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Zorluk: OrtaBasic Care and Comfort

A client is 48 hours post-operative following a right above-the-knee amputation and reports phantom limb sensations. The healthcare team is focusing on promoting optimal long-term mobility and physical comfort. Which action should the nurse implement?

  1. Assist the client into a prone position for 20 to 30 minutes, three to four times a day.Cevap
  2. B
    Elevate the right residual limb continuously on a pillow while the client is resting in bed.
  3. C
    Encourage the client to sit upright in a bedside chair for the majority of the day.
  4. D
    Assign the unlicensed assistive personnel (UAP) to monitor the residual limb for changes in skin temperature.

Cevap

The nurse should assist the client into a prone position for 20 to 30 minutes, three to four times a day to prevent hip flexion contractures.
Following an above-the-knee amputation, the prevention of hip flexion contractures is essential for the future fitting and use of a prosthetic device. Assisting the client into a prone position for 20 to 30 minutes several times a day fully extends the hip joint, counteracting the flexion that naturally occurs when the client is sitting or lying supine. This is a standard core nursing intervention for maintaining optimal joint mobility.

Adım Adım Çözüm

1
Identify the time elapsed since the surgical procedure.
The client is 48 hours post-operative.
Nursing interventions for amputation care change based on the surgical timeline, specifically concerning elevation after the first 24 hours.
2
Determine the primary mobility complication associated with above-the-knee amputations.
Hip flexion contractures are the most significant risk that can impair future prosthetic fitting and mobility.
Prolonged flexion of the hip joint must be actively avoided to preserve a full range of motion.
3
Select the nursing intervention that directly counteracts hip flexion.
Prone positioning is chosen over elevation or prolonged sitting.
Lying flat on the stomach fully extends the hip joint, counteracting the flexion that occurs in a supine or sitting position.

Anahtar Kavram

Prevention of hip flexion contractures in post-amputation clients through proper positioning
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Konular

Basic Care and Comfort

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