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Difficulty: EasyBasic Care and Comfort

A nurse on a surgical rehabilitation unit is caring for a client who is 48 hours post-operative following a right above-the-knee amputation. Which intervention should the nurse implement?

  1. Assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.Answer
  2. B
    Elevate the client's residual limb continuously on a firm pillow.
  3. C
    Maintain the client in a high-Fowler's position when resting in bed.
  4. D
    Delegate the evaluation of the surgical incision's healing progress to the assistive personnel.

Answer

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 multiple times a day. This position allows the hip joint to extend completely, counteracting the natural tendency of the hip flexor muscles to shorten and form a contracture following a lower extremity amputation. Preventing a contracture is crucial for successful prosthetic training.

Step-by-Step Solution

1
Identify the client's procedure and the current post-operative timeframe.
The client is 48 hours post-operative for a right above-the-knee amputation.
The timeframe determines the appropriate clinical interventions, as immediate post-op care differs from care provided after the initial 24 hours.
2
Recall the primary mobility and anatomical complications associated with an above-the-knee amputation.
Hip flexion contractures are a major risk due to muscle imbalance and prolonged periods of sitting or limb elevation.
Contractures can severely impair the client's future ability to be fitted for and successfully use a prosthesis.
3
Evaluate each nursing intervention for its effect on hip alignment and safe care practices.
Prone positioning actively extends the hip joint. Elevation or high-Fowler's positioning flexes the hip joint. Delegation of an evaluation is an unsafe practice.
Interventions must promote joint extension to counteract the risk of contractures, and assessments must remain the responsibility of the registered nurse.

Key Concept

Prevention of flexion contractures following lower extremity amputation
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Topics

Basic Care and Comfort

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