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Zorluk: OrtaBasic Care and Comfort

The nurse is reviewing the care plan for a client who is 48 hours postoperative following a right below-the-knee amputation. Which interventions are appropriate to include in the client's basic care and comfort management? Select all that apply.

  1. Assist the client into a prone position for 30 minutes, three to four times a day.Cevap
  2. B
    Elevate the right residual limb continuously on a stack of pillows to manage edema.
  3. C
    Delegate the daily inspection of the surgical site and surrounding skin to the unlicensed assistive personnel (UAP).
  4. Wash the residual limb daily with mild soap and water, ensuring the skin is patted completely dry.Cevap
  5. E
    Encourage the client to sit in a bedside chair with hips flexed for at least four continuous hours daily.

Cevap

The appropriate interventions are assisting the client into a prone position several times a day and washing the residual limb daily with mild soap and water.
To prevent hip flexion contractures, which can severely impair future prosthetic use and mobility, the client should be placed in a prone position for 20 to 30 minutes, three to four times a day. Additionally, basic hygiene involving gentle washing with mild soap and water, followed by complete drying, is essential to maintain skin integrity, provide comfort, and prevent infection at the surgical site.

Adım Adım Çözüm

1
Analyze the client's postoperative timeframe and clinical needs.
The client is 48 hours post-amputation; the primary goals for basic care are preventing contractures, maintaining skin integrity, and promoting mobility.
Understanding the timeline is crucial, as certain interventions (like elevation) change after the first 24 hours.
2
Evaluate the positioning options provided.
Prone positioning prevents contractures and is correct. Elevation on pillows and prolonged sitting cause contractures and are incorrect.
Hip flexion contractures are a major complication following lower extremity amputations that impede future prosthetic use.
3
Evaluate the delegation and hygiene options.
Delegating assessment to a UAP is outside their scope of practice. Gentle washing and drying of the limb is standard, appropriate basic care.
Ensuring safe delegation and standard infection prevention are core components of basic care and comfort.

Anahtar Kavram

Post-amputation basic care and contracture prevention
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Konular

Basic Care and Comfort

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