A nurse is caring for a client who sustained a shoulder dislocation during a basketball game. Which nursing intervention should be the priority?
1Apply heat to reduce muscle spasms and promote circulation
2Immobilize the affected arm and assess neurovascular status✓ 정답
3Encourage active range of motion exercises to prevent stiffness
4Administer prescribed analgesics and reassess pain level
해설
Immobilizing the affected arm and assessing neurovascular status is the priority to prevent further injury and detect complications like nerve or vascular damage. Other interventions, such as applying heat or encouraging motion, are not initial priorities and may worsen the condition.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with an acute shoulder dislocation. The core principle is the nursing process and prioritization, specifically applying the Key Point!ABCs and safety first framework. In musculoskeletal trauma, after ensuring airway, breathing, and circulation are stable, the immediate priority is to prevent further injury and assess for neurovascular compromise, which is a potential limb-threatening complication.
Answer Rationale: The correct answer is Immobilize the affected arm and assess neurovascular status. This is the priority because:
1. Immobilization: Prevents movement of the dislocated joint, which reduces pain, prevents further damage to surrounding ligaments, blood vessels, and nerves, and prevents a simple dislocation from becoming a more complex injury.
2. Neurovascular Assessment: A dislocated shoulder can compress or damage the brachial plexus and the axillary artery. Early detection of compromise (e.g., diminished pulses, pallor, paresthesia, paralysis, pain) is critical to prevent permanent disability or tissue necrosis. This assessment follows the Key Point!5 Ps of Neurovascular Assessment: Pain, Pallor, Pulselessness, Paresthesia, and Paralysis.
Distractor Analysis: Watch out for confusion! Option ① (Apply heat) is incorrect. In the acute phase (first 24-48 hours), the standard is to apply cold to reduce swelling, inflammation, and pain. Heat can increase swelling and bleeding, potentially worsening the injury.
Option ③ (Encourage active ROM) is incorrect and dangerous. Active range of motion should never be encouraged immediately after a dislocation. The joint needs to be immobilized and often requires reduction by a physician first. Early motion can cause further damage.
Option ④ (Administer analgesics) is an important supportive intervention but is not the priority. Pain management is crucial for patient comfort and cooperation, but it comes after ensuring the limb's safety and stability. You must first immobilize to prevent exacerbating the pain and assess for complications.
Related Concepts: This prioritization follows the Maslow's Hierarchy of Needs and Nursing Process. Physiological safety (preventing neurovascular damage) takes precedence over comfort (pain management) and health education/restoration (preventing stiffness). The sequence is: Stabilize (Immobilize) → Assess (Neurovascular status) → Treat (Pain, swelling) → Rehabilitate (ROM later).
Concept Summary
Concept
Description
Clinical Application
Shoulder Dislocation
Most commonly anterior; humeral head displaced from glenoid fossa.
Patient presents with severe pain, deformity ("squared-off" shoulder), arm held in slight abduction/external rotation.
Neurovascular Assessment (5 Ps)
Critical post-injury/post-procedure assessment for limb viability.
Immobilization (sling, splint). Absolute rest to protect structures.
Controlled, gradual ROM exercises as prescribed by PT/MD to restore function and prevent adhesive capsulitis (frozen shoulder).
Pain Management
Analgesics (e.g., opioids, NSAIDs) for severe pain. Assess before & after administration.
Transition to oral NSAIDs (e.g., ibuprofen) for inflammation and mild pain.
Anatomy, Physiology & Pharmacology Points
Anatomy at Risk: Anterior shoulder dislocation can injure the axillary nerve (causing deltoid weakness and loss of sensation over lateral shoulder) and the axillary artery.
Pathophysiology: Trauma forces the humeral head out of the joint capsule, tearing ligaments (like the glenohumeral ligaments) and labrum. This causes immediate pain, muscle spasm, and potential neurovascular compression.
Pharmacology: Common medications include opioid analgesics (e.g., morphine) for severe initial pain and NSAIDs (e.g., naproxen) for inflammation. Muscle relaxants (e.g., cyclobenzaprine) may be used for associated spasms.
5 Ps of Neurovascular Check: Remember "Please Protect Peripheral Parts Promptly" (Pain, Pallor, Pulselessness, Paresthesia, Paralysis).
Hot vs. Cold: "Heat is for Healing (chronic), Cold is for Controlling (acute)" swelling and bleeding.
High-Frequency NCLEX Topics
This integrates several high-yield NCLEX concepts: prioritization, musculoskeletal emergency care, neurovascular assessment, and patient safety. The NCLEX loves to test your ability to distinguish between a correct action and the first or most important action. Always ask yourself: "What will cause the most harm if I don't do it first?"
Watch Out for Question Variations!
Symptom Identification: "The nurse assesses a client with a shoulder dislocation. Which finding requires immediate intervention?" (Answer: Absent radial pulse or numbness/tingling in fingers).
Post-Reduction Care: "Following closed reduction of a shoulder dislocation, the nurse's priority action is to..." (Answer: Assess neurovascular status of the affected extremity).
Patient Education: "Which instruction is most important for the nurse to give a client discharged after a shoulder dislocation?" (Answer: "Wear the immobilizer as directed and return immediately if you experience numbness, increased pain, or color changes in your hand.").
Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in an urgent care clinic. A 22-year-old male basketball player is brought in by his friends. He is holding his right arm slightly away from his body, supporting it with his left hand. He reports a "pop" and immediate severe pain after falling on an outstretched arm. You observe an obvious deformity of the right shoulder contour.
Nursing Intervention Strategy:
Immediate Assessment & Action (Priority):
Quickly assess ABCs (stable in this case).
Do not attempt to move or reduce the joint.
Gently immobilize the arm in the position of comfort using a sling or by splinting it against the torso with padding.
Perform a focused neurovascular assessment on the affected arm: Check radial pulse, capillary refill (Normal: < 3 seconds), color, temperature, sensation (light touch on fingers), and motor function (ability to wiggle fingers). Compare to the unaffected side.
Document findings meticulously: "Right shoulder anterior deformity. Radial pulse palpable but weaker than left. Capillary refill 4 seconds. Reports numbness in thumb and index finger. Able to weakly wiggle all fingers."
Collaborative Care:
Notify the physician/advanced practitioner immediately.
Prepare for and assist with closed reduction (often done with procedural sedation).
After reduction, re-assess neurovascular status and apply a shoulder immobilizer or sling as ordered.
Supportive Care:
Apply an ice pack (wrapped in a towel) to the shoulder to reduce swelling.
Administer prescribed analgesics (e.g., IV morphine) and reassess pain using a pain scale.
Elevate the arm if possible (with pillows) to promote venous return.
Educate on the RICE protocol (Rest, Ice, Compression, Elevation) for home management.
Discuss follow-up for physical therapy to restore strength and range of motion and prevent recurrence.
Patient Safety and Precautions:
Never apply heat to a fresh musculoskeletal injury.
Never encourage the patient to "try to move it" or attempt to "pop it back in."
Monitor closely for Watch out for confusion!Compartment Syndrome signs, though more common in forearm/leg fractures: severe pain unrelieved by analgesics, pain on passive stretch, paresthesia, pallor, pulselessness (late sign).
Be aware of sedation precautions if procedural sedation is used for reduction.
Nursing Procedure & Medication FlowProcedure: Applying a Sling for Immobilization
1. Explain the procedure to the patient.
2. Support the affected arm in a position of comfort (usually slight flexion at the elbow, across the abdomen).
3. Place the triangular bandage under the arm with the point toward the elbow.
4. Bring the top end over the shoulder on the unaffected side and the bottom end over the affected shoulder.
5. Tie the ends at the side of the neck (pad the knot for comfort).
6. Secure the point of the bandage at the elbow with safety pins or tape.
7. Re-check neurovascular status post-application.
Medication: Opioid Analgesic (e.g., Morphine) Administration
- Indication: Moderate to severe acute pain.
- Precautions: Assess baseline respiratory rate, oxygen saturation, and level of consciousness. Have naloxone (Narcan) available.
- Monitoring: Re-assess pain level 15-30 minutes after IV administration. Monitor for respiratory depression, hypotension, nausea, and sedation.
A Word from Your Senior Nurse
"In the rush of an injury, it's tempting to want to 'do something' like give pain meds right away. But remember, your first job is to be a protector. Immobilizing that joint and checking those pulses and nerves is the most critical thing you can do in those first moments. That quick neuro check is your baseline – if something changes later, you'll know it. This mindset of 'stabilize and assess before treating' applies to so many emergencies. On the NCLEX and in real life, thinking in this order will keep your patients safe and make you a standout nurse."