An orthopedic unit nurse assumes care of a client who underwent a right above-the-knee amputation (AKA) twenty-four hours ago. The client's vital signs are currently stable, but they remain at high risk for physiological complications that could impede future rehabilitation. Which of the following nursing actions is most appropriate to reduce the client's risk of adverse physiological outcomes?
- Assist the client into a prone position for twenty to thirty minutes, three to four times a day.Answer
- BContinuously elevate the residual limb on two pillows to minimize postoperative edema.
- CMaintain the bed in a high-Fowler's position for the majority of the day to enhance lung expansion.
- DMonitor for early signs of hemorrhagic shock by assessing for bradycardia and a widening pulse pressure.
Answer
The most appropriate action is to assist the client into a prone position for twenty to thirty minutes multiple times a day to prevent hip flexion contractures.
Following an above-the-knee amputation, the flexor muscles are naturally stronger than the extensors, pulling the hip into a flexed position. Placing the client in a prone position for short periods multiple times a day physically stretches these flexor muscles, effectively preventing the formation of a hip flexion contracture. This risk reduction strategy is crucial because a severe contracture makes fitting and successfully using a prosthetic leg nearly impossible.
Step-by-Step Solution
Key Concept
Prevention of hip flexion contractures following lower extremity amputation
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