What are the appropriate nursing diagnoses and interventions for a post-operative patient over 65 years old with a closed fractured hip and a medical history of osteoarthritis?

Nursing Diagnoses and Interventions for Post-Operative Hip Fracture in Elderly Patients with Osteoarthritis

For a post-operative hip fracture patient over 65 with osteoarthritis, prioritize nursing diagnoses addressing acute pain, impaired physical mobility, risk for falls, risk for acute confusion, and risk for malnutrition, with interventions focused on multimodal pain management, early mobilization, cognitive monitoring, nutritional supplementation, and prevention of complications. 1

Priority Nursing Diagnoses

1. Acute Pain Related to Surgical Trauma and Osteoarthritis

Interventions:

• Administer regular scheduled paracetamol (acetaminophen) as the foundation of pain management, augmented by carefully titrated opioid analgesia as indicated 1
• Include pain evaluation as part of routine postoperative nursing observations every 2-4 hours 1
• Reduce opioid doses by half in elderly patients to prevent cognitive dysfunction 1
• Avoid codeine completely as it causes constipation, emesis, and postoperative cognitive dysfunction 1
• Monitor pain levels during remobilization, as analgesia requirements vary considerably during this phase 1
• Recognize that peripheral nerve blockade is rarely effective beyond the first postoperative night 1

2. Impaired Physical Mobility Related to Hip Fracture and Osteoarthritis

Interventions:

• Initiate early mobilization with immediate full weight-bearing postoperatively to prevent recumbency complications and reduce mortality 2
• Coordinate with physiotherapists for early postfracture introduction of physical training and muscle strengthening 3
• Implement long-term continuation of balance training and multidimensional fall prevention programs 1, 3
• Recognize that oxygenation and respiratory function improve with mobilization 1
• Monitor for complications that may impede mobilization including chest infection, silent myocardial ischaemia, and urinary tract infection 1

3. Risk for Acute Confusion Related to Age, Surgery, and Anesthesia

Interventions:

• Implement multimodal optimization of postoperative care including adequate analgesia, nutrition, hydration, electrolyte balance, appropriate medication, bowel habit regulation, and mobilization 1
• Recognize that postoperative cognitive dysfunction occurs in 25% of hip fracture patients 1
• Regularly assess cognitive function using standardized tools 1
• Use haloperidol or lorazepam only for short-term symptom control when absolutely necessary 1
• Avoid cyclizine due to antimuscarinic side effects in older persons 1
• Identify and treat precipitating factors: chest infection, silent myocardial ischaemia, urinary tract infection 1

4. Risk for Imbalanced Nutrition: Less Than Body Requirements

Interventions:

• Provide oral nutritional supplements postoperatively to improve dietary intake and reduce risk of complications 1
• Recognize that up to 60% of hip fracture patients are clinically malnourished on admission 1
• Administer nutritional supplementation and employ dietetic assistants, as this may reduce mortality and length of stay 1
• Ensure adequate calcium (1000-1200 mg/day) and vitamin D (800 IU/day) intake 3
• Monitor nutritional status regularly as part of routine postoperative care 1

5. Risk for Deficient Fluid Volume Related to Postoperative Status

Interventions:

• Encourage early oral fluid intake rather than routine prescription of intravenous fluids 1
• Recognize that hypovolemia is common in this population 1
• Monitor fluid balance closely, particularly in the first 24-48 hours postoperatively 1
• Remove urinary catheters as soon as possible to reduce risk of urinary tract infection 1

6. Impaired Gas Exchange Related to Age and Postoperative Status

Interventions:

• Administer supplemental oxygen postoperatively for at least 24 hours 1
• Recognize that older patients are at high risk of postoperative hypoxia 1
• Monitor oxygen saturation continuously in the immediate postoperative period 1
• Encourage mobilization to improve oxygenation and respiratory function 1

7. Risk for Infection Related to Surgical Wound and Advanced Age

Interventions:

• Perform wound assessment and care as part of routine postoperative monitoring 1
• Monitor for signs of surgical site infection, urinary tract infection, and chest infection 1
• Remove urinary catheters promptly to reduce infection risk 1
• Assess and regulate bowel and bladder function to prevent complications 1

8. Risk for Impaired Skin Integrity Related to Immobility and Age

Interventions:

• Conduct regular assessment for pressure sores as part of routine postoperative care 1
• Implement pressure ulcer prevention protocols including repositioning and pressure-relieving devices 1
• Ensure early mobilization to reduce pressure injury risk 1

Critical Nursing Care Parameters

Staffing Requirements

• Ensure ward care with a nurse:patient ratio of 1:4 for hip fracture patients 1
• Provide regular input from physicians specialized in medicine for the elderly 1

Monitoring Requirements

• Conduct routine systems examinations regularly 1
• Perform regular assessment of cognitive function 1
• Monitor renal function postoperatively 1
• Assess bowel and bladder function routinely 1
• Evaluate nutritional status systematically 1

Multidisciplinary Coordination

• Participate in an individually tailored, multidimensional, and multidisciplinary team intervention to ensure adequate dietary intake, improve clinical outcomes, and maintain quality of life 1
• Coordinate care with physiotherapists, occupational therapists, social workers, and family members 1
• Facilitate orthogeriatric collaboration for optimal patient-centered care 1

Secondary Prevention Nursing Responsibilities

Osteoporosis Management

• Ensure systematic evaluation for subsequent fracture risk in all patients aged 50 years and over 2, 3
• Coordinate ordering of outpatient DEXA scan, vitamin D level, calcium level, and parathyroid hormone level 2
• Educate patients about disease burden, risk factors for fractures, follow-up requirements, and duration of therapy 1

Fall Prevention

• Implement multidimensional fall prevention strategies as part of rehabilitation 1, 3
• Ensure long-term continuation of balance training programs 3
• Educate patients about fall risk factors and prevention strategies 1

Common Pitfalls to Avoid

• Never use codeine for pain management in elderly hip fracture patients due to constipation, emesis, and cognitive dysfunction risk 1
• Avoid routine intravenous fluid prescription when oral intake is possible 1
• Do not delay catheter removal as this increases urinary tract infection risk 1
• Avoid cyclizine in older persons due to antimuscarinic effects 1
• Do not rely on peripheral nerve blockade beyond the first postoperative night 1
• Never delay mobilization as this increases mortality and complication rates 2