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Difficulty: HardBasic Care and Comfort

A client is recovering on the surgical unit 48 hours after a right below-the-knee amputation. During the morning assessment, the client reports a pain level of 6 on a 0-to-10 scale in the absent right foot. The residual limb exhibits mild, non-pitting edema. Which of the following positioning interventions is most appropriate for the nurse to implement?

  1. A
    Elevate the residual limb on a pillow to promote venous return and decrease edema.
  2. Assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.Answer
  3. C
    Place the client in a high-Fowler's position with a rolled towel placed under the right knee.
  4. D
    Transfer the client to a bedside chair to sit upright for consecutive 4-hour intervals.

Answer

The most appropriate positioning intervention is to assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.
The correct action is to assist the client into a prone position several times a day. This position is vital for clients with lower extremity amputations because it extends the hip joint, preventing the flexor muscles from shortening. Preventing hip flexion contractures is a primary nursing goal, as contractures can make it impossible for the client to bear weight or use a prosthetic device in the future.

Step-by-Step Solution

1
Identify the client's post-operative time frame and procedure.
The client is 48 hours post-operative following a below-the-knee amputation.
The time since surgery dictates the appropriate positioning interventions, as protocols change after the first 24 hours.
2
Determine the primary risk factor related to positioning for this specific client.
The primary risk is the development of hip and knee flexion contractures.
Flexion contractures can prevent the successful fitting and use of a prosthetic limb, permanently impairing mobility.
3
Evaluate the safety of elevating the edematous limb at this stage of recovery.
Elevation on a pillow is unsafe at 48 hours, as the risk of hip flexion contracture outweighs the benefit of edema reduction.
While elevation is used in the first 24 hours to minimize swelling, continuing this practice causes the flexor muscles to shorten.
4
Select the positioning intervention that actively prevents the identified risk.
Prone positioning is selected.
The prone position forces the hip into extension, stretching the flexor muscles and effectively preventing contracture formation.

Key Concept

Prevention of flexion contractures following lower extremity amputation
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Topics

Basic Care and Comfort

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