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Hip fractureHip fracture marks an immense impact on the health care system, principally on the geriatric care. Case incidence is usually connected with morbidity, mortality and medical care cost. The prevalence of hip fractures is projected to rise with the growing elderly population as case occurrence increases with age.

 Hip fracture is a common case with the elderly in association to osteoporosis and fall. In the study of Leslie et al (2009), it was stated that the incidence of hip fractures is an index of osteoporosis burden with the majority of the costs is directly attributed to osteoporotic conditions. Conversely, Järvinen and colleagues (2008) asserted that osteoporosis is not the strongest risk factor for fracture among older people but falling. They explained that when a person falls, the type and severity of the fall determines the fracture occurrence—thus, fall prevention means preventing fracture. This theory was supported by Formiga et al (2008), falls are common phenomenon in the elderly and hip fracture is one of the most common types of fracture occur always secondary to fall. Moreover, their study affirmed that hip fracture is one of the most devastating injuries experienced by elderly people and may lead to permanent disability, institutional care or death.

“People who have suffered falls are at greater risk of falling again”, (Lord et al, 2007; Formiga et al, 2008). Persons who suffered from hip fracture have the increased probability of acquiring fractures again including recurrent hip fracture (Melton et al, 2009)

Progressive loss of muscle strength and functional capacity leading to loss of independence in ambulation and living are the alarming results of hip fracture. Study have shown that more than half of its victims lose the ability to walk independently with distinct increased morbidity and mortality rates in men and women (LeBoff et al, 2008).

Hip Fracture Nursing Care Plan

Nursing AssessmentPhysical examinations include patient’s age, vital signs esp. blood pressure (for the possibility of orthostatic hypotension), LOC, cognitive and thought process level, hearing and sight abilities, level of balance and coordination, degree of injury, ROM, pain scale, weight and BMI.Also, muscular strength and agility, osteoporosis risk assessment and fall risk assessment.Diagnostic studies on bone mass density and muscle mass.

Medical history that affects strength, mobility, balance and coordination.

Presence of hematoma, open wound, infection, inflammation and swelling on affected site obtained after injury.

Presence of environmental hazards.

Nursing Diagnoses*Risk for injury related to weakness; Potential/Actual for physical injury; Altered protection; Potential/Actual for trauma; Potential for disuse syndrome; Risk for peripheral neurovascular dysfunction related to swelling, constricting devices, or impaired venous return; Risk for infection related to altered protein metabolism and inflammatory response; Impaired skin integrity related to edema, impaired healing, and thin and fragile skin; Alteration in comfort, pain; Acute pain related to fracture, orthopedic problem, swelling, or inflammation; Activity intolerance; Altered health maintenance; Impaired home maintenance management; Impaired physical mobility related to pain, swelling, and possible presence of an immobilization device; Impaired tissue perfusion: Sleep pattern disturbance; Disturbed thought processes related to mood swings, irritability, anxiety and depression; Knowledge deficit; Impaired communication; Altered verbal and thought process; Ineffective individual and family coping; Altered sensory-perceptual;  Self-care deficit related to weakness, fatigue, muscle wasting, and altered sleep patterns; Altered role performance; Chronic low self-esteem; Impaired social interaction; Social isolation; Spiritual distress; Risk for situational low self-esteem: disturbed body image and/or functional impairment related to impact of musculoskeletal disorder; Disturbed body image related to altered physical appearance, impaired sexual functioning, and decreased activity level; Altered compliance; Risk for ineffective therapeutic regimen management related to insufficient knowledge or lack of available support and resources.
PlanningIn the care for patients with hip fracture, the major goals include decreased risk for injury, prevention of another occurrence of fall and injury, decreased risk for infection, improved skin integrity, relief of pain, improved mobility, adequate neurovascular function, improved mental function, increased ability to carry out self-care activities (as indicated), positive self-esteem; improved body image, health promotion and absence of complications.
Implementation*Decreasing risk for injury:Medications can facilitate in avoiding and stopping disruptive behavior of the patient as well as his/her depression and anxiety.Creating a protective environment and ensuring the presence of side rails will help prevent falls, fractures and other forms of injuries. The patient who is very weak may need help from the nurse for movement when NOT contraindicated to prevent falls or bumping into sharp parts of furniture.

Passive physical activity is needed to strengthen muscles, enhance balance, avoid disuse atrophy, and stop progressive bone demineralization. Passive exercises and massage can strengthen muscles. The nurse encourages good posture when lying on bed.

Food rich in protein, vitamin D and calcium are recommended to lessen muscle wasting and osteoporosis. Study have shown that women with extremely low vitamin D levels had reduced lower extremity muscle function and increased falls 1 year later according to LeBoff and colleagues (2008). Anemia management can also be added in the plan of care as research revealed that anemia impede functional mobility thus decreasing physical performance during post hip fracture surgery rehabilitation (Foss et al, 2008).

Decreasing risk for infection:

The patient should prevent unnecessary exposure to others with infections.

The nurse regularly assesses the patient for minute signs of infection since the anti-inflammatory effects of corticosteroids may cover the typical signs of inflammation and infection.

Meticulous handwashing and aseptic techniques in handling patient’s lines, injections or wound care, if any.

Dietary management that boosts immune system and tissue healing should also be included.

Promoting skin integrity:

Strict skin care is needed to prevent traumatizing the fragile skin of the patient. Use of lukewarm water or tap water with hypo-allergenic soap for daily meticulous skin care. Always maintain the skin warm and dry from moist

Using adhesive tape is avoided since it can irritate the skin and tear the fragile tissue when the tape is removed.

The nurse regularly assesses the skin and bony prominences and assists and suggests the patient to change positions often to avoid skin breakdown. Prevent sources of friction causing sores.

Relieving pain:

The nurse should properly evaluate pain related to musculoskeletal problems by determining the exact site, describing the intensity and nature of the pain to help identify its cause, if applicable.

Psychological, pharmacologic and physical methods to control pain are also useful (e.g., guided imagery, distraction, focusing, backrubs, quiet environment, etc.) as well as diversional activities may be use to lessen pain perception.

Discomfort is lessened with immobilization to prevent friction over fractured joints. Elevation of an edematous part helps venous return and minimizes discomfort.

Cold compress if not contraindicated, relieves swelling and directly minimizes discomfort by diminishing nerve stimulation.

Analgesics are usually prescribed to control severe pain of muscular spasm and musculo-skeletal injury.

Improving mobility:

The patient’s mobility is affected by swelling, pain and/or any immobilizing equipments. The nurse must assess and support edematous extremities with pillows or instruments.

Pain should be managed before an injured part is moved by giving medication in time for it to take effect and by supporting the injured part when it is moved.

The nurse supports movement within the confines of therapeutic immobility.

The patient must do passive/active range-of-motion exercises of uninvolved joints, and, if not contraindicated, the nurse teaches gluteal-setting and quadriceps-setting isometric exercises to maintain the muscles needed for ambulation (see if the use of assistive devices (e.g., crutches, walker, wheelchair) is anticipated, the nurse encourages the patient to practice with them to facilitate their safe use and to promote earlier independent mobility.

Encouraging rest and activity:

Pain, fatigue, weakness, and muscle wasting makes it hard for the patient to perform normal activities. Nonetheless, the nurse should encourage moderate, if not contraindicated activities to avoid complications of immobility and encourage better self-esteem. Insomnia usually contributes to the pain and fatigue of the patient. It is essential to help the patient plan and space rest periods for the entire day. Efforts are made to support a relaxing, quiet environment for sleep and rest.

Maintaining adequate neurovascular function:

Edema, trauma, or immobilization may adverse affect tissue perfusion. The nurse must regularly evaluate neurovascular status (i.e., temperature, color, pulses, capillary refill, motion, edema, pain, sensation, occurrence of pressure sores) of the extremity and report the findings. When circulation is compromised, the nurse performs measures to restore sufficient circulation, which include immediately notifying the physician, elevating the extremity and releasing constricting wraps or casts as prescribed.

Improving thought processes:

Explanations to the patient and family members about the cause of emotional instability are important in helping them cope with the mood swings, irritability and depression brought about by pain and debilitating conditions. Psychotic behavior may occur in a few patients and should be reported.

The nurse encourages the patient and family members to communicate their feelings and concerns.

The nurse must orient the patient and family of the hospital set-ups and all the procedures to be made. It is also essential that the patient is oriented to time, place and persons surrounds him/her.

Providing self-care:

Thorough care in providing activities of daily living is recommended. Privacy must be observed during the performance of ADL. Movements on the affected fractured sites are contraindicated.

Helping the patient maintain self-esteem and improving body image:

Patients may require help in accepting changes in body image, reduced self-esteem or incapacity to do their roles and responsibilities.

The nurse promotes a trusting relationship to enable patients to verbalize concerns and anxieties and helps them assess their feelings about changes in self-concept.

The nurse clarifies any misconceptions the patients and family may have and assists them work through modifications required to adapt to alterations in physical capacity and to reclaim positive self-esteem. The patient and family may benefit from the discussion of the effects the changes have had on his/her self-concept and relationships with others. Edema and weight gain might be changed by a low-sodium, low-carbohydrate diet and a high-protein intake may minimize a number of the other problematic symptoms.

Promoting health

The nurse helps the patient in tasks that encourage health.

The nurse evaluates hydration and nutritional status. The nurse monitors fluid intake, urinary output, urinalysis findings, and complaints of burning on urination. Sometimes, patients may minimize their fluid intake to lessen bedpan use. A little fracture pan or diaper may be more comfortable for the patient to use. An indwelling catheter must be employed if absolutely needed to lessen the risk of urinary tract infection. UTI should be addressed before surgery when surgery is imperative.

Deep breathing, coughing and use of the incentive spirometer are done to improve respiratory function during the debilitated stage.

The nurse offers skin care, paying special attention to pressure points. It is necessary to implement the use of pressure-reducing surfaces (i.e., special mattresses) to prevent skin breakdown.

The nurse orients the patient and the family on the need for assistance with ADL and the therapeutic regimen during convalescence so that sufficient support is accessible when the patient is discharged.

Altering the home environment may be necessary to adjust to the altered mobility of the patient.

Referral to the social worker and the case manager may be required to make sure of a smooth transition to home care.

Referral to a dietitian may help the patient in choosing proper foods that are also low in calories and sodium.

Improving bowel elimination:

Constipation is a problem associated to medications and immobility. Early institution of a high-fiber diet, increased fluids and the use of prescribed stool softeners assist in preventing or minimizing constipation. Thus, the nurse monitors the patient’s food intake, bowel sounds and bowel activity.

EvaluationGood prognosis and complete healing of hip fracture rely on the prevention of occurrence of another fall and injury—fall prevention is a must during rehabilitation and to prevent recurrence of hip fracture.Fast bone healing and recuperation is attainable without the presence of infection, it is also important that heath care providers should maintain aseptic and clean techniques in handling the patient. Prevention of nosocomial infection is also a great concern.Rest, sleep, relaxation and cooperation to interventions are parallel to relief of pain. Pain can be managed by the use of bio-behavioral interventions and pharmacological management.

Bed sores, skin problems and poor tissue perfusion are preventable complications of immobility.

Hip fracture is a debilitating condition, it is the responsibility of the nurse to provide and/or assist with self-care and ADLs.

Immobility causes muscle wasting, make sure that both affected and unaffected site will have proper form of exercises to maintain muscular mass, strength and agility in preparation of early ambulation and prevention of disability.

It is important that care giver, patient, family and the health team are cooperating during the entire course of treatment. Cooperation from both parties and consent is a must for every planned interventions or activities. The health team should explain every procedure properly before seeking for consent. It is important to include the patient, family, care givers in the plan of care.

Improved mental function, thought process, self-esteem and body-image.

Prevent respiratory, urinary and bowel complications brought about by immobility.

Adequate food intake should be monitored to gain back strength and energy for patient’s fast recovery and in preparation for rehabilitation.

Doenges, Moorhouse & Curr (2008); Smeltzer & Bare (2004)*

Effective fall prevention management aimed at reducing the prevalence of hip fracture should target individuals who are at risk of falling. Fall risk management should be addressed in order to implement preventive strategies by providing appropriate interventions to reduce the risk. Hospitalization and other medical care services concerning fracture and its rehabilitation is expensive but will not prevent fracture cases—while, the potential impact of preventive efforts in the population has no any cost.

Hip and other forms of fracture are preventable, and prevention provides additional health benefits beyond treatment can do.

References:

  •  Doenges, M.E., Moorhouse, M.F. & Curr, A.C. (2008). Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales, 11th ed. Philadelphia:
  • F.A. Davis Company. Formiga, F. et al (2008). Factors Associated With Hip Fracture-Related Falls among Patients With a History of Recurrent Falling. Bone, 43, 941–944.
  • Foss, N.B. et al (2008). Anemia Impedes Functional Mobility After Hip Fracture Surgery. Age and Ageing, 37, 173–178.
  • Järvinen, T.L.N. et al (2008). Shifting the Focus in Fracture Prevention from Osteoporosis to Falls. British Medical Journal, 336(7636), 124–126.
  •  LeBoff, M.S. et al (2008). Vitamin D-deficiency and Post-fracture Changes in Lower Extremity Function and Falls in Women with Hip Fractures. Osteoporosis International, 19(9), 1283–1290.
  • Leslie, W.D. et al (2009). Trends in Hip Fracture Rates in Canada. Journal of the American Medical Association, 302(8), 883–889.
  • Lord, R.S. et al (2007). Falls in Older People: Risk Factors and Strategies for Prevention, 2nd ed. England: Cambridge University Press.
  • Melton, L.J. et al (2009). Secular Trends in Hip Fracture Incidence and Recurrence. Osteoporosis International, 20(5), 687–694.
  • Smeltzer, S.C. & Bare, B.G. (2004). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 10th Ed. PA: Lippincott Williams & Wilkins.
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She is currently working as a medical-surgical nurse at Ministry of Health, Sultanate of Oman. A writer, blogger, researcher, correspondent and publication consultant for nursing journal and health-related educational websites. Her field of specialization focused on Intensive Care and Emergency Management. She is now taking up MAN major in Adult Health Nursing at the University of the Philippines Open University. A nursing professor for 8 years in the Philippines and served as a staff nurse at UST hospital. A caring and devoted nurse who introduced a “Pinay Nightingale” in the land of the pharaohs. A nurse by profession, an educator by devotion and a writer / researcher by passion.