Question

An 87 year old female is admitted to the hospital with a diagnosis of a hip fracture secondary to a fall in her home.

What clinical manifestations would you expect to see when assessing this patient?

What would be three nursing management considerations for this patient pre-operatively?

What would be three nursing management considerations post-surgical repair?

What would your neurovascular assessment of the lower extremity include? Are there any positioning considerations, if so what are they?

Answer 1

Hip fracture in elderly is a major public health problem in the United States. Early detection and treatment are necessary to prevent increased morbidity and mortality. Rapid detection is also important to ensure the quality of life. Elderly women are at the highest risk group for hip fracture.

A hip fracture is a serious injury, with complications that can be life-threatening. The risk of hip fracture rises with age.

Clinical manifestations are clear in most cases but patients may have normal gait and complain only of vague pain in their buttocks, knees, thighs, groin, or back especially when cognitive impairment is present.

Clinical manifestations:

• Severe pain
• Diffuse or localized aching pain in the anterior groin or thigh region
• Inability to bear weight

• Hip fracture due to stress may present more subtly, reporting pain in the anterior groin or thigh.
• Pain increases with activity and can persist longer and progress even without activity
• Antalgic gait pattern may present.
• Inability to move and bear weight on the affected side
• Stiffness, bruising and swelling of the affected side of hip
• Shortened leg on the affected side
• An antalgic gait pattern is often present
• Turning outward of your leg on the side of your injured hip

Preoperative nursing management

Nursing diagnosis :

• Acute pain related to fracture, muscle spasm and soft tissue injury
• Impaired physical mobility related to fracture
• Risk for infection related to presence of open fracture

Preoperative nursing management

• Relieving pain: Assessment of pain characteristics, comfortable position and devices, careful handling of affected extremity, Traction, pain medications, splinting
• Maintaining adequate neuro-vascular function: Proper positioning, Trochanter roll - towards unaffected side, Peripheral assessment
• Promoting Health: Nutritious foods, small and frequent meal
• Improved mobility: Ambulatory aids, encourage use of trapezes, aid in mobility, keep everything possible handy, offer assistance
• Helping the patient maintain self-esteem: client teaching, ventilate feelings, encouragement, develop IPR
• Control edema
• Wound management
• Prevent further injury
• Use aseptic technique while caring the patient
• Monitor vitals and signs of infection

Post-operative nursing management

Nursing diagnosis:

• Pain related to fracture, soft tissue damage, muscle spasm, and surgery
• Impaired skin integrity related to surgical incision
• Risk for impaired urinary elimination related to immobility
• Impaired physical mobility related to fractured hip
• Risk for infection related to surgical incision

Nursing management

Prevent infection:

• A sterile dressing of any wounds.

Care during client transfer:

• Immobilize a fractured extremity using splint
• Minimize movements
• Handle the patient carefully

Client and family teaching:

• About activity restrictions and necessary lifestyle modifications.
• Use of assistive devices
• Administer prescribed medications

Prevent potential complications:

• Check vitals frequently
• Monitor for neurovascular problems

Neurovascular status assessment is essential for early recognition of neurovascular deterioration or compromise. Neurovascular compromise may lead to permanent deficits, loss of extremity and even death. It can occur late after fracture, surgery or cast application. The aim of the Neurovascular status is to prevent permanent damage to the limb through early recognition of neurovascular compromise.

The frequency of assessment:

Every 1 hourly for the first 24 hours after injury, surgery or application of the cast.

Then every 4 hourly for a next 48hours

Increase the frequency of assessment if deviations from baseline observations are present.  

Points to remember:

Obtain baseline data on admission and at regular intervals

Compare the extremities - Bilateral Extremity Assessment

Report abnormalities as soon as possible

Use Doppler if needed to check pulses

Documentation includes characteristics like Color, Temperature, Capillary Refill, Pulse Strength, Edema, Sensation, Pain, and Motor Strength.

Lower extremity assessment:

Check distal pulses –Dorsalis Pedis

Check for edema and its note the characteristics, Sensation, Pain, Muscle strength(0-5)

Check for compartment syndrome:

Elevating the extreemity is ver important in preventing it