A nurse is caring for a client who sustained a posterior hip dislocation following a motor vehicle accident. Which nursing intervention should be the priority?
1Apply ice packs to the affected hip for 20 minutes every hour
2Encourage early ambulation to prevent complications
3Position the client in a supine position with legs extended
4Maintain the client in a position of comfort and immobilize the affected extremity✓ 정답
해설
Immobilizing the affected extremity prevents further injury and neurovascular compromise in posterior hip dislocation. Other options are secondary: ice reduces swelling but isn't the priority, early ambulation is contraindicated, and supine positioning may not be optimal.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing intervention for a patient with a posterior hip dislocation. The core principle is preventing further injury and neurovascular compromise. A posterior hip dislocation, often from a high-impact trauma like a motor vehicle accident, involves the femoral head being forced out of the acetabulum (hip socket) backward. This can stretch or compress the nearby sciatic nerve and compromise blood vessels. The immediate nursing priority is to Key Point! maintain the dislocation in its current position to avoid damaging nerves or vessels further until definitive reduction (realignment) can be performed by a physician.
Answer Rationale: The correct answer is Key Point!Maintain the client in a position of comfort and immobilize the affected extremity. This intervention directly addresses the primary risk. Immobilization prevents movement that could worsen the dislocation or cause neurovascular injury. Keeping the patient comfortable helps reduce muscle spasms and anxiety, which can also contribute to further injury. This action aligns with the nursing process by first ensuring safety (Assessment/Implementation for safety) before addressing other needs like pain or swelling.
Distractor Analysis:
Watch out for confusion!Apply ice packs to the affected hip: While applying ice is a correct intervention to reduce swelling and pain, it is a secondary priority. The ABCs (Airway, Breathing, Circulation) and prevention of further injury (like neurovascular damage) always take precedence over comfort measures like ice.
Watch out for confusion!Encourage early ambulation: This is contraindicated and dangerous for a dislocated joint. Ambulation before reduction can cause severe damage to nerves, blood vessels, and articular cartilage. Early mobilization is a goal after the joint has been reduced and stabilized.
Watch out for confusion!Position the client in a supine position with legs extended: This is incorrect and potentially harmful. For a posterior hip dislocation, the affected leg is typically held in a characteristic position: flexed, adducted (pulled toward the midline), and internally rotated. Forcing it into a supine, extended position could cause pain and further injury. The leg should be supported in its current, often flexed, position.
Related Concepts: This scenario tests the application of emergency musculoskeletal care principles. Key related assessments include frequent neurovascular checks (assessing pulses, capillary refill, sensation, and movement distal to the injury) and managing pain, which is typically severe. The definitive treatment is closed or open reduction under sedation or anesthesia.
Concept Summary
• Priority: Immobilize to prevent neurovascular injury.
• Pathophysiology: Posterior dislocation risks sciatic nerve injury.
• Characteristic Position: Hip flexed, adducted, internally rotated.
• Contraindication: Do not move or bear weight on the joint.
• Definitive Care: Physician-performed reduction.
Side-by-Side Comparison!
Intervention
Priority & Rationale
Timing
Immobilize & Maintain Position
HIGHEST PRIORITY. Prevents further neurovascular injury.
Immediate, pre-reduction.
Apply Ice (RICE Principle)
Secondary. Manages swelling and pain.
After immobilization is secured.
Assess Neurovascular Status
Concurrent High Priority. Monitors for complications.
Immediate and ongoing.
Encourage Ambulation
Contraindicated. Can cause severe damage.
Only post-reduction and rehabilitation.
Anatomy, Physiology & Pharmacology Points
• Anatomy: The sciatic nerve runs posterior to the hip joint. A posterior dislocation puts it at direct risk for compression or stretch injury, which can lead to foot drop and loss of sensation.
• Physiology: Disruption of blood supply (e.g., to the femoral head) can lead to avascular necrosis (AVN), a long-term complication.
• Pharmacology: Pain management will involve opioids (e.g., morphine) and muscle relaxants. Sedation (e.g., with benzodiazepines like midazolam) is often used during the reduction procedure.
Memory Tips
• Acronym: P.R.I.C.E. for acute musculoskeletal injury: Protect (immobilize), Rest, Ice, Compression, Elevation. Note that "Protect" comes first!
• Mnemonic for Posterior Dislocation Position: "F.A.I.R." – Flexed, Adducted, Internally Rotated.
High-Frequency NCLEX Topics
This integrates prioritization (Maslow's Hierarchy, ABCs), neurovascular assessment, and contraindicated actions for specific injuries. NCLEX loves to test if you know what not to do (like ambulating a dislocated hip).
Watch Out for Question Variations!
• Instead of asking for the priority intervention, it could ask: "Which finding requires immediate notification to the physician?" Answer: Signs of neurovascular compromise (e.g., absent pedal pulse, numbness).
• It could be framed as a pediatric question (developmental dysplasia of the hip) where immobilization (with a Pavlik harness) is also key.
• The scenario could shift to post-reduction care, where priorities change to monitoring for re-dislocation, managing pain, and initiating prescribed weight-bearing status.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in the Emergency Department. Mr. Jones, 32, arrives via ambulance after his car was T-boned. He is alert but in severe pain. His right leg is visibly shortened and rotated inward, held in a flexed position. He states he cannot move his toes and has a "pins and needles" sensation in his foot.
Nursing Intervention Strategy:
1Immediate Assessment & Immobilization (Priority!)Do not attempt to straighten the leg. Place pillows or rolled blankets under the knee and ankle to support the leg in its current flexed, adducted position. Apply a temporary immobilizer if available per protocol. This is your first action.
2Concurrent Neurovascular AssessmentPerform the "6 Ps" check: Pain, Pallor, Pulselessness, Paresthesia (tingling), Paralysis (movement), Poikilothermia (coolness). Document findings meticulously and compare to the unaffected limb.
3Pain ManagementAdminister prescribed IV analgesics (e.g., morphine) and assess effectiveness. Pain can exacerbate muscle spasms.
4Prepare for ReductionAssist with obtaining X-rays (confirm diagnosis), starting IV access, and preparing for procedural sedation. Educate the patient about the reduction process.
5Post-Reduction CareAfter the physician reduces the hip, reassess neurovascular status. Apply ice as ordered. The leg may be placed in traction or an abduction brace to maintain stability.
Patient Safety and Precautions:
• Contraindication: Never apply heat to an acute dislocation; it increases swelling and bleeding.
• Medication Caution: Use caution with opioids and sedatives; monitor respiratory status closely, especially post-reduction.
• Key Monitoring: Serial neurovascular checks are non-negotiable. Any deterioration is a medical emergency.
Nursing Procedure & Medication Flow
• Immobilization Procedure: Use pillows/blankets for support → Secure with soft ties if needed (avoid tight circulation) → Reassess position and comfort frequently.
• Medication Administration: For severe pain, IV opioids are first-line. Administer slowly, monitoring for respiratory depression (Respiratory rate < 12/min is a concern). Have naloxone (Narcan) available.
A Word from Your Senior Nurse
"In trauma, your first instinct might be to 'fix' the obvious deformity, but in nursing, our first job is to prevent making it worse. Holding that leg still isn't passive—it's an active, critical intervention that protects the nerve and blood supply. When you see a deformity like this, think 'support, don't straighten.' That mindset protects your patient during the most vulnerable time and buys time for the definitive treatment. On the NCLEX and in real life, safety before comfort is a golden rule."
Posterior Hip Dislocation — A traumatic injury where the femoral head is displaced posteriorly out of the acetabulum (hip socket), often from high-impact force with the hip flexed (e.g., dashboard injury in MVA). Presents with hip flexion, adduction, and internal rotation.
Neurovascular Compromise — Impairment of nerve function and blood circulation to a limb, a critical complication of dislocations and fractures. Signs include the "6 Ps": Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia (coolness).
Immobilization — The therapeutic act of preventing movement of an injured body part. In acute dislocation, it is the priority to prevent further injury to nerves, vessels, and soft tissues until definitive reduction.
Sciatic Nerve — The largest nerve in the body, running posterior to the hip joint. It is at high risk of injury in a posterior hip dislocation, which can result in foot drop and loss of sensation in the leg and foot.
Reduction — The medical procedure to realign a dislocated joint back into its normal anatomical position. For a hip dislocation, this is typically performed under sedation or anesthesia by a physician.