Managing Patients with Hip Fracture

Patients with hip fracture are susceptible to foreseeable and potentially avoidable complications. An interprofessional team approach to care that uses evidence-based strategies for prevention, early detection, and proactive care to avoid complications are the key to optimal patient outcomes.

EMERGENCY ROOM

The majority of these patients will enter the hospital via the emergency department. Consideration must be given to provide an environment that is sensitive to the care needs of this vulnerable population. Increasingly, hospitals are providing spaces in their emergency departments designed to accommodate the needs of older adults and avoid the negative consequences associated with an overstimulating environment. Early implementation of multifactorial interventions aimed at reducing complications in this vulnerable population, starting in the emergency department, has proven beneficial (Arshi, Rezzadeh, Stavrakis, Bukata, & Zeegen, 2019; Bjorkelund et al., 2011; see Chapter 44, Care of the Older Adult in the Emergency Department).

TIMELY SURGERY

Delays to surgery greater than 24 to 48 hours increase the risk of complications, delirium, and mortality. Hommel et al. (2008) found higher mortality at 4 months among medically fit patients with administrative delay to surgery compared to patients with no delay and longer hospital stays for those with delays greater than 24 hours. In a study of 38,020 patients with hip fractures, Daugaard et al. (2012) concluded that avoiding surgical delay is the most important factor in reducing mortality for hip-fracture patients. A systematic review seeking to answer the questions of the effect of early hip-fracture surgery on patients 60 years or older on all-cause mortality and postop complications found early surgery reduced the incidence of pressure injury, postoperative pneumonia, and mortality (Simunovic et al., 2010). A retrospective review of American College of Surgeons National Quality Database from 2006 to 2013 of 17,459 patients who sustained hip fracture found delay to surgery prolonged length of stay; however, there was no reported difference in postoperative readmission, postoperative infection, or mortality. Interestingly, 74% of the patients reviewed in this study underwent surgery within 48 hours (S. M. Mitchell et al., 2018). Nurses can play an important role in advocating for timely access to surgery.

DELIRIUM

A.  Determine patient’s preadmission cognitive status and cognitive presentation on admission using a standardized tool and information from family.

B.  Screen for delirium every 12 hours using an evidence-based tool.

C.  Educate patient and family on the increased risk of delirium with hip fracture and how they can help prevent and cope with it.

D.  Prevent/address the factors that may contribute to delirium, for example, pain, urine retention, infection, constipation, sensory impairment, sleep, metabolic disturbances, medications, alcohol withdrawal, dehydration, and environmental over-/understimulation.

E.  Reassess cognitive status before care transition.

MALNUTRITION

A.  Assess for malnutrition on admission using a standardized screening tool.

B.  Consult registered dietitian for comprehensive assessment if malnourished or if the patient is unable to tolerate the diet.

C.  Screen for dysphagia and refer to a speech or occupational therapist if dysphagia is suspected.

D.  Adopt protocols that minimize fasting before surgery. Evidence supports the benefits of:

  1. Solid food up to 8 hours before surgery
  2. Clear fluids up to 2 to 4 hours before surgery
  3. Clear fluid high-carbohydrate drink 2 to 4 hours before surgery, for example, clear juice

E.  Postsurgery nutrition

  1. Provide a regular diet as tolerated the day of surgery.
  2. Monitor nutritional intake. Inform dietitian or physician if intake is consistently less than 50% of the diet provided.
  3. Provide scheduled administration of high-protein, high-calorie nutritional supplements in addition to ordered diet.

PAIN

A.  Assume your patient has moderate to severe pain. Recognize that unmanaged pain increases complications, impedes recovery, and increases mortality.

B.  Assess pain and pain history on admission using a comprehensive validated tool.

C.  Consider any painful comorbid conditions and prehospital analgesic use in the pain management plan, for example, arthritic joint pain exacerbated by immobility.

D.  Assess valid pain scale with vital signs; differentiate between acute and chronic pain.

E.  Assess using a validated sedation scale every hour for 24 hours and then every 4 hours thereafter. Adjust analgesic dosing according to the scale.

F.   Time the administration of analgesics such that their peak effect coincides with physiotherapy and mobility.

G.  Use a pharmacological and nonpharmacological multimodal approach to reduce the need for opioids.

H.  Advocate for regional blocks (nerve/compartment).

I.   Ensure that geriatric-appropriate analgesics/doses are prescribed and administered.

J.   Use regularly scheduled doses of analgesics while pain persists.

CONSTIPATION

A.  Assess prehospital bowel habits and management.

B.  Assess for BM daily, including size, consistency, and color.

C.  Assume your patient will be constipated as a result of immobility, analgesics, and pain.

D.  Use a standardized geriatric-appropriate bowel protocol.

E.  Administer prophylactic laxatives as ordered unless contraindicated, for example, diarrhea, multiple daily moderate to large BMs.

F.   Ensure adequate fluid intake and a high-fiber diet where appropriate, for example, bran, prunes, applesauce, and dates.

G.  Encourage ambulation to promote bowel function. Avoid bedpans; ambulate to the toilet.

CATHETER-ASSOCIATED URINARY TRACT INFECTION

A.  Avoid indwelling catheters. Use an indwelling catheter only if evidence-based criteria are met, for example, Centers for Disease Control and Prevention (CDC) criteria (Gould et al., 2010).

B.  Reassess the need for the catheter each shift and remove as soon as possible, within 36 hours after surgery.

C.  Use an evidence-based nursing protocol to guide insertion, hygiene, and management of the catheter and drainage system.

PRESSURE ULCER PREVENTION

A.  Conduct a head-to-toe pressure-point assessment on admission and then each shift.

B.  Use an evidence-based pressure ulcer risk-screening tool (i.e., Braden Scale) to identify areas to be monitored and addressed.

C.  Implement a written care plan to address any underlying risk factors as indicated (e.g., immobility, nutrition, moisture, etc.).

D.  Consider using pressure reduction mattresses and chair surfaces routinely for hip-fracture patients.

E.  Ensure that patients are repositioned every 2 hours (some patients may do this independently).

F.   Mobilize and assess toileting needs every 2 to 3 hours while awake.

G.  Ensure nutrition and hydration are monitored and needs are met.

H.  Implement a written care plan to address any skin injury or breakdown as per evidence-based clinical guidelines.

VENOUS THROMBOEMBOLISM

A.  Recognize that hip-fracture patients are at high risk for VTE.

B.  Advocate for evidence-based treatment.

C.  Ensure that treatment is initiated as prescribed.

D.  Monitor for adverse events, for example, bleeding, bruising, or rashes with chemoprophylaxis or skin breakdown and circulatory impairment with compression stockings or pneumatic compression sleeves.

E.  Encourage leg exercises and early, frequent mobilization.

F.   Encourage fluid intake of six cups minimum daily unless contraindicated.

G.  Educate patients and families on detection and prevention of VTE at home and actions to take if VTE is suspected.

FLUID AND ELECTROLYTE IMBALANCE

A.  Monitor fluid balance after surgery.

B.  Review lab values and report abnormalities to medical practitioner as indicated.

C.  Ensure adequate fluid intake, minimum 6 cups per day or as per fluid restrictions.

D.  Assess for clinical signs of dehydration (hypotension, headache, dry mouth, oliguria, and skin turgor) or overload (edema, cough, and coarse breath sounds). Follow up with medical practitioner as indicated.

MOBILITY

The nurse is responsible for ensuring timely and consistent postoperative mobility.

A.  Request that family provide sturdy footwear with a closed heel and toe.

B.  Ensure that an individually fitted walker is available at the bedside.

C.  Teach bed exercises: Buttock tightening, foot circles, dorsal and plantar flexion of both feet. Remind patient to do exercises every hour while awake.

D.  Teach the importance of mobility in healing and restoring function.

E.  Establish mobility goals with patient.

F.   Assist patient to:

  1. Sit at the bedside, stand, and/or walk on the day of surgery.
  2. Get up in a chair for at least two meals each day beginning the day after surgery.
  3. Walk every day after surgery at least three times with increasing distances.

TRANSITIONS FROM HOSPITAL TO HOME

A.  Both verbal and written instructions on preparing to go to the next level of care should begin early in the hospital stay (see Chapter 36, Fluid Overload: Identifying and Managing Heart Failure Patients at Risk of Hospital Readmission). 

B.  For those going to a rehabilitation facility, handoff should include information on surgical procedure/activity restrictions and cognitive status, including delirium assessment results, diet/appetite, sleep strategies, and pain management.

C.  For those going directly home, determine home-assistance requirements and assist patients to make arrangements. Stress the importance of frequent ambulation, healthy diet, adequate sleep, pain management, and follow up to ensure adequate bone health.

D.  Educate patients on early warning signs of “red flags” and what to do (e.g., VTE, delirium, infection, dislocation, and constipation).

E.  Assess medication management skills, and develop a plan for medication review and safety at home.

F.   Consult with occupational or physical therapists to assess and address the need for home modifications and equipment.

G.  Arrange a home follow-up phone call or home visit from a healthcare professional for support, teaching, and problem-solving.

H.  Provide information for follow-up with orthopedic surgeon.

Include information on the surgical procedure/activity restrictions, the importance of frequent ambulation, healthy diet, sleep strategies, bone health, and pain management.

SECONDARY FRACTURE PREVENTION

A.  Ensure consultation with fracture liaison service before discharge.

  1. Evaluation of bone health and fracture risk
  2. Evaluate for referral to fall prevention program
  3. Ongoing osteoporosis management

ABBREVIATIONS

BM              Bowel movement

VTE             Venous thromboembolism

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Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

REFERENCES

Arshi, A., Rezzadeh, K., Stavrakis, A. I., Bukata, S. V., & Zeegen, E. N. (2019). Standardized hospital-based care programs improve geriatric hip fracture outcomes: An analysis of the ACS-NSQIP targeted hip fracture series. Journal of Orthopaedic Trauma, 33(6), e223–e228. doi:10.1097/BOT.0000000000001443. Evidence Level V.

Bjorkelund, K. B., Hommel, A., Thorngren, K. G., Lundberg, D., & Larsson, S. (2011). AQ: Please provide primary weblink for the reference “Bjorkelund et al. (2011).”The influence of perioperative care and treatment on the 4-month outcome in elderly patients with hip fracture. AANA Journal, 79(1), 51–61. Evidence Level III.

Daugaard, C. L., Jørgensen, H. L., Riis, T., Lauritzen, J. B., Duus, B. R., & van der Mark, S. (2012). Is mortality after hip fracture associated with surgical delay or admission during weekends and public holidays? A retrospective study of 38,020 patients. Acta Orthopaedica, 83(6), 609–613. doi:10.3109/17453674.2012.747926

Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare Infection Control Practices Advisory Committee. (2010). Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control and Hospital Epidemiology, 31(4), 319–326. doi:10.1086/651091. Evidence Level I.

Hommel, A., Ulander, K., Bjorkelund, K. B., Norrman, P. O., Wingstrand, H., & Thorngren, K. G. (2008). Influence of optimised treatment of people with hip fracture on time to operation, length of hospital stay, reoperations and mortality within 1 year. Injury, 39(10), 1164–1174. doi:10.1016/j.injury.2008.01.048

Mitchell, S. M., Chung, A. S., Walker, J. B., Hustedt, J. W., Russell, G. V., & Jones, C. B. (2018). Delay in hip fracture surgery prolongs postoperative hospital length of stay but does not adversely affect outcomes at 30 days. Journal of Orthopaedic Trauma, 32(12), 629–633. doi:10.1097/BOT.0000000000001306. Evidence Level IV.

Simunovic, N., Devereaux, P. J., Sprague, S., Guyatt, G. H., Schemitsch, E., Debeer, J., & Bhandari, M. (2010). Effect of early surgery after hip fracture on mortality and complications: Systematic review and meta-analysis. Canadian Medical Association Journal, 182(15), 1609–1616. doi:10.1503/cmaj.092220. Evidence Level I.