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Difficulty: HardBasic Care and Comfort

A nurse is managing the basic care and comfort of an older adult client who is 48 hours postoperative following a right above-the-knee amputation. The client reports mild discomfort in the residual limb and requests that it be elevated on a soft pillow. Which of the following nursing actions is the most appropriate?

  1. Explain the importance of contracture prevention and assist the client into a prone position for 20 to 30 minutes.Answer
  2. B
    Elevate the residual limb on a soft pillow to decrease dependent edema and promote venous return.
  3. C
    Delegate to the unlicensed assistive personnel (UAP) the task of assessing the residual limb for surgical site bleeding prior to repositioning.
  4. D
    Reassure the client that decreased joint flexibility is a normal physiological change of aging and maintain the client in a high-Fowler's position.

Answer

Explain the importance of contracture prevention and assist the client into a prone position for 20 to 30 minutes.
After the first 24 hours following a lower extremity amputation, elevating the residual limb on a pillow is strictly contraindicated as it promotes the development of hip flexion contractures. The most appropriate action is to assist the client into a prone position for 20 to 30 minutes, 3 to 4 times a day, to actively stretch the hip flexor muscles and prevent contractures, while explaining the rationale for this intervention to ensure client cooperation.

Step-by-Step Solution

1
Analyze the client's postoperative timeline and surgical procedure.
The client is 48 hours post-op for a right above-the-knee amputation (AKA).
The postoperative timeline is critical because positioning protocols change dramatically after the first 24 hours to prevent immobility complications.
2
Evaluate the client's request to elevate the residual limb on a pillow.
Identify that elevation on a pillow at this stage causes prolonged hip flexion.
While elevation reduces edema in the first 24 hours, prolonged hip flexion after 24 hours rapidly leads to hip flexion contractures, severely complicating future prosthetic use.
3
Select the nursing intervention that promotes comfort while preventing contractures.
The prone position extends the hip joint and actively stretches the flexor muscles.
Lying prone for 20 to 30 minutes, 3 to 4 times a day, is the evidence-based standard to prevent contractures in AKA clients.

Key Concept

Prevention of hip flexion contractures following lower extremity amputation
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Topics

Basic Care and Comfort

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