Collaborative and multidisciplinary care approach
Effective treatment for an elderly client with a hip fracture requires a multidisciplinary team approach. This collaboration involves several healthcare professionals working together to optimize the patient's recovery and long-term outcomes.
- Orthopedic Surgeon: Performs surgical repair, which is needed in almost all cases of hip fracture. The type of surgery, such as open reduction and internal fixation (ORIF) or hip replacement (arthroplasty), depends on the fracture's severity and location.
- Geriatrician: Specializes in the medical care of older adults and helps manage comorbidities, review medications, and optimize the patient's overall health. Geriatric input often begins upon admission.
- Anesthesiologist: Provides pain control during surgery and may administer nerve blocks to minimize reliance on opioids, which can cause delirium in older patients.
- Nurses: Implement the plan of care, focusing on wound management, monitoring for complications, assisting with mobility, and providing patient education.
- Physical Therapists (PT): Start early mobilization, sometimes within 24 to 48 hours of surgery, and guide the patient through exercises to regain strength, balance, and gait.
- Occupational Therapists (OT): Help patients regain independence in daily activities like dressing, bathing, and eating. They also recommend assistive devices and home modifications.
- Dietitian: Assesses and optimizes the patient's nutritional status, emphasizing protein, calcium, and vitamin D for bone healing and muscle preservation.
Initial and perioperative management
Upon admission, the patient will receive initial care to stabilize their condition and prepare for surgery. Most hip fractures are repaired surgically within 24 to 48 hours of the injury to improve outcomes.
- Pain Management: The patient will receive immediate analgesia, potentially including a nerve block, to control severe pain while minimizing systemic side effects from opioids.
- Immobilization: Temporary immobilization, such as Buck's traction, may be used preoperatively to reduce muscle spasms and stabilize the fracture.
- Preoperative Preparation: The patient will be assessed for other medical conditions and will receive prophylactic antibiotics to prevent infection and anticoagulants to prevent blood clots.
Postoperative interventions and rehabilitation
After surgery, the focus shifts to recovery, rehabilitation, and complication prevention.
- Early Mobilization: Assisted transfers and ambulation begin as soon as medically and surgically cleared, often the day after surgery. This helps prevent complications associated with immobility.
- Physical Therapy Regimen:
- In-hospital: The physical therapist will guide the patient through gentle range-of-motion exercises, ankle pumps, and exercises to strengthen the quadriceps and gluteal muscles.
- Post-discharge: Patients continue rehabilitation at a facility or at home. A program of progressive resistance training, balance training, and gait training is standard.
- Positioning and Hip Precautions: Depending on the type of surgery, specific hip precautions must be followed to prevent dislocation. This may include maintaining hip abduction with a pillow and avoiding excessive hip flexion.
- Compression and Anticoagulation: The patient will wear compression stockings or use mechanical compression boots, and continue taking prescribed blood-thinning medication to prevent venous thromboembolism (VTE).
Risk management and patient education
Preventing complications and re-injury is a cornerstone of the long-term plan of care for an elderly client with a hip fracture.
- Preventing Complications: The care team will closely monitor for signs of infection, delirium, pneumonia, and pressure sores. Early mobilization and deep breathing exercises are crucial preventative measures.
- Fall Prevention: A comprehensive fall risk assessment is performed, and the patient and family are educated on how to create a safer home environment. This includes removing rugs, improving lighting, and installing grab bars.
- Osteoporosis Management: A bone density test and ongoing treatment for osteoporosis with supplements (calcium, vitamin D) or medication is essential to reduce the risk of a future fracture.
Plan of Care comparison: Acute vs. Subacute Phases
| Feature | Acute (In-hospital) Phase | Subacute (Post-discharge) Phase |
|---|---|---|
| Primary Goal | Pain management, fracture stabilization, complication prevention | Functional recovery, strength building, independence |
| Mobility | Early assisted ambulation, transfers, gait training with assistive devices | Progressive resistance exercises, balance training, functional tasks |
| Pain Management | Multimodal analgesia, nerve blocks to minimize side effects | Scheduled medications, non-pharmacological methods |
| Complication Focus | VTE prevention, infection, pressure sores, delirium | Fall prevention, secondary fracture prevention |
| Rehabilitation Setting | Primarily in-hospital with physical and occupational therapy | Rehabilitation facility or home-based therapy |
| Patient Education | Postoperative care, hip precautions, importance of mobility | Home safety, assistive device use, fall prevention |
Conclusion
A holistic and multidisciplinary plan of care is paramount for an elderly client with a right hip fracture to ensure a safe and effective recovery. Key interventions include prompt surgical repair followed by aggressive pain management, early and frequent mobilization with physical and occupational therapy, and careful monitoring for potential complications such as VTE and delirium. Looking beyond the immediate hospital stay, the plan must incorporate robust fall prevention and osteoporosis management strategies to address the underlying risks and minimize the chance of future fractures. Patient education is an ongoing process, equipping the client and their family with the knowledge needed for a successful recovery journey and long-term functional independence.
