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Zorluk: ZorBasic Care and Comfort

A practical nurse is providing basic care for a client who is 48 hours postoperative following a right above-the-knee amputation (AKA). The client reports muscle spasms and discomfort in the affected limb. Which of the following nursing actions should the nurse implement to promote comfort and prevent complications? Select all that apply.

  1. Assist the client into a prone position for 20 to 30 minutes several times a day.Cevap
  2. B
    Elevate the right residual limb on a pillow while the client is resting in bed.
  3. Wrap the residual limb with an elastic compression bandage using a figure-eight pattern.Cevap
  4. D
    Encourage the client to sit upright in a bedside chair for 4 continuous hours daily.
  5. Place a trochanter roll alongside the outer aspect of the right thigh and hip.Cevap

Cevap

The correct actions are to assist the client into a prone position, wrap the limb with an elastic compression bandage using a figure-eight pattern, and place a trochanter roll alongside the outer aspect of the hip.
After a lower extremity amputation, preventing hip flexion contractures and managing edema are critical priorities for the practical nurse. Assisting the client into a prone position extends the hip joint and stretches flexor muscles. Applying a figure-eight compression bandage minimizes swelling, reduces spasm-related pain, and shapes the limb. Using a trochanter roll prevents improper external rotation of the affected leg, ensuring comfortable and correct anatomical alignment.

Adım Adım Çözüm

1
Analyze the client's postoperative time frame and surgical procedure.
The client is 48 hours post-above-the-knee amputation (AKA).
Interventions change based on the postoperative timeline, particularly regarding safe limb positioning.
2
Evaluate the risk of complications associated with AKA.
The primary mobility complication is a hip flexion contracture, and the primary comfort issue is edema and muscle spasms.
Identifying risks guides the selection of safe and effective basic care measures.
3
Select interventions that prevent contractures and reduce edema while avoiding contraindicated positions.
Prone positioning, figure-eight compression, and trochanter rolls are safe. Pillow elevation and prolonged sitting are contraindicated.
Evidence-based positioning ensures comfort without compromising future mobility and prosthesis fitting.

Anahtar Kavram

Postoperative positioning and comfort measures for lower extremity amputation
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