An older adult client is receiving morning care 48 hours after undergoing a right above-the-knee amputation. When implementing hygiene, mobility, and comfort measures, which actions are appropriate for the practical nurse to take? Select all that apply.
- Assist the client into a prone position for 20 to 30 minutes multiple times a day.Answer
- BElevate the right residual limb on two pillows to minimize postoperative swelling.
- Wash the residual limb with mild soap and water, ensuring the skin is patted completely dry.Answer
- DMaintain the client in a continuous high-Fowler's position when resting in bed.
- Instruct the client to perform active range-of-motion exercises on the unaffected extremities.Answer
Answer
The appropriate actions are assisting the client into a prone position periodically, washing and thoroughly drying the residual limb, and instructing the client to perform active range-of-motion exercises on unaffected extremities.
Correct basic care for an amputation after 24 hours prioritizes the prevention of contractures and the maintenance of skin integrity. Periodic prone positioning directly stretches the hip flexor muscles, counteracting the tendency for the joint to contract. Gentle hygiene with thorough drying prevents skin breakdown and fungal growth. Encouraging range-of-motion on unaffected limbs promotes systemic circulation and preserves the strength needed for future transfers and ambulation.
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Key Concept
Postoperative Basic Care and Comfort: Amputation Positioning and Hygiene