A 65-year-old woman is brought to the emergency department after slipping on ice and landing on her right side. She reports severe pain in her right hip and is unable to bear weight. The nurse observes that her right leg appears shortened and externally rotated, suggesting a hip fracture with risk of neurovascular compromise. What is the priority nursing assessment for this patient?
Emergency assessment of suspected hip fracture with neurovascular compromise risk
1Assess the patient's pain level using a 0-10 numeric rating scale
2Check distal pulses, capillary refill, and sensation in the affected extremity✓ 정답
3Obtain a complete medical history including current medications
4Measure and document the patient's vital signs
해설
Neurovascular assessment (distal pulses, capillary refill, sensation) is the priority to detect complications like compromised circulation or nerve damage that could lead to permanent disability. Other assessments (pain, vital signs, history) are important but secondary.
Core Nursing ExplanationKey Concept Analysis: This question tests the application of nursing priorities in a trauma patient with a suspected hip fracture. The core principle is the ABCs (Airway, Breathing, Circulation) and Key Point! the immediate threat to life or limb. In this scenario, the patient's airway, breathing, and general circulation (vital signs) are not described as compromised. The explicit risk is neurovascular compromise to the affected limb. A fracture can cause swelling, bleeding, or bone displacement that compresses or damages blood vessels and nerves, potentially leading to compartment syndrome, ischemia, or permanent nerve damage. Therefore, the priority is to assess the viability and function of the extremity distal to the injury.
Answer Rationale: Key Point! Option ②, checking distal pulses, capillary refill, and sensation, is the priority neurovascular assessment. This directly evaluates the "5 Ps" of neurovascular status: Pain, Pallor, Pulselessness, Paresthesia (tingling/numbness), and Paralysis. Early detection of changes allows for immediate intervention (e.g., fracture reduction, surgical consultation, fasciotomy) to prevent irreversible tissue damage or loss of the limb.
Distractor Analysis:
Watch out for confusion! Option ① (Assess pain): While pain management is a crucial part of nursing care, assessing its intensity on a scale is not the priority when a specific, immediate threat to limb viability (neurovascular compromise) has been identified. Pain is one component of the neurovascular assessment but not the first action.
Option ③ (Obtain medical history): A thorough history is essential for safe care planning (e.g., allergies, anticoagulant use) but is a secondary assessment after immediate threats to life and limb are addressed.
Option ④ (Measure vital signs): This is a fundamental and important assessment. However, in this specific scenario, the patient's general circulation (implied by stable vital signs) is not the primary concern; the localized circulation to the injured extremity is. Vital signs would be assessed concurrently or immediately after the neurovascular check.
Related Concepts: This question integrates trauma nursing, orthopedic emergencies, and the nursing process. The correct answer reflects the "assess before you act" principle for a specific, identified risk. Following the neurovascular assessment, nursing interventions would include immobilizing the limb, administering analgesics as ordered, and preparing for diagnostic imaging (X-ray) and potential surgery.
Concept Summary
Concept
Description
Nursing Implication
Neurovascular Assessment (5 Ps)
Systematic check of Pain, Pallor, Pulselessness, Paresthesia, Paralysis distal to an injury or cast.
Priority action for fractures, compartment syndrome, or post-operative orthopedic patients to prevent limb loss.
Hip Fracture (Femoral Neck/Femur)
Common in elderly after a fall. Classic signs: shortened, externally rotated leg, severe pain, inability to bear weight.
In trauma, address threats to life first, then threats to limb or function.
Side-by-Side Comparison!
Assessment Priority
When It's the Priority
When It's Secondary
Neurovascular Check
Any injury with risk of compartment syndrome (fractures, crush injuries, tight casts), post-operative limb surgery.
Patient is unstable (e.g., hypotensive, hypoxic). ABCs take precedence.
Pain Assessment
Patient is stable, no immediate life/limb threat. Integral part of holistic care and the 5th vital sign.
When a more critical assessment (e.g., airway, bleeding, neurovascular status) is required first.
Vital Signs
Initial assessment for any patient, especially in trauma (to assess for shock). Part of the "Circulation" in ABCs.
When a specific, localized threat (like a pulseless extremity) is identified and requires immediate action.
Anatomy, Physiology & Pharmacology Points
Anatomy: The femoral artery and sciatic nerve are key structures at risk in a hip fracture. Assessing the dorsalis pedis and posterior tibial pulses evaluates arterial flow.
Physiology: Compartment syndrome occurs when pressure within a muscle compartment exceeds capillary perfusion pressure, leading to ischemia and necrosis. The "5 Ps" are the clinical signs.
Pharmacology: Pain management often involves IV opioids (e.g., morphine) initially. NSAIDs may be used but cautiously in the elderly. Prophylactic anticoagulants (e.g., enoxaparin) are standard to prevent DVT (Deep Vein Thrombosis).
Priority Rule: Think "Life before Limb." If the patient isn't dying (ABCs stable), save the limb next (neurovascular check).
Hip Fracture Signs: Remember "Short and Out" – the leg is shortened and externally rotated.
High-Frequency NCLEX Topics
Prioritization questions like this are extremely common on the NCLEX-RN. The exam tests your ability to sequence nursing actions, not just know what they are. Always ask yourself: "What action, if delayed, will cause the most harm to this patient right now?"
Priority Intervention: "After assessing neurovascular status, what is the nurse's next priority?" (Answer: Immobilize the limb to prevent further injury).
Patient Education: "What should the nurse teach a patient with a new cast to report immediately?" (Answer: Increased pain, numbness, tingling, or inability to move fingers/toes).
Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in the ED. Mrs. Jones, 65, is on a stretcher after a fall. She is alert, breathing comfortably, and her skin is warm and dry. Her right leg is visibly deformed. She rates her pain as 8/10.
Nursing Intervention Strategy:
Immediate Assessment (Priority): Perform a focused neurovascular assessment on the right lower extremity. Palpate the dorsalis pedis and posterior tibial pulses. Check capillary refill on the great toe (< 3 seconds is normal). Assess sensation by lightly touching different areas of the foot and asking, "Can you feel this? Does it feel the same as the other foot?" Ask her to wiggle her toes.
Concurrent Actions: While your partner stabilizes the limb, you can quickly obtain vital signs. Apply oxygen if needed and establish IV access.
Interventions: Immobilize the limb as found (do not try to straighten it). Administer prescribed analgesics (often IV morphine). Apply ice packs to the hip area if not contraindicated by skin integrity.
Monitoring & Documentation: Document neurovascular findings before and after any intervention (e.g., splinting, medication). Re-assess every 15-30 minutes or per protocol. Monitor for signs of shock (tachycardia, hypotension) from possible internal bleeding.
Patient Safety and Precautions:
Do NOT attempt to reduce (realign) the fracture. This requires physician oversight and often analgesia/sedation.
Handle the limb gently to prevent further neurovascular injury or displacement.
Be vigilant for compartment syndrome: Pain out of proportion to injury and pain on passive stretching of muscles are early signs. Pulselessness is a late sign.
Nursing Procedure & Medication FlowNeurovascular Check Procedure:
1. Explain the procedure to the patient.
2. Pain: Ask location, quality, severity. Is it increasing?
3. Pallor/Pulses: Compare color and temperature to the unaffected side. Palpate pulses bilaterally. Use a Doppler if pulse is not palpable.
4. Capillary Refill: Press on nail bed or pulp of toe until blanched, release, and time return of color.
5. Paresthesia/Paralysis: Assess light touch sensation and active range of motion (e.g., "Wiggle your toes.").
6. Document all findings clearly and objectively.
Analgesia Administration: For severe pain, IV opioids are first-line. Administer slowly, monitoring for respiratory depression (especially in elderly). Re-assess pain after 15-30 minutes.
A Word from Your Senior Nurse
"In the rush of the ED, it's easy to get caught up in tasks. Remember your foundational framework: ABCs and then the specific threat. For Mrs. Jones, her deformed leg is the obvious problem, but your expert nursing judgment tells you the invisible problem—compromised blood flow or nerve damage—is what could cost her the leg. By making that neurovascular check your absolute first hands-on assessment, you're being her advocate and guardian. On the NCLEX and in practice, this kind of critical thinking—seeing beyond the obvious to the most dangerous possibility—is what defines a safe and excellent nurse."
Neurovascular Assessment — A systematic evaluation of the circulatory and neurological status of an extremity, focusing on the "5 Ps": Pain, Pallor, Pulselessness, Paresthesia, and Paralysis. It is a priority nursing action for patients with fractures, casts, or post-operative limb surgery.
Hip Fracture — A break in the proximal femur, commonly the femoral neck or intertrochanteric region. Classic signs include severe pain, inability to bear weight, and a shortened, externally rotated lower extremity on the affected side.
Compartment Syndrome — A serious condition where increased pressure within a muscle compartment compromises blood flow, leading to ischemia and potential tissue necrosis. It is a surgical emergency. Early signs include pain out of proportion and pain on passive stretch.
The 5 Ps — A mnemonic for the key components of a neurovascular assessment: Pain, Pallor, Pulselessness, Paresthesia (abnormal sensation like tingling), and Paralysis. These signs indicate potential neurovascular compromise.
Nursing Priorities — The sequence in which a nurse addresses patient problems, typically following the ABC (Airway, Breathing, Circulation) framework, then moving to disability (neurological/neurovascular status) and exposure/environment. It guides clinical decision-making in emergencies.