During morning rounds, a licensed practical nurse is providing hygiene and comfort measures for a client who had a right above-the-knee amputation two days ago. The client currently reports moderate phantom limb discomfort. Which actions should the nurse incorporate into the care plan for this shift? Select all that apply.
- Assist the client into a prone position for 20 to 30 minutes several times a day.Answer
- BElevate the right residual limb on two stacked pillows while the client is resting in a supine position.
- Gently wash the intact skin of the residual limb with mild soap and water, then pat it completely dry.Answer
- DInstruct the assistive personnel to evaluate the healing progress of the surgical site while assisting with the bed bath.
- EAssume a newly assessed resting heart rate of 118 bpm with mild hypotension is an expected response to phantom limb discomfort.
- Encourage the client to perform active range-of-motion exercises with 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 encouraging active range-of-motion exercises for the unaffected extremities.
Appropriate basic care for a client 48 hours post-amputation includes implementing prone positioning to stretch hip flexors and prevent contractures, meticulously cleaning and drying the residual limb to maintain skin integrity, and utilizing active range-of-motion exercises to preserve strength in unaffected limbs.
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Key Concept
Postoperative Basic Care and Complication Prevention Following Amputation