An 82-year-old patient with a fractured hip is scheduled for surgery in 2 hours. The patient reports severe pain (8/10) and appears anxious. Which nursing intervention should be the priority?
1Administer prescribed analgesic medication and provide comfort measures✓ 정답
2Encourage deep breathing exercises and early mobilization
3Apply ice packs to the affected hip area
4Position the patient in high Fowler's position for comfort
해설
Pain management is the priority for a patient with severe pain (8/10) and anxiety preoperatively, as uncontrolled pain can lead to complications and interfere with preparation. Other interventions like breathing exercises or positioning are important but secondary to immediate pain relief.
Core Nursing ExplanationKey Concept Analysis: This question assesses the ability to prioritize nursing interventions using the Maslow's Hierarchy of Needs and the Nursing Process. The core theme is managing a patient's preoperative needs. The patient has two primary issues: severe pain (8/10) and anxiety. From a pathophysiological perspective, severe pain activates the sympathetic nervous system ("fight-or-flight" response), leading to increased heart rate, blood pressure, and stress hormone levels (e.g., cortisol). This physiological state can increase the risk of Key Point!preoperative complications such as cardiac ischemia, poor wound healing, and can also exacerbate anxiety, creating a vicious cycle. Effective pain management is a fundamental physiological need and a prerequisite for the patient to cooperate with other preoperative preparations.
Answer Rationale: The priority intervention is Administer prescribed analgesic medication and provide comfort measures. Key Point! In the immediate preoperative period (<2 hours), managing severe, acute pain is the top priority. Unrelieved pain is not only a source of suffering but also a significant physiological stressor that can negatively impact surgical outcomes. Administering analgesia addresses the most urgent physiological need (pain) and can indirectly help reduce anxiety. Providing comfort measures (e.g., calm reassurance, gentle touch) is a holistic, non-pharmacological adjunct that supports the primary intervention.
Distractor Analysis:
Watch out for confusion!Option ② (Encourage deep breathing exercises and early mobilization): While deep breathing can help manage anxiety, and early mobilization is a key postoperative goal, it is contraindicated and unsafe for a patient with an acute, unstable hip fracture preoperatively. Encouraging movement could cause further injury, displacement, or severe pain.
Watch out for confusion!Option ③ (Apply ice packs to the affected hip area): Applying ice (cryotherapy) is an excellent intervention for reducing swelling and providing some analgesic effect in musculoskeletal injuries. However, for a patient reporting severe pain (8/10), it is a supportive or adjunct measure, not the priority. Pharmacological intervention is required for rapid and effective relief of severe pain.
Watch out for confusion!Option ④ (Position the patient in high Fowler's position for comfort): Positioning can aid comfort, but high Fowler's (sitting nearly upright) is typically used for respiratory difficulties (e.g., in heart failure or COPD). For a hip fracture patient, maintaining proper alignment and immobilization (often with slight hip flexion and neutral rotation as per protocol) is more important. This option does not address the primary problem of severe pain.
Related Concepts: This scenario integrates preoperative care, pain management principles, and gerontological considerations. Elderly patients may have altered pharmacokinetics (drug metabolism) and are more susceptible to the adverse effects of both pain and certain analgesics, requiring careful assessment and monitoring.
Use both pharmacological (analgesics) and non-pharmacological (comfort measures) approaches. Assess pain before and after intervention.
Hip Fracture Care (Pre-op)
Maintain immobilization, proper alignment. Avoid movements that cause internal rotation or adduction of the hip.
Maslow's Hierarchy
Physiological needs (air, water, food, shelter, sleep, clothing, reproduction) must be met before higher-level needs (safety, love/belonging, esteem, self-actualization). Pain relief is a physiological need.
Side-by-Side Comparison!
Intervention
When it's a Priority
When it's Secondary/Contraindicated
Administer Analgesia
Patient reports moderate to severe acute pain; Pre-op to reduce stress response.
If patient is hemodynamically unstable (e.g., hypotensive) or has respiratory depression.
Apply Ice (Cryotherapy)
Acute injury (first 24-48 hrs) to reduce swelling and inflammation; Mild pain.
As sole treatment for severe pain; Over neurovascularly compromised areas; In patients with cold intolerance.
Deep Breathing Exercises
Postoperatively to prevent atelectasis; For managing mild anxiety.
Pre-op for an unstable fracture (pain may prevent deep inspiration); In acute respiratory distress.
Anatomy, Physiology & Pharmacology Points
Hip Fracture Patho: Usually a fracture of the femoral neck or intertrochanteric region. Causes severe pain due to periosteal nerve irritation, muscle spasm, and inflammation.
Common Pre-op Analgesics: Opioids (e.g., morphine, hydromorphone) for severe pain. NSAIDs (e.g., ketorolac) may be used with caution in elderly. Always monitor for respiratory depression, sedation, and hypotension.
Memory Tips
PPP for Pre-op Pain: Prioritize Pain relief, then Prepare the patient, then Provide psychological support.
Maslow First: Remember "Airway, Breathing, Circulation" (ABCs) are the ultimate physiological priorities. Severe pain threatens physiological stability, so it's high on the list.
High-Frequency NCLEX Topics
NCLEX loves testing priority-setting and safety. A patient in severe pain is a common scenario. The exam expects you to know that unmanaged pain is harmful and that addressing it is often the first step before other comfort or teaching measures.
Watch Out for Question Variations!
Shift from Symptom to Intervention: Instead of "Which symptom is priority?" it becomes "Which intervention is priority?" The logic is the same: treat the most urgent problem.
Postoperative Version: "A patient 4 hours post hip replacement has severe pain and is refusing to use the incentive spirometer. What is the priority?" Answer: Manage the pain first, then encourage spirometry.
Adding a Complication: "The patient with hip fracture and severe pain becomes hypotensive (BP 88/50)." Now, the priority might shift to assessing for shock/hemorrhage before giving certain analgesics.
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on an orthopedic unit. Mr. Johnson, an 82-year-old with a history of osteoporosis, fell at home and was admitted with a right femoral neck fracture. He is scheduled for an open reduction internal fixation (ORIF) in two hours. He is clutching the side rail, grimacing, and rates his pain as 8/10. He states, "I'm so scared about this surgery."
Nursing Intervention Strategy:
Assessment (First & Ongoing):
Pain: Use PQRST or OLDCARTS to assess characteristics. Check vital signs (tachycardia, hypertension may indicate pain/stress).
Neurovascular Status of the affected limb: Check pulses (dorsalis pedis, posterior tibial), capillary refill, sensation, movement, and temperature. Compare to unaffected side. This is a baseline assessment critical for postoperative comparison.
Anxiety: Assess level and contributing factors (fear of surgery, pain, loss of independence).
Immediate Intervention (Priority):
Administer the prescribed opioid analgesic (e.g., morphine 2-4 mg IV). IV route is preferred preoperatively for rapid onset and predictable absorption.
While preparing/administering, use therapeutic communication: "Mr. Johnson, I'm going to give you medication for your pain right now. It should start working in a few minutes. I'll stay with you."
Provide simple comfort measures: Ensure the bed is in a safe, low position; adjust lighting; offer a cool cloth to his forehead.
Reassessment & Preparation:
Reassess pain in 15-30 minutes after IV medication. Goal is to reduce pain to a tolerable level (e.g., 3-4/10).
Once pain is better controlled, you can proceed with other preoperative tasks: verify consent, ensure NPO status, perform skin prep, administer preoperative antibiotics if ordered, and provide brief, calm explanations of what to expect.
Address anxiety with clear, concise information and emotional support. "The anesthesiologist will be here soon to talk with you. They will make sure you are asleep and comfortable during the procedure."
Patient Safety and Precautions:
Fracture Immobilization: Do not move or turn the patient without proper support (e.g., using a trapeze, log-rolling if necessary). The leg may be in traction or a splint.
Medication Safety: In the elderly, start with lower doses of opioids due to reduced metabolism. Monitor closely for oversedation, respiratory depression (rate <8/min), and orthostatic hypotension.
Fall Prevention: Keep call light within reach, side rails up per protocol. A patient in severe pain may make sudden, unsafe movements.
Nursing Procedure & Medication FlowAdministering IV Opioid Analgesic Preoperatively:
1. Verify: Check the "Rights" of medication administration. Confirm the order matches the patient's weight/renal function.
2. Assess: Obtain baseline vital signs, pain score, respiratory rate, and level of consciousness.
3. Prepare: Draw up medication. For IV push, dilute if recommended and administer slowly over 3-5 minutes.
4. Monitor: Stay with the patient during and for several minutes after administration. Observe for adverse effects (itching, nausea, dizziness).
5. Reassess: Evaluate pain relief and vital signs at 15-30 minutes. Document response.
A Word from Your Senior Nurse: "In moments like these, your patient is experiencing one of the most vulnerable times in their life. Your ability to swiftly and competently manage their pain does more than just lower a number on a scale—it builds trust, reduces physiological stress, and sets the stage for a better recovery. Remember, you are their advocate. If the prescribed medication isn't effective, you must communicate that to the provider. Never let a patient suffer in severe pain because 'it's almost time for surgery.' Your compassionate, skilled intervention in the preoperative phase is a powerful example of holistic, patient-centered care."