Nursing care
Fractures nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Fractures nursing care centres on neurovascular checks distal to the injury before anything else. Assess the five Ps — pain, pallor, pulselessness, paresthesia, paralysis — every one to two hours in the acute phase. Immobilise the limb, elevate to heart level, apply ice, and treat pain early. Pain out of proportion to the injury, or pain unrelieved by analgesia, is compartment syndrome until proven otherwise.
What it is and why it happens
A fracture is a break in bone continuity, ranging from a hairline crack to a full displaced break with bone ends out of alignment. Mechanism matters: high-energy trauma such as a motor vehicle collision produces comminuted or open fractures, while low-energy falls in an older adult with osteoporosis often produce a hip or wrist fracture from minimal force.
Closed fractures leave skin intact; open fractures breach the skin and carry infection risk that changes your priorities immediately. Pathological fractures occur through bone weakened by disease — malignancy, osteoporosis, Paget's disease — and can happen with little or no trauma at all, which is worth asking about when the history doesn't match the injury.
How it presents — what you will actually see
Expect localised pain that worsens with movement or palpation, swelling, bruising, and deformity if the fracture is displaced. The limb may show shortening, rotation, or an angle that shouldn't be there. Crepitus — a grating sensation on movement — confirms bone-on-bone friction and you should not deliberately elicit it.
Function is lost or markedly reduced: the patient cannot bear weight or use the limb normally. Open fractures show visible bone or a wound communicating with the fracture site. In children, remember that a greenstick fracture may present with far less deformity than an adult fracture of similar force, because paediatric bone bends before it breaks.
Nursing assessment priorities
Neurovascular assessment comes before comfort measures and before imaging. Check the five Ps distal to the injury — pain, pallor, pulselessness, paresthesia, and paralysis — and document a baseline immediately, then reassess every one to two hours or per unit protocol. Compare bilaterally: a cool, pale, pulseless limb next to a warm pink one is your clearest signal.
Pain out of proportion to the injury is compartment syndrome until it is excluded. Do not accept a pain score alone; ask whether the pain is worsening despite splinting and analgesia, and whether it increases with passive stretch of the muscles in that compartment. Assess for open wounds, active bleeding, and signs of shock in multi-trauma patients, and confirm tetanus status for any open fracture.
Interventions and what to do first
Immobilise the fracture above and below the joint before the patient is moved, using a splint or backslab to prevent further soft tissue and neurovascular injury. Elevate the limb to heart level to reduce swelling and apply ice intermittently, unless compartment syndrome is suspected, in which case elevation above heart level is avoided because it can further compromise perfusion.
Treat pain promptly and reassess its response — analgesia that fails to touch the pain is itself a red flag, not just an inconvenience. Prepare the patient for X-ray or CT, keep the limb NPO status clarified early if surgery is likely, and for open fractures, cover the wound with a sterile dressing and administer prophylactic antibiotics as ordered without delay. Document neurovascular findings before and after any splinting or repositioning.
Complications to watch for
Compartment syndrome is the complication that cannot wait: rising, unrelieved pain, tense swelling, and a pulse that is present until very late are your warning signs, since pulselessness is a late and unreliable indicator. Fat embolism syndrome typically appears twenty-four to seventy-two hours after a long bone fracture and presents with sudden dyspnoea, petechiae across the chest and axillae, and confusion.
Watch also for deep vein thrombosis, particularly with prolonged immobility, and for infection at open fracture or pin sites — fever, increasing redness, or purulent drainage need prompt reporting. Malunion, nonunion, and avascular necrosis are longer-term risks that surface in follow-up rather than the acute stay, but they start with how well the fracture was reduced and immobilised from the outset.
Patient teaching before discharge
Teach the patient to recognise and report the same five Ps you have been assessing — increasing pain, numbness, tingling, or a cold, pale limb are reasons to seek care immediately, not to wait for the next appointment. Explain cast or splint care: keep it dry, do not insert objects to scratch beneath it, and report any foul odour or drainage.
Cover weight-bearing restrictions specifically, since these vary by fracture site and fixation method and getting it wrong risks displacement. Reinforce analgesia use, constipation prevention if opioids are prescribed, and the importance of attending follow-up imaging. For older adults, address fall prevention and, where relevant, osteoporosis screening, since one fragility fracture significantly raises the risk of another.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our med-surg practice questions are the closest set to what this page covers.
One question from the med-surg set
A client with chronic obstructive pulmonary disease has an oxygen saturation of 88% on 2 L/min via nasal cannula and is alert with no distress. What should the nurse do first?
Rationale
In COPD a saturation of 88–92% is the therapeutic target, not an emergency, and this client is alert with no distress. The first action is the independent nursing intervention that is least invasive and most likely to help: sit them up and reassess. Turning the oxygen up to 6 L/min risks blunting the hypoxic drive, and calling rapid response or drawing an ABG escalates ahead of an assessment you have not finished.
Answer: B
Common questions
What are the five Ps of neurovascular assessment in fractures?
Pain, pallor, pulselessness, paresthesia, and paralysis, assessed distal to the fracture site. They should be checked and documented at baseline, then reassessed regularly through the acute phase. A change in any one of them, especially worsening pain, warrants immediate escalation.
Why shouldn't you elevate a limb above the heart if compartment syndrome is suspected?
Elevation above heart level reduces arterial inflow pressure to the limb, which can worsen perfusion in a compartment that is already compressed. The standard advice is to elevate to heart level, not above it, when compartment syndrome is a concern.
How is a fracture different from a sprain on assessment?
A fracture typically shows deformity, crepitus, and inability to bear weight or use the limb, while a sprain causes pain and swelling around a joint without bony deformity. Imaging is needed to confirm the distinction when clinical findings overlap.
What NCLEX-style scenario commonly tests fracture care?
Expect a question describing a casted limb with increasing pain unrelieved by prescribed analgesia, sometimes with pallor or diminished pulse — the correct answer is to notify the provider promptly because this points to compartment syndrome, not simply to give more analgesia.
When is an open fracture a surgical emergency?
An open fracture needs prompt surgical debridement and antibiotics because the break in skin integrity exposes bone to contamination, raising the risk of osteomyelitis. Delayed treatment increases infection risk, so wound coverage and antibiotic administration should not wait for theatre availability.
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