The nurse is providing education to a patient who will undergo an upper extremity amputation. What should the nurse emphasize as the priority nursing intervention in the immediate post-operative period?
Managing phantom limb pain
Ensuring proper prosthetic fitting
Elevating the residual limb on a pillow
Assessing the surgical incision for infection
The Correct Answer is D
The priority nursing intervention in the immediate post-operative period after an upper extremity amputation is to assess the surgical incision for infection. Early detection of signs of infection, such as redness, swelling, warmth, or drainage, is crucial to prevent complications and promote healing.
a. Managing phantom limb pain: While managing phantom limb pain is important, it may not be the priority nursing intervention immediately after the surgery. Assessing the surgical incision for infection and monitoring for any complications take precedence.
b. Ensuring proper prosthetic fitting: Prosthetic fitting is essential for functional outcomes, but it may not be the priority in the immediate post-operative period. It is addressed during the rehabilitation phase.
c. Elevating the residual limb on a pillow: Elevating the residual limb on a pillow is typically recommended for lower extremity amputations to reduce edema and promote venous return, not for upper extremity amputations.
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Related Questions
Correct Answer is C
Explanation
Inspecting the skin under the prosthetic device daily is essential to prevent skin breakdown and pressure ulcers. Continuous pressure and friction from the prosthetic device can cause skin irritation and breakdown, and early detection allows for timely intervention and prevention of complications.
a. Applying a topical antibiotic to the residual limb daily: Applying a topical antibiotic daily is not recommended unless specifically prescribed by the healthcare provider for a wound or infection. Routine use of topical antibiotics can lead to antibiotic resistance.
b. Massaging the residual limb with lotion to improve circulation: Massaging the residual limb with lotion may be beneficial for comfort, but it is not a preventive measure for skin breakdown. Excessive massage can cause skin irritation.
d. Wearing a compression bandage over the prosthetic device: While compression bandages may be used as part of post-operative care, wearing a compression bandage over the prosthetic device is not a standard preventive measure for skin breakdown.
Correct Answer is D
Explanation
A non-healing surgical wound is a significant complication of amputation that may require revision surgery. Revision surgery involves re-intervention on the surgical site to address wound healing issues and promote better outcomes.
a. Phantom limb sensation: Phantom limb sensation is a common experience after amputation but does not typically require revision surgery. It is a neurological phenomenon related to the brain's perception of the missing limb.
b. Skin breakdown and pressure ulcers: Skin breakdown and pressure ulcers can occur around the residual limb due to pressure and friction from the prosthetic device. While they require attention and management, they may not always necessitate revision surgery.
c. Infection at the surgical site: Infection at the surgical site is a serious complication, but it is typically managed with appropriate antimicrobial therapy and wound care. In some cases, infection may lead to revision surgery, but it is not an automatic indication.
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