Care of the Older Adult With Fragility Hip Fracture   34  

Anita J. Meehan, Ami Hommel, Karen Hertz, Valerie MacDonald, and Ann Butler Maher

OVERVIEW

The global incidence of fragility hip fractures continues to rise on an annual basis making it one of the most common causes of hospital admission following trauma for older adults. In 1990, the global incidence of hip fracture was approximately 1.26 million; conservative estimates indicate that this number will burgeon to between 4.5 and 6.3 million by 2050 (Gullberg, Johnell, & Kanis, 1997). Fragility fracture treatment is expensive. Annual cost to treat fragility fractures in the United States in 2005 was $17 billion, with hip fractures accounting for 72% of these expenses (Burge et al., 2007); these costs will increase with the growing aging population. Rehabilitation is not always successful. A study by Bertram, Norman, Kemp, and Vos (2011) found that 1 year after fragility hip fracture, 29% of patients did not achieve their prefracture level of function for activities of daily living (ADL).

Despite advances in anesthesia, nursing care, and surgical techniques, this injury can be overwhelming for both patient and family, often resulting in permanent disability and increased reliance on others. Evidence-based interventions to reduce common complications and prevent secondary fractures are crucial to maximize recovery for individuals as well as decrease mortality and contain health care costs. Nurses are in an optimal position to make a significant difference for patients who suffer a fragility fracture.

BACKGROUND AND STATEMENT OF PROBLEM

Hip fracture is the most devastating of all fragility fractures with risk of long-lasting disability and significant morbidity and mortality (Bass, French, Bradham, & Rubenstein, 2007). Although the vast majority of people who suffer a hip fracture are older females, the number of men suffering from fragility hip fracture is increasing, with as many as one third of all hip fractures occurring in men (Gullberg et al., 1997).

As the age of patients sustaining hip fracture continues to trend upward and include more of the very old (older than 90 years), the incidence of coexisting medical problems and subsequent complications will increase (Bergström et al., 2009). Studies show that many of those who survive do not regain their prefracture level of independence (Andrew, Freter, & Rockwood, 2005; Bentler et al., 2009; Bertram et al., 2011). According to the American Academy of Orthopaedic Surgeons (AAOS) position statement on hip fractures in seniors (AAOS, 1999), 44% of nursing home admissions for fracture are result from a hip fracture; as many as 50% of these individuals lived independently before hip fracture, but were unable to walk unaided after fracture.

Mortality rates after hip fracture are significant as well, with rates reported as 10% within 1 month and from 18% to 33% after 1 year (Bentler et al., 2009). Functional decline and subsequent death are attributable to the complex interplay of surgical stress, comorbidity, prefracture frailty, and level of physical and cognitive functions. Although the fracture itself is responsible for less than half of the deaths (Parker & Johansen, 2006), families often identify the hip fracture as playing a central role in the patient’s decline.

Decades of research shows that half of those who sustain a fragility hip fracture have had a previous fragility fracture (Edwards, Bunta, Simonelli, Bolander, & Fitzpatrick, 2007; Gallagher, Melton, Riggs, & Bergstrath, 1980). Despite evidence demonstrating benefits of early detection of osteoporosis and implementation of strategies to reduce fracture risk (Akesson et al., 2013, Greene & Dell, 2010; Newman, Ayoub, Starkey, Diehl, & Wood, 2003), studies reveal that these recommendations are not being applied in practice (Ellanti et al., 2014; Mitchell, 2013; Sobolev, Sheehan, Kuramoto, & Guy, 2015).

Nurses are ideally positioned to play a pivotal role in preventing or ameliorating common complications associated with fragility hip fracture, such as pain, delirium, venous thromboembolism (VTE), malnutrition, pressure ulcers, infections, fluid and electrolyte imbalances, and functional decline, and to manage programs focused on secondary fracture prevention.

DEFINITION OF FRAGILITY HIP FRACTURE

A fragility fracture is defined as a break in the bone resulting from low-impact trauma, such as falling from a standing height or less, or one that occurs in the absence of significant trauma. Hip fracture is a collective term for different types of fractures in the proximal end of the femur. The type and location of the fracture will determine how the fracture is repaired, specific postoperative restrictions, and how quickly healing will progress. Hip fracture location can be broadly categorized into two areas: intracapsular and extracapsular. Intracapsular fractures occur within the capsule that forms the hip joint and involve the head and neck of the femur. Fractures outside the capsule are further described as trochanteric or subtrochanteric fractures.

The most common location for a fragility hip fracture is the femoral neck (45%–53%) followed by intertrochanteric fractures (38%–49%) and, less often, subtrochanteric fractures (5%–15%; Marks, Allegrante, Ronald MacKenzie, & Lane, 2003; Figure 34.1). A large prospective study of more than 220,000 persons found that people who suffered fractures around the trochanters tended to be older with poorer health status, longer hospital stays, and poorer functional recovery (Fox, Magaziner, Hebel, Kenzora, & Kashner, 1999).

FIGURE 34.1

Common sights of hip fracture.

Adapted from the Centre for Hip Health and Mobility.

SURGICAL REPAIR OF HIP FRACTURE

When the bone breaks, the broken pieces may remain in their original position and the fracture is said to be nondisplaced. A displaced fracture occurs if the broken pieces move out of alignment. Surgical treatment approaches depend on a variety of factors, including quality of the bone and postsurgical rehabilitation potential. A nondisplaced fracture may be stabilized using percutaneously inserted pins (Figure 34.2). If the fracture is displaced, or out of alignment, the blood supply to the area is often compromised and patients will generally do better if some of the components of the hip are replaced. If both the ball and the socket, or acetabulum, are replaced the procedure is referred to as a total hip replacement (Figure 34.2). If only the head of the femur is replaced, the procedure is referred to as a hemiarthroplasty (Figure 34.3). A nondisplaced fracture around the trochanters may be repaired with a large screw that slides within the barrel of a plate that is screwed to the side of the femur. This type of fixation will stabilize the fracture over time by impacting the broken area on itself, thus stimulating new bone growth, and is called a dynamic or compression hip screw (Figure 34.4). A subtrochanteric fracture, distal to the trochanters is commonly fixed with an intermedullary rod and stabilized with a large screw (Figure 34.5). Regardless of the type of fixation, postoperatively the goal is to advance the patient to maximum weight-bearing status as quickly as possible. The type of surgical fixation and quality of the bone will determine weight-bearing limitations and/or postoperative positioning restrictions.

FIGURE 34.2

Total hip replacement (right hip) and cannulated screws (left hip).

Image courtesy of Dr. K.G. Thorngren, Lund University Hospital.

FIGURE 34.3

Hip procedures.

Adapted from the Centre for Hip Health and Mobility.

FIGURE 34.4

Compression or dynamic hip screw.

Image courtesy of Mr. Phillip Roberts, University Hospital of North Midlands.

FIGURE 34.5

Intramedullary rod.

Image courtesy of Mr. Phillip Roberts, University Hospital of North Midlands.

Fracture Repair as a Palliative Measure

The 1-year mortality rate following hip fracture is around 30% (Pugely et al., 2014). Those most likely to die in the first year have advanced age, severe comorbidity, poor ambulation abilities, severe dementia, and reside in a facility (Hu, Jiang, Shen, Tnag, & Wang, 2012; Pugely et al., 2014; Wiles, Moran, Sahota, & Moppett, 2011). The fall and hip fracture may be precipitated by a cardiorespiratory, metastatic, or neurological condition. For patients with advanced age, severe comorbid illness, and high dependency needs, the hip fracture surgery may be viewed as a palliative intervention performed with the goal of reducing pain and improving the quality of life (Ko & Morrison, 2014a, 2014b; Leland, Teno, Gozalo, Bynum, & Mor, 2012). For more detailed information, see Chapter 37, “Palliative Care Models.”

PATHOPHYSIOLOGY

Fragility hip fracture is a painful sequela of poor bone quality and a traumatic event, often involving a fall. In adults, small amounts of bone mineral are lost as osteoclast cells clean up old bone, in a process known as resorption. These bone minerals are replaced by bone-building cells called osteoblasts in a process known as remodeling. With aging, the loss of bone occurs progressively and asymptomatically, accelerating in women after menopause. When the balance tips toward excessive resorption, bones weaken (osteopenia) and over time can become brittle and prone to fracture (osteoporosis). Based on a number of factors, men develop greater bone strength as they mature and lose bone strength more slowly, in part because of a more gradual loss in sex hormone levels with aging (Willson, Nelson, Newbold, Nelson, & LaFleur, 2015).

A fracture is often the first indication of diminished bone health. Approximately 10 million people in the United States have osteoporosis and as the population continues to age an increasing number of people will be affected by this disease (Wright et al., 2014).

Risk Factors for Fragility Hip Fracture

Falling is the leading cause of hip fracture in older adults. Determination of the circumstances precipitating a fall and fracture is essential to illuminate underlying issues that need to be addressed in addition to the fracture. Intrinsic factors, such as acute medical conditions, exacerbation of chronic conditions, visual or balance problems as well as extrinsic factors including environmental factors and life style, contribute to increasing the risk of falling.

Intrinsic Fall Risk Factors

Normal age-related changes affecting vision, hearing loss, balance and/or gait disturbances coupled with a slowed reaction time are factors that contribute to increased fall risk in older adults. In addition, many older adults have underlying chronic conditions or an acute event that may result in a fall. A neurologic event, cardiac condition, dehydration, urge incontinence, or underlying infection may contribute to increasing the risk of falling and subsequent fracture. Medications may have anticholinergic side effects that increase fall/fracture risk, for example, dizziness or blurred vision.

Sarcopenia is an age-related decline in muscle bulk and quality that may escalate the risk of fracture, especially if associated with diminished functional mobility, reduced lower quadriceps strength, and poor balance or body sway. Sarcopenia and osteoporosis are linked from a biological and functional perspective and increase fracture risk in the elderly. The elevated fracture risk from sarcopenia and osteoporosis is a result of the decline of muscle mass and strength, the decrease in bone mineral density (BMD), and limited mobility (Tarantino et al., 2015).

Extrinsic Fall Risk Factors

Environmental tripping hazards, for example, small pets, clutter, or poor fitting footwear, may contribute to increasing fall risk. Alcohol or drug use may impair balance and/or cause drowsiness or delirium. Another concern in this population is elder abuse. Inspect the patient as part of the admitting head-to-toe assessment to ensure that the circumstances of the fall are consistent with the pattern of injury. (For more detailed information, see Chapter 13, “Mistreatment Detection”; Chapter 19, “Preventing Falls in Acute Care”; and Chapter 28, “Substance Misuse and Alcohol Use Disorders.”)

Diminished Bone Strength

The other risk factor that contributes to increasing the risk of fragility fracture is bone loss associated with aging. There are several factors that increase the risk of bone loss.

Assessment of Bone Health and Fracture Risk

There are two widely used measures to determine bone health and fracture risk. The World Health Organization (WHO) developed the Fracture Risk Assessment Tool (FRAX) in 2008 (Kanis, Johnell, Oden, Johansson, & McCloskey, 2008). The FRAX is a major achievement in helping to determine which patients may suffer a fragility fracture (Vernon & King, 2011) as well as those who may be candidates for pharmacological therapy for osteoporosis (Watts, 2011). The FRAX contains 12 variables used to calculate risks such as BMD, including age, low body mass index, previous fragility fracture, parental history of fracture, glucocorticoid treatment, current smoking status, rheumatoid arthritis history, alcohol intake, and other secondary causes of osteoporosis. The FRAX takes approximately 20 minutes to complete, and provides a qualitative estimate of 10-year fracture risk. Its intended use is for those not currently being treated for osteoporosis. The FRAX is commonly administered in conjunction with dual-energy x-ray absorptiometry (DEXA scan; www.shef.ac.uk/FRAX/tool.jsp).

The DEXA scan is the most widely used method to evaluate BMD. The WHO uses BMD measured by the DEXA to define osteoporosis. A DEXA scan measures the density of bone at two areas, the proximal femur and the lumbar spine. The results are reported as a T- and a Z-score. The standard measure T-score is 0.0 representing bone density of a young healthy individual at peak bone health. According to WHO criteria (Kanis et al., 2008) a T-score higher than −0.1 is considered normal bone density, a T-score between −1.0 and −2.5 is considered osteopenia, and a T-score below −2.5 is considered osteoporosis. The Z-score is a comparative measure of persons of the same age and gender as the patient and can be used to evaluate men, children, and premenopausal women. A Z-score measure of −2.0 is considered low bone mass for chronological age and a Z-score of above −2.0 is considered within the expected range for age (National Osteoporosis Foundation [NOF], 2010).

Although BMD using the DEXA is considered the gold standard surrogate marker of bone health, and assessment of fracture risk is completed using the FRAX, there are newer measures being reported in the literature that hold promise as measures of bone health and treatment monitoring (Fitton, Astroth, & Wilson, 2015). Bone turnover markers (BTM) are measures of byproducts of protein secreted by bone-forming osteoblasts, measured in serum, and bone-resorbing osteoclasts, measured in urine. Unlike the DEXA, which evaluates specific skeletal sites, these markers reflect global skeletal activity and have the potential to be used to monitor effectiveness of treatment (Kleerekoper, 2001). Another approach under investigation is the use of MRI to evaluate bone marrow adipose tissue (BMAT). A study conducted by Li et al. (2014) found that women with osteopenia and osteoporosis had a higher marrow fat content compared to those with normal BMD. There is growing attention to the use of bone turnover markers and BMAT as biomarkers for bone quality (Burch et al., 2014; Li et al., 2014; Tang et al., 2010).

COMMON COMPLICATIONS AND EVIDENCE-BASED NURSING CARE STRATEGIES

Although in most cases surgical repair is crucial, optimal outcome depends on an interprofessional approach to care. Advanced age, chronic conditions, and diminished physical and cognitive reserves expose older adults with fragility hip fracture to an increased risk for the development of specific geriatric syndromes. Nursing care that includes evidence-based strategies to engage both patient and family in learning about risk factors, prevention, and management of complications such as delirium, pressure ulcers, VTE, malnutrition, constipation, fluid and electrolyte imbalances, functional decline, infections, and prevention of secondary fractures is crucial (Maher et al., 2012, 2013).

Although many of these complications are experienced by hospitalized older adults and most are discussed elsewhere in this book, they coalesce in the hip fracture patient population to increase morbidity and mortality and significantly reduce the individual’s prospects for maximum functional recovery. Nurses play a vital role in ameliorating these risk factors and ensuring optimal outcomes.

PAIN: SIGNIFICANCE IN HIP-FRACTURE PATIENTS

A fall, hip fracture, and surgical repair are painful assaults injuring the skin, muscle, and bone. Older patients with hip fractures are at high risk of unmanaged pain with higher rates of delirium, impaired mobility, and long-term functional impairment as a result (Bjorkelund, Hommel, Thorngren, Lundberg, & Larsson, 2011; Morrison et al., 2003). Unmanaged pain disturbs sleep, diminishes appetite, and may also increase the risk of delirium (American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009; Vaurio, Sands, Wang, Mullen, & Leung, 2006). Painful conditions, such as osteoarthritis, osteoporotic fractures, degenerative spine disease, cancer, and neuralgias, increase in prevalence with age and may add to the pain experience for patients with hip fracture (American Geriatrics Society Panel on the Pharmacological Management of Persistent Pain in Older Persons, 2009).

Nursing Management Strategies to Address Pain

There is a paucity of evidence on pain management for patients with hip fractures. Studies often exclude those with delirium, dementia, and/or severe comorbid illness because of challenges with communication and obtaining consent. Approximately 40% of the population, the most vulnerable, are often excluded. Expert opinion supplements the evidence for this section.

As functional mobility is the key to recovery, a balanced approach to pain management is required to achieve both mobility and comfort. Frequent evidence-based pain assessment is the foundation for effective pain management. Using an evidence-based pain history tool and screening health records for preexisting painful conditions and prior pain treatments illuminate potential sources of discomfort and considerations for the treatment plan. Assessing and recording pain intensity using a valid scale with vital signs make the pain assessment visible and help ensure that pain is assessed on a regular basis (Purser, Warfield, & Richardson, 2014). The specific pain scale used would be based on the patient’s comprehension and preference (Herr & Titler, 2009). For patients with severe cognitive impairment, one should use a validated pain behavior scale (Herr, Coyne, McCaffery, Manworren, & Merkel, 2011). For information on specific pain assessment tools, see Chapter 18, “Pain Management.”

A multimodal approach to analgesia helps maximize the synergistic effect of analgesics while decreasing the dose requirement of any one medication, thereby limiting their adverse effects (Kehlet & Dahl, 2003). A combination of a geriatric-appropriate opioid together with acetaminophen and regional analgesia (e.g., nerve block) may manage pain while reducing side-effects such as sedation and delirium (Kang et al., 2013). Nonpharmacological strategies, such as relaxation exercises, physiotherapy, and application of heat or cold, may reduce opioid requirements and improve comfort (Abou-Setta et al., 2011; Pellino et al., 2005). Nonsteroidal anti-inflammatory medications are usually not recommended because of their higher rates of adverse effects, such as bleeding and cardiovascular complications, in older patients (American Geriatrics Society 2012 Beers Criteria Update Expert Panel, 2012).

Minimizing sedation while maximizing pain control is a goal to facilitate mobility. Strategic timing of analgesics can help alleviate the increased pain of mobilization and reduce the need for additional opioid doses. Identify the time of the peak effect of the specific analgesic and route of administration and administer the analgesic when peak effect will coincide with physiotherapy or ambulation.

Nerve block (e.g., femoral and fascial iliacal) is effective in relieving the acute pain of hip fracture compared with standard care (Abou-Setta et al., 2011; AAOS, 2014). The nerve block is typically administered before surgery and provides substantial perioperative pain relief reducing the need for opioid analgesia and the risk of delirium (Beaudoin, Nagdev, Merchant, & Becker, 2010). Nurse-initiated fascial iliacal blocks have improved pain management effectiveness and safety (Dochez et al., 2014).

Managing moderate to severe pain after hip fracture usually involves the administration of opioids. Older adults are more susceptible to the adverse effects of opioids and a “start low/go slow” approach to opioid administration is advised. This approach is not appropriate if the patient was on opioid therapy before admission as a higher dose may be required. An individualized approach considering the patient’s opioid use history with careful monitoring and titration of analgesic to achieve an acceptable pain level is essential.

Strategies to Manage Adverse Effects of Analgesics

Oversedation is a serious adverse effect of opioid therapy that could lead to respiratory failure. According to Pasero (2009), the level of sedation increases gradually and is a warning sign requiring a prompt reduction in opioid use with more frequent monitoring. The first 24 hours of opioid therapy are the riskiest time, and sedation assessment using a validated tool every hour is recommended, with reduction to every 4 hours thereafter if the patient is stable (Pasero, 2009). The Pasero Sedation Scale is recommended as a validated tool that defines levels of sedation as well as actions to take for patient comfort and safety.

Constipation is highly likely to occur and increases the risk of abdominal and rectal pain, delirium, agitation, and bowel obstruction (Neighbour, 2014). Although individual bowel habits vary, in general, the goal is that the patient has a moderate to large bowel movement (BM; e.g., at least 8 ounces) every 48 hours (Auron-Gomez & Michota, 2008) and daily monitoring of BMs is required. The pre-emptive use of laxatives, a high-fiber diet, and fluids are recommended (Neighbour, 2014).

Other practice recommendations include:

Nausea and vomiting are potential adverse effects of opioids and are typically managed with antiemetic medication. However, medications with anticholinergic properties should be avoided, as they can cause delirium (American Geriatrics Society 2012 Beers Criteria Update Expert Panel, 2012). Delirium can also be an adverse effect of analgesics; however, delirium is also associated with unmanaged pain. Assessing and adjusting the medication or reducing the dose of analgesics are interventions that may reduce the analgesic contribution to delirium (Maher et al., 2012). For more information on analgesic adverse effects, see Chapter 18.

DELIRIUM: SIGNIFICANCE IN HIP-FRACTURE PATIENTS

Delirium is the most common complication associated with hip fracture. Studies reveal that between 16% and 62% of patients develop delirium following hip fracture (Bitsch, Foss, Kristensen, & Kehlet, 2004; J. J. White, Khan, & Smitham, 2011). One of the strongest predictors of postoperative delirium is preoperative cognitive dysfunction (Oh et al., 2014). Cognitive impairment is common in this population; Griffiths et al. (2012) report that approximately 25% of hip fracture patients have a moderate cognitive impairment. Lundstrom, Stenvall, and Olofsson (2012) studied 129 patients with hip fracture who developed postoperative delirium and found that patients with delirium superimposed on dementia (54%) displayed hyperactive symptoms, while those without base line dementia more commonly displayed symptoms of hypactive delirium.

Multiple studies report that delirium is independently associated with a variety of adverse outcomes including pressure ulcers, functional decline, institutionalization, and death (Andrew et al., 2005; Bellelli et al., 2014; Krogseth, Wyller, Engedal, & Juliebo, 2014; McAvay et al., 2006). Patients with persistent delirium are 2.9 times more likely to die within 1 year than those whose delirium resolves (Kiely et al., 2009). The ability to differentiate between dementia and delirium is important because unlike dementia, the cognitive changes in delirium are potentially preventable, and are likely reversible. Despite its prevalence, significant cost, and negative outcomes, nurses and physicians often fail to recognize delirium, especially when dementia or the hypoactive form of delirium is present (Lemiengre et al., 2006; Steis & Fick, 2008).

Nursing Management Strategies for Delirium

Determination of baseline cognition is an essential first step in the assessment of delirium. In addition, patients who have developed delirium in the past are at increased risk for recurrance so it is important to ask about any prior episodes. It is also important to ask about alcohol or other drug use in order to avoid having the patient experience withdrawal symptoms during hospitalization. Often family is the best source of this information. Although delirium cannot be prevented in every instance, optimal results are achieved by clinicians who are knowledgable of the risk factors and take preventive action. Martinez, Tobar, and Hill (2015), who conducted a systematic review of nonpharmacological, multicomponent interventions for delirium, found that strategies such as ensuring access to sensory aids, providing a restful environment, ensuring adequate hydration and nutiriton, and adequate and appropriate pain control are effective in reducing incident delirium and recommend inclusion as a standard of care for older adult inpatients. Vigilant screening and documenting of cognitive assessment will increase the liklihood that delirium is detected early and underlying causes identified and addressed. Delirium is a frightening experience for the patient and family. Conversations should be initiated with families on admission to educate them on the risks and reinforce the vital role they play in providing a sense of familiarity, comfort, and reassurance (American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults, 2015).

The management of postoperative pain can be especially challenging in the delirious patient. It is not uncommon for the surgeon to withdraw or reduce analgesia as a way to reduce agitation associated with acute confusion. However, inadequate pain control may also contribute to delirium (Morrison et al., 2003). (For more detailed information, see Chapter 17, “Delirium: Prevention, Early Recognition, and Treatment,” and Chapter 18.)

MALNUTRITION: SIGNIFICANCE IN HIP-FRACTURE PATIENTS

It is estimated that as many as 63% of patients with fragility hip fracture are malnourished at the time of admission (Wyers et al., 2010). Circumstances before and surrounding the fall and fracture coupled with processes of care, such as prolonged restriction of solid food while awaiting surgery, combine to increase the risk for malnutrition. The stress of the acute injury and surgical intervention results in postoperative nutritional intake that routinely fails to meet energy and protein requirements, contributing to further deterioration in nutritional status (Bell, Bauer, Capra, & Pulle, 2013). Surveys of dietary intake of patients recovering from hip fracture reveal a less-than-optimal dietary intake (Lumbers, New, Gibson, & Murphy, 2001).

Lack of adequate nutrition leads to lowered cognitive function, lean muscle wasting, weakness, and impaired cardiac function, all of which contribute to impaired mobility and an increased risk of developing postoperative complications (Wyers et al., 2010). Duration of preoperative fasting is also a precipitating and modifiable risk factor for postoperative delirium (Radtke et al., 2010). A descriptive cohort study of 428 older adults with hip fractures revealed that preoperative fasting of 12 hours or longer was a risk factor for development of delirium and an increased risk for mortality at 4 months postoperatively (Bjorkelund et al., 2011). Fry, Pine, Jones, and Meimban (2010) looked at the records of more than 800,000 surgical patients from more than 13,000 hospitals and found that malnutrition was an independent risk factor for developing a number of hospital-acquired infections (Table 34.1).

Although common preoperative fasting time in the United States remains “NPO (nothing by mouth) after midnight,” a growing number of organizations have endorsed liberalizing food and fluid restrictions (American Society of Anesthesiologists Committee, 1999; American Society of Anesthesiologists Committee on Preoperative Fasting, 1999; Braga et al., 2009). Evidence supports that patients with no specific risk of aspiration may drink clear fluids up to 2 hours before anesthesia and have solid foods up to 6 hours before surgery. The maximum period of oral fasting should be no greater than 12 hours under any circumstances (Shiga, Wajima, & Ohe, 2008).

TABLE 34.1

Complications Associated With Malnutrition

Adapted from Fry, Pine, Jones, and Meimban (2010).

Emerging evidence suggests that in addition to liberalizing fasting restrictions, in select patients, prescribing a clear carbohydrate-rich beverage, such as apple juice, to be consumed 2 to 3 hours before surgery, can reduce the negative consequences of preoperative fasting, which include postoperative nausea and vomiting, loss of muscle strength, and postoperative insulin resistance (Hausel et al., 2001; Melis et al., 2006; Nygren, Thorell, & Ljungqvist, 2015; Yagci et al., 2008).

The AAOS guidelines for management of hip fractures in the elderly (Roberts & Bronx, 2014), the European Pressure Ulcer Advisory Panel (EPUAP), and National Pressure Ulcer Advisory Panel (NPUAP, 2014) support offering a high-protein oral nutritional supplement in addition to regular diet for patients at nutritional risk caused by chronic or acute illness following surgery. A systematic review of nutritional interventions provided to older adults recovering from hip fracture found only weak evidence to support benefits of protein and energy feedings; however, the authors did note the lack of a consistent definition of malnutrition in the studies reviewed. The reviewers did comment that patients who were malnourished benefitted more from high-protein oral supplements more than those who were not malnourished (Avenell & Handoll, 2010).

Nursing Management Strategies for Malnutrition

Nutritional screening is suggested for all hospitalized patients (Mueller, Compher, Druyan, & American Society for Parenteral and Enteral Nutrition [ASPEN] Board of Directors, 2011). Prompt referral to a registered dietitian for at-risk patients should be a nursing priority and is essential in order to curtail the negative consequences associated with malnutrition (Jefferies, Johnson, & Ravens, 2011). Nurses should be aware of the potential for swallowing problems in this population. A prospective cohort study of 181 patients after hip-fracture surgery found that 34% presented with oropharyngeal dysphasia within 72 hours after surgery. Common factors in those with swelling problems included preexisting dementia, postoperative delirium, and preexisting respiratory problems (Love, Cornwell, & Whitehouse, 2013). Early identification and referral to speech therapy for a more comprehensive swallow evaluation are essential to avoid aspiration pneumonia.

Implementation of protocols that liberalize preoperative fasting in accordance with existing guidelines should be advocated for patients who have no specific risk of aspiration, for example, gastroparesis. Evidence-based protocols should include orders to advance the diet as tolerated after surgery (Association of Anaesthetists of Great Britain & Ireland, 2014). Nursing staff should monitor dietary intake and notify a dietitian if a consistent pattern of consuming less than 50% of meals is observed. For patients who are malnourished, incorporating a high-protein oral nutritional supplement, as part of the daily medication pass, is an effective strategy to enhance the likelihood of consumption and embed a nutritional intervention into the routine process of care (Breedveld-Peters et al., 2012; Dillabough, Mammel & Yee, 2011; Meehan et al., 2016). For more detailed information, see Chapter 10, “Nutrition.”

FLUID AND ELECTROLYTE IMBALANCE: SIGNIFICANCE IN HIP-FRACTURE PATIENTS

Patients admitted for hip fracture are at risk of dehydration, electrolyte disturbances, fluid overload, and heart failure because of advanced age and comorbid conditions (Bukata et al., 2011). White, Rashid, and Chakladar (2009) found renal dysfunction in 36% of patients admitted with hip fracture, whereas Carbone et al. (2010) cited the incidence of heart failure as 21% in this patient population.

Dehydration

Older adults admitted with hip fracture often present with dehydration for a variety of reasons. These include preexisting restricted fluid intake, diminished thirst reflex with subsequent diminished fluid intake, and prolonged time from injury to discovery and initiation of care. Many patients who suffer from incontinence or frequency self-regulate fluid intake to reduce the risk of incontinence or they may have difficulty accessing toilet facilities. Diuretic use is high in this patient group and may be partly responsible for altered fluid balance.

Because dehydration diminishes perfusion to both organs and tissues, it is implicated in the development of a range of conditions and complications prevalent in the hip-fracture population, such as delirium, acute kidney injury (AKI), pressure ulcers, falls, VTE, and urinary tract infections.

Fluid Overload/Heart Failure

Preexisting heart failure or renal conditions that increase fluid load will worsen with the stress of the injury and subsequent surgery. This diminished cardiac and renal function renders the frail older adult more susceptible to fluid overload. For a detailed discussion, see Chapter 30, “Fluid Overload: Identifying and Managing Heart Failure Patients at Risk of Hospital Readmission.”

Electrolyte Imbalance/Acute Kidney Injury

Electrolyte imbalances, particularly hyponatremia and hypokalemia, are common in the postoperative period, reflecting limited renal reserve (Maher et al., 2013). Diuretics and inappropriate maintenance of intravenous fluids may exacerbate the situation. Limited renal reserve is also reflected in the high risk of AKI in hip-fracture patients, which is estimated to be 16% (Bennet, Berry, Goddard, & Keating, 2010) and is associated with prolonged hospital stay, increased morbidity and mortality, and poor outcome (Ulucay et al., 2012).

Older patients admitted to hospital for emergency surgery are at increased risk of AKI and its associated pre- and postoperative complications. Risk factors include preexisting comorbid conditions, age, complex polypharmacy, and use of diuretics, nephrotoxic medications such as angiotensin-converting enzyme inhibitors (ACE inhibitors) used in the management of hypertension and heart failure, and nonsteroidal anti-inflammatory drugs (NSAIDs) used for pain relief. Time spent down before discovery as well as immobility before surgery also increases the risk of rhabdomyolysis. The most significant complication of rhabdomyolysis is AKI (Torres, Helmstetter, Kaye, & Kaye, 2015).

Nursing Management Strategies: Fluid and Electrolyte Imbalances

Optimized perioperative fluid management helps in controlling the frequent incidence of dehydration in hip-fracture patients while avoiding volume overload, which is crucial as many of these patients have coexisting cardiac disease (Bukata et al., 2011). Strict fluid balance monitoring that begins in the emergency department (ED) and continues throughout the acute hospitalization is essential.

Dehydration

Factors that add to the normal risk of dehydration in this population include preoperative fasting and surgical blood loss. A short period of preoperative fasting supported by intravenous fluids with early resumption of oral intake in the postoperative period is optimal. Environmental factors, such as limited access to fluids, visual impairments, and drinking containers that are difficult to handle, may compound the problem. Hourly rounding that includes proactive offering of fluids as well as mouth care are two important nursing interventions.

Fluid Overload

Ensure that regular diuretics are administered as prescribed, monitor vital signs, maintain accurate documentation of fluid balance, and promptly report alterations in the patient’s clinical and cognitive status.

The stress of surgery leads to an increased secretion of the antidiuretic hormone (ADH), which impairs the ability to excrete sodium and water. Symptoms to monitor include urinary output less than 30 mL/hr, increasing blood pressure, shortness of breath, moist breath sounds, and dependent edema.

Electrolyte Imbalance/AKI

AKI, previously referred to as acute renal failure, is an abrupt change in kidney function signaled by a rise in serum creatinine and a reduction in urine output (Pakula & Skinner, 2015). This type of injury usually occurs within 48 hours of one or more precipitating events, such as a hip fracture. Baseline renal function is an independent predictor for AKI (Ulucay et al., 2012), but establishment of this may be difficult in hip-fracture patients, as they may be acutely dehydrated on admission with or without the presence of some chronic renal dysfunction.

Close monitoring of fluid balance, particularly decreasing urine output and rising serum creatinine, is essential to early identification of this significant clinical problem.

AKI is managed with renal replacement therapy, a topic that is beyond the scope of this protocol (Ftouh & Lewington, 2014; Pakula & Skinner, 2015).

PRESSURE ULCER: SIGNIFICANCE IN HIP-FRACTURE PATIENTS

Older adults undergoing surgical repair of a fragility hip fracture constitute a high-risk population for developing pressure ulcer. A major factor that increases risk in this population is the long periods of immobility before, during, and after surgery. A meta-analysis (Simunovic et al., 2010) revealed that earlier surgery was associated with a lower risk of death and lower rates of postoperative complications, such as pneumonia and pressure ulcers, among older patients with hip fracture. Baumgarten et al. (2012) showed that patients who had surgical repair longer than 24 hours after admission had a higher rate of postsurgical pressure ulcers than those who had surgery within 24 hours of admission, suggesting that reducing delays to surgery may reduce the risk of developing pressure ulcer. Patients with fragility hip fracture are an important group to target for assessment of risk factors and implementation of strategies to prevent these wounds.

Nursing Management Strategies to Avoid Pressure Ulcers

A head-to-toe skin assessment on admission with examination of pressure points every shift is an important strategy to proactively avoid development of pressure ulcers. Before surgery, it is important to ensure that the heels are off loaded and free from pressure. Patients should be cared for on pressure-relieving mattresses throughout the continuum of care, including the ED, the perioperative area, and the nursing unit. Interoperative padding of bony prominences and avoidance of friction and shearing forces are also imperative to avoid skin tears. These patients will require assistance with repositioning, especially before surgery. Adequate pain relief, both before and after surgery, is crucial to reduce fear of repositioning. As patients with hip fracture often have poor nutritional status and are fasting before surgery, the risk of developing pressure ulcer increases. However, it is possible to reduce this risk by introducing an evidence-based pathway that includes early surgery and optimizing fluid and nutritional balance, which is a clinical imperative for these vulnerable patients (Hommel, Bjorkelund, Thorngren, & Ulander, 2007). For a more detailed discussion, see Chapter 24, “Preventing Pressure Ulcers and Skin Tears.”

VTE: SIGNIFICANCE IN HIP-FRACTURE PATIENTS

VTE is a serious, potentially fatal, surgical complication in patients operated on for hip fracture and one of the principal causes of perioperative morbidity and mortality (Carpintero et al., 2014). It is, therefore, no surprise that prophylaxis is recommended in evidence-based clinical practice guidelines (AAOS, 2014; Falck-Ytter et al., 2012; National Institute for Health and Clinical Excellence (NICE; 2010) and has long been a part of standard treatment protocols.

Patients sustaining hip fracture are at increased risk of VTE resulting from advanced age, delay to surgery, blood vessel damage secondary to the fracture as well as the operative repair (Prisco, Cenci, Silvestri, Emmi, & Ciucciarelli, 2014), cardiac and respiratory comorbidities (Falck-Ytter et al., 2012), and delay to postoperative mobilization. Patients with orthopedic trauma are also more vulnerable to coagulation activation from tissue and bone injury as well as reduced venous emptying perioperatively (Cionac Florescu, Anastase, Munteanu, Stoica, & Antonescu, 2013).

Nursing Strategies to Avoid Vte

Mobilization

Prevention of VTE is the key. Early mobilization and adequate hydration are essential components of VTE prevention. Encourage patients to mobilize as soon as practical after surgery and to undertake leg exercises as instructed in order to get the calf muscles pumping and limit blood stasis. Request that family provide sturdy footwear with a closed heel and toe and ensure that an individually fitted walker is available at the bedside. Offer and encourage fluid intake in accordance with any limitations.

Pharmacologic Prophylaxis

There is no way to predict which patients will develop VTE (Cionac Florescu et al., 2013) and therefore pharmacologic prophylaxis must be administered to all patients with hip fractures unless contraindicated (Marsland, Mears, & Kates, 2010). However, as soon as the hemorrhagic risk is under control, pharmacologic prophylaxis should be started if the thrombotic risk persists (Prisco et al., 2014). Current treatment with aspirin or clopidogrel is not a contraindication for pharmacologic prophylaxis (AAOS, 2014).

Pharmacologic agents recommended for VTE prophylaxis include primarily low-molecular-weight heparin (LMWH) or fondaparinux (Falck-Ytter et al., 2012; NICE, 2010; Prisco et al., 2014). LMWH interrupts the clotting cascade at various levels, whereas fondaparinux is a specific Factor Xa inhibitor. Agents, such as unfractionated heparin and aspirin, among others, may be used depending on individual patient circumstances.

Nursing strategies include administering medications within the prescribed time schedule and monitoring the patient for adverse effects, primarily bleeding. Other complications include liver function abnormalities, skin rashes, and bruising.

Mechanical Prophylaxis

The most important intervention for VTE prevention is the mechanism of walking. Establish mobility goals and stress the importance of mobility in healing and restoring functional recovery as well as VTE prevention.

Until such time as the patient is ambulatory or when resting in bed, mechanical prophylaxis may also include intermittent (or sequential) compression devices and graduated compression stockings. The magnitude of individual benefit from these mechanical treatment methods is unclear as they are usually combined with pharmacologic methods (Cionac Florescu et al., 2013).

Intermittent pneumatic compression devices (IPCD) provide a good alternative to anticoagulation and may be used alone for VTE prophylaxis in patients at high risk of bleeding (Koo, Choi, Ahn, Kwon, & Cho, 2014). They can also be used in conjunction with pharmacologic prophylaxis (Falck-Ytter et al., 2012). However, many IPC units are large and bulky making correct application difficult for patients after discharge and increasing fall risk. Smaller portable, battery-powered units are an alternative. Foot compression requires higher pressures than calf compression so patient cooperation with therapy may be problematic. When part of a patient’s treatment plan, ensure correct application and continuous use for the recommended time period daily.

A recent Cochrane Review (Sachdeva, Dalton, Amaragiri, & Lees, 2014) concluded that graduated compression/anti embolic stockings (GCS) diminish the risk of VTE in hospitalized patients with evidence favoring their use in orthopedic surgery. However, in a review of the literature specific to hip-fracture patients, Alsawadi and Loeffler (2012) were unable to find sufficient evidence to support use of GCS in combination with LMWH for VTE prevention. Compression stockings can be difficult and painful for patients and caregivers to apply correctly and thus compliance with their appropriate use is a concern. Most commonly cited adverse effects are skin irritation and skin breakdown. To prevent development of a pressure sore from compression stockings, Bukata et al. (2011) suggest stockings be removed while the patient is in bed. Although rare, pain and numbness could be early warning signs of compartment syndrome or peroneal nerve injury, which have been described in the literature as complications (Güzelküçük, Skempes, & Kumnerddee, 2014; Hinderland, Ng, Paden, & Stone, 2011).

In light of these issues, there is variability in usage. The Institute for Clinical Systems Improvement in the United States (Jobin et al., 2012) notes that GCS are routinely used though there is little evidence supporting their efficacy. They are recommended by the NICE Guidelines in the United Kingdom (NICE, 2011) but national hip fracture care guidance in both Sweden and Canada no longer includes use of compression stockings (A. Hommel, personal communication, March 23, 2015; V. MacDonald, personal communication, March 29, 2015).

It is recommended that stockings are removed at least once daily for hygienic purposes and to inspect skin condition as this is the most notable complication associated with their use. Stockings should be discontinued if there is marking, blistering, or discoloration of skin, particularly over heels and bony prominences, or if the patient has associated pain, numbness, or discomfort. The nurse is advised to use caution and clinical judgment when applying antiembolism stockings over wounds. If edema or postoperative swelling develops, legs are remeasured and stockings refitted.

GCS are contraindicated in patients with diagnoses such as arterial disease, peripheral arterial bypass graft, peripheral neuropathy, leg deformities, and certain skin conditions and cardiac failure (NICE, 2010).

Patient Education

VTE prophylaxis usually continues past the acute care period. In preparation for discharge, patients and/or their families and care providers require both verbal and written information addressing:

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