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Zorluk: OrtaBasic Care and Comfort

A nurse is caring for a 65-year-old client who underwent a left above-the-knee amputation two days ago. The client reports intermittent phantom limb pain and is preparing for future physical rehabilitation. Which of the following nursing interventions is most appropriate to promote optimal mobility and comfort?

  1. A
    Keep the residual limb continuously elevated on a pillow while the client is in bed.
  2. B
    Inform the family that the client's sudden disorientation and confusion are normal physiological responses to aging.
  3. Assist the client into a prone position for 20 to 30 minutes, three to four times a day.Cevap
  4. D
    Delegate the task of evaluating the surgical dressing for signs of bleeding to the unlicensed assistive personnel (UAP).

Cevap

The most appropriate intervention is to assist the client into a prone position for 20 to 30 minutes, three to four times a day.
Prone positioning for 20 to 30 minutes several times a day is a critical intervention for clients with a lower extremity amputation. This position actively stretches the flexor muscles of the hip and prevents the development of hip flexion contractures. Preventing these contractures is essential because a contracted hip joint makes it extremely difficult or impossible for the client to be properly fitted for and use a prosthetic limb during rehabilitation.

Adım Adım Çözüm

1
Identify the time elapsed since the client's surgery and the specific procedure performed.
The client is two days (48 hours) post-operative following an above-the-knee amputation.
Post-operative positioning guidelines change significantly after the first 24 hours to prevent long-term musculoskeletal complications.
2
Analyze the physiological risks associated with lower extremity amputations.
The most common and debilitating complication related to physical mobility is the development of a hip flexion contracture.
Contractures occur when flexor muscles remain in a shortened position for prolonged periods, which can ultimately prevent the successful fitting and use of a prosthetic limb.
3
Evaluate each intervention option against evidence-based basic care, safety, and positioning guidelines.
Prone positioning correctly stretches the hip flexors. Continuous elevation on a pillow promotes contractures. Evaluating dressings cannot be delegated to UAPs. Sudden confusion requires acute medical assessment, as it is not normal aging.
Selecting the correct nursing action requires synthesizing knowledge of proper client positioning, delegation constraints, and normal aging versus pathological changes.

Anahtar Kavram

Post-operative Positioning and Contracture Prevention for Amputations
Tahmini Süre:1m 15s
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Konular

Basic Care and Comfort

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