Hip fractures are among the most frequent fractures presented to the emergency department and orthopedic trauma teams. Hip fracture, or femur neck fracture, is described as a fracture of the proximal femur between the femoral head and 5 cm distal to the lesser trochanter. In the U.S., the yearly incidence per 100,000 is thought to be between 197 to 201 for men and 511 to 553 for women. Incidence increases with age, and the average age of clients presenting with a hip fracture is 80 years old. An estimated 340,000 hip fractures occur each year. Estimates indicate that in 2040, approximately 500,000 hip fractures will occur.
Hip fractures are classified into the following:
- Intracapsular. Fractures proximal to the capsular insertion are described as intracapsular. This includes the femoral head and neck fractures. Low bone mass due to osteoporosis causes the bones to become more fragile, making them more prone to breaking. Because of this, intracapsular fractures are also called fragility fractures, because they typically occur after minimal trauma.
- Extracapsular. Fractures distal to the capsular insertion are termed extracapsular fractures. This includes trochanteric, intertrochanteric, and subtrochanteric fractures. Extracapsular fractures are typically caused by severe direct trauma.
The location of the fracture and the amount of angulation and comminution play integral roles in the overall morbidity of the client, as does the preexisting physical condition of the individual. Fractures of the proximal femur are extremely rare in young athletes and are usually caused by high-energy motor vehicle accidents or significant trauma during athletic activity. Other causes may be an underlying disease process such as Gaucher disease, fibrous dysplasia, or bone cysts.
The majority of hip fractures result from falls in the older adult population. Risk factors for falls in the older adult population are numerous, but those with a strong independent association are a previous history of falls, gait abnormalities, the use of walking aids, vertigo, Parkinson disease, and antiepileptic medications. Many clients have multiple risk factors, and this, along with age-associated reduced bone quality, is the cause of most hip fractures.
Hip fractures are considered stress fractures, which were mainly seen in military recruits due to a triad of activities that is new, strenuous, and highly repetitive. Stress fractures occur in normal bone undergoing repeated submaximal stress. As the bone attempts to remodel, osteoclastic activity occurs at a greater rate than osteoblastic activity. When these cumulative forces exceed the structural strength of bone, stress fracture occurs. Stress fractures occur mainly at the femoral neck and are classified as either tension (at the superior aspect of the femoral neck) or compression (at the inferior aspect of the femoral neck).
Nursing interventions for a client diagnosed with hip fracture include the prevention of falls, strengthening of the bone quality, and lifestyle modifications. The following are nursing diagnoses associated with hip fracture.
- Acute Pain
- Risk for Peripheral Neurovascular Dysfunction
- Impaired Physical Mobility
Hip Fracture Nursing Care Plan
Below are sample nursing care plans for the problems identified above.
Effective pain management is critical since the pain has been found to increase morbidity from hip fractures. Even at rest, pain after hip fracture is relatively high. Furthermore, studies have shown that pain is typically undertreated in the older adult hip fracture population. Severe pain significantly increases delirium in older adult clients and is associated with longer time to mobilization, increased hospital stay, and decreased functional outcomes. Hung et al. advocate the importance of optimal pain control following a hip fracture to minimize complications of pain and immobility ranging from delirium to functional loss and death.
- Acute Pain
- Muscle spasms
- Injury to the soft tissue
- Movement of bone fragments
- Anxiety and stress
- The use of immobility devices or traction
- Verbalizations of pain
- Facial mask of pain
- Distracted behaviors
- Narrowed focus
- Guarding, protective behavior
- Autonomic responses
- Altered muscle tone
After implementation of nursing interventions, the client is expected to:
- Report the relief of pain.
- Demonstrate the use of relaxation skills and diversional activities.
- Display a relaxed manner, be able to participate in activities, and sleep and rest accordingly.
- Prevent further incidences of falls and injuries.
- Prevent the development of complications associated with pain.
|Assess and document reports of pain or discomfort.||Assess the location and characteristics of the client’s pain, including intensity (scale of 0-10), relieving, and aggravating factors. These may influence the choice of, and monitor the effectiveness of interventions. Testing may reveal a painful hip with limited range of motion, especially in internal rotation. Pain is also noted upon attempted passive hip motion.|
|Note nonverbal pain cues.||Many factors, including the level of anxiety, may affect perception and reaction to pain. The absence of pain expression does not necessarily mean a lack of pain. Listening to the reports of family members/significant others regarding the client’s pain may also help.|
|Evaluate any reports of unusual or sudden pain or deep, progressive, and poorly localized pain unrelieved by analgesics.||Development of this type of pain may signal developing complications, such as infection, tissue ischemia, or compartment syndrome.|
|Maintain immobilization of the hip through bed rest, cast, and traction.||Immobilization relieves pain and prevents bone displacement/extension of tissue injury. Preoperative skin or skeletal traction was traditionally standard care in this client population. The theory is that by maintaining the lower limb stretched, using 5 to 10 pounds, intracapsular pressure and pain are decreased, and fracture reduction is made easier.|
|Support the injured hip and elevate.||Elevation promotes venous return, decreases edema, and may reduce pain.|
|Perform or supervise passive or active ROM exercises.||ROM exercises maintain the strength and mobility of unaffected muscles and facilitate the resolution of inflammation in injured tissues.|
|Provide alternative comfort measures.||Comfort measures such as massage and back rub improve general circulation and reduce areas of local pressure and muscle fatigue.|
|Introduce diversional activities appropriate for the client’s age, physical abilities, and personal preferences.||Diversional activities prevent boredom, reduce muscle tension, and can increase muscle strength. It may also enhance coping abilities.|
|Provide emotional support and encourage the use of stress management techniques.||Progressive relaxation, deep-breathing exercises, and visualization or guided imagery are stress management techniques that refocus the attention, promote a sense of control, and enhance coping abilities in the management of the stress of the traumatic injury and pain, which may exist for an extended period.|
|Administer medications before care activities.||Inform the client that it is important to request medication before the pain becomes severe. It promotes muscle relaxation and enhances the client’s participation in activities.|
|Apply cold or ice pack first 24 to 72 hours and as necessary as ordered.||The cold application reduces edema and hematoma formation and decreases pain sensation. The length of application depends on the degree of client comfort and whether the skin is carefully protected.|
|Administer pain medications as indicated.||Opiates can be used at all stages of pain management to treat mild to severe pain. NSAIDs are used for their analgesic properties and act by inhibiting both cyclooxegenase isoenzymes.|
|Introduce complementary and alternative medicine.||Two CAM practices were identified as having been used with hip fracture clients: acupressure and the Jacobson relaxation technique. Bilateral auricular acupressure can be performed at sites known to decrease pain and anxiety (shenmen, hip, valium point). Using these body points, areas can be stimulated to direct body flow. The Jacobson relaxation technique is a two-step process of contracting and relaxing specific muscles.|
|Maintain continuous intravenous or patient-controlled analgesia (PCA).||Optimal pain management is essential to permit early mobilization and physical therapy and to maintain an adequate blood level of analgesia, preventing fluctuations in pain relief with associated muscle tension or spasms.|
|Provide information about transcutaneous electrical nerve stimulation (TENS).||TENS uses electrodes to apply electrical energy to peripheral nerves to treat acute and chronic musculoskeletal pain. Electrical stimulation can be administered at varying amplitudes and frequencies, depending on the indication.|
Risk for Peripheral Neurovascular Dysfunction
The blood supply to the femoral head plays an important role when deciding the management of hip fractures. The main arterial supply to the femoral head is from the medial and lateral circumflex femoral arteries. These vessels give branches that pass proximally through the joint capsule to supply the femoral head. In intracapsular fractures, these vessels can be damaged, which results in avascular necrosis of the femoral head.
- Risk for Peripheral Neurovascular Dysfunction
- Reduction of blood flow
- Direct vascular injury
- Excessive edema
- Tissue trauma
- Not applicable; the presence of signs and symptoms establishes an actual diagnosis
After implementation of nursing interventions, the client is expected to:
- Maintain tissue perfusion and adequate urinary output..
- Display palpable peripheral pulses.
- Exhibit warm, dry skin and normal sensation.
- Display normal level of consciousness and stable vital signs.
|Evaluate the presence and quality of peripheral pulses distal to the injury.||Assessing peripheral pulses and checking Doppler pressures to assure vascular patency is very important. Decreased or the absence of pulse may reflect vascular injury and necessitates an immediate medical evaluation of the circulatory status.|
|Assess capillary return, skin color, and warmth distal to the fracture.||Return of color should be rapid (3-5 seconds). White, coll skin indicates arterial impairment. Cyanosis suggests venous impairment. Peripheral pulses, capillary refill, skin color, and sensation may be normal even in the presence of compartment syndrome because superficial circulation is usually not compromised.|
|Assess the entire length of the injured area or extremity for swelling and edema formation.||The increasing circumference of the injured extremity may suggest general tissue swelling or edema but may also reflect hemorrhage.|
|Note reports of pain extreme for the type of injury or increasing pain on passive movement and development of paresthesia.||Continued bleeding or edema formation within a muscle enclosed by tight fascia can result in impaired blood flow and ischemic myositis or compartment syndrome, necessitating emergency interventions to relieve pressure and restore circulation.|
|Assess for tenderness, swelling, or pain on dorsiflexion of the foot.||There is an increased potential for thrombophlebitis and pulmonary emboli in clients who have been immobile for several days. However, the absence of Homan’s sign is not a reliable indicator in many people, especially older adults, because they often have reduced pain sensation.|
|Monitor vital signs.||Inadequate circulating volume compromises systemic tissue perfusion. It is always useful to assess the client’s cardiovascular and respiratory status prior to undergoing hip surgery.|
|Perform neurovascular assessments.||Note changes in motor and sensory function. An impaired feeling, numbness, tingling, and increased or diffuse pain occur when circulation to the nerves is inadequate or nerves are damaged.|
|Assess the tissues around the cast edges for tough places and pressure points.||Assess for burning sensation under the cast. These factors may be the cause of or be indicative of tissue pressure or ischemia, leading to breakdown and necrosis.|
|Maintain elevation of the injured area unless contraindicated.||Elevation promotes venous drainage and decreases edema. However, if the client is experiencing an increased compartment pressure, the elevation of the extremity actually impedes arterial flow, decreasing perfusion. Casts can also cause arterial-venous insufficiency.|
|Encourage the client to routinely exercise digits or joints distal to the injury.||If not contraindicated, the client may ambulate as soon as possible. This may enhance circulation and reduce the pooling of blood, especially in the lower extremities.|
|Monitor the position and location of the supporting ring of splints or sling.||Traction apparatus can cause pressure on the vessels and nerves, particularly in the axilla groin, resulting in ischemia and possibly permanent nerve damage.|
|Apply cold packs around the fracture site for short periods of time on an intermittent basis as indicated.||The cold application reduces edema and hematoma formation, which could impair circulation. The length of cold application is usually 20 to 30 minutes at a time.|
|Monitor hematocrit and hemoglobin count and coagulation studies.||These results assist in the calculation of blood loss and needs and the effectiveness of replacement therapy. Coagulation deficits may occur secondary to major trauma, in presence of fat emboli, or during anticoagulant therapy.|
|Administer IV fluids and blood products as needed.||Initial management begins in the emergency department. The client can lose up to 1 liter of blood from proximal femoral fractures, and thus fluid replacement and blood transfusion should be early considerations.|
|Administer medications as indicated.||Oral or intravenous analgesia should be administered, but achieving adequate pain control can be challenging. Anticoagulants may be given prophylactically to reduce the threat of deep vein thrombosis.|
|Apply anti embolic hose or sequential pressure hose or compression boots, as indicated.||These types of equipment decrease venous pooling and may enhance venous return, thereby reducing the risk of thrombus formation.|
|Assist in bivalving or splitting the cast as needed.||Bivalving or splitting may be done on an emergency basis to relieve restriction and improve impaired circulation resulting from compression and edema formation in the injured extremity. The wadding under the cast may also be restrictive.|
|Prepare to assist with surgical interventions such as fasciotomy, as indicated.||Failure to relieve pressure or correct compartment syndrome within 4 to 6 hours of onset can result in severe contractures, loss of function, and disfigurement of extremity distal to the injury, possibly necessitating amputation.|
|Review electromyography (EMG) and nerve conduction velocity (NCV) studies.||These procedures may be performed to evaluate nerve injury or dysfunction and its effect on muscle function. This is more likely performed during the rehabilitation phase.|
|Assist in arthroplasty or hemiarthroplasty, as indicated.||Arthroplasty is shown to be superior to fixation in older adult clients diagnosed with intracapsular hip fractures with regard to pain, postoperative functions, and complications. Early failure of fixation is often due to non-union or re-displacement of the fracture, while late failure is commonly the result of avascular necrosis.|
Impaired Physical Mobility
The overreaching health care challenge after hip fracture and surgery is to maximize mobility and encourage older adults to return to their usual activities of daily living and engage in physical activity. Following a hip fracture, men generally have higher rates of morbidity and mortality. Some studies suggest that a higher proportion of men have impaired walking one year after hip fracture. The transition from hospital to home is a key time during the recovery process as there may be no one there to encourage older adults to be active, and this places them at risk for sitting too much and increased negative health consequences.
- Impaired Physical Mobility
- Pain or discomfort
- Neuromuscular skeletal impairment
- Limb immobilization
- Psychological immobility
- Imposed restrictions
- Inability to move purposefully within the environment
- Reluctance to attempt movement
- Limited range of motion
- Decreased muscle strength or control
After implementation of nursing interventions, the client is expected to:
- Regain and maintain mobility at the highest possible level.
- Maintain a position of function.
- Increase strength and function of affected and compensatory body parts.
- Demonstrate techniques that enable resumption of activities, especially activities of daily living.
|Assess the degree of immobility produced by the injury.||The client may be restricted by self-perception out of proportion with actual physical limitations requiring information and interventions to promote progress toward wellness. Information about physical activity obtained from surveys and subjective reports provides essential information about an older adult’s perception of their activity level.|
|Monitor blood pressure with the resumption of activity. Note reports of dizziness.||Postural hypotension is a common problem following prolonged bed rest and may require specific interventions, such as a tilt table with gradual elevation to an upright position. Measure the client’s vital signs while they are supine, sitting, and standing .|
|Auscultate bowel sounds and monitor elimination habits.||Bed rest, analgesics use, and dietary habits changes can slow peristalsis and produce constipation. Nursing measures that facilitate elimination may prevent or limit complications.|
|Perform a thorough assessment of the client’s prior bowel habits.||This provides a baseline for comparison with post-surgical concerns. The long-term use of opioids for pain and limited mobility causes constipation in orthopedic clients. Constipation is a major issue and needs immediate and ongoing attention.|
|Encourage the client to participate in diversional or recreational activities. Maintain a stimulating environment.||This provides an opportunity for the release of energy, refocuses attention, enhances the client’s state of self-control and self-worth, and aids in reducing social isolation. Women engage in more light physical activity and have less sedentary time throughout the day. Women may engage in more functional daily activities (e.g household chores) than men and thus reduce their sedentary time .|
|Instruct the client in active, or assist with passive, ROM exercises of affected and unaffected extremities.||ROM exercises increase blood flow to the muscles and bones to improve muscle tone; maintain joint mobility, and prevent contractures, atrophy, and calcium resorption from disuse.|
|Encourage the use of isometric exercises, starting with the unaffected areas.||Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. However, if the client is experiencing acute bleeding or edema, these exercises are contraindicated .|
|Provide footboard and trochanter rolls, as appropriate.||These are useful in maintaining the functional position of extremities, and the feet, and preventing complications such as contractures or footdrop .|
|Encourage self-care activities if possible, such as bathing, shaving, and oral hygiene.||Self-care activities improve muscle strength and circulation, enhance client control in situations, and promote self-directed wellness. In a review of the minute-by-minute recordings from the ActiGraph in a study, most activities were focused on times in which activities of daily living were likely occurring (e.g. early morning bathing and dressing, toileting during the middle of the night) .|
|Mobilize the client as soon as possible.||To avoid or minimize complications of immobility, mobilize the client as soon as possible and to the fullest extent possible. Mobilization efforts such as dangling, sitting, and early ambulation depend on the client’s unique circumstances during hospitalization, such as disease/illness process, procedures performed, and surgery type.|
|Assist with mobility by means of wheelchair, walker, crutches, and/or canes as soon as possible. Instruct them in the safe use of mobility aids.||Early mobility reduces complications of bed rest, such as phlebitis, and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and client safety.|
|Reposition the client regularly and encourage coughing and deep breathing exercises.||This prevents or reduces the incidence of skin and respiratory complications- decubitus ulcer, atelectasis, or pneumonia. Teach the client deep breathing and coughing exercises to prevent atelectasis. Proper positioning and repositioning every 2 hours help protect the skin and minimize the potential for breakdown .|
|Encourage increased fluid intake of 2,000 to 3,000 ml/day within cardiac tolerance.||This keeps the body well hydrated, decreasing the risk of urinary infection and stone formation, and helps prevent constipation. Adequate fluid intake may also help liquefy pulmonary secretions, aiding in the easier mobilization of secretions.|
|Encourage the client to consume a diet high in protein, carbohydrates, vitamins, and minerals, but limit protein content until after the first bowel movement.||In the presence of musculoskeletal injuries, early good feeding is needed as nutrients required for healing are rapidly depleted. This can have a profound effect on muscle mass, tone, and strength. Protein foods increase the contents in the small bowel, resulting in gas formation and constipation. Therefore, the gastrointestinal function should be fully restored before protein foods are increased.|
|Provide an increased amount of roughage and fiber in the diet. Limit gas-forming foods.||Adding bulk to the stool helps prevent constipation. Gas-forming foods may cause abdominal distention, especially in the presence of decreased intestinal motility. Therefore, it is best to increase these foods after the first bowel movement.|
|Support the client’s emotional and mental health.||Monitor the client’s emotional status every shift, and be attuned to any behavioral or mood changes. Offer support and empathy, and allow the client to express their feelings in a nonjudgemental manner. Any identified concerns should be reported and monitored to ensure the client’s continued psychological health.|
|Refer the client to a physical or occupational therapist and/or rehabilitation specialist.||This is useful in creating aggressive individualized activity or exercise programs. The client may require long-term assistance with movement, strengthening, and weight-bearing activities as well as the use of adjuncts, like walkers, crutches, canes; elevated toilet seats; pickup sticks, or reachers; and help for women with actions such as hooking a brassiere.|
|Refer the client to a dietitian or nutrition team, as indicated.||The client with fractures, especially when associated with trauma, may have special nutritional considerations; for example, they may need enteral or parenteral feedings to maximize the healing of tissues and bones. Nutritional status affects both the client’s potential for developing immobility-related complications and the client’s ability to regain mobility.|
|Refer the client to a psychiatric clinical nurse specialist or therapist, as indicated. Provide information about support groups for the client’s condition.||The psychological impact due to impaired mobility and immobility can be devastating. Provide the client and family with information about support groups and community resources as appropriate for any identified physiological, psychological, spiritual, and financial needs.|
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