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Difficulty: MediumBasic Care and Comfort

An individual is recovering in the surgical unit 48 hours after undergoing a right below-the-knee amputation. As part of basic care and comfort, which of the following interventions should be implemented? Select all that apply.

  1. Place the client in a prone position for 20 to 30 minutes multiple times a day.Answer
  2. B
    Prop the right residual limb on a stack of pillows to continually minimize swelling.
  3. C
    Apply physical restraints immediately if the client becomes confused and reaches for the surgical dressing.
  4. Assist the client with active range-of-motion exercises for the left leg and upper extremities.Answer
  5. Examine the skin around the residual limb carefully for early signs of pressure or breakdown.Answer

Answer

The appropriate interventions include placing the client in a prone position, assisting with range-of-motion exercises for the unaffected extremities, and examining the skin around the residual limb.
The correct options focus on maintaining mobility and preventing complications. Placing the client in a prone position several times a day stretches the flexor muscles and prevents hip flexion contractures. Assisting with active range-of-motion exercises on unaffected limbs maintains muscle strength essential for future ambulation and transfers. Examining the skin around the surgical site is a vital basic care measure to detect early signs of breakdown and maintain tissue integrity.

Step-by-Step Solution

1
Analyze the client's postoperative timeframe (48 hours) and procedure (below-the-knee amputation) to identify specific mobility and skin care needs.
Determined that the initial 24-hour acute phase has passed, shifting focus to contracture prevention and mobility preservation.
Postoperative guidelines change based on the time elapsed since surgery, particularly regarding elevation.
2
Evaluate the positioning options against the risk of flexion contractures.
Identified that prone positioning prevents contractures, while prolonged pillow elevation causes them.
Preventing contractures is crucial for ensuring the client can successfully use a prosthesis in the future.
3
Review the safety and comfort measures regarding confusion and skin integrity.
Recognized that skin inspection is mandatory, while immediate physical restraint violates safety protocols.
Nurses must prioritize least restrictive measures for confusion and proactively monitor for pressure injuries.
4
Select all options that promote safe recovery, maintain unaffected muscle strength, and adhere to appropriate positioning guidelines.
Selected the options for prone positioning, range-of-motion exercises, and skin inspection.
These actions collectively support the objective of basic care and comfort within the practical nurse's scope.

Key Concept

Postoperative Positioning and Mobility for Amputations
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Topics

Basic Care and Comfort

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