A patient is having active bleeding in lower limb. Which is a priority nursing intervention?

NORCET 5 Prelims - Sept 2023 (Shift-2)

Medical Surgical Nursing

Easy

Appeared in: NORCET 5 Prelims - Sept 2023 (Shift-2)

Explanation

The immediate priority in managing active external bleeding is to stop the blood loss directly at its source.
Applying firm, direct pressure over the wound is the most effective and rapid first-line intervention to achieve hemostasis.
This action compresses the bleeding vessel against the underlying bone, promoting clot formation and preventing further volume loss, which can lead to hypovolemic shock.

Option A: DVT sleeves (sequential compression devices) are designed to prevent blood clots in the deep veins of the legs, not to control active, external hemorrhage. They would be completely ineffective for this purpose.
Option C: Blood transfusion is a replacement therapy, not a primary intervention to stop bleeding. It is performed after hemorrhage control is attempted and if significant blood loss has occurred, leading to hemodynamic instability. It requires time for typing and cross-matching.
Option D: Oxygen administration is a supportive measure to improve tissue oxygenation in a patient who may be developing shock from blood loss. It does not stop the bleeding itself, which is the primary problem.

Visual 1: Diagram - A step-by-step illustration showing how to apply direct pressure to a limb wound, including the use of gauze and hand placement.
Visual 2: Flowchart - A decision-making flowchart for managing external hemorrhage, starting with direct pressure, then elevation, and escalating to tourniquet application if needed.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Prioritization of nursing interventions for active external hemorrhage in the correct sequence, documenting the action clearly, and monitoring for the expected response.
In any setting, a nurse's first action for catastrophic external hemorrhage is to apply direct pressure. This simple action can be life-saving and prevents the patient from progressing to irreversible hypovolemic shock.
This principle is part of the 'Stop the Bleed' campaign and follows the C-ABC (Catastrophic hemorrhage, Airway, Breathing, Circulation) protocol used in trauma care, prioritizing hemorrhage control above all else.
What if? If direct pressure fails to control the bleeding and it is a catastrophic limb hemorrhage, the next priority intervention would be the application of a tourniquet proximal to the wound.

How to Approach the Question

First, identify the core problem in the clinical scenario: 'active bleeding'.
Next, recognize the keyword 'priority'. This asks for the most important and immediate action.
Evaluate each option based on its ability to solve the primary problem. The primary problem is blood loss.
Option A (DVT sleeves) is for clot prevention, not bleeding control. Eliminate it.
Options C (transfusion) and D (oxygen) are supportive or secondary treatments. They do not stop the bleeding source.
Option B (direct pressure) is the only action that directly addresses and controls the source of the bleeding. Therefore, it is the highest priority.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing interventions for active external hemorrhage.
Stem keywords: active bleeding, lower limb, priority nursing intervention
Lead-in keywords: priority
Clinical cues: The term 'active bleeding' indicates an ongoing, urgent problem that requires immediate intervention to prevent significant blood loss.

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