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Difficulty: HardBasic Care and Comfort

A 72-year-old client is 48 hours post-operative following a right above-the-knee amputation (AKA). The client is experiencing intermittent confusion, reports a "burning" sensation in the right foot, and frequently attempts to touch the surgical dressing. Which nursing action is most appropriate to promote the client's basic care, comfort, and safety?

  1. A
    Prop the right residual limb on two stacked pillows to minimize ongoing edema and relieve discomfort.
  2. B
    Delegate to the unlicensed assistive personnel (UAP) to evaluate the intensity and characteristics of the phantom limb pain.
  3. Assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.Answer
  4. D
    Apply soft bilateral wrist restraints to prevent the client from compromising the surgical site.

Answer

Assist the client into a prone position for 20 to 30 minutes every 3 to 4 hours.
Assisting the client into a prone position is the most appropriate action. Following an above-the-knee amputation, clients are at a high risk for developing hip flexion contractures. Lying prone for 20 to 30 minutes several times a day stretches the flexor muscles of the hip and maintains joint extension, which is crucial for future weight-bearing and successful prosthetic use.

Step-by-Step Solution

1
Analyze the client's post-operative timeline.
The client is 48 hours post-operation for an above-the-knee amputation.
Timing dictates appropriate positioning interventions; standard care interventions change drastically after the first 24 hours.
2
Evaluate the clinical risks associated with the procedure.
A major complication of an above-the-knee amputation is the development of a hip flexion contracture.
Contractures severely impair future mobility and the ability to use a prosthetic limb effectively.
3
Select the intervention that mitigates the primary physiological risk while addressing safety guidelines.
Assisting the client into a prone position several times a day stretches the hip flexors.
This is an evidence-based positioning practice for basic care and comfort in clients with lower extremity amputations, while avoiding improper delegation and premature use of restraints.

Key Concept

Prevention of flexion contractures following lower extremity amputation
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Topics

Basic Care and Comfort

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