# 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?

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> subject: Adult Health

## 문제

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?

## 보기

1. Encourage the client to lie prone for 30 minutes three times daily
2. Monitor the residual limb for signs of infection and ensure proper wound care **✔ 정답**
3. Begin range-of-motion exercises to the affected extremity immediately
4. Teach the client phantom limb pain management techniques

**정답: 2**

## 해설

Infection prevention is the priority to avoid life-threatening sepsis. Other interventions are important but not immediate threats.

## 심화 해설

Understanding the Priority: Immediate Postoperative Complication Prevention

In the first 24 to 48 hours following an above-knee amputation, the nursing priority is guided by the ABCs (Airway, Breathing, Circulation) and the prevention of immediate life-threatening complications. While contracture prevention, pain management, and mobility are important aspects of long-term rehabilitation, the most serious acute complication that can arise from the surgical site itself is a severe infection. A surgical site infection (SSI) can rapidly progress to systemic sepsis, wound dehiscence, or osteomyelitis in the residual femur, jeopardizing the patient's recovery and potentially leading to further surgical revision [3].

Why Infection Monitoring is the Priority

The residual limb presents a large wound with extensive tissue disruption, creating an ideal environment for bacterial proliferation. Patients undergoing major lower limb amputation (MLLA) frequently have comorbidities such as diabetes mellitus and peripheral vascular disease, which inherently impair immune response, microcirculation, and tissue healing [1,3]. These factors exponentially increase the risk of a SSI. A systematic review analyzing wound complications post-MLLA highlights that SSIs are a common and significant source of morbidity, directly influencing the length of hospital stay and the success of subsequent prosthetic fitting [3]. If an infection is not identified and managed early through meticulous wound assessment and care, it can dissect along fascial planes or become deeply seated, leading to a prosthetic joint infection-like scenario in the residual bone, which is notoriously difficult to treat and often requires aggressive surgical debridement or higher-level revision .

Analysis of Incorrect Options

*   Option 1 (Prone Positioning): Lying prone is a critical intervention to prevent hip flexion contracture, a common complication after above-knee amputation. However, a contracture is a subacute or chronic complication that develops over days to weeks. While important for rehabilitation, it does not pose the same immediate, life-threatening risk as an uncontrolled wound infection in the initial 24-hour postoperative period.

*   Option 3 (Immediate Range-of-Motion): Initiating range-of-motion exercises is essential for maintaining joint mobility and preventing contractures. However, the timing is key. Immediately postoperatively, the focus must be on stabilizing the fresh surgical wound and managing acute edema. Aggressive early movement without proper wound stabilization could disrupt the suture line and increase the risk of bleeding or dehiscence, making infection control the more foundational priority.

*   Option 4 (Phantom Limb Pain Management): Phantom limb pain is a complex neuropathic phenomenon that is a valid and significant concern for amputees. Teaching management techniques is a necessary nursing intervention. However, phantom pain is a sensory and psychological complication, not a physiological one that directly threatens the patient's systemic stability or limb viability in the immediate postoperative window. Pain management is secondary to identifying a process like infection that can cause systemic inflammatory response syndrome (SIRS) or sepsis.

Clinical Integration of Evidence

The foundational principle here is that infection prevention and control are paramount in the acute phase. The clinical practice guideline for diabetic foot disease, a leading cause of amputation, emphasizes that concurrent infection is a primary factor contributing to mortality in these patients . This underscores that the surgical wound is not just a local issue but a portal for systemic illness. The systematic review on postoperative dressings further validates this focus, as the entire research question revolves around which dressing type (rigid vs. non-rigid) best reduces the primary outcome of SSI, confirming that wound care is the central clinical concern immediately after MLLA [3]. By prioritizing a focused assessment for signs of infection—such as purulent drainage, increasing erythema beyond the wound edge, unusual edema, and foul odor—and ensuring aseptic technique during dressing changes, the nurse directly mitigates the highest-morbidity risk identified in the evidence [2,3].References (research sources)

- [3]The effectiveness of rigid versus non-rigid dressings in reducing surgical site infections following major lower limb amputations: a systematic review.Meta-analysis/systematic reviewHeinz J, Moulder Z, Staniland T, Lathan R, Smith G, Chetter I. (2026) · DOI: 10.1186/s13643-026-03180-3

## 임상 시나리오

Acute Post-Amputation MonitoringPrioritizing Infection Prevention in the First 24-48 Hours
The surgical site is the priority assessment. A surgical site infection (SSI) can rapidly progress to sepsis or wound dehiscence. Inspect the dressing for strike-through bleeding and monitor for early signs of infection: erythema, purulent drainage, and increasing pain.

Patients with diabetes mellitus or peripheral vascular disease are at exponentially higher risk due to impaired microcirculation and immune response. Maintain strict aseptic technique during dressing changes and ensure proper wound care to protect the residual limb.

CautionDo not delay antibiotic therapy or wound culture if infection is suspected. A missed SSI can lead to osteomyelitis of the residual femur, requiring surgical revision and significantly delaying prosthetic fitting.

## 핵심 개념

- **Surgical Site Infection (SSI)** — An infection occurring at the surgical incision site within 30 days post-operation, a major cause of morbidity in amputations due to impaired healing from comorbidities like diabetes.
- **Above-Knee Amputation (AKA)** — Surgical removal of the lower limb through the femur; associated with large wound surfaces and high risk of complications like infection and contracture.
- **Wound Dehiscence** — Partial or complete separation of the wound edges, a serious complication of SSI that can expose underlying tissues and require further surgical intervention.
- **Hip Flexion Contracture** — A common complication post-AKA where the hip flexors shorten, preventable by prone positioning but not the priority over life-threatening infection in the acute phase.
- **Phantom Limb Pain** — Painful sensations perceived in the amputated limb; management is crucial for rehabilitation but secondary to preventing acute physiological deterioration.

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