Day 1 After Hip Fracture Repair: Competing Priorities in an Older Adult
Mrs. Tran, 81, is day 1 after open reduction and internal fixation of a right intertrochanteric femur fracture. She has mild vascular dementia; at baseline she is oriented to person and place and uses a walker. She takes oxycodone 5 mg every 4 hours as needed, last dose 90 minutes ago. Her indwelling catheter was removed 6 hours ago. She has not voided since removal, says she feels like she has to go but cannot, and a bladder scan shows 520 mL. She is restless and attempting to climb over the side rail to reach the bedside commode, repeating that she must get to the bathroom now. Pain is 4/10 at rest. On her sacrum is a 2.5 cm shallow open area with a red-pink wound bed and intact blistering along one edge; the hydrocolloid dressing placed yesterday is curled at two edges. Braden score 13. Unlicensed assistive personnel are on the unit and ask what they should do.
1. Rank the client's three problems and state your first three actions with rationale.
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Ranking: (1) the unrelieved bladder distention and the agitation-driven fall risk, which are one problem in practice; (2) the sacral wound; (3) rest-of-shift concerns such as pain control and delirium screening. A 520 mL bladder with inability to void is urinary retention, and the climbing behavior is most likely driven by it. The immediate dangers are a fall with a freshly repaired hip and, if untreated, bladder overdistention and infection.
First three actions:
- Safety first - stay with her, lower the bed, put the call light in reach, ensure nonskid footwear, and get help before attempting transfer. Do not leave her alone trying to climb out.
- Toilet now - assist to the commode with two-person standby assistance appropriate to her weight-bearing status, provide privacy and time, and run water or use a warm compress to promote voiding.
- If she cannot void, re-scan the bladder and notify the provider for an order for intermittent catheterization; do not wait for a shift-end report. Also assess whether pain and constipation are contributing to the agitation and consider a delirium screen.
2. What can be delegated to the assistive personnel, and what must the RN retain? Explain the boundary.
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Delegation is bounded by stability, predictability, and whether the task requires nursing judgment.
May delegate: vital signs and recording of intake and output; bringing the commode and assisting with toileting and hygiene for a client whose mobility plan is already established; positioning and turning reminders; cueing her to use the call light; observing and reporting skin changes, new confusion, or complaints of pain; assisting with meals.
RN retains: the focused assessment (bladder scan interpretation, abdominal palpation, wound assessment and staging), the decision to catheterize, the dressing change and any debridement, pain assessment and evaluation of analgesia, fall and delirium risk evaluation, care planning, and teaching the client and family. The RN also decides whether the client can bear weight per the surgical order.
The boundary: assistive personnel can perform a task and report findings, but they cannot interpret a 520 mL bladder scan or decide that the hydrocolloid needs changing. If the client becomes more confused or tries to climb out, that is a change in condition requiring RN reassessment, not a task to hand off.
3. How should the nurse manage the sacral wound, given that the client must be positioned off the sacrum and has a curled dressing?
Read the worked answer
First, reassess. A curled hydrocolloid hides the wound and traps moisture, so it should be changed per orders to allow full inspection, measurement, and documentation of the wound bed, edges, exudate, and the blistering edge. Blistering and moisture at the margin may indicate moisture-associated skin damage from incontinence rather than pressure alone - the distinction changes the plan (barrier products and containment versus pure pressure offloading), and pressure injury staging must reflect the deepest visible tissue. With a Braden score of 13, she is at moderate-to-high risk.
Offloading: reposition at least every 2 hours with a 30-degree lateral tilt and pillows to keep the sacrum fully off the mattress; keep the head of bed at or below 30 degrees when clinically allowed; use a pressure-redistribution surface; do not massage the area. Moisture: check for incontinence after catheter removal, cleanse gently, apply a barrier product, and contain urine. Nutrition: request a dietitian review for protein and calorie needs. Document and report.