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Difficulty: HardBasic Care and Comfort

A client is receiving care 72 hours after a right above-the-knee amputation. The client reports a dull ache in the residual limb and asks the practical nurse to place a pillow underneath it for support. Which action should the nurse take?

  1. Explain that elevating the limb on a pillow at this stage increases the risk of developing a hip flexion contracture.Answer
  2. B
    Place a soft pillow under the residual limb to promote venous return and alleviate the aching.
  3. C
    Elevate the foot of the bed to reduce the swelling while avoiding direct pressure on the incision.
  4. D
    Assist the client into a continuous high Fowler's position to stretch the hip flexor muscles.

Answer

The correct action is to explain that elevating the limb on a pillow at this stage increases the risk of developing a hip flexion contracture.
After the first 24 hours following a lower extremity amputation, the residual limb should not be elevated on a pillow. Elevating the limb or maintaining prolonged flexion at this stage significantly increases the risk of developing a hip flexion contracture, which can severely impair future mobility and prosthetic fitting. The nurse must provide education regarding this risk and utilize alternative comfort measures.

Step-by-Step Solution

1
Identify the type of surgery and the time elapsed.
The client had a right above-the-knee amputation 72 hours (3 days) ago.
Postoperative protocols for amputation change significantly after the first 24 hours.
2
Determine the physiological risks associated with positioning at this stage.
The primary risk after 24 hours is the development of a hip flexion contracture due to prolonged flexion of the joint.
Contractures can severely limit mobility and complicate or prevent the successful fitting of a prosthesis.
3
Evaluate the client's request against safety guidelines.
Placing a pillow under the limb promotes hip flexion and is strictly contraindicated at 72 hours.
The nurse must prioritize long-term mobility and prevent complications over the requested short-term comfort measure.
4
Select the appropriate nursing intervention.
The nurse should deny the pillow request while providing education on the risk of contractures.
Client education promotes understanding and adherence to necessary positioning restrictions.

Key Concept

Postoperative Positioning for Amputation
Estimated Time:1m 0s
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Topics

Basic Care and Comfort

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