Examkin

Question

Difficulty: Very hardBasic Care and Comfort

A nurse is managing the hygiene and comfort of an older adult client who is 24 hours post-operative following a right total hip arthroplasty (posterior approach). The client reports severe sacral and heel discomfort and requests assistance with a bed bath and repositioning. Which nursing intervention is the most appropriate to ensure safe basic care and comfort?

  1. Place an abduction wedge between the client's lower extremities, utilize assistance to turn the client onto the unaffected left side, and float the heels off the mattress using a pillow placed under the calves.Answer
  2. B
    Elevate the head of the bed to a high-Fowler's position to allow the client to wash their face, turn the client onto the right operative side, and vigorously massage both heels with moisturizing lotion.
  3. C
    Delegate the repositioning to the unlicensed assistive personnel (UAP), explicitly instructing them to cross the client's right ankle over the left to completely offload the sacrum during the bath.
  4. D
    Attribute the heel discomfort to age-related degenerative joint changes, provide a PRN oral analgesic, and place a tightly rolled towel directly beneath the client's heels to elevate them.

Answer

The correct intervention is to place an abduction wedge between the client's legs to maintain alignment, turn the client onto the unaffected side to relieve sacral pressure, and float the heels by placing a pillow underneath the calves.
Clients recovering from a posterior approach total hip arthroplasty are at a high risk for hip dislocation if the joint is flexed beyond 90 degrees, adducted, or internally rotated. Using an abduction wedge between the legs safely prevents adduction while turning and resting. Turning the client onto their unaffected (left) side offloads pressure from the sacrum and the surgical site. Furthermore, placing a pillow lengthwise under the calves effectively 'floats' the heels off the mattress, relieving pressure without causing tissue damage or compromising lower extremity circulation.

Step-by-Step Solution

1
Identify the surgical precautions for the client's specific procedure.
A posterior approach total hip arthroplasty requires preventing hip flexion greater than 90 degrees, hip adduction, and internal rotation.
Violating these precautions can cause an immediate and severe dislocation of the new hip prosthesis.
2
Evaluate the client's complaints of sacral and heel discomfort.
The discomfort is recognized as an early warning sign of tissue ischemia and potential pressure injury development.
Immobile, older adult clients are at a high risk for skin breakdown over bony prominences, requiring immediate pressure offloading.
3
Select the intervention that simultaneously addresses hygiene needs, pressure relief, and surgical safety.
Using an abduction wedge prevents adduction during turning, rolling to the unaffected side offloads the sacrum safely, and floating heels with a calf pillow relieves heel pressure.
This combination of actions satisfies all safety parameters while maximizing the client's basic care and comfort.

Key Concept

Postoperative Positioning and Pressure Injury Prevention
Estimated Time:2m 0s
Rate this question

Topics

Basic Care and Comfort

More questions from this topic