# A nurse is assessing a 72-year-old patient on the second postoperative day following a below-knee amputation of the left leg due to complications from diabetes mellitus and chronic osteomyelitis. Which assessment finding would be the most concerning and require immediate intervention?

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> subject: Adult Health

## 문제

A nurse is assessing a 72-year-old patient on the second postoperative day following a below-knee amputation of the left leg due to complications from diabetes mellitus and chronic osteomyelitis. Which assessment finding would be the most concerning and require immediate intervention?

## 보기

1. Phantom limb pain rated 6/10 on the pain scale
2. Serosanguineous drainage on the surgical dressing
3. Edema in the residual limb extending 2 cm above the incision
4. Cool, pale skin with absent pulse in the residual limb **✔ 정답**

**정답: 4**

## 해설

Cool, pale skin with absent pulse indicates vascular compromise requiring immediate intervention to prevent tissue necrosis. Phantom pain, drainage, and edema are expected findings that are less urgent.

## 심화 해설

Clinical Context

This patient is in the early postoperative period following a below-knee amputation (BKA), a major lower limb amputation often necessitated by complications of diabetes mellitus and chronic osteomyelitis. The underlying disease processes—diabetic neuropathy, peripheral arterial disease (PAD), and compromised tissue repair—continue to place the patient at high risk for postoperative complications, particularly vascular compromise and poor wound healing [2]. The nurse's primary focus is differentiating expected postoperative findings from indicators of acute limb-threatening ischemia.

Answer Analysis

The correct answer is **Option 4**. Let's examine each finding to understand why.

**Option 1: Phantom limb pain rated 6/10 on the pain scale.**

Phantom limb pain is a very common and expected sensory experience after amputation. While it requires thorough assessment and a multimodal pain management approach, a pain score of 6/10 in the immediate postoperative period does not signal an acute, life- or limb-threatening emergency. It is a priority for comfort and rehabilitation but is not the most concerning finding requiring immediate intervention.

**Option 2: Serosanguineous drainage on the surgical dressing.**

A moderate amount of serosanguineous drainage—a thin, pinkish fluid composed of serum and blood—is a normal finding in the inflammatory phase of wound healing during the first few days after surgery. The nurse should mark the drainage edge on the dressing, note the amount and characteristics, and continue to monitor. This finding alone does not indicate a complication.

**Option 3: Edema in the residual limb extending 2 cm above the incision.**

Postoperative edema is an expected physiological response to surgical trauma and inflammation. Edema extending a few centimeters proximal to the incision is common and is managed with proper residual limb positioning, compression wraps, and elevation as prescribed. While excessive or worsening edema requires attention, this presentation is not the most immediately concerning finding.

**Option 4: Cool, pale skin with absent pulse in the residual limb.**

This is the **most concerning finding** and demands immediate action. The combination of a cool, pale limb and an absent previously palpable pulse is a classic presentation of acute arterial occlusion in the residual limb. In a patient with diabetes and PAD, the arterial supply is already compromised due to atherosclerotic disease and impaired perfusion [2]. A new occlusion can result from thrombosis, embolus, or vasospasm, leading to limb-threatening ischemia. Without rapid intervention to restore blood flow, tissue necrosis will occur, potentially requiring revision to a higher-level amputation. This finding constitutes a vascular emergency and must be reported to the surgeon immediately.

Pathophysiology Connection

The "5 P's" of acute arterial occlusion—Pain, Pallor, Pulselessness, Paresthesia, and Poikilothermia (coolness)—are critical assessment markers. The finding of cool, pale skin with an absent pulse directly reflects a cessation of oxygenated blood flow to the tissues. In the context of a diabetic foot complication that has already led to a major amputation, the vascular reserve is severely limited [1,2]. The underlying peripheral arterial disease that contributed to the initial ulcer and infection is a systemic condition that also affects the more proximal vessels supplying the residual limb [2]. This makes the stump highly vulnerable to any further reduction in perfusion. The nurse's immediate recognition and reporting of this vascular assessment finding is the most critical step in preserving the limb length and preventing further morbidity.

References (research sources)

- [2]Comprehensive Management of Diabetic Foot Ulcers: Current Evidence and Practice.Research articleKim JM, Kang SM, Jung JH, Kim KC, Ahn S, Kim CH, Park TS, Park IB. (2026) · DOI: 10.1111/1753-0407.70221

## 임상 시나리오

Post-Amputation Vascular EmergencyRecognizing Acute Arterial Occlusion
The most critical postoperative assessment after amputation is monitoring for acute arterial occlusion. The classic signs are the 6 Ps: Pain, Pallor (cool, pale skin), Pulselessness (absent Doppler signals), Paresthesia, Paralysis, and Poikilothermia (coldness).

Immediate intervention is required to salvage the limb. The window for revascularization is typically 4-6 hours before irreversible nerve and muscle damage occurs. Notify the surgeon immediately and prepare the patient for potential Doppler ultrasound, angiography, or emergency thrombectomy.

CautionDo not confuse normal postoperative edema with the pallor and coldness of ischemia. While edema is expected, a pale, pulseless, and cool limb is a surgical emergency. Never apply heat or elevate the limb above the heart level in suspected arterial occlusion, as this can worsen ischemia.

## 핵심 개념

- **Phantom Limb Pain** — Painful sensations perceived in the amputated portion of the limb, a common postoperative phenomenon requiring multimodal analgesia.
- **Serosanguineous Drainage** — Thin, pinkish wound drainage composed of serum and blood, normally present during the inflammatory phase of healing.
- **Arterial Occlusion** — Blockage of an artery, often by a thrombus or embolus, leading to ischemia characterized by the 6 Ps: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia.
- **Residual Limb** — The remaining portion of a limb after amputation, requiring careful monitoring for healing, edema, and vascular integrity.
- **Below-Knee Amputation (BKA)** — Surgical removal of the leg below the knee joint, often performed for irreversible ischemia, infection, or trauma.

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