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Difficulty: HardBasic Care and Comfort

The healthcare team is reviewing the mobility and comfort orders for a client who underwent a right above-knee amputation two days ago. Which intervention should the nurse implement to prevent long-term musculoskeletal complications?

  1. A
    Elevate the residual limb on a firm pillow when the client is resting in bed.
  2. Place the client in a prone position for 30 minutes three times a day.Answer
  3. C
    Assist the client to sit in a bedside chair for continuous intervals of two to three hours.
  4. D
    Maintain the residual limb in a state of slight abduction and external rotation.

Answer

Place the client in a prone position for 30 minutes three times a day.
Placing a client with an above-knee amputation in a prone position for 20 to 30 minutes several times a day stretches the hip flexor muscles. This directly prevents the development of hip flexion contractures, which are severe complications that can prevent the future use of a prosthesis.

Step-by-Step Solution

1
Identify the primary long-term complication risk for a client with an above-knee amputation (AKA).
The major risk is a hip flexion contracture, which can permanently impair the client's ability to use a prosthetic device.
Understanding the pathophysiology of post-amputation recovery directs appropriate nursing interventions.
2
Evaluate the timeline post-surgery (two days ago).
After the first 24 hours, interventions must shift from edema management (elevation) to contracture prevention.
Elevation after 24 hours actively promotes hip flexion contractures.
3
Analyze the given options against evidence-based positioning protocols.
Prone positioning stretches the hip flexor muscles, countering the tendency for them to shorten and contract.
Selecting the option that directly mitigates the identified risk.

Key Concept

Post-amputation contracture prevention
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Topics

Basic Care and Comfort

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