Nursing care
Hip Fracture nursing care: what to assess and what to do first
Written and reviewed by Dana Whitfield, RN, MSN · 4 min read · Updated September 2026
Short answer
A hip fracture typically presents with a shortened, externally rotated leg and inability to bear weight. Surgery is prioritised within 24 to 48 hours because delay raises mortality and complication risk. Nursing care centres on preventing the three consequences of lying still: delirium, pressure injury, and pneumonia, alongside pain control and neurovascular monitoring.
The pathophysiology in one pass
Most hip fractures in the population you will nurse occur at the femoral neck or intertrochanteric region, usually from a low-impact fall in an older adult with osteoporosis rather than high-energy trauma. Reduced bone density means the fracture can happen from a stumble, not a collision, and this matters because it shapes what other injuries you screen for and what the patient's baseline mobility was before admission.
The mechanical result is the classic clinical deformity: the affected leg appears shortened and externally rotated compared to the unaffected side, caused by muscle pull on the fractured fragments. Blood supply to the femoral head is at risk in femoral neck fractures specifically, which is why time to surgery matters as much for tissue viability as for mobility. The longer the delay, the higher the risk of avascular necrosis alongside the systemic complications of prolonged immobility.
Assessment findings that matter
Look at the leg before you touch it: shortening and external rotation are visible on inspection and should prompt immediate immobilisation and analgesia rather than attempts to reposition the limb. Pain is usually severe and localised to the groin or hip, worse on any attempted movement.
Assess neurovascular status distal to the injury: pedal pulses, capillary refill, sensation, and movement in the toes, documented as a baseline before and after any manipulation or surgery. Check for signs of concealed blood loss, since hip fractures can bleed substantially into the surrounding tissue, and assess for head injury or other fractures from the same fall. Cognitive status on admission is also worth documenting clearly, because postoperative delirium is common and you need a baseline to recognise it.
What the exam asks about this
Expect a question describing the shortened, externally rotated leg and asking you to identify the likely diagnosis or the immediate nursing action, which is to immobilise the limb and notify the provider rather than attempt to correct the position yourself.
Time-to-surgery questions test whether you know the 24 to 48 hour window and why delay is avoided: rising rates of pneumonia, pressure injury, and delirium the longer the patient remains immobile and in pain preoperatively. Priority-setting items will ask you to sequence pain management, neurovascular checks, and surgical preparation, and postoperative questions will test early mobilisation versus prolonged bed rest as the correct choice once the patient is stable.
Nursing interventions in priority order
Immobilise the affected limb immediately, using a splint or traction device as ordered, and avoid unnecessary repositioning that could displace the fracture or worsen pain. Manage pain proactively rather than reactively, since undertreated pain is itself a driver of delirium in older adults.
Prepare the patient for surgery within the 24 to 48 hour window: bloodwork, ECG, and medical optimisation happen in parallel with orthopaedic workup, not sequentially after it. Begin pressure injury prevention immediately on admission, not after surgery, with repositioning schedules and heel protection, since the patient is at risk from the moment mobility is lost. Start deep breathing and incentive spirometry education preoperatively so the patient already knows the routine when it matters most, in the postoperative period.
Medications and monitoring
Analgesia is central and often multimodal, combining opioids with non-opioid agents to control pain while limiting sedation that worsens delirium risk. Venous thromboembolism prophylaxis, typically a low molecular weight heparin, is standard given the combined risk of surgery and immobility, alongside mechanical measures such as compression devices.
Monitor haemoglobin postoperatively, since blood loss from both the fracture and surgery can be significant enough to require transfusion. Track fluid balance and renal function, particularly in older patients on multiple medications, and monitor for signs of fat embolism syndrome in the days following fracture and fixation, including dyspnoea, confusion, and a petechial rash.
When to escalate
Escalate immediately for any loss of distal pulses, sensation, or movement, which suggests neurovascular compromise and needs urgent surgical review rather than routine reassessment. New or worsening confusion should prompt evaluation for delirium causes, including undertreated pain, infection, hypoxia, and electrolyte disturbance, rather than being dismissed as expected in an older postoperative patient.
Sudden dyspnoea, tachycardia, or a falling oxygen saturation in the days after fixation needs urgent assessment for fat embolism or pulmonary embolism. Fever, wound changes, or rising inflammatory markers postoperatively should be escalated promptly, since infection in a fixed fracture carries serious consequences for both the hip and the patient's overall recovery trajectory.
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
Why is the leg shortened and externally rotated in a hip fracture?
Muscle groups attached around the hip pull unopposed on the fractured bone fragments, causing the classic visible deformity. It is one of the most reliable bedside signs of hip fracture and should prompt immobilisation without attempting to reposition the limb yourself.
Why does surgery happen within 24 to 48 hours for a hip fracture?
Delay beyond this window is associated with higher rates of pneumonia, pressure injury, delirium, and mortality, since the patient is immobile and in pain until fixation. Medical optimisation happens in parallel with surgical preparation rather than delaying it.
What three complications does hip fracture nursing care aim to prevent?
Delirium, pressure injury, and pneumonia, all consequences of prolonged immobility and pain in an often older, frailer patient. Early mobilisation, repositioning, and respiratory exercises target these directly.
What are the signs of fat embolism after a hip fracture?
Sudden dyspnoea, confusion, tachycardia, and a petechial rash, usually appearing within 24 to 72 hours of fracture or fixation. It is a medical emergency and needs immediate escalation.
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