Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse on the medical-surgical unit. An 82-year-old female, Mrs. Jones, is admitted from the ED after a fall at home. She has a confirmed left femoral neck fracture and is scheduled for an open reduction and internal fixation (ORIF) in the morning. She is alert but in significant pain, rating it 8/10.
Nursing Intervention Strategy:- 1Immediate Action & AssessmentUpon receiving the patient, first ensure the affected leg is immobilized. This is often done with a splint or by placing pillows longitudinally along the leg to prevent internal or external rotation. Then, perform a focused assessment: Pain (PQRST), neurovascular status of the affected limb (check pulses, capillary refill, sensation, movement, color, temperature - compare to unaffected side), vital signs, and skin integrity.
- 2Pain ManagementAdminister prescribed analgesics (often IV opioids like morphine) promptly. Reassess pain after 30 minutes. Consider non-pharmacological methods like applying an ice pack (wrapped in a towel) to the hip area for 20-minute intervals, but only after the limb is stabilized.
- 3Preoperative Preparation & TeachingOnce the patient is more comfortable, begin preoperative education. Explain deep breathing and coughing exercises using an incentive spirometer. Discuss the importance of early mobilization post-op (as ordered) to prevent complications. Complete preoperative checklists (NPO status, consent, lab work, skin prep).
- 4Ongoing Monitoring & SafetyPerform neurovascular checks every 1-2 hours initially. Monitor for signs of complications: increased pain, pallor, pulselessness, paresthesia, paralysis (the 5 P's of compartment syndrome), or symptoms of fat embolism (sudden dyspnea, confusion, petechiae). Keep the side rails up and the call light within reach. Use a fracture bedpan.
Patient Safety and Precautions:
* Key Point! Never attempt to "straighten" or significantly move a fractured limb. Immobilize it in the position found unless there is a loss of pulse.
* Elderly patients are highly susceptible to delirium from pain, medications, and the unfamiliar environment. Reorient frequently, ensure adequate lighting, and involve family.
* Be vigilant for signs of opioid-induced respiratory depression, especially in this age group.
Nursing Procedure & Medication Flow
Immobilization Procedure: 1) Explain the procedure to the patient. 2) Gently support the limb above and below the fracture site. 3) Place pillows along the entire length of the leg to maintain neutral alignment. 4) Use a trochanter roll or abductor pillow if available to prevent external rotation. 5) Document the position and the patient's response.Opioid Administration (e.g., Morphine): 1) Check the order and the "Rights" of medication administration. 2) Assess baseline pain level, respiratory rate, and oxygen saturation. 3) Administer IV push slowly. 4) Stay with the patient, monitor for adverse effects (respiratory rate < 12/min, sedation, hypotension). 5) Reassess pain in 30 minutes. Have naloxone (Narcan) readily available.
A Word from Your Senior Nurse
"In the rush of an admission, it's easy to want to jump to the most visible need—like the patient's crying out in pain. But remember your trauma basics: first, do no further harm. Securing that fracture is the single most important thing you can do in those first minutes. It's the foundation upon which all other care—pain management, comfort, teaching—is built. On the NCLEX and at the bedside, thinking in terms of 'what protects the patient from immediate danger?' will almost always lead you to the right answer. You've got this!"