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Difficulty: MediumBasic Care and Comfort

A nurse is developing a plan of care for a client who is 48 hours postoperative following a right below-the-knee amputation (BKA). Which of the following nursing interventions should the nurse include to promote comfort, mobility, and healing? Select all that apply.

  1. Position the client in a prone position for 20 to 30 minutes several times a day.Answer
  2. B
    Elevate the residual limb continuously on a pillow to reduce postoperative swelling.
  3. C
    Encourage the client to sit in a bedside chair for 4 hours at a time to build endurance.
  4. D
    Delegate the assessment and cleansing of the surgical incision to the assistive personnel.
  5. Wrap the residual limb with an elastic compression bandage using a figure-eight technique.Answer
  6. Instruct the client to perform active range-of-motion exercises on the unaffected extremities.Answer

Answer

The correct interventions are positioning the client prone several times a day, wrapping the limb with a figure-eight technique, and instructing the client to perform active range-of-motion exercises on unaffected extremities.
The correct interventions focus on preventing contractures, promoting circulation, and maintaining strength. Prone positioning actively stretches the hip flexors, preventing contractures. A figure-eight elastic wrap shapes the limb for a prosthesis while minimizing edema. Active range-of-motion exercises ensure the client retains the upper body and unaffected leg strength necessary for future transfers and ambulation.

Step-by-Step Solution

1
Analyze the client's postoperative timeline (48 hours post-amputation).
The client has passed the initial 24-hour acute phase where edema management is the primary goal.
After 24 hours, nursing priorities must shift from managing acute swelling to preventing contractures and preparing the client for mobility.
2
Evaluate the positioning and mobility options for contracture prevention.
Prone positioning is identified as beneficial, while continuous elevation and prolonged sitting are harmful.
Maintaining the hip in a flexed position (via pillows or prolonged sitting) after 24 hours leads to hip flexion contractures, which can prevent the successful use of a prosthesis.
3
Review the principles of delegation and wound care for the residual limb.
Incision assessment cannot be delegated to assistive personnel, and the limb should be wrapped using a figure-eight method.
Assistive personnel lack the scope of practice to assess healing surgical wounds. A figure-eight wrap provides even compression without creating a tourniquet effect that restricts circulation.

Key Concept

Postoperative Care and Positioning for Lower Extremity Amputation
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Topics

Basic Care and Comfort

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