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Zorluk: ZorBasic Care and Comfort

A nurse is planning care for a client who is 48 hours post-operative following a right above-the-knee amputation (AKA) due to complications of peripheral arterial disease. Which of the following positioning interventions is most appropriate to include in the client's plan of care?

  1. A
    Elevate the right residual limb on a pillow while the client is resting in a supine position.
  2. B
    Maintain the client in a high Fowler's position while in bed to facilitate deep breathing.
  3. Assist the client into a prone position for 30 minutes three to four times a day.Cevap
  4. D
    Position a trochanter roll alongside the right thigh to maintain external rotation of the hip.

Cevap

Assist the client into a prone position for 30 minutes three to four times a day.
Following an above-the-knee amputation, the client is at high risk for developing a hip flexion contracture, which can permanently impair mobility and the ability to bear weight on a prosthesis. Assisting the client into a prone position for 20 to 30 minutes, 3 to 4 times a day, actively extends the hip joint and stretches the flexor muscles, effectively preventing contractures.

Adım Adım Çözüm

1
Analyze the client's surgical procedure and timeline.
The client had a right above-the-knee amputation (AKA) 48 hours ago.
The timeline is critical because therapeutic positioning rules change drastically after the first 24 hours post-operation.
2
Identify the primary positioning complication associated with an AKA.
Hip flexion contracture is a severe structural complication that can prevent the client from using a prosthesis.
Understanding the complication risk guides the selection of appropriate preventative positioning.
3
Evaluate the given options based on their effect on the hip joint.
Elevation and high Fowler's position promote hip flexion. Prone positioning actively promotes hip extension.
Nursing interventions must counter the physiological tendency of the hip flexor muscles to tighten and contract.

Anahtar Kavram

Prevention of hip flexion contractures following an above-the-knee amputation
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