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Zorluk: ZorBasic Care and Comfort

An older adult client is receiving morning care 48 hours after undergoing a right above-the-knee amputation. When implementing hygiene, mobility, and comfort measures, which actions are appropriate for the practical nurse to take? Select all that apply.

  1. Assist the client into a prone position for 20 to 30 minutes multiple times a day.Cevap
  2. B
    Elevate the right residual limb on two pillows to minimize postoperative swelling.
  3. Wash the residual limb with mild soap and water, ensuring the skin is patted completely dry.Cevap
  4. D
    Maintain the client in a continuous high-Fowler's position when resting in bed.
  5. Instruct the client to perform active range-of-motion exercises on the unaffected extremities.Cevap

Cevap

The appropriate actions are assisting the client into a prone position periodically, washing and thoroughly drying the residual limb, and instructing the client to perform active range-of-motion exercises on unaffected extremities.
Correct basic care for an amputation after 24 hours prioritizes the prevention of contractures and the maintenance of skin integrity. Periodic prone positioning directly stretches the hip flexor muscles, counteracting the tendency for the joint to contract. Gentle hygiene with thorough drying prevents skin breakdown and fungal growth. Encouraging range-of-motion on unaffected limbs promotes systemic circulation and preserves the strength needed for future transfers and ambulation.

Adım Adım Çözüm

1
Evaluate the client's postoperative timeframe and surgical type.
The client is 48 hours post-op from an above-the-knee amputation (AKA).
Timeframe dictates positioning rules; after 24 hours, preventing contractures becomes the primary positioning goal.
2
Identify positioning interventions that prevent hip flexion contractures.
Prone positioning is indicated; elevation on pillows and prolonged high-Fowler's positioning are contraindicated.
Hip flexors must be stretched (prone) rather than continuously flexed (sitting or elevated) to ensure future ambulation with a prosthesis.
3
Select appropriate basic hygiene and mobility measures.
Gentle washing with thorough drying and active range-of-motion for unaffected limbs are selected.
These measures safely maintain skin integrity and prevent complications of immobility within the LPN scope of practice.

Anahtar Kavram

Postoperative Basic Care and Comfort: Amputation Positioning and Hygiene
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Konular

Basic Care and Comfort

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