The nurse is providing care for a patient with expressive aphasia. Which intervention does the nurse expect to find in the patient's plan of care? (Select all that apply.)

A. Lying prone as prescribed: While lying prone can help prevent hip flexion contractures, it is not directly related to promoting ambulation. It is typically part of post-operative care to prevent contractures in the hip, but ambulation primarily depends on upper body strength and prosthetic training.
B. Maintaining residual limb elevation: Elevation of the residual limb is important immediately postoperatively to reduce swelling, but prolonged elevation can lead to contractures, which can hinder ambulation.
C. Promoting coordination exercises: Coordination is important, but for ambulation, building strength, especially in the upper body, is crucial to support the use of assistive devices and maintaining balance.
D. Building upper body strength: This is essential for promoting ambulation as it helps the patient in using assistive devices like crutches or walkers and in transferring safely. Upper body strength is crucial for balance and mobility with a prosthetic limb.

A. Clean pins with hydrogen peroxide four times daily. Hydrogen peroxide is not recommended for routine pin care as it can damage tissue and delay healing. Overuse can also lead to the formation of oxygen bubbles in the tissue, which may cause complications. Recommended cleaning solutions often include saline or a mild antiseptic, depending on the facility's protocol.
B. Monitor pin sites at least daily: Regular monitoring of pin sites is essential to detect early signs of infection or complications such as redness, swelling, warmth, or discharge. Early detection allows for prompt intervention, which is crucial in preventing more severe infections and complications.
C. Loosen screws holding the pins during cleaning. Loosening screws can destabilize the fixation device and disrupt the bone alignment, potentially causing injury and delaying healing. Screws and pins should remain securely tightened unless adjustments are being made by a qualified healthcare provider.
D. Use strict aseptic technique for pin care: Using strict aseptic technique helps prevent the introduction of microorganisms at the pin sites. This is critical because external fixation devices create a direct pathway for pathogens to enter the body, which can lead to serious infections like osteomyelitis.
E. Follow agency protocol for pin care: Each healthcare facility may have specific protocols and guidelines for pin care based on evidence-based practices. Following these protocols ensures that the care provided is consistent and meets the latest standards for infection control and patient safety.
F. Avoid touching the pins. While it is crucial to avoid unnecessary handling of pins to prevent contamination, touching the pins during necessary cleaning and care using aseptic technique is allowed. Completely avoiding touching the pins could result in inadequate cleaning and care.