Developmental Factors In The Care Of The Adolescent Amputee
Bernadette Dorsch Curry, R.N., M.S. *
Amputation is an extremely stressful event for any individual and the entire health team must call upon all its professional talents and resources to provide a therapeutic environment, both physically and psychosocially. When the patient is an adolescent there are several factors related to his developmental stage that are pertinent to the physical and emotional aspects of the situation. These factors must be considered in order to provide care that is appropriate to the patient in terms of his adolescence as well as his physical condition.
An holistic approach where the patient is viewed as a total entity, comprised of many facets, is necessary. The foundation of this approach is a keen understanding of adolescence per se in order to plan and implement measures effectively to help the patient achieve optimal physical and psychosocial functioning. This calls for interdisciplinary action and diligent communication by the health team in the postoperative period. Therapeutic support, appropriate to the developmental stage of the patient, is vital at this time since the immediate and stark reality of the situation may negate much of the preoperative support and instruction he received. All health team members should be aware of the mind set and perceptions of adolescents which lead to behaviors characteristic of this particular stage of development.
Adolescence is defined as a descriptive term of the period during which an emotionally immature individual in the second decade of life approaches the culmination of his physical and mental growth  . The adolescent is in a stage of transition, and is neither child nor adult. During this time the individual experiences considerable turmoil in striving for identity, maturity, and independence, and certain behaviors common to most adolescents surface. The adolescent is egocentric and has an inflated sense of his own worth. He invariably places his needs and interests above those of others. In other words, he feels the whole world should revolve around him.
Adolescents are also idealistic and tend to view issues in terms of what might be possible with little regard for the practicality of the situation . This idealism often leads to a high degree of criticism of others, especially adults. Though the adolescent may think and speak idealistically, he manifests the childlike behavior of wanting immediate gratification. He tends to operate on the urgency of instinctual and emotional needs. Patience is not often found in adolescents. Ambivalence is an expected trait since the youngster is changing his role. He is leaving behind familiar childhood behaviors and attempting to be mature. This cannot happen instantly and consequently mercurial behavior develops whereby the adolescent behaves as a child in one instance and an adult the next.
Acceptance is a critical issue since adolescence is a time for social development and expansion. Peer relations take on major importance. Since the adolescent tends to feel insecure as a result of his changing status and lack of experience, the peer group may serve as a refuge. Acceptance by peers is highly valued. Despite a desire for individuality, the adolescent strives to fit into the current acceptable pattern. He is greatly influenced by the expectations of his cohorts.
Extremely pertinent to the subject of amputation is the importance adolescents place on their bodies. This is a time of rapid change and the individual may not be able to adapt as quickly as the changes occur. Consequently coordination can be affected. In addition, not all parts of the body grow at the same rate at the same time during this growth spurt, a condition that leads to periods when the youngster is dissatisfied because he is not as perfectly proportioned as he thinks he should be.
It is at this point in life when the youngster begins to take great interest in grooming. Hours may be spent in front of a mirror combing each strand of hair into place. These hours are not necessarily idle preening since he may be "taking inventory" of himself for comparison of his own characteristics with those of his peers. A large degree of self perception in the adolescent results from comparison with others . An intact body image is vitally important to the self concept of the adolescent. The impact of amputation is further compounded by the fact that adolescents have a heightened sense of indestructibility. They ascribe to the "it can never happen to me" syndrome more so than other age groups.
These traits lead to numerous implications for the health team to consider in the postoperative and rehabilitation phases. Many disciplines comprise the health team, and the various members view the patient from different perspectives. This allows the team to develop a truly holistic approach and to set immediate and long term goals that utilize many and varied resources.
The role of team coordinator may be assumed by different members at different times as dictated by the priority of the needs of the patient. Initially, the physician is usually the coordinator. As the postoperative period progresses, the nurse may function as team leader since this professional role allows for long periods of direct contact and opportunity for thorough physical and psychosocial assessment. As recovery progresses into the rehabilitation phase the roles of the physical therapist and the prosthetist take on increasing importance. Each discipline serves as coordinator at the appropriate time, yet has an important role throughout the entire process.
The extent and diversity of the team is determined by the needs of the individual patient and may include social worker, tutor, psychologist, clergy, community health nurse, and others. Continual assessment by the entire team is essential to modify goals and plan and implement appropriate care. Communication is a key factor in efficient and effective team activities. It is especially important to include the adolescent in planning since, by nature, he wants to have some influence and a degree of control over the plans proposed for him. This arrangement will also help to increase his self esteem at a time when it may be severely threatened.
The timing and nature of the amputation will have considerable impact in the postoperative period. Was the surgical procedure done on an emergency basis? Was it an elective surgery that gave the patient time to begin the grieving process early? Did the incident cause him to miss a significant event in his life such as graduation or a prom? To the adolescent these are important issues. Does the nature of the surgery hold threat or promise for the patient? Was the surgery of a type that will increase cosmetic or functional worth, as in the case of a congenital defect? Did the surgery entail loss of a part vital to the lifestyle and aspirations of the patient? Did the procedure shatter visions of a career and numerous hours of labor already spent in preparation to be an accomplished athlete or artist; or simply just be like everybody else? These are sobering thoughts at any age, but can be particularly devastating when one is a teen-ager and sees his life as just beginning.
The health team must understand each of these factors in order to function efficiently and effectively. The team sets the tone for recovery, and can do many things to help the adolescent cope with his situation and participate in the treatment regime. The immediate postoperative physical needs of the patient involve basic therapeutic measures such as those that promote healing, prevent infection, and decrease pain. Care of the operative site is essential for future functional and cosmetic value, but attendance to the physical needs should not preclude meeting psychosocial needs as well. The team should strive to keep the patient informed of the nature and purpose of various treatments and procedures, in order to increase his level of cooperation and sense of participation. Since the adolescent seeks immediate gratification, it is important to praise and reassure him as he makes efforts. It is also important to set several short term goals rather than a few long term goals to give the patient a sense of achievement and motivation for continuing his efforts. A chart of daily and/ or weekly goals can be used when the patient is engaged in exercises to maintain muscle tone and circulation and prevent edema or atrophy prior to application of a prosthesis. A similar chart or checklist can be a helpful tool when the patient is learning to use and care for his prosthesis.
A supportive team will take steps to strengthen and maintain the body image of the adolescent. If not possible before surgery, the patient should speak with the prosthetist early in the postoperative period to help develop an understanding and allay fears and misconceptions regarding the prosthesis. It also allows the prosthetist to gain insight into the lifestyle and capabilities of the patient, factors that affect selection and application of the prosthesis. Since adolescents tend to be active individuals, durability of the prosthesis is a prime consideration. The patient should be allowed a role in making decisions that involve cosmetic versus functional aspects. Adolescent growth spurts require the prosthetist to anticipate more frequent prosthetic modifications than with other patients. These considerations along with early fitting and use of the prosthesis will allow the adolescent to incorporate the prosthesis into his body image more readily. Delay in use of a prosthesis can not only cause physical problems but also increases the number of psychosocial accommodations the patient must undergo.
Hospitalization interferes with peer relations which are very significant to the adolescent. The team must provide for means to maintain existing peer relations. When the patient is able to keep in contact with friends there are many beneficial effects. Peer visits not only provide diversion and recreation but offer support and encouragement. In addition, contact through the recovery process facilitates understanding and acceptance of the situation by friends. It can also alleviate the growing apprehension by the patient as to what his friends will think of him when he returns to his daily routine. Team members should review visitation policies and hospital recreation activities to insure for appropriate growth and development of the adolescent during his confinement. Access to a telephone, the lifeline of teenagers, is important especially when distance prohibits visiting.
The team should encourage interaction with other adolescent patients. These interactions are not only recreational but offer the patients an opportunity to share feelings and exchange information about their situations. These types of relationships are very supportive and beneficial.
The immobilization imposed by both the amputation and hospitalization can have a profound effect on independence. The adolescent finds the independence that he sought and was achieving gradually has been severely limited. This can lead to a high level of frustration and depression. Since the life experiences and coping mechanisms of the adolescent are not as developed as those of the adult, the health team must emphasize capabilities and talents, large or small, and help develop new ones when necessary. Allowing for choices in the daily routine is a simplistic yet effective way of giving a semblence of independence.
The entire health team must be mindful not to focus on the amputation to the point that sight is lost of the fact that a total individual is involved. A therapeutic environment will address every facet of the adolescent. The patient does not live in a vacuum, and will require physical and psychological support from family. Family members have also suffered a loss by this experience and are not apt to be supportive when their needs are not considered. Efforts must be made to help parents accept and understand the situation. The health team must be prepared to deal with parental needs that range from coping with guilt feelings to financial concerns. In the frenzy of activity to meet the needs of the patient, the needs of siblings can be easily neglected. The brothers and sisters need explanations of events and should be given opportunities to express their own fears and feelings. It is important that younger brothers and sisters understand that amputation will not necessarily happen to them when they get older. Siblings should be helped to understand why so much attention is directed to the patient, and how they themselves can be helpful. Undue focus on the patient will only increase his dependence and lead to misconceptions and conflicts within the family setting.
Summary
The health team must function to meet the needs of all patients in an holistic manner. Inherent in that concept is the understanding of the developmental stage of the patient. The needs of adolescents are different from those of children and adults and must be addressed accordingly. Though commonalities exist among the behaviors and needs of adolescents, individual differences must be anticipated. Interdisciplinary communication and application of the expertise of each team member will involve all facets of the patient and facilitate optimal recovery. The health team must implement a plan of care that is based on developmental concepts, yet formulated as individually as the prosthesis is designed.
References:
- Horrocks, J.E., The psychology of adolescence. Boston: Houghton Mifflin Co., Boston, 1962
- Piaget, J., in Phillips, J. The origin of intellect: Piaget's Theory. W.H. Freeman and Co., San Francisco, 1969
- Schimel, J. M.D. Your child in adolescence. New York: Signet Books, New York, 1970
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