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Zorluk: OrtaBasic Care and Comfort

A nurse is providing care for a client who is 48 hours post-operative following a right above-the-knee amputation. The nurse is updating the care plan to prevent the development of a hip flexion contracture. Which nursing intervention is most appropriate to achieve this goal?

  1. Assist the client to lie in a prone position for 20 to 30 minutes three to four times a day.Cevap
  2. B
    Elevate the residual limb on a firm pillow while the client is resting in bed.
  3. C
    Encourage the client to sit upright in a bedside chair for at least six hours daily.
  4. D
    Direct the unlicensed assistive personnel (UAP) to assess the client's hip joint flexibility during morning care.

Cevap

The most appropriate intervention is to assist the client to lie in a prone position for 20 to 30 minutes multiple times a day.
Placing a client with an above-the-knee amputation in a prone position for short intervals multiple times a day is the standard prophylactic measure to prevent hip flexion contractures. This position utilizes gravity to fully extend the hip joint, stretching the flexor muscles that are highly prone to shortening.

Adım Adım Çözüm

1
Identify the primary complication being targeted.
The complication is a hip flexion contracture, which occurs when the hip flexor muscles shorten and tighten due to continuous or prolonged flexion.
Understanding the pathology of the complication dictates the appropriate physiological counter-positioning.
2
Evaluate the mechanical effect of each positioning option on the hip joint.
Prone positioning fully extends the hip joint. Conversely, placing pillows under the limb or sitting in a chair flexes the hip joint.
Therapeutic interventions must actively counteract the physical shortening of the flexor muscles to maintain full range of motion for future prosthetic training.
3
Consider nursing delegation parameters.
Assessment of the joint cannot be delegated to a UAP.
Safe nursing practice dictates that the registered nurse must perform all clinical assessments.

Anahtar Kavram

Prevention of flexion contractures following a lower extremity amputation requires avoiding prolonged joint flexion and actively extending the affected joint through therapeutic prone positioning.
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Basic Care and Comfort

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