Nursing Care Plan for Hip Fracture Surgery

Examining Potential Post-Operative Complications for Hemiarthroplasty
Hemiarthroplasty refers to the operation that is commonly used for the treatment of a fractured hip. This operation is similar to that of a total hip replacement, but it only involves the replacement of half the hip. In most cases, the operation only replaces the ball portion of the hip joint. As with any other orthopedic surgery, there are complications that are associated with this surgery. Some of the complications might be medical and others related directly to the surgical treatment itself (Smith, Aboelmagd, Hing, & Macgregor, 2016). It is estimated that medical complications affect approximately 20 percent of patients with hip fracture. The majority of these complications are mostly postoperative complications. This paper will analyze the post-operative complications of a 38-year-old male patient who underwent a left hip hemiarthroplasty. The complications that might affect the patient will be discussed and the etiology of the complications presented. A care plan will be provided showing how the complications could be addressed. The role of the physiotherapist will be discussed with an aim to show how they can promote recovery and prevent complications. Finally, education will be offered to the patient before discharge in order to support their recovery at home.
Post-Operative Complications Risk Factors
The likelihood of a patient having post-operative complications is usually influenced by the type of surgery, perioperative management, and the patient's pre-existing comorbid state. Anesthesia can cause many post-operative complications, but they are mostly centered around the airway, circulatory, or respiratory systems. There are also instances of patients reacting abnormally to anesthetic drugs. Hemorrhage is another risk factor associated with post-operative complications (Carpintero et al., 2014). Hemorrhage can be classified as primary, reactionary, or secondary. Primary hemorrhage would occur when a vessel is cut during the surgery, reactionary hemorrhage occurs when the blood pressure of the patient rises at the end of the operation causing vessels that were not bleeding before to start bleeding, and secondary hemorrhage occurs mainly due to an infection that causes damage to a vessel. Atelectasis refers to the collapse of the areas of the lungs, which might result in post-operative pulmonary complications like hypoxia (Breathnach, Karip, McCoy, Cleary, & Quinlan, 2016). Post-operative pain needs to be assessed and managed quickly. Pain is normally an indicator of something not being right and it is best to analyze and establish why the patient is feeling the pain. Before prescribing an analgesic, there are considerations to be made pertaining to the patient.
Infection is another risk factor for post-operative complications. Wounds should be checked constantly to ensure that they are not infected especially within the first week after surgery. The wound should also not have any redness or discharge. Wound sinus occurs after normal healing and it is considered to be a late infectious complication (Carpintero et al., 2014). The surgical injury could also lead to post-operative complications. There might be unavoidable tissue damage during the surgery. This damage could have far reaching implications, for example, a patient might become impotent after undergoing prostate surgery. A patient can also suffer from urinary problems after surgery.
Potential Post-Operative Complications for Mr. Wolfe
The major complication that might affect Mr. Wolfe after the hip surgery is heart failure. This is mainly because he currently has high blood pressure and his BP of 143/89 indicates that he is in hypertension stage 1. Mr. Wolfe is at risk of deep vein thrombosis (DVT) mainly because of his high blood pressure. DVT is the formation of blood clots within a deep vein mostly in the legs. DVT is a major risk that is associated with surgery in the lower extremities like a hip replacement. If the patient does not move for a long period of time they are likely to develop the condition this is because the calf muscles will not contract and this will prevent blood circulation resulting in the formation of blood clots within the veins. A decreased blood flow rate referred to as venous stasis can also lead to DVT (Whiting et al., 2015). Mr. Wolfe has a high blood pressure and this indicates that his blood is not flowing as expected. With a decreased blood flow, there is an increased risk of him developing blood clots anywhere within his body. In order to prevent this complication, there is need to ensure that the patient stays active and offer intermittent pneumatic compression when possible.
Post-operative pulmonary complications are defined as anomalies of the lung that result in an identifiable disease that has an adverse impact on the clinical course of the patient. Pulmonary embolism (PE) is one potential complication that is associated with the pulmonary. PE is a blockage of an artery in the lungs by something that has traveled from elsewhere within the body through the bloodstream. PE is mostly caused by DVT and it results in breathlessness that might come on gradually or suddenly, chest pain that might become worse when the patient breathes, or sudden collapse of the patient (Carpintero et al., 2014). In most cases, PE is caused by a blood clot that had formed in the leg and travels to the lungs. For Mr. Wolfe, there is potential for him developing PE because he is at risk of developing DVT. Prevention of DVT would also result in the prevention of PE. A patient who has undergone surgery is always at risk of developing PE because they are immobile for long periods. After hip surgery, the patient might find it hard to move and they would prefer to lie in bed and not exercise, which might increase their risk of developing the condition (Carpintero et al., 2014).
Urinary tract infections are the most common cause of nosocomial infection and they affect about 12 percent to 61 percent of all patient who undergo hip surgery or fractures (Lanting, Odum, Cope, Patterson, & Masonis, 2015). Urinary tract infections have been shown to prolong hospital stay by 2.5 days and they also result in a higher mortality rate. The single most important risk factor related to urinary tract infection is the urinary catheter. It is recommended that indwelling catheters be removed within 24 hours of insertion. This will reduce the risk factor of the patient. In the case of Mr. Wolfe, he still has his catheter and the nurse should ensure that it is removed as soon as possible to reduce the risk of infection.
Pressure scars occur when there is an imbalance between the extrinsic mechanical forces that are acting on the skin and the soft tissues and the intrinsic susceptibility to the tissue to collapse (Frisch et al., 2014). The most frequent cause of pressure scars is an acute hip fracture, and approximately 35 percent of decubitus ulcers occur at the end of the first week of hospitalization. A patient with a history of smoking is also at a high risk of developing pressure scars. Our patient is a heavy smoker and he is at risk of developing pressure scars. Therefore, it would be prudent to ensure that nursing care is focused on prevention, there is aggressive skin care, and good nutrition is offered in order to prevent the evolution of ulceration.
Gastrointestinal postoperative stress ulcer is one of the well documented medical complications that patients who have undergone hip surgery suffer (Carpintero et al., 2014). For patients with a history of gastroduodenal ulcers, this condition will most likely develop if they underwent any major surgery. In order to prevent gastrointestinal bleeding, one should use pump inhibitors, and antacids, which have both been shown to be effective in this clinical situation. These methods have been shown they minimize the mortality and morbidity associated with the condition.
Since the patient is a carpenter there is a likelihood of them developing musculoskeletal complications. The patient spends long hours standing and moving heavy materials, which might aggravate their left hip. The muscle tissues of the hip are likely to be strained especially if they have not fully healed and this might increase their wear and tear. The patient is a heavy smoker and smoking has been known to have an effect on the musculoskeletal system of the individual.
It is estimated that 10 percent of patients who undergo hip fracture surgery will have cognitive complications after their surgery (Carpintero et al., 2014). However, most of these complications are mild. Delirium is one of the complications that patients will suffer especially after their surgery. Patients might reveal hyperactive or hypoactive cognitive status. Therefore, it is vital that a nurse looks out for either of this in the patient. As shown in the case Mr. Wolfe has a GCS of 14 and this means that he is conscious and responding to most of the nurse's interactions and requests, which would make it easy for the nurse to establish if he is suffering from delirium.
The Role of The Physiotherapist in Preventing Complications and Promoting Recovery
The physiotherapist will assess the patient's level of mobility, endurance, strength, and other physical abilities to establish the impact of the patient's injury on their physical function at work, rest, or play. The physiotherapist is charged with diagnosing the condition and developing the treatment plan aimed at restoring the patient's movement and reducing their pain or any limitations to the patient's movement. While treating the condition, the physiotherapist will assist the patient to understand the effect the condition will have on their normal functions. It is the physiotherapist's responsibility to measure the patient's progress regularly and adjust the treatment accordingly. Physiotherapists will also advise the patient on how they can manage the condition independently and they will assist the patient to prevent avoidable complications or recurrences (Aasvang, Luna, & Kehlet, 2015). This will be aimed at ensuring that the patient's recovery progresses well and there is no likelihood of them being hospitalized for the same condition. With a hip fracture, the advice provided will be in line with the patient's current work and health status, some recommendations might be made to change the lifestyle in order to promote the patient's recovery. The physiotherapist would also advise the patient on how they can prevent potential health problems before they arise. It is the responsibility of the physiotherapist to preempt some of the health problems that a patient might suffer and advise them accordingly to ensure that they do not arise.
Education Required for Mr. Wolfe Prior to Discharge to Support His Recovery at Home
It is essential to educate Mr. Wolfe on the importance of exercise when he is discharged. Most of the patients who undergo hip fracture surgery develop complications because they do not leave the bed. The patient should stay active and follow the exercise instructions provided by the health care provider. The patient should also be advised on what to expect in regards to his recovery. The normal occurrences like having bruises around the incision, the skin around the incision being red, or having a small watery fluid draining from their incision. These should be considered as normal and there is no need for alarm. However, in case they experience a foul smell or drainage that lasts longer than 3 days after their surgery then they should seek medical advice immediately. The patient can continue with his normal work, but he should ensure that he learns how to prevent any falls by having a clean working environment. Mr. Wolfe should also be discouraged from carrying any heavy items. Putting a lot of pressure and weight on the hip before it has fully healed might cause it fracture again and this will result in hospitalization. Since the patient lives alone, it is recommended that he seeks assistance from a close friend or relative to ensure that they have someone looking after them at all times. If there is no one who can be at home to assist the patient, then a trained caregiver should be recommended for the patient to assist them at home in the first 1 to 2 weeks.
Conclusion
This paper has shown that hip fractures could result in deadly complications if the patient is not well taken care of, but with proper nursing and medication this procedure could be smooth and the patient would recover fully in a short time. Understanding the medical complications related to the condition is vital to ensure that nurses can be on the lookout for these complications and be prepared to handle them when they manifest themselves. Post-operative complications are avoidable and they should be mitigated early to increase the patient's mortality. Education should also be offered to the patient on how they can manage the condition once they are discharged in order to promote recovery and reduce the chance of hospitalization.


Appendix
NURSING CARE PLAN
Potential Complication
Nursing intervention
Rationale for intervention

1. Risk of Infection
1. Encourage good handwashing by the patient and staff (Polnaszek et al., 2015).

1. Hand washing has been shown to be the single most effective method for preventing infections especially for patients (Polnaszek et al., 2015).


2. Maintain the patency of the drainage devices, and note characteristics of wound discharge (Prestmo et al., 2015).



2. This will assist in reducing the risk of infection by preventing the accumulation of blood and secretions in the joint space. Purulent, odorous, nonserous drainage is an indication of infection and continuous drainage from the incision may reflect developing skin tract (Prestmo et al., 2015).


3. Assessing the skin/incision color, integrity, and temperature. Nurse should take note of any presence of erythema or inflammation (Lopes & de Souza, 2017).
3. This will provide information regarding the status of the healing process and it also alerts the staff to early signs of infection (Lopes & de Souza, 2017).



Potential Complication
Nursing intervention
Rationale for intervention

2. Peripheral Neurovascular Dysfunction
1. Assessing the motion and sensation of the operated extremity (Prestmo et al., 2015).


1. In case there is increasing pain, tingling, or numbness, the patient is unable to perform expected movements might suggest nerve injury, compromised circulation, or dislocation of prosthesis, which would require immediate intervention (Prestmo et al., 2015).


2. Palpate pulses on both sides. Nurse should evaluate capillary refill and the skin color and temperature. Comparison should be made with the non-operated limb (Polnaszek et al., 2015).



2. In case there is diminished or absent pulses, pallor, blanching, delayed capillary refill time, coldness of skin, and cyanosis would reflect there is diminished circulation or perfusion. Comparing with the unoperated limb would offer the clues to establish if the neurovascular problem is generalized or localized (Polnaszek et al., 2015).


3. Monitoring the amount and characteristics of drainage on the dressings and from the suction device. Special attention should be paid to swelling in the operative area (Lopes & de Souza, 2017).
3. This may indicate there is excessive bleeding and hematoma formation, which could potentiate neurovascular compromise (Lopes & de Souza, 2017).




Potential Complication
Nursing intervention
Rationale for intervention

3. Acute Pain
1. Assess the reports of pain, and note the intensity, location, and duration (Lopes & de Souza, 2017).
1. This would provide the necessary information to establish effective interventions and monitoring if the interventions are effective in alleviating the pain (Lopes & de Souza, 2017).


2. Providing comfort measure and diversional activities. Encourage stress management techniques, and provide therapeutic touch as appropriate (Prestmo et al., 2015).


2. This reduces muscle tension, refocuses the patient's attention, promotes sense of control, and it may enhance the patient's coping abilities in the management of their discomfort or pain, which might persist for an extended period of time (Prestmo et al., 2015).


3. Investigate any reports of sudden, severe joint pain with muscle spasms and any changes in joint mobility. Investigate any sudden, sever chest pain with restlessness and dyspnea (Polnaszek et al., 2015).

3. The early recognition of any developing problems like dislocation of prosthesis or pulmonary emboli will provide an opportunity for prompt intervention and the prevention of more serious complications (Polnaszek et al., 2015).



Potential Complication
Nursing intervention
Rationale for intervention

4. Deficient Knowledge
1. Stress the importance of continuing with the prescribed exercise or rehabilitation program within the patient's tolerance this include cane, crutch, weight bearing exercises, walking, swimming, or stationary bicycling (Polnaszek et al., 2015).
1. Exercises will increase muscle strength and joint mobility. A majority of patients will be involved in formal rehabilitation or outpatient homecare programs. Muscle aching would indicate there is too much weight bearing or activity, which signals a need to cut back on the exercise or activity (Polnaszek et al., 2015).


2. Review the process of the disease, surgical procedure, and the future expectations.
2. This will provide the requisite knowledge base from which the patient can make better and informed decisions or choices.


3. Encourage the patient to alternate resting periods with activity.
3. This will assist the patient in conserving energy for healing and it also prevents undue fatigues, which can increase the risk of injury or falls.





References
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Breathnach, O., Karip, E., McCoy, G., Cleary, M., & Quinlan, J. (2016). Post-operative prevention of venous thromboembolism in hip and knee arthroplasty surgery: a study of the combined use of low molecular weight heparin and rivaroxaban. J. Orthop. Res. Physiother., 2, 020.
Carpintero, P., Caeiro, J. R., Carpintero, R., Morales, A., Silva, S., & Mesa, M. (2014). Complications of hip fractures: A review. World journal of orthopedics, 5(4), 402-411.
Frisch, N. B., Wessell, N. M., Charters, M. A., Yu, S., Jeffries, J. J., & Silverton, C. D. (2014). Predictors and complications of blood transfusion in total hip and knee arthroplasty. The Journal of arthroplasty, 29(9), 189-192.
Lanting, B. A., Odum, S. M., Cope, R. P., Patterson, A. H., & Masonis, J. L. (2015). Incidence of perioperative events in single setting bilateral direct anterior approach total hip arthroplasty. The Journal of arthroplasty, 30(3), 465-467.
Lopes, G. D., & de Souza, S. R. (2017). Factors that interfere with quality of life after total hip arthroplasty. Northeast Network Nursing Journal, 18(2).
Polnaszek, B., Mirr, J., Roiland, R., Gilmore-Bykovskyi, A., Hovanes, M., & Kind, A. (2015). Omission of physical therapy recommendations for high-risk patients transitioning from the hospital to subacute care facilities. Archives of physical medicine and rehabilitation, 96(11), 1966-1972. e1963.
Prestmo, A., Hagen, G., Sletvold, O., Helbostad, J. L., Thingstad, P., Taraldsen, K., . . . Lamb, S. E. (2015). Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. The Lancet, 385(9978), 1623-1633.
Smith, T. O., Aboelmagd, T., Hing, C., & Macgregor, A. (2016). Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Bone Joint J, 98(9), 1160-1166.
Whiting, P. S., Molina, C. S., Greenberg, S. E., Thakore, R. V., Obremskey, W. T., & Sethi, M. K. (2015). Regional anaesthesia for hip fracture surgery is associated with significantly more peri-operative complications compared with general anaesthesia. International orthopaedics, 39(7), 1321-1327.