Nursing Clinical Practice Guide
Clinical Scenario: You are assigned to Mr. Johnson, an 78-year-old admitted from the ED with a left femoral neck fracture after a fall. He is on Buck's traction, awaiting surgery in the morning. He reports pain at 7/10 and is anxious about moving.
Nursing Intervention Strategy:1. Assessment: First, perform and document neurovascular checks (CMS) on the affected leg every 1-2 hours: Circulation (color, temperature, capillary refill, pedal pulses), Motion (ability to wiggle toes), Sensation (light touch on toes). Assess pain level and characteristics.2. Immobilization & Safety: Ensure traction weights are hanging freely, not resting on the bed. Use a fracture bedpan. Log-roll the patient for linen changes or skin care, keeping the leg in alignment. Place a trapeze bar on the bed for the patient to move themselves without using the affected leg.3. Complication Prevention: Apply sequential compression devices (SCDs) to the unaffected leg. Administer prescribed low-molecular-weight heparin (LMWH). Perform passive range-of-motion exercises on the unaffected limbs.4. Pain & Education: Administer scheduled and PRN analgesics. Apply ice packs to the hip area, wrapped in a towel, for 20 minutes at a time. Explain all procedures to reduce anxiety.
Patient Safety and Precautions:• Contraindication: Do not elevate the head of the bed more than 20-30 degrees if in traction, as this reduces its effectiveness.• Medication Caution: LMWH injections are given subcutaneously in the abdomen. Avoid massaging the site. Monitor for signs of bleeding.• Key Monitoring: Any change in CMS findings, sudden increase in pain, or swelling is a red flag requiring immediate notification of the surgeon.
Nursing Procedure & Medication Flow
Pre-op Neurovascular Check (CMS) Procedure:1. Explain the procedure to the patient.2. Circulation: Palpate the dorsalis pedis and posterior tibial pulses. Compare to the unaffected side. Check capillary refill (should be < 3 seconds). Observe for pallor or cyanosis.3. Sensation: Gently touch the top and bottom of the foot. Ask, "Can you feel this? Does it feel the same as the other foot?"4. Motion: Ask the patient to "wiggle your toes." Do not move the limb for them.5. Document findings clearly: "Pedal pulses 2+, cap refill 2 sec, sensation intact, toes wiggled spontaneously."
A Word from Your Senior Nurse
"In the rush to manage pain or prevent a pressure ulcer, it's easy to forget the most basic rule: first, do no harm. That fractured bone is like a knife edge near major blood vessels. Your number one job before surgery is to keep it still. In clinical practice, I've seen a patient's leg turn cold and pulseless in minutes after an accidental kick against the bed rail. Those neurovascular checks aren't just a task on a list—they are your early warning system. On the NCLEX, when you see 'fracture' and 'pre-op,' let your mind scream 'IMMOBILIZE!' first. Everything else comes after."