A 65-year-old client with a fractured hip is scheduled for surgery in the morning. Which nursing action is the highest priority to prevent complications during the preoperative period?
1Maintain the affected leg in proper alignment and immobilization✓ 정답
2Administer prescribed pain medication every 4 hours
3Encourage deep breathing and coughing exercises
4Monitor vital signs every 2 hours
해설
Maintaining proper alignment and immobilization of the fractured hip is the highest priority to prevent further displacement, neurovascular compromise, and additional tissue damage before surgery.
Core Nursing ExplanationKey Concept Analysis: This question assesses the ability to prioritize nursing interventions for a patient with a fractured hip in the preoperative period. The core principle is preventing further injury and complications before definitive surgical repair. The primary threats to a patient with an unstable fracture are: 1) Displacement of bone fragments, which can damage surrounding tissues, 2) Key Point!Neurovascular compromise due to pressure or injury from bone fragments or swelling, and 3) Increased pain and bleeding.
Answer Rationale: Key Point! Maintaining proper alignment and immobilization is the highest priority because it directly addresses the most immediate and serious risks. Proper immobilization (e.g., using pillows, splints, or traction as ordered) prevents movement of the fracture fragments. This action:
Prevents further displacement and tissue damage.
Minimizes the risk of injuring adjacent nerves and blood vessels, which is critical to assess via CMS checks (Circulation, Motor, Sensory).
Reduces pain and the risk of fat embolism (a potential complication of long bone fractures).
Is a foundational safety measure upon which all other care depends.
Distractor Analysis:
Watch out for confusion! Option ② (Administer pain medication) is important for comfort and reducing muscle spasms, but it is a supportive measure, not the highest priority for preventing physical injury. Pain management follows safety.
Option ③ (Encourage deep breathing and coughing) is a standard preoperative teaching to prevent atelectasis and pneumonia. While important, it is a general measure for any surgical patient and does not address the specific, acute risk posed by the unstable fracture itself.
Option ④ (Monitor vital signs every 2 hours) is a routine assessment for stability. It helps detect complications like shock or infection but is a monitoring action, not an intervention to prevent the primary complication of the fracture.
Related Concepts: This prioritization follows the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. Preventing physical harm (safety and physiological integrity) takes precedence over comfort, teaching, and routine monitoring. In trauma and orthopedic nursing, "Key Point! Immobilize first" is a golden rule.
Concept Summary
Concept
Key Takeaway
Preoperative Care for Fractures
Priority is stabilizing the injury to prevent further harm (displacement, neurovascular damage).
Neurovascular Assessment (CMS)
Critical nursing action: Check Circulation (pulses, color, temperature, capillary refill), Motor (movement), Sensory (sensation) distal to the injury.
Prioritization Framework
Use ABCs and Maslow's. Actual threats to physiological integrity (safety from injury) outrank potential threats (like pneumonia) or comfort needs.
Always the first action for an unstable fracture before surgery.
Administer Analgesia
Intermediate - Addresses pain, which is important but secondary to safety.
If pain is so severe it is causing physiological stress (e.g., tachycardia, hypertension) or preventing necessary care.
Preoperative Teaching (DB&C)
Important - Prevents postoperative complications (respiratory).
After the limb is stabilized; a key teaching moment before surgery.
Routine Vital Sign Monitoring
Standard - Provides baseline data and detects changes.
If vital signs become unstable (e.g., signs of hypovolemic shock), monitoring frequency increases and becomes part of a higher-priority intervention.
Anatomy, Physiology & Pharmacology Points
Anatomy: The hip joint involves the femoral head and acetabulum. A fracture can disrupt the rich blood supply to the femoral head, risking avascular necrosis.
Physiology: Immobilization reduces movement at the fracture site, minimizing further soft tissue damage, bleeding, and the release of fat globules from bone marrow (risk factor for fat embolism).
Pharmacology (Related to Distractors): Pain medications like opioids can cause respiratory depression. While important, their administration does not supersede the physical safety measure of immobilization.
Memory Tips
Acronym: "FIRST" for Fracture Care: Fix/Immobilize first, Inspect CMS, Relieve pain, Support with teaching, Track vitals.
Think of the Bone as a Knife: An unstable fracture is like a sharp bone fragment that can cut nerves and vessels if moved. Your first job is to "sheath the knife" (immobilize it).
High-Frequency NCLEX Topics
NCLEX loves testing prioritization and "first" actions. Orthopedic injury questions often hinge on: 1) Immobilize, 2) Assess neurovascular status (CMS), 3) Manage pain. Always choose the action that prevents the most immediate life- or limb-threatening complication.
Watch Out for Question Variations!
Shift from "Action" to "Assessment": "What is the priority assessment for a client with a fractured hip?" The answer would be neurovascular status (CMS checks), which is the assessment directly linked to the priority intervention of immobilization.
Postoperative Focus: After surgery, the priority might shift to preventing dislocation of the new joint (e.g., maintaining abduction with a pillow, avoiding hip flexion >90 degrees).
Adding a Complication: "A client with a hip fracture develops sudden dyspnea and confusion." Now the priority shifts to suspected fat embolism (manage airway, administer oxygen, notify physician).
Nursing Clinical Practice GuideClinical Scenario: You are the night shift nurse caring for Mr. Johnson, a 65-year-old admitted after a fall. He has a confirmed, displaced right femoral neck fracture and is scheduled for a total hip arthroplasty at 7:00 AM. He is on bed rest.
Nursing Intervention Strategy:
Immediate Action & Assessment:
Ensure the affected leg is supported in a neutral position with pillows or a splint as per protocol. Do not attempt to "straighten" the leg.
Perform and document a CMS assessment immediately: Palpate the dorsalis pedis and posterior tibial pulses, check capillary refill (< 3 seconds), assess toe movement and sensation, and note skin color and temperature. Compare to the unaffected leg.
Ongoing Care:
Reassess CMS every 1-2 hours and with any patient movement or complaint of increased pain/numbness.
Administer prescribed analgesics (often IV opioids) to keep pain manageable, assessing effectiveness and respiratory status.
Once the limb is stable, begin preoperative teaching: "Mr. Johnson, to prevent lung problems after surgery, I'm going to teach you how to do deep breathing and cough effectively. Let's practice now."
Monitor vital signs per order, watching for tachycardia or hypotension, which could indicate bleeding or shock.
Patient Safety and Precautions:
Contraindication: Never place the patient in a position that causes internal or external rotation of the fractured hip, as this can displace fragments.
Key Monitoring: The earliest sign of compartment syndrome is often "pain out of proportion" to the injury and pain on passive stretching of the muscles. This is a surgical emergency.
Communication: Clearly inform all team members (aides, radiology techs) that the limb must be log-rolled or carefully supported during any moves.
Nursing Procedure & Medication FlowImmobilization Procedure:
1. Explain the procedure to the patient to reduce anxiety and gain cooperation.
2. Use sufficient pillows to support the entire length of the leg, from the heel to the thigh.
3. Maintain alignment of the hip, knee, and ankle. The heel should be off the bed to prevent pressure ulcers.
4. Use a trochanter roll alongside the hip to prevent external rotation.
5. Document the position used and the patient's tolerance.
Medication Administration: When giving IV opioids preoperatively:
- Assess pain level before and after (using a pain scale).
- Monitor respiratory rate, depth, and oxygen saturation closely, especially with the first dose.
- Have naloxone (Narcan) readily available per protocol.
A Word from Your Senior Nurse
"In the rush of a busy unit, it's easy to focus on the scheduled tasks like giving meds on time or doing routine vitals. But for this patient, the single most important thing you do all night is to keep that leg still and check those toes. I've seen a simple repositioning by a well-meaning aide cause a nerve palsy because the fracture wasn't properly supported. Your vigilant assessment and immobilization are what protect the patient from permanent damage before the surgeon can even step into the room. This is the essence of nursing: being the guardian of the patient's safety during their most vulnerable hours."
Neurovascular Compromise — Impaired blood flow (circulation) or nerve function (motor/sensory) to a limb, often due to pressure, swelling, or injury. A critical complication of fractures and immobilization devices.
CMS Assessment — A systematic check of Circulation (pulses, color, temperature, capillary refill), Motor (movement), and Sensory (sensation) distal to an injury or cast. The cornerstone of orthopedic nursing assessment.
Immobilization — The act of making a body part incapable of moving, using devices like splints, casts, or traction. The primary initial intervention for fractures to prevent further injury.
Preoperative Teaching — Patient education provided before surgery, including instructions on deep breathing, coughing, incentive spirometry, and mobility to prevent postoperative complications like atelectasis and pneumonia.
Compartment Syndrome — A serious condition where increased pressure within a muscle compartment compromises blood flow, leading to tissue ischemia and necrosis. A surgical emergency. Early signs include pain out of proportion and pain with passive stretch.