2. FRACTURE OBJECTIVES
Summarize the physiology of the musculoskeletal system relate to
mobility.
Examine the relationship between mobility and fractures.
Identify common occurring alterations (fractures) in mobility and
their related therapies.
Asses the patient for risk factors for fracture
Apply knowledge of clinical manifestations of fracture to care of
patient
Improve patient safety by applying knowledge of the
pathophysiology to care of the patient with fracture
complications
Discuss collaborative interventions used to reduce and promote the
healing of fractures.
Select nursing interventions which promote bone healing while
minimizing complications
3. HIP FRACTURE OBJECTIVES
Discuss how a hip fracture impacts an older adult
Describe clinical manifestations of fractured hip
Improve patient safety by applying knowledge of
pathophysiology to the care of the patient with hip
fracture complications.
Describe diagnostic, laboratory, and collaborative
interventions used to treat hip fractures.
Use nursing process and patient centered care to discuss
culturally competent care of the patient undergoing
surgical repair of the hip.
4. This online presentation is for personal use
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Transcripts of the presentation and/or the
presentation itself is not to be posted in any
format
Failure to follow these rules will be considered
academic dishonesty and will be subject to
the same consequences, including possible
dismissal from the program
5. CONCEPT--MOBILITY
A fracture is a broken bone. It can range from
a thin crack to a complete break. Bone can
fracture crosswise, lengthwise, in several
places, or into many pieces. Most fractures
happen when a bone is impacted by more
force or pressure than it can support.
7. FRACTURES
Strength of Force vs. the Strength of Bone
Trauma
Direct vs. Indirect force
• Direct blow
• Crushing
• Compression
• Twisting
Open/Closed
Complete/Incomplete
Displaced/Comminuted
8. FRACTURES MOST COMMON IN OLDER ADULT
POPULATION
Most Common fractures: Hip, pelvis, wrist,
arm, or spine
Half of Caucasian women over the age of 50
will fracture their hip, spine, or wrist at some
time
1.5 million persons have fractures related to
osteoporosis each year
9. CLINICAL MANIFESTATIONS OF FRACTURE
• PAIN- caused by damage to bone, surrounding
soft tissue, ligaments and tendons and
Muscle Spasms
• Deformity or misalignment if bone displaced
• Swelling due to inflammation
• Hypovolemia/shock or ecchymosis
11. Clot forms in one
of the deep
veins
Symptoms:
Redness, Warmth
of skin, Leg pain,
Cramping,
Swelling
Prevention:
Early Surgery
Anticoagulation
Compression Strategie
s
Treatment:
Bedrest
Anticoagulants
Vena Cava Filter
COMPLICATIONS: DEEP VEIN THROMBOSIS
12. COMPLICATIONS OF DEEP VEIN THROMBOSIS
(DVT)
Cerebrovascular Accident (CVA)
Pulmonary Embolism
13. COMPLICATIONS:
Fat Embolism Syndrome:
Fat emboli are released from closed long bone or
pelvic fractures into the blood stream where they
cause:
Dyspnea that may progress to respiratory failure
A Petechial Rash/Buccal Mucosa
Neurologic Symptoms (confusion, restlessness,
seizures or coma)
Increased risk of infection, especially with:
Open fractures
External fixation devices
Immunocompromised patients
15. CAST CARE
Plaster and Fiberglass available
Plaster casts 48 hours to dry; avoid getting wet after
Nursing care for patients with both types of casts:
Monitor neurovascular status
Monitor for compartment syndrome
Teach how to care for cast at home
Cast care:
Keep clean and dry
Don’t place objects in cast
Notify physician of symptoms of compartment
syndrome
17. TRACTION
SKIN
To control muscle
spasms
Maintain alignment
Traction if skeletal pins
infected
Monitor condition of skin
Keep weights off ground
SKELETAL
More weight needed
to align fracture
Pins placed under
surgical conditions
Nursing maintain
alignment, pin care
21. NURSING IMPLEMENTATION:
E F F E C T I V E
PA I N
M A N A G E M E N T
Provide pain meds as
needed
Use elevation, ice,
relaxation
techniques.
Support above and
below extremity
P R O V I D E
P R O P E R
A L I G N M E N T
Teach cast and splint
care
If in traction, keep
aligned in bed and
ensure that weights
are free hanging
22. NURSING IMPLEMENTATION
P R O M O T E
M O B I L I T Y
Reposition every 1-2
hours if not OOB
yet
Ambulate
Teach to use crutches
and walker
N E U R O VA S C U L A R
S TAT U S
5Ps
Pain
Pulses
Pallor
Paresthesia
Paralysis/Paresis
24. NURSING IMPLEMENTATION
P R E V E N T
I N F E C T I O N
Change dressings
Provide pin care
Monitor both sites for
s/s infection
D I S C H A R G E
I N S T R U C T I O N S
Monitoring for
complications
How to take pain
medications
Injury prevention
Assess knowledge of
how to use cane/
crutches/walker
Home care needed?
25. A PATIENT WITH A HEALING FRACTURE USES
CRUTCHES TO GO DOWN THE STEPS. WHICH
PATTERN IS CORRECT?
A. Extend affected extremity forward, place crutch
down
B. Step down with unaffected extremity and crutch
first
C. Step down with affected extremity first, follow with
crutch and other leg
D. Step down with unaffected extremity first, follow
with crutch and other leg
26. OSTEOPOROSIS
Metabolic bone disorder in which person experiences loss
of bone mass, increased bone fragility and increased risk
of fractures
Caused by changes in balance of the activity of osteoblasts
that form new bone and osteoclasts that resorb bone
After age 35 bone breakdown outpaces new bone growth
Bone is lost at a greater rate if one’s diet is low in Calcium
and Vitamin D
Loss of estrogen also increases rate of bone loss (after
hysterectomy, menopause)
Osteoporosis affects: Shaft (diaphysis) and metaphysis of
the bone.
27.
28. RISK FACTORS: INFLUENCED BY HOW MUCH BONE
MASS ACHIEVED IN YOUR 20’S
U N M O D I F I A B L E
Thin, female, having
small frame
Fracture after age 50
Family history of
fracture
European Americans
and Asians more at
risk
Men 10 – 15 years later
onset
M O D I F I A B L E
Menopause
Calcium deficiency
High protein diet
Sedentary Lifestyle
Substance Abuse
Medications
32. DIAGNOSIS
• Acute pain of the lower spine, related to vertebral compression
• Deficient knowledge, related to osteoporosis and treatment to
prevent further damage
• Imbalanced nutrition: Less than body requirements, related to inadequate
intake of calcium
• Risk for injury, related to effects of change in bone structure
secondary to osteoporosis
ASSESSMENT
Possibly asymptomatic
Back, pelvic or hip pain after lifting, bending, or stooping
Problems with balance
Decline in height from venebral compression
Pathological fractures
Appearance of thin, porous bone on x-ray
33. EXPECTED OUTCOMES
• Verbalize a decrease in back pain.
• Be able to describe ways to treat her osteoporosis and prevent further complications.
• Verbalize an understanding of the current research and treatment regarding osteoporosis.
• Verbalize how stopping smoking can help prevent further progression of osteoporosis.
• Seek consultation for supplements and medications to prevent further bone loss.
• Design a program of physical activity to prevent complications of osteoporosis.
• Verbalize safety precautions to prevent fractures due to falls.
PLANNING AND IMPLEMENTATION
• Teach back strengthening exercises.
Assess current knowledge base
• Refer to an osteoporosis support group, provide current literature.
• Provide realistic, yet optimistic, feedback about loss of height and bone integrity and the
potential outcomes of treatment.
Instruct dietary and calcium supplements.
EVALUATION
What went well
What needs to be changed
34.
35.
36. TYPES OF HIP FRACTURES
Intracapsular
within the joint capsule
Extracapsular
below the capsule
37. HIP FRACTURES
More common in women > 65
Secondary to osteoporosis
Affects 1 in 5 women by age 80
Most common reason = falls
Morbidity/Mortality
20%-27% will die within 1 year
25% recovery within a year
Most are unable to return home and
independence
38. PREVENTION
• Weight bearing exercises
• Home safety inspection
• Collaboration with physician/pharmacist to assess
how meds affect balance and bone density
• Avoidance of alcohol
• Attention to bone health
• Mobility assessment
39. NURSE AS PROFESSIONAL: FALL PREVENTION
Many reportable Falls related to:
Problems with Fall risk assessment process
Inconsistent use of interventions
Miscommunication about risk of falls
Not assigning patients to high risk category when necessary
One third of falls with injury were related to bathroom use
40% had taken psychiatric medications (anti-anxiety or anti-
psychotics)
Staff had rounded within last 30 minutes
42. COLLABORATIVE INTERVENTIONS:
Diagnostic studies
Bucks traction (until surgery)
Surgical options (depend on bone injury and patient health)
Open reduction internal fixation
Hemi-arthoplasty (ball and socket replaced)
Arthroplasty (total hip replaced)
Pain management
Physical therapy after surgery
Social services arranges rehab or alternative form of care after discharge
43. PRE-OP NURSING CARE INTERVENTIONS
Address chronic health issues
Manage muscle spasm and pain
Analgesics/muscle relaxants/Antibiotics
RICE
X-ray, MRI, CT
CBC, PT/INR
45. COLLABORATIVE CARE: SURGERY INTERVENTION
Open Reduction Internal
Fixation (ORIF)
Total Hip
Arthroplasty (THA)
Hemiarthroplasty
46. Cemented: bonds bone to bone
Can become loose and require revision
Cementless: long-term stability
Patient with high activity level and life expectancy
>25 years
Biologic fixation relies on growth of bone into the
surface
Risks for both:
Infection
Clots
Joint breakdown
TOTAL HIP ARTHROPLASTY (THA)
49. NURSING PROCESS: ASSESSMENT
Assess additional medical problems/ trauma from fall
Pre and Post Op:
Assess alignment
Neurovascular status
Cognition
Pain--Amount of pain and disability
Vital signs
Post Op:
Monitor incision site for evidence of infection/ swelling
50. NURSING PRE/POST SURGERY
GOALS/OUTCOMES
-The patient will verbalize understanding of surgery.
-The patient will participate in post-opt exercises to increase
mobilization.
-The patient will be free from any DVTs.
-The patient will demonstrate correctly how to use the trochanter
roll to help hip alignment.
-The patient will demonstrate how to properly change positions to
relieve pressure with a little pain possible.
-The patient will demonstrate how to properly use trapeze bar
when transferring in bed.
51.
52. PRE-OP NURSING CARE TEACHING
INTERVENTIONS/IMPLEMENTATIONS
Provide reassurance regarding
pain relief
Explain and practice post-op
Activities:
Turn, cough and deep breathe
Exercises – isometric (no joint movement) of
quads and glutes
Dorsiflexion and plantar flexion of foot
53. PRE-OP NURSING CARE
INTERVENTIONS/IMPLEMENTATIONS
Homeostasis/Perfusion:
Labs to assess CBC, functioning of
kidneys and liver
Chest X-ray and EKG
Fit for support hose
Wear for 6-8 weeks
Or explain SCDs
Use of anticoagulants
Physical therapy consult
Use of trapeze; exercises
(When surgery is planned
can provide education
ahead of time.)
54. THA: POST-OP NURSING CARE
INTERVENTIONS/IMPLEMENTATIONS
Early ambulation- 1st post-op
day
With walker and PT with
cemented
Partial weight bearing with non-
cemented
Assess dressing, drainage
tubes and vital signs
Expect 200-500ml drainage
in 1st 24 hours
Expect 120ml by 48 hours
55. NURSING PROCESS :
INTERVENTIONS/IMPLEMENTATIONS
Post –Operatively: Abduction pillow
• Teach and assist with correct positioning of the hip
• Position using abduction pillow
• Monitor for DVT symptoms and administer anticoagulants
• Assist with breathing exercises and monitor for symptoms of
pneumonia
• If patient has limited mobility, turn q2 and monitor condition of skin.
• Encourage good hygiene/ sterile dressing changes
56. PATIENT EDUCATION: HIP PROSTHESIS
INTERVENTIONS/IMPLEMENTATIONS PRE/POST-OP
DO NOT’S
No adduction
No sitting on chairs without arm rests
No low chairs
No internal rotation
No flexing hip greater than 90˚
No putting on shoes and socks for 8 weeks without device
No crossing legs or feet
57. PATIENT EDUCATION: HIP PROSTHESIS
INTERVENTIONS/IMPLEMENTATIONS PRE/POST-OP
DO’S
Use high-backed chair with arm rests
Use elevated toilet seats
Use chair in tub or shower
Use pillow or abductor brace between legs when lying or
turning
Maintain hip in neutral position
Notify dentist before dental work
Notify MD if severe pain or loss of function
58. NURSING PROCESS
INTERVENTIONS/IMPLEMENTATIONS
P S Y C H O S O C I A
L S U P P O R T
Older adults may be very
distressed by event
Create environment of trust
which promotes patient
and family discussion of
feelings
Refer to homecare or rehab
as needed
D I S C H A R G E
P L A N N I N G
Be sure patient understands
hip precautions
Assess knowledge of ability
to correctly use abduction
pillow and walker or cane
Review weight
bearing restrictions
Review meds
