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Zorluk: ZorBasic Care and Comfort

A nurse is caring for a client who underwent a left above-the-knee amputation 48 hours ago. The client reports mild discomfort in the residual limb and requests to be repositioned. Which of the following nursing actions is most appropriate to promote comfort and prevent musculoskeletal complications?

  1. Assist the client into a prone position for 20 to 30 minutes, several times a day.Cevap
  2. B
    Elevate the residual limb continuously on a pillow while the client is supine.
  3. C
    Maintain the client in a high-Fowler's position when resting in bed.
  4. D
    Delegate the assessment of the skin integrity on the residual limb to the unlicensed assistive personnel.

Cevap

Assist the client into a prone position for 20 to 30 minutes, several times a day.
Following an above-the-knee amputation, the client is at a very high risk for developing hip flexion contractures, which can impede future rehabilitation and prosthetic use. Assisting the client into a prone position for 20 to 30 minutes, 3 to 4 times a day, actively stretches the hip flexor muscles and prevents contracture formation. This is a critical basic care and comfort measure.

Adım Adım Çözüm

1
Analyze the client's post-operative timeline and surgical procedure.
The client is 48 hours post-operative from a left above-the-knee amputation.
The precise timeframe determines which positioning interventions are indicated and which are contraindicated.
2
Identify the primary musculoskeletal complication associated with this specific procedure.
The most significant risk is the development of hip flexion contractures.
Contractures can severely impair the client's ability to use a prosthesis and mobilize in the future.
3
Evaluate the safety and efficacy of each proposed positioning or delegation action.
Prone positioning actively stretches the hip flexors, while elevation or high-Fowler's positioning continuously flexes the hip. Delegation of assessment is unsafe.
Interventions must directly counteract the tendency for the flexor muscles to shorten without violating scope of practice.

Anahtar Kavram

Post-amputation positioning and contracture prevention
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Konular

Basic Care and Comfort

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