The nurse assesses the patient and determines that he may be at risk for altered peripheral tissue perfusion. Which activity should the nurse include in patient teaching to prevent decreased per-fusion to his extremities while he is on bed rest?

Question

a. Avoid any fluids by mouth until the pa-tient begins passing gas.
b. Flex and rotate the ankles several times every hour while awake.
c. Rest quietly to allow the maximum action of the opioid analgesics.
d. Stay positioned on either side with pillows between the legs.

Answer 1

B
The nurse instructs the patient to perform ankle flexion and rotation to promote venous return from the lower extremities, which helps prevent thromboembolic complications and increases arterial perfusion to provide oxygen for the tissues while the patient is not ambulating. Passing gas has no correlation to decreased perfusion in the patient's lower extremities. Pain needs to be controlled, but this has little to do with potential impaired tissue perfusion in the lower extremi-ties. Placing pillows between the legs when positioned on the side provides comfort and is a pas-sive method of preventing compression of the lower leg by the upper one. This is not the most effective way of preventing perfusion to the lower extremities.