as miraculous as the painting on the ceiling of the Sistine Chapel, where God's finger reaches toward Man's limp hand to give him life. Microsurgery evolved from the ability to use microscopes in surgery in the early 1960s and from the first successful attempts in 1962 to replant an arm and then in 1965 to replant a thumb. Since that time, operative techniques and experience, improved instruments, vein grafting, development of replant teams, patient-selection criteria, joint reconstruction or replacement, tenolysis or tendon grafting, and nerve and soft tissue reconstruction have increased in success.1 Pain management has improved, but vigilance for its effectiveness remains very important. Poorly managed pain can lead to maladaptive psychological and emotional reactions, such as anger, anxiety, phobic reactions, and somatization, which can lead to less adaptive physical and functional recovery and prolonged disability.2 Inadequate pain control stimulates the sympathetic nervous system to release epinephrine and norepinephrine. They act on the vascular smooth muscles to produce vasoconstriction, which can restrict blood flow to the replanted tissue. Prolonged vasoconstriction may result in ischemia and potential thrombus formation.3

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HISTORICAL PERSPECTIVE

Psychiatrists, Drs Isaac Schweitzer and Maj-Britt Rosenbaum4, noted that 60% of replant patients had a psychiatric diagnosis and needed intervention comparable to burn patients, cardiac surgery patients, amputation patients, renal transplant mastectomy patients, and hysterectomy patients. Since their observations, studies on the psychological aspects of microsurgery finger replantation patients have corroborated and amplified their findings.5 Grunert6 found that 92% of such patients had nightmares at the beginning of the course of recovery, 88% had flashbacks, 84% had affective lability, 12% had difficulty with concentration and attention, and 10% had cosmetic concerns. In 1984, two surgeons, Sharzer and Strauch, joined Schweitzer's research team. Together, they studied 50 patients over 2 years. They noted that 28% had an evidence of preaccident psychopathology, 54% had a recent stressful life event, and 54% had an adverse postoperative emotional reaction, which was positively linked with family dysfunction.7

In the first few postoperative weeks, 28% of these patients had a diagnosis of adjustment disorder with anxious mood, impairment of concentration, recurrent nightmares, and constant feelings of apprehension, tremor, and exaggerated startle reactions. Three patients developed panic states. Fourteen patients developed symptoms of depression, usually several weeks after hospitalization. They were diagnosed with adjustment disorder with depressed mood, exhibiting sadness, despondency and withdrawal, lack of cooperativeness, sleep disturbance, disturbed appetite and irritability, and abnormal dependency persisting for 1 week or longer. Patients with a history of substance abuse developed significant postoperative depression. The research team realized that excessive psychic distress in these patients could impair or even prevent recovery.7 Psychological factors contributed to a substantial variation in deficits of strength, fine motor control, and sensation. A patient's cooperation and motivation in treatment and rehabilitation were vital. What was unique to replant patients was the psychological task of reintegration of the severed body part.8

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RECOVERY PERSPECTIVE

There are levels of recovery in the patient's journey that nurses can support. Given the intensive amount of time and attention these patients require around the clock, nurses can assist with the patient's need to know what is happening and their need to have some sense of control of their situation. A nursing care plan can promote the psychological task of reintegration of the severed body part. In addition to promoting physical healing, nursing care can focus on lowering the risk for spiritual distress, anxiety, depression, and dysfunctional grief (see Nursing Care Plan in Exhibit 1).

EXHIBIT 1-a Nursing Care Plan for Finger Replantation Patients

EXHIBIT 1-a Nursing Care Plan for Finger Replantation Patients

EXHIBIT 1-b Nursing Care Plan for Finger Replantation Patients

EXHIBIT 1-b Nursing Care Plan for Finger Replantation Patients

EXHIBIT 1-c Nursing Care Plan for Finger Replantation Patients

EXHIBIT 1-c Nursing Care Plan for Finger Replantation Patients

EXHIBIT 1-d Nursing Care Plan for Finger Replantation Patients

EXHIBIT 1-d Nursing Care Plan for Finger Replantation Patients

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Recovery Level 1: Preaccident

What was the patient experiencing in his or her life that might have led to the circumstances of the accident? Listen for preoccupation with multiple stressors, family dysfunction, trouble with work, substance abuse, and for possible undiagnosed and untreated depression. These questions can be asked by an RN in the ER or by the family and patient when the patient is fully awake before or at the best time after surgery.

Ask about suicidal ideation, plan, and history directly if they are not mentioned in the patient's conversation.

“Are you thinking of ending your life? Do you have a plan? Has anyone in your family or among your friends ever ended his or her life? On the day of the accident, were there other people present? What did they say or do? Have you ever experienced abuse of any kind? Describe alcohol or drug use? Do you have supportive people in your community? Were you having any difficulties with family members? Do you have a physical or medical condition that saddens you? Have you felt helpless and hopeless? Have you experienced chronic pain or illness of any kind before the accident?”9

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Recovery Level 2: Initial Response

Immediately after surgery, patients are often in a state of numbness or shock—a relative calm or dreamlike state. He or she may not seem to grasp what is said. These are typical responses that people have right after the experiences of severe trauma and near escape from death. These are present almost universally, not only in patients who have had the most violent and horrifying experiences, but also in less severe cases.7

This numb, dreamlike state was evident in our patients when they returned from the recovery room. We had attributed this solely to the effects of long surgeries and anesthesia but it was also a result of the accident. Families are eager for information and especially what to expect and how to help. They are more anxious than the patient until several hours later as the patient begins to be more aware of where he or she is awakening.

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Recovery Level 3: Anxiety Breakthrough

The accident may have felt life threatening to this patient. Body integrity is disrupted. A new fear can emerge for the physical survival of the body part. Associated fears then arise—such as the effect on personal function, occupation and income, and appearance and sexual attractiveness. Worries surface about acceptance by family and friends and the need for further surgery that may mean disability, mutilation, and death.7

Symptom management in the early stages of recovery can help to prevent unmitigated, unremitting stress. Encourage patients to use the massage services of the hospital and teach them deep-relaxation skills. Encourage unhurried conversations with family, friends, and caregivers. Use the hospital's interpretation services as needed.6 Request assistance from chaplain services as needed.

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Recovery Level 4: Recognition of Loss

Patients may experience fantasies of complete return to normal or ungrounded fears of total failure. Feelings of sadness, despondency, anger, frustration, hopelessness, and helplessness are natural. The process of mourning for the body part begins. There may be a severe adjustment reaction with depression if this stage is not successfully negotiated. Preaccident psychopathology, especially substance abuse, recent stressful life events, and family dysfunction, each predispose the patient to significant postoperative depression.7

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Recovery Level 5: Acceptance

Immediately after the accident, the injured body part is perceived as separate from one's body and irretrievable. When it is reattached, the part looks foreign—swollen, discolored, and not a part of one's own body. There may be no sensation or movement.7 Sensation can take time to return, if at all, during the healing process. Movement seems to take focused attention and will power from the patients. If asked by surgeons or nurses, patients may try to move their fingers.

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Recovery Level 6: Integration

A patient experiencing replanted fingers must give up the previously uninjured form and reintegrate a new but altered and partially defective replanted part.7 Integration begins at the first moment of injury. Given the millions of hand injuries that happen in the United States each year and the extra risk of these types of injuries in certain kinds of disasters (earthquakes, landslides, ice storms, tornados, etc), early education included in disaster education or first-aid education can make a difference in saving a body part for replantation. Knowing simply to put a cutoff finger wrapped in gauze in a sealed baggie, to immerse the bag in ice water (not on ice), and to take it and the patient to the same hospital immediately and calling to notify the hospital on the way can help increase the likelihood of finger survival.

According to Dr Hattori,10 pain in affected fingers is more frequent in the amputation closure group, while successful replant patients experience minimal pain, a better functional outcome, better appearance, and higher patient satisfaction. Early psychiatric consults for flashbacks, nightmares, phantom-limb sensations, emotional lability, and cosmetic concerns to normalize adjustment can help integration.6 About 34% of flashbacks are a recall of events, 47% are images of the injured part as it was seen right after the accident, and 13% are projected images of injuries as being more extensive than they actually were. If patients are experiencing replay flashbacks, they actively see in their mental images ways in which the injury might have been avoided. They have a 95% likelihood of returning to their former employment.11

How has the patient coped in the past with injury or illness? When coping with a crisis, a patient needs to maintain his or her sense of autonomy and control. Information and explanations helps the individual make sense of his or her own circumstances. Families also need information and emotional support.11 This is where an informational handout for families to read on return from the recovery room is very beneficial (see Replant Recovery Journal).

Denial of injury or its significance can be a patient's way of tolerating the magnitude of what has happened. Tolerating the situation can give encouragement to face the next stage of treatment. It is common to have a persistent state of disbelief and shock, particularly if the injury occurred during familiar activities.11

Nurses are perceived by plastic surgeons as having a primary role in screening patients for pertinent psychological history. Nurses can be involved with research into the most effective drugs and alternative treatments. Since psychological complications are much more prevalent than physical problems like hematomas and infection, the focus for plastic surgeons is considered to be improving patients' emotional and psychological results from surgery.12

Swedish researchers investigating acute traumatic stress note that dissociative symptoms—feelings of unreality—can occur. The uncertainty about what will happen plays an important role in creating threat, making the situation extremely stressful.13 A strategy for patient coping is to have the patient compare the current situation to something that would be worse. In this way the threat becomes altered, even though the real circumstance does not change. This helps to increase adjustment to a new body image.13

In relation to a patient's sense of unreality, in his studies about phantom-limb sensations, Dr Ramachandran14 found that the input of sensations to the cortex of the brain changed after a limb was cut off. The neural areas that represented the thumb and fingers began to receive messages from the skin near the end of the stump. With a piece of cotton, he could map out the regions on the stump that now corresponded to each finger and thumb. Brain-imaging studies support the fact of this change. Ramachandran later found evidence that these changes could occur very quickly after part of a limb was removed. This may be part of what happens when a digit is cut off and reimplanted. The sensory cortex corresponding to the finger begins to take impulses from the limb proximal to the loss. The messages from the replanted finger may have to compete with these sensations before that part of the sensory cortex feels the finger as the original finger.

This perspective on integration can be corroborated by toe-to-finger replantation. Restoration of the original image of the amputated finger as well as recovery of some sensory and motor functions are important in perceiving transplanted toes as fingers. According to Chu,15 of 60 patients, 77% perceived their transplanted toes as fingers. It was attached to the finger place. It had the function of a finger. It functioned as a finger when in use. It looked like a finger, not a toe.

“Trying to keep the situation under control” is the number 1 coping strategy for hypertension, nonserious acute illnesses, myocardial infarction, chronic obstructive pulmonary disease, chronic renal failure in addition to finger replantation. Allow the patient to decide when and how help should be given.16

From another perspective, nurses can now use a biopsychosocial approach for finger replantation surgery patients and others who have similar needs. Nurses can deliberately evolve their skills with each clinical experience and with their studies in the field. Patients and their families can benefit with early information, support, and a sense of what to expect, including the possibility of an unpredictable outcome. Patients can regain a sense of control from the beginning with education and increasing understanding, as they are assisted to do all they can do for themselves.

Trauma nurses have a vital role in promoting psychological and physical healing on a replant-recovery journey.

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REFERENCES

1. O'Hara M, Lineaweaver W. Microsurgical replantation: development and current status. Crit Care Nurs Q. 1990;13:1–11.
2. Meyer T. Psychological aspects of mutilating hand injuries. Hand Clin. 2003;19:41–49.
3. Harton H. Initial postoperative management of replantation patients in critical care. Crit Care Nurs Q. 1990;13:35–46.
4. Schweitzer I, Rosebaum M. Psychiatric aspects of replantation surgery. Gen Hosp Psychiatry. 1982;4:271–279.
5. Mallette P, Ring D. Attitudes of hand surgeons, hand surgery patients, and the general public regarding psychologic influences on illness. J Hand Surg. 2006;31:1362–1366.
6. Grunert B, Smith CJ, Devine CA, et al.. Early psychological aspects of severe hand injury. J Hand Surg. 1988;13:177–180.
7. Schweitzer I, Rosenbaum M, Sharzer L, Strauch B. Psychological reactions and process following replantation surgery: a study of 50 patients over 2 years. Plast Reconstr Surg. 1984;70:97–103.
8. Schweitzer I, Rosenbaum M, Sharzer L, Strauch B. Liason consultation psychiatry with patients who have replantation surgery to the upper limb. Aust N Z J Psychiatry. 1986;20:38–43.
9. Kongable G. Psychosocial aspects of medically compromised persons. Psychiatric Nursing Contemporary Practice. 3rd ed. 2005:746–767.
10. Hattori Y, Doi K, Ikeda K, Estrella E. A retrospective study of functional outcomes after successful replantation versus amputation closure for single fingertip amputations. J Hand Surg. 2006;31:811–818.
11. Wallace B, Herbert C. Managing the psychosocial problems associated with replantation surgery. Crit Care Nurse Q. 1990;13:55–63.
12. Borah G, Rankin M, Wey P. Psychological complications in 281 plastic surgery practices. Plast Reconstr Surg. 1999;104:1241–1248.
13. Gustafsson M, Persson L, Amilon A. A qualitative study of stress factors in the early stage of acute traumatic hand injury. J Adv Nurs. 2000;32:1333–1340.
14. Ramachandran VS, Blakeslee S. Phantoms in the Brain: Probing the Mysteries of the Human Mind. New York, NY: William Morrow and Company Inc; 1998
    15. Chu NS. Perception of transplanted toes following toe-to-finger transplantation. J Clin Exp Neuropsychol. 1998; 20:599–602.
    16. Gustafsson M, Ahlstrom G. Emotional distress and coping in the early stage of recovery following acute traumatic hand injury: A questionnaire survey. Int J Nurs Stud. 2006;43:557–565.
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    Text From Finger Replant Recovery Journey: A Handbook for Patients and Families

    You are recovering from finger microsurgery that may have lasted from 4 to 12 hours. Your surgeons, using specially designed microscopes, put the blood vessels in your injured finger back together. They line up the parts of your fingers, so the nerves can grow back into their sheaths. Your brain may need time to register those sensations again. It usually takes awhile for this to happen because the injured nerve in your finger takes time to grow. Your finger may feel as if it is not real. This is normal.

    You are also recovering from an injury that may be frightening. Both surgeons and psychiatrists have noticed that many people with this injury feel anxious afterward, even though their fingers have been reimplanted successfully. This is normal. There are health professionals available to talk with you about these anxious feelings.

    Sometimes people feel shocked and disconnected when first awakening from surgery. Many people have felt this way. It is a normal reaction to a trauma. As you recover, you are going to feel more and more in control of the situation.

    Nurses check your finger circulation every hour by touching a long sterile Q-tip to your fingertip. If the skin goes pale and comes back to normal color within a certain time, then your circulation is good. If it takes too long, the nurse will inform your doctor.

    The nurses are checking the oxygen-carrying capacity of your blood when they watch the pulse oximetry machine. They also watch you, as well as check your vital signs, do a complete assessment, watch your laboratory test results, talk with you, and ensure your comfort and safety.

    It may seem difficult at first to move with IV lines, and a large dressing, but it is important to move around as much as possible. The nurses and physical therapist will show you how.

    Your doctors will change the large dressing on your arm and hand. You do not have to look at the first change if you do not want to. If you do, remember that you are recovering from surgery, so at first, the attached finger(s) may look strange, but that will change. This is a good time to ask the doctors as many questions as you like.

    As soon as your doctors decide it is possible to work your fingers again, they will talk with your rehabilitation team to set up appointments for you to begin relearning how to use your hand.

    Please remember that the doctors and nurses need to hear your concerns and questions. They need you to let them know what is going on with you. You are a partner in your care.

    It is okay to feel anger, disappointment, fear, and guilt over what happened. All of this is a natural part of grieving for your hand as it once was. It is normal to go through the stages of grief, as we would with any major change.

    Stage 1 is when you don't want to believe that it really happened. Sometimes a person has to stay in their stage for awhile until he or she gets the strength to move to the next point.

    Stage 2 is when people get angry about what they have lost. They may feel guilty about what they believe they did and blame others. Blaming does not work. When a person can realize what he or she is actually responsible for, like being in the wrong place at the wrong time, having a body that can get injured, or being too worried about something else to use safeguards, then it is time for that person to move on to the next level.

    Stage 3 is when a person tries to bargain with life, “If only I had…if only I could…” but their situation is still the same. You may be able to feel your finger and learn how to use your hands in a different way.

    Stage 4 is about testing different solutions to your situation. This is a good time to work with the rehabilitation team and ask all the questions you need to ask.

    Stage 5 occurs as your current situation becomes real and you accept what you cannot change, and you are grateful for what you have. You may go back to the previous stages briefly, but you still move forward. If you get stuck and feel depressed, please let your nurses and doctors know as soon as possible.

    Keywords:

    Finger replantation; Microsurgery; Psychosocial; Trauma nurse

    © 2011 Society of Trauma Nurses