Nursing Clinical Practice Guide
Clinical Scenario: Mr. Johnson, 72, is admitted to your orthopedic unit after a fall at home. He has a confirmed right hip fracture and is scheduled for surgery tomorrow morning. He is on bed rest with Buck's traction applied for comfort and alignment.
Nursing Intervention Strategy:- 1AssessmentPerform frequent neurovascular assessments (CMS): Check Circulation (capillary refill, pedal pulses, color/temperature), Movement (toes), and Sensation (light touch on foot). Document any changes. Assess pain using a numeric scale.
- 2Pain ManagementAdminister scheduled and PRN analgesics as ordered. Reposition carefully, supporting the entire leg.
- 3Pre-op Preparation & EducationReinforce deep breathing and coughing exercises to prevent atelectasis. Explain the surgical procedure and post-op mobility restrictions (e.g., "hip precautions").
- 4Post-op CareMaintain abduction, log-roll for turning, use a raised toilet seat and chair. Monitor incision site, drains, and vital signs. Aggressively prevent DVT with sequential compression devices (SCDs) and anticoagulants.
Patient Safety and Precautions:- Never flex the hip >90 degrees, adduct, or internally rotate the operative leg after a total hip arthroplasty (THA).
- Be vigilant for signs of compartment syndrome (severe pain unrelieved by meds, pallor, paresthesia, pulselessness, paralysis) – though more common in long bone fractures, it's a critical emergency.
- Monitor for signs of fat embolism syndrome (FES) – confusion, petechial rash, respiratory distress – especially in the first 72 hours.
Nursing Procedure & Medication Flow
Procedure: Applying Buck's (Skin) Traction
1. Explain the procedure to the patient.
2. Clean and dry the skin on the affected leg.
3. Apply foam traction boots or adhesive strips along the medial and lateral aspects of the leg.
4. Secure the traction rope to the spreader bar and run it over a pulley at the foot of the bed.
5. Hang the prescribed weight (usually 5-10 lbs). Ensure the weight hangs freely, not touching the bed or floor.
6. Check the skin under the boot every 2-4 hours for redness or breakdown.
Medication: Enoxaparin (Lovenox) for DVT Prophylaxis- 1ActionLow molecular weight heparin (LMWH); inhibits Factor Xa.
- 2Dose/RouteTypically 40 mg subcutaneously (SQ) once daily.
- 3Key Nursing PointAdminister in the abdomen, at least 2 inches from the umbilicus. Do not aspirate or massage the site. Rotate sites. Monitor for signs of bleeding (bruising, hematuria, tarry stools).
A Word from Your Senior Nurse
"In the chaos of the ED or on a busy ortho floor, spotting that classic 'shortened and externally rotated' leg is a moment of critical recognition. It tells you instantly that this isn't just a bad bruise – it's a life-changing fracture that needs a swift, systematic response. Your role goes beyond identifying it. You're the one ensuring that leg stays immobilized, that the pain is controlled, and that you're constantly checking those toes for circulation. You're also the patient's coach and advocate through a tough recovery. Remember the 'why' behind every intervention – why we use abductor pillows, why we give blood thinners, why we log-roll. That understanding transforms you from a task-doer into a thinking, protective nurse, which is exactly what the NCLEX and, more importantly, your future patients, need you to be."