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Zorluk: OrtaBasic Care and Comfort

An adult client is recovering on the surgical unit 48 hours after undergoing a right above-the-knee amputation. To prevent complications related to immobility and promote optimal physical comfort, which action should the nurse take?

  1. A
    Elevate the residual limb on a pillow while the client is resting in bed to minimize swelling.
  2. Assist the client into a prone position for 20 to 30 minutes several times each day.Cevap
  3. C
    Assign a nursing assistant to evaluate the condition of the skin around the surgical dressing.
  4. D
    Position the client in a high-Fowler's angle during daylight hours to encourage deep breathing.

Cevap

Assist the client into a prone position for 20 to 30 minutes several times each day.
Following an above-the-knee amputation, the client is at high risk for developing a hip flexion contracture, which can complicate or completely prevent rehabilitation with a prosthesis. Assisting the client into a prone position for 20 to 30 minutes, three to four times a day, stretches the flexor muscles and prevents contracture formation.

Adım Adım Çözüm

1
Identify the client's postoperative timeline and surgical procedure.
The client is 48 hours post-right above-the-knee amputation.
The timeline dictates which interventions are safe and which are contraindicated.
2
Determine the greatest mobility and positioning risk for a client with this specific amputation.
The most significant risk is the development of a hip flexion contracture.
Contractures severely limit joint mobility and can permanently prevent the future use of a prosthetic limb.
3
Evaluate the given options against contracture prevention strategies.
Prone positioning physically extends the hip joint, whereas elevating the limb or utilizing a high-Fowler's position promotes prolonged hip flexion.
To prevent flexion contractures, the joint must be periodically stretched in full extension.

Anahtar Kavram

Preventing hip flexion contractures following lower extremity amputation
Tahmini Süre:1m 0s
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Konular

Basic Care and Comfort

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