CONCEPT MOBILITY HIP FRACTURES

HIP FRACTURE OBJECTIVES Explain the exemplar hip fractures (including definition, antecedents, and attributes). Analyze conditions which place a patient at risk for hip fractures. Recognize the negative and positive consequences of hip fractures. Discuss the interrelated concepts that work together to ensure positive outcomes related to hip fractures.

HIP FRACTURE OBJECTIVES Discuss the interrelated concepts that if depleted or impaired can cause a negative consequence in ensuring positive outcomes of hip fractures. Apply the nursing process (including collaborative interventions) for individuals experiencing a hip fracture and promote normal healing.

HIP FRACTURE Common among older adults 90% due to fall 320,000 hospital admission annually By age 90 approximately 33% of all women and 17% of men 30% will die within 1 year of injury Hip fracture occurs more frequently in women because of osteoporosis. Will die within 1 year of injury due to medical complications caused by the fracture or resulting in immobility. Many older adults with hip fracture will also develop disabilities needing long term care.

HIP FRACTURE DEFINED Fracture of the proximal third of the femur Intracapsular fracture- fractures that occur within the hip joint capsule (femoral neck) These fractures are often associated with osteoporosis and minor trauma 1. Capital – fracture of the head of the femur 2. Subcapital – fracture just below the head of the femur. 3. Transcervical – fracture of the neck of the femur. Extracapsular fracture- occur outside the joint capsule These fractures are usually caused by severe direct trauma or a fall  

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. FRACTURE OF HIP Fig. 63-17. Femur with location of various types of fracture. 6 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

RISK FACTORS Complete mobility and strength to immobility Chronic health problems 65 years of age and older, more frequent Environmental hazards Women due to osteoporosis Post menopausal women Trauma Multiple medication usage

CLINICAL MANIFESTATIONS External rotation Muscle spasm Shortening of extremity Severe pain Radiograph (X-ray) 8 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

COLLABORATIVE CARE Open reduction Closed reduction Surgical repair Buck’s traction Open reduction Correction of bone alignment through surgical incision Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails Closed reduction Nonsurgical, manual realignment of bone fragments to previous anatomic position Traction and countertraction manually applied to bone fragments to restore position, length, and alignment

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. FRACTURE OF HIP Fig. 63-18. Types of internal fixation for a hip fracture. A, Femoral head endoprosthesis. B, Type of hip compression screw with side plate. 10 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. BUCK’S TRACTION Buck’s traction is most commonly used for fractures of the hip and femur. Fig. 63-10. Buck’s traction. Most commonly used for fractures of the hip and femur. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. FRACTURES Fig. 63-10. Buck’s traction. Most commonly used for fractures of the hip and femur. 12 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

NURSING MANAGEMENT NURSING ASSESSMENT Objective Data Complete physical and focused assessment Deformity or unnatural position of affected limb Edema and ecchymoses Muscle spasm Tenderness and pain Loss of function Numbness, tingling, loss of distal pulses Pallor and cool skin or bluish and warm distal to injury Ecchymosis Hematoma ↓ or absent pulse distal to injury ↓ skin temperature Delayed capillary refill Paresthesias ↓ or absent sensation Hypersensation Muscle weakness Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

NURSING MANAGEMENT NURSING ASSESSMENT Subjective data Past health history Traumatic injury Bone or systemic disease Prolonged immobility Osteopenia Osteoporosis Medications Use of corticosteroids (osteoporotic fracture) Analgesics Surgery or other treatments Previous musculoskeletal surgeries

NURSING MANAGEMENT NURSING ASSESSMENT Subjective data Health perception–health management Estrogen replacement therapy Calcium supplements Activity-exercise Loss of motion or weakness Muscle spasms Cognitive-perceptual Sudden and severe pain in affected areas Numbness, tingling, loss of sensation

NURSING MANAGEMENT NURSING ASSESSMENT Neurovascular assessment: Peripheral vascular assessment Color Temperature Capillary refill Peripheral pulses Edema Peripheral neurologic assessment Sensation Motor function Pain

NURSING MANAGEMENT NURSING DIAGNOSIS Acute Pain Risk for Peripheral Neurovascular Dysfunction Risk for Infection Impaired Physical Mobility Disturbed Sensory Perception: Tactile Ineffective Self-Health Management ND related to Postoperative Surgical Procedure

NURSING MANAGEMENT PLANNING Overall goals Have physiologic healing with no associated complications Achieve maximal rehabilitation potential Obtain pain relief adequate to allow for rest and comfort Experience no complications as a result of fracture or treatment Experience no ongoing loss of function as a result of fracture Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

NURSING MANAGEMENT INTERVENTIONS Closed Reduction Buck’s Traction – immobilization and manage muscle spasms Maximum of 24 to 48 hours inspect exposed skin regularly assess bony prominences maintain appropriate extremity alignment NV assessment monitor and maintain weights External rotation of hip can occur when skin traction is used on lower extremities. Nurse can correct this position by placing a pillow, sandbag, or rolled-up draw sheet along greater trochanteric region of the femur NV assessment is frequent every hour or every 2 hours. Bucks traction used for a maxiumum of 24 to 48 hours

NURSING MANAGEMENT INTERVENTIONS Open Reduction and Internal Fixation Surgical repair Early immobilization Decreases risk of major complications Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails Surgical repair is the preferred method of managing intracapsular and extracapsular hip fractors. Disadvantages: post surgical complications, anesthesia

NURSING MANAGEMENT INTERVENTIONS Preoperative Care: Pain control Traction Analgesics Muscle relaxants Comfortable positioning Safety measures Neurovascular assessment Teaching Exercising unaffected leg and arms Overhead trapeze bar Post operative surgical ex: TCDB, infection control, DVT prevention

NURSING MANAGEMENT INTERVENTIONS Post operative Care: Monitor VS and Neurovascular assessment I &O Respiratory activities ex: TCBD and Incentive Spirometry Pain control Analgesics Muscle relaxants Comfortable positioning/alignment Safety measures Elevate extremity Incision Care Constipation Use of abductor splint or pillow between the knees when turning from side to side for alignment

Explain collaborative care of hip fracture.

Patient and Caregiver Teaching Prevent prosthesis dislocation Large pillow between legs when turning Avoid extreme hip flexion Avoid turning onto affected side

NURSING MANAGEMENT NURSING IMPLEMENTATION Health promotion Public should be taught to take appropriate safety precautions. Nurses should advocate for personal actions to decrease injuries. Encourage moderate exercise to keep muscles strong and maintain balance. Calcium and vitamin D intake Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

NURSING MANAGEMENT AMBULATORY AND HOME CARE Psychosocial problems Short-term rehabilitative goals Transition from dependence to independence in performing simple activities of daily living Preserve or ↑ strength and endurance Long-term rehabilitative goals Prevent problems associated with musculoskeletal injury Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26