A nurse is caring for a client who underwent an above-knee amputation 24 hours ago. Which nursing intervention should be the priority to prevent the most serious complication?
1Encourage the client to lie prone for 30 minutes three times daily
2Monitor the residual limb for signs of infection and ensure proper wound care✓ 정답
3Begin range-of-motion exercises to the affected extremity immediately
4Teach the client phantom limb pain management techniques
해설
Infection prevention is the priority to avoid life-threatening sepsis. Other interventions are important but not immediate threats.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention in the immediate postoperative period (24 hours) following an above-knee amputation (AKA). The core concept is postoperative complication prevention, specifically identifying the most serious, life-threatening risk during this phase. While the client faces multiple challenges, the nurse must prioritize based on Key Point! the ABCs (Airway, Breathing, Circulation) framework and the principle of Maslow's Hierarchy of Needs, where physiological needs and safety from life-threatening conditions come first.
Answer Rationale: The correct answer is ② Monitor the residual limb for signs of infection and ensure proper wound care. In the first 24-48 hours post-amputation, the surgical site is a fresh wound, highly vulnerable to bacterial invasion. An infection in this large, traumatic wound can rapidly progress to cellulitis, osteomyelitis, sepsis, or necrotizing fasciitis, all of which are life-threatening. Monitoring for signs like increased redness, warmth, swelling, purulent drainage, foul odor, fever (>38°C or 100.4°F), or elevated white blood cell count (WBC > 10,000/µL) is a critical, immediate nursing action. Proper wound care, including maintaining a sterile dressing and aseptic technique during changes, is the primary defense against this complication.
Distractor Analysis:
Watch out for confusion! Option ①, "Encourage the client to lie prone for 30 minutes three times daily," is an important intervention to prevent hip flexion contractures. However, this is a rehabilitative and preventive measure for a long-term complication, not the priority in the first 24 hours when the patient is likely still recovering from anesthesia and managing acute pain.
Option ③, "Begin range-of-motion exercises to the affected extremity immediately," is incorrect and potentially harmful. In the immediate postoperative period, the residual limb must be stabilized to promote healing, reduce pain, and prevent hemorrhage. Aggressive ROM too soon can disrupt the surgical site, cause bleeding, and increase pain.
Option ④, "Teach the client phantom limb pain management techniques," addresses phantom limb sensation/pain, which is a common and distressing experience. However, while assessment for this is important, structured teaching about management (e.g., mirror therapy, medications) typically occurs later in the recovery process, once the immediate physiological threats are controlled and the patient is more alert and receptive.
Related Concepts: The nursing process dictates that after a major surgery, the initial focus is on assessment and prevention of immediate postoperative complications: hemorrhage, infection, and compromised circulation. Other amputation-specific care includes monitoring for hematoma formation, managing edema (often with a rigid dressing or elastic shrinker), and providing emotional support for body image disturbance.
Nursing Clinical Practice GuideClinical Scenario: You are the day-shift nurse for Mr. Johnson, a 68-year-old with a history of peripheral arterial disease (PAD) and uncontrolled diabetes mellitus (DM), who underwent a right above-knee amputation yesterday due to gangrene. He is on IV antibiotics (Cefazolin) and patient-controlled analgesia (PCA) with morphine.
Nursing Intervention Strategy:
1. Assessment (Every 4 hours and as needed):
1Residual Limb (Stump):Inspect the dressing for amount and character of drainage (serosanguinous is expected; bright red or excessive indicates bleeding). Note any odor. When permitted, inspect the incision for Key Point! the classic signs of infection: Redness, Edema, Heat, Pain, Purulent Exudate (REHPP).
2Vital Signs:Monitor for fever (infection), tachycardia, and hypotension (signs of bleeding or sepsis).
3Pain:Assess location, character (phantom vs. incisional), and intensity using a pain scale. Differentiate incisional pain from phantom sensations.
4Circulation & Sensation:Assess the condition of the remaining left leg for pulses, color, warmth, and sensation, as the underlying PAD likely affects both limbs.
2Implementation & Patient Safety:
Wound Care:Maintain strict aseptic technique during dressing changes per hospital protocol. Ensure the dressing is snug but not constrictive. Position the limb as ordered (often elevated on pillows initially to reduce edema, but avoid prolonged hip/knee flexion).
Infection Prevention:Administer IV antibiotics on time to maintain therapeutic blood levels. Perform meticulous hand hygiene before and after contact.
Fall Prevention:Keep the bed in low position with side rails up. Remind the patient not to try to get out of bed without assistance, as they may forget the amputation (a phenomenon called "forgetting").
Nursing Procedure & Medication FlowResidual Limb Dressing Change & Inspection:
1. Gather supplies: sterile gloves, sterile dressing tray, normal saline, measuring tape (for limb circumference), and new sterile dressing/bandage.
2. Provide analgesia 30 minutes prior if needed.
3. Perform hand hygiene. Don clean gloves to remove old dressing; observe and document drainage.
4. Discard gloves, perform hand hygiene again. Don sterile gloves.
5. Gently clean the incision with normal saline from the incision line outward.
6. Inspect the suture line and surrounding skin. Measure circumference if ordered to monitor edema.
7. Apply new sterile dressing. Secure without creating a tourniquet effect.
8. Position the limb appropriately (e.g., extended on the bed, avoid pillows under the knee).
A Word from Your Senior Nurse: "In the fast-paced world of post-op care, it's easy to get caught up in tasks. Remember, your most powerful tool is your assessment. That moment you take to really look at the dressing, feel for warmth, and talk to your patient about their pain isn't just a checkbox—it's how you catch a brewing infection before it becomes sepsis. For your NCLEX, they love to test your ability to prioritize. Always ask yourself: 'What can kill my patient first?' In this case, it's not the contracture or the phantom pain—it's the invisible bacteria trying to invade that fresh wound. Think like a nurse, protect like a guardian."
Above-Knee Amputation — Surgical removal of the lower limb above the knee joint, often due to severe trauma, peripheral vascular disease, or uncontrolled infection/gangrene.
Phantom Limb Pain/Sensation — The perception of pain or sensation (itching, tingling) in the limb that has been amputated. It is a neuropathic pain phenomenon originating in the brain and spinal cord.
Sepsis — A life-threatening organ dysfunction caused by a dysregulated host response to infection. A post-op wound infection can be the source.
Hip Flexion Contracture — A shortening of the hip flexor muscles leading to a permanent bent-hip posture. A common complication after lower limb amputation if proper positioning (prone lying, avoiding pillow under knee) is not maintained.
Aseptic Technique — A set of specific practices and procedures performed under carefully controlled conditions to minimize contamination by pathogens. It is fundamental in wound care and dressing changes.