الفهرس 
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Abstract
Limb amputation is one of the most physically and psychologically devastating events that can happen to a person. Major limb amputation causes major disfigurement, it renders people less mobile and at risk for loss of independency (Osborn et al., 2010). Amputation causes a variety of physical, emotional, social, and financial stressors that challenge the individual’s ability to maintain emotional well-being and, in some instances, may promote maladaptive reactions leading to poor psychosocial adjustment. How people cope with their amputation depends upon their unique make-up, previous life experiences, support systems, and the meaning they give to their amputation (El Sebaee & Mohamed, 2011). Understanding the effects of stress, coping, and adaptation is essential. Furthermore, appreciating the impact of stress on human behavior enhances the assessment process and helps the nurse to identify patient strengths, resources, and interventions that can reduce the deleterious effects of stress (Boyed, 2008).
Aim of the study
The aim of this study was to assess types and levels of stressors as well as coping strategies among patients with limb amputation.
Research questions
This study is based on answering the following questions:
- What are the types of stressors facing patients with limb amputation?
- What are the levels of stressors among patients with limb amputation?
- What are the coping strategies for patients with limb amputation?
Research setting
The study was conducted in El-Demerdash Hospital – affiliated to Ain Shams University Hospitals. Inpatient wards are: emergency, orthopedic surgery, plastic surgery, vascular surgery, and general surgery departments. Each department has a fixed day for emergency and a fixed day for outpatient clinic.
Subjects of the study
The subjects were 60 patients with limb amputation, fulfilling the following criteria: Adults (both sexes) with unilateral major amputated limb and free from any physical disability and neurological or psychotic disorder. Tools of data collection
Data were collected using the following tools:
1- Interviewing Questionnaire:
It was designed by the researcher in simple Arabic language after reviewing related literature. The questionnaire was used two times during hospitalization and one month after surgery. It is composed of two parts:
A- First part: Socio demographic characteristics:
It includes data such as; age, gender, marital status, educational level, occupation, income, health insurance, treatment cost and residence.
B- Second part: health status assessment:
It deals with medical background data of patients with limb amputation that contains 2 parts: patient’s past history and physical assessment.
2- Amputation Stressors Questionnaire (ASQ) which was used to assess types and levels of stressors facing patients with limb amputation. It includes 7 categories; physical, social, work related, financial, psychological, body image related and hospital stay stressors.
3-Ways of Coping Questionnaire (WCQ) which was used to assess mental and behavioral efforts to deal with stressors among patients with limb amputation. It includes 3 categories active, seeking support and avoidant coping strategies.
Pilot study
A pilot study was carried out on six hospitalized patients with limb amputation and after one month during follow up visits. The necessary modifications were done as a result of the pilot study.
The main findings of this study revealed that:
• An analysis of demographic characteristics of studied sample showed that near half of the studied sample (48.3%) aged between 41-60 years, and half of them (50%) are married. More than third of study sample were illiterate (35%) and 31.7% were secondary educated, 31.7% are employees whereas quarter of the sample (25%) were unemployed. Two thirds of the sample had insufficient income (66.6%). Most of them (91.7%) lived with family and 61.7% were the sole breadwinners of their families.
• An analysis of health status assessment showed that three quarters of the studied sample (75%) suffered from chronic illnesses in which diabetes represents the highest percentage among studied sample (46.7%) moreover, diabetic foot represents the highest parentage (45%) among studied sample followed by vascular diseases and trauma with equal percentage (25%). Most of the studied sample (96.7%) had lower limb amputation and more than half of them had amputation at below knee level (58.3%). Most of the studied sample (93.3%) felt post operative pain and less than half of them (45%) had phantom and residual pain as well.
• Regarding the comparison of pain intensity and wound complication, they had improved among studied sample from the time of hospitalization to one month after surgery. This can explain the significant difference (P ˂0.01 & ˂0.05 respectively). Concerning ADLs, independency increased among studied sample from the time of hospitalization which can explain the significant difference (P= ˂0.05).
• An analysis of amputation related stressors showed that patients with limb amputation are faced with a variety of physical, social, work related, financial, psychological, body image and hospital stay stressors during hospitalization and after one month of surgery. Level of physical, work, financial and psychological stressors were improved while social, and body image related stressors were increased from time of hospitalization to one month after surgery. The highest level of stressors during hospitalization was the physical stressors while after one month, was body image related stressors. There were statistically significant differences between the studied sample from the time of hospitalization to one month after surgery regarding physical and work stressors (p ˂0.01).
• There were statistically significant differences between the studied sample from the time of hospitalization to one month after surgery regarding active and seeking support, avoidant as well as total coping (p˃0.05), so that, using ways of coping positively was increased from the time of hospitalization to one month after surgery.
• An analysis of relations between amputation related stressors and total coping among studied sample showed that there were significant differences among studied sample from the time of hospitalization to one month after surgery between total coping and financial and psychological stressors (p˃0.05). Moreover, there was a significant difference between coping and body image related stressors (p˃0.01).
It is concluded that patients with limb amputation patients with limb amputation experienced a variety of stressors during hospitalization and after one month of surgery that included physical, social, work, financial, psychological, body image and hospital stay stressors. The highest level of stressor during hospitalization was physical stressors while after one month, they were was body image related stressors. The most common way of coping used by patients was seeking support. There were statistically significant differences among the studied sample in relation to psychological and body image related stressors with coping. However, there are many real problems during this period, physically as well as emotionally; amputation related stressors and ways of coping were significantly improved from the time of hospitalization to one month after surgery so that patients with limb amputation were directed to adaptation and in the process of acceptance stage.
In the light of these findings, it is recommended that:
1) For nurses:-
- Development of psycho-educational programs for nurses regarding physical, psychological, social and spiritual support for patients with limb amputation to enhance their coping.
- Comprehensive nursing management protocol dealing with amputation related stressors should be available to help such patients for adjustment.
2) For patients and their families:-
- Establishment of rehabilitation program for patients who undergo limb amputation involving their families through multidisciplinary team for successful community reintegration. This can be implemented when patients are encouraged to maintain control over their environment by helping them to take responsibility for their physical, emotional, behavioral and health maintenance.
- Development of educational program for patient with limb amputation regarding stress management and adaptive coping to enhance their ability to deal with amputation related stressors.
- Providing psychological counseling in which psychological support will help to insure that emotional issues are adequately addressed. Religious counseling program which emphasize on spiritual solutions to patient stress problems
3) For research:-
- Further researches are needed to: assess quality of life of patients with limb amputation during rehabilitation period.
- Focusing on assessing body image related stressors and stigma of disability because of its importance for patients with limb amputation.
- Replication of the study is required to investigate the
coping strategies of patients with amputation after 3 and 6 months and after one year.
- Further study to examine and compare coping strategies among patients with upper versus lower and minor versus major limb amputation.