What is the optimal post-operative care plan for an elderly patient with multiple comorbidities and a recent history of fall and surgery for a right femur fracture?

Optimal Post-Operative Care Plan for Elderly Patient with Right Femur Fracture s/p ORIF

Continue the current comprehensive orthogeriatric comanagement approach with emphasis on early mobilization, aggressive nutritional supplementation, vitamin D/calcium optimization, multimodal pain management with opioid caution, and systematic fall prevention—this multidisciplinary strategy is essential for reducing mortality and maintaining functional independence in frail elderly patients with hip fractures and multiple comorbidities. 1

Pain Management

Multimodal analgesia with scheduled acetaminophen plus PRN opioids is the evidence-based standard, avoiding NSAIDs given this patient's renal dysfunction (low albumin suggests possible GFR <60) and chronic anemia. 1

• Continue PRN oxycodone for breakthrough pain, but implement scheduled acetaminophen (unless contraindicated) as the foundation of pain control 1
• Monitor closely for opioid-related adverse effects including sedation, constipation, and serotonin syndrome risk given concurrent use of duloxetine, vortioxetine, and buspirone 1
• Consider femoral nerve block or fascia iliaca block if pain control remains inadequate, as these can be administered by trained staff and provide superior analgesia 1
• Aggressive bowel regimen is mandatory with opioid use—continue current lactulose, senna, docusate, and polyethylene glycol; escalate if no bowel movement within 48-72 hours 1

Surgical Site and Wound Care

• Maintain current wound care for right hip surgical staples—monitor daily for signs of infection (erythema, drainage, warmth, dehiscence) 1
• Continue non-adherent dressing for left elbow skin tear with daily assessment for healing progression 1
• Document contusion resolution at right knee and left thigh 1

Mobilization and Rehabilitation

Early mobilization with physical therapy is critical for survival and functional recovery—delays increase mortality risk substantially. 1

• Maintain toe-touch weight-bearing precautions as ordered by orthopedic surgery 1
• Initiate physical therapy daily focusing on transfer training, muscle strengthening, and progressive weight-bearing as tolerated 1
• Begin balance training and multidimensional fall prevention exercises as soon as medically stable—this should continue long-term beyond acute rehabilitation 1
• Avoid overly aggressive therapy in early postoperative period (first 2-4 weeks) as this may increase fixation failure risk 1, 2
• Set individualized mobility goals: aim to restore pre-fracture functional status 1

Nutritional Optimization

Severe protein-calorie malnutrition (prealbumin 11, albumin 2.9, total protein 4.6) is a critical barrier to wound healing, fracture healing, and survival. 1

• Escalate nutritional intervention immediately: continue Pro-Stat but add high-protein oral supplements targeting 1.2-1.5 g/kg/day protein intake 1
• Formal dietary consultation is mandatory—not optional—for this degree of malnutrition 1
• Monitor weekly weights and daily caloric/protein intake logs 1
• Consider appetite stimulants if oral intake remains inadequate despite supplementation 1

Calcium and Vitamin D Supplementation

Adequate calcium (1000-1200 mg/day total intake) and vitamin D (800 IU/day) are foundational for fracture healing and secondary fracture prevention. 1

• Continue vitamin D supplementation 800 IU daily for documented deficiency (level 25.9) 1
• Ensure total calcium intake reaches 1000-1200 mg/day through diet plus supplementation 1
• Recheck vitamin D level in 8-12 weeks 1
• The hypocalcemia (8.4) is likely related to hypoalbuminemia; consider ionized calcium if symptomatic (paresthesias, tetany, seizures) 1

Anemia Management

Chronic anemia (Hgb 8.1) increases risk of myocardial and cerebral ischemia in elderly patients and impairs functional recovery. 1

• Continue ferrous sulfate supplementation 1
• Recheck CBC per facility protocol; transfusion threshold in elderly hip fracture patients should be higher than standard triggers (consider transfusion if Hgb <8 g/dL or symptomatic) 1
• Evaluate for ongoing blood loss, nutritional deficiency contribution, and chronic disease 1
• Monitor for signs of cardiac or cerebral ischemia given baseline cardiovascular disease 1

Blood Pressure Management

• Current BP 155/71 is mildly elevated but may be pain-related 1
• Continue amlodipine; reassess BP after optimizing pain control 1
• Avoid aggressive BP lowering that could impair cerebral perfusion in elderly patients 1

Respiratory Management

• Continue current regimen: budesonide nebulizer, ipratropium-albuterol, Advair, PRN albuterol for chronic respiratory failure 1
• Maintain head-of-bed elevation to prevent aspiration and optimize respiratory mechanics 1
• Monitor SpO₂ during mobilization and sleep 1

Diabetes and Neuropathy Management

• A1c 5.8 indicates good glycemic control; continue current duloxetine and pregabalin for neuropathy 1
• Continue blood glucose monitoring per SNF protocol 1
• Be vigilant for serotonin syndrome given multiple serotonergic agents (duloxetine, vortioxetine, buspirone) plus oxycodone 1

Fall Prevention and Safety

This patient is at extremely high risk for subsequent fracture—20-25% of hip fracture patients sustain another fracture within one year. 1

• Maintain strict fall precautions: low bed, non-skid footwear, bed/chair alarms, adequate lighting 1
• All transfers must be staff-assisted—patient is dependent for ADLs and at very high fall risk 1
• Reinforce call-light use for all mobility needs 1
• Address modifiable fall risk factors: optimize vision, review medications for sedating effects, ensure adequate footwear 1
• Long-term balance training and fall prevention exercises are essential beyond acute rehabilitation 1

Secondary Fracture Prevention

Systematic evaluation for osteoporosis and pharmacological treatment is mandatory in all patients over 50 with fragility fractures. 1

• Arrange DXA scan of spine and hip once medically stable (can be deferred until after acute rehabilitation but should not be forgotten) 1
• Consider initiating bisphosphonate therapy (alendronate or risedronic acid) or denosumab even without DXA in this frail elderly patient with confirmed fragility fracture—the fracture itself confirms high risk 1
• Evaluate for secondary causes of osteoporosis: thyroid function (already checked—normal), vitamin D (low—being treated), calcium, parathyroid hormone if indicated 1
• Patient education regarding fracture risk, importance of adherence to osteoporosis treatment, and fall prevention strategies 1

Cognitive and Mood Management

• Continue current psychiatric medications: lamotrigine, duloxetine, buspirone, vortioxetine 1
• Monitor for delirium daily using standardized assessment—common in elderly post-operative patients and increases mortality 1
• Encourage participation in activities and social engagement to support mood 1

Bladder and Bowel Management

• Continue vibegron and mirabegron for urinary incontinence 1
• Maintain scheduled toileting program to preserve continence and skin integrity 1
• Continue aggressive bowel regimen as above given opioid use 1

Monitoring and Follow-Up

• Daily nursing assessments: pain scores, wound checks, bowel movements, intake/output, fall risk 1
• Weekly weights to monitor nutritional status 1
• Repeat CMP and CBC per facility protocol (typically weekly initially) 1
• Orthopedic surgery follow-up for staple removal (typically 10-14 days post-op) and fracture healing assessment 1
• Coordinate with primary care or endocrinology for long-term osteoporosis management and secondary fracture prevention 1

Critical Pitfalls to Avoid

• Inadequate pain control delays mobilization and increases mortality—be aggressive with multimodal analgesia 1, 3
• Delayed mobilization significantly increases mortality risk—physical therapy should begin immediately once medically stable 1
• Failure to address malnutrition impairs wound healing, fracture healing, and immune function—this requires urgent escalation 1
• Serotonin syndrome risk is real with this medication regimen—monitor for agitation, confusion, tremor, hyperreflexia, diaphoresis, hyperthermia 1
• Forgetting secondary fracture prevention condemns patient to high risk of subsequent fracture—osteoporosis treatment must be initiated 1
• Overly aggressive early physical therapy can cause fixation failure—balance early mobilization with appropriate precautions 1, 2