What is the recommended nursing care plan for a post-operative patient with a closed fractured hip and a medical history of osteoarthritis (Degenerative Joint Disease)?

Nursing Care Plan for Post-Operative Closed Hip Fracture with Osteoarthritis

Post-operative hip fracture patients with osteoarthritis require immediate implementation of orthogeriatric comanagement with a nurse-to-patient ratio of 1:4, focusing on multimodal pain control, early mobilization, prevention of complications, and aggressive rehabilitation to reduce mortality and restore pre-fracture functional status. 1

Immediate Post-Operative Monitoring (First 24-48 Hours)

Vital Signs and Respiratory Management

• Administer supplemental oxygen for at least 24 hours post-operatively, as older patients are at high risk of hypoxia 1
• Monitor oxygen saturation continuously and recognize that oxygenation improves with mobilization 1
• Perform routine vital sign assessments every 2-4 hours initially 1

Pain Management Protocol

• Continue regular paracetamol (acetaminophen) administration as the foundation of analgesia 1
• Augment with carefully titrated opioid analgesia only as needed, recognizing that requirements vary considerably during remobilization 1
• Include pain evaluation as part of every routine nursing observation 1
• Note that peripheral nerve blocks are rarely effective beyond the first post-operative night 1
• Avoid excessive opioid use due to increased risk of falls, delirium, and mortality in elderly patients 2

Fluid Balance and Nutrition

• Encourage early oral fluid intake rather than routine IV fluid administration, as hypovolemia is common 1
• Remove urinary catheters as soon as possible to reduce urinary tract infection risk 1
• Recognize that up to 60% of hip fracture patients are malnourished on admission 1
• Provide nutritional supplementation to reduce mortality and potentially shorten length of stay 1
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D (800 IU/day) 1, 3

Cognitive and Behavioral Monitoring

Delirium Prevention and Management

• Monitor for postoperative cognitive dysfunction/acute confusional state, which occurs in 25% of hip fracture patients 1
• Implement multimodal optimization including: adequate analgesia, nutrition, hydration, electrolyte balance, appropriate medication, bowel management, and early mobilization 1
• Actively identify and treat complications: chest infection, silent myocardial ischemia, urinary tract infection 1
• Use haloperidol or lorazepam only for short-term symptom control 1
• Avoid cyclizine due to antimuscarinic side effects in older persons 1

Early Mobilization Strategy (Critical for Outcomes)

Mobilization Timeline

• Begin mobilization as early as the first post-operative day to prevent thromboembolism, pressure ulcers, pneumonia, and deconditioning 1, 2
• Coordinate with physiotherapy for weight-bearing exercises and gait retraining 1
• Recognize that early mobilization improves oxygenation and respiratory function 1

Exercise Protocol

• Implement early finger and extremity motion exercises immediately to prevent edema and stiffness 1, 3
• Progress to aggressive range-of-motion exercises as pain allows 1
• Include quadriceps strengthening exercises, which improve mobility, leg extension power, and functional scores 4
• Continue balance training long-term for fall prevention 1, 3

Complication Prevention

Thromboembolic Prophylaxis

• Administer pharmacologic VTE prophylaxis with low molecular weight heparin as soon as safe post-operatively 1, 5
• Use mechanical prophylaxis (intermittent pneumatic compression) if anticoagulation is contraindicated 5
• Monitor for signs of deep vein thrombosis or pulmonary embolism 1

Skin Integrity

• Perform regular skin assessments to prevent pressure ulcers, particularly in immobilized patients 1
• Reposition patient every 2 hours if mobility is limited 1
• Use pressure-relieving devices as needed 1

Infection Surveillance

• Monitor surgical site for signs of infection: redness, warmth, drainage, increased pain 1
• Assess for urinary tract infection, especially if catheter was used 1
• Monitor for respiratory infections, particularly pneumonia 1

Multidisciplinary Coordination

Team Communication

• Ensure regular input from physicians specialized in geriatric medicine (orthogeriatricians) 1
• Coordinate care with physiotherapists, occupational therapists, social workers, and family members 1
• Facilitate communication between nursing staff and the multidisciplinary team regarding patient progress 1

Patient and Family Education

• Provide printed information describing typical care pathways for hip fracture patients to patients, carers, and relatives 1
• Educate about the importance of early mobilization and rehabilitation 1
• Discuss fall prevention strategies and home safety modifications 1, 3
• Explain medication regimens, particularly pain management and osteoporosis prevention 1

Rehabilitation Planning

Functional Goals

• Aim to return patient to pre-fracture levels of activity and residence through patient-centered care 1
• Identify individual goals and needs early in the rehabilitation process 1, 3
• Recognize that rehabilitation constitutes the majority of inpatient stay and continues after discharge 1

Secondary Fracture Prevention

• Actively consider secondary prevention of falls and osteoporosis in the early post-operative period, as subsequent fragility fractures carry particularly poor prognosis 1
• Implement fall prevention strategies including home safety assessment and balance training 2
• Coordinate with physicians regarding anti-osteoporotic medication initiation 1, 3

Osteoarthritis-Specific Considerations

Joint Protection

• Monitor for increased pain in other joints affected by osteoarthritis during mobilization 6
• Adjust activity levels to accommodate pre-existing joint disease while still promoting early mobilization 6
• Recognize that patients with osteoarthritis may have more comorbidities and be more sedentary, requiring additional encouragement 6

Pain Management Adjustments

• Consider that patients with pre-existing osteoarthritis may have chronic pain requiring different analgesic strategies 6
• Balance adequate pain control with the need to avoid excessive sedation that impairs mobilization 1

Critical Nursing Observations

Daily Assessment Checklist

• Pain level and analgesic effectiveness 1
• Cognitive status and signs of delirium 1
• Wound healing and infection signs 1
• Nutritional intake and hydration status 1
• Bowel and bladder function 1
• Mobility progress and participation in therapy 1
• Neurovascular status of affected limb 5
• Signs of thromboembolic complications 1, 5

Red Flags Requiring Immediate Physician Notification

• Acute confusion or significant cognitive decline 1
• Signs of compartment syndrome or neurovascular compromise 5
• Chest pain, shortness of breath, or signs of pulmonary embolism 1
• Wound dehiscence or purulent drainage 1
• Inability to participate in mobilization due to severe pain 1

Discharge Planning

Preparation for Transition

• Recognize that only 44% of patients admitted from home are discharged back home within 30 days 1
• Begin discharge planning early, coordinating with social services for potential placement needs 1
• Arrange home health services, durable medical equipment, and outpatient therapy as needed 1
• Ensure patient and family understand medication regimens, activity restrictions, and follow-up appointments 1