Plan of Nursing Care: Care of the Elderly Patient With a Fractured Hip
Nursing Diagnosis: Acute pain related to fracture, soft tissue damage, muscle spasm, and surgery
Goal: Relief of pain
Nursing Interventions
Rationale
Expected Outcomes
1 Assess type and location 1 Pain is expected after fracture; soft tissue
• Patient describes
. of patient's pain
. damage and muscle spasm contribute to
and rates pain on
whenever vital signs are discomfort; pain is subjective and is best
scale of 0 to 10
obtained and as needed. evaluated on a pain scale of 0 to 10 and through
• Expresses
description of characteristics and location,
confidence in
which are important for identifying cause of
efforts to control
discomfort and for proposing interventions.
pain
Continuing pain may indicate development of
• Expresses
neurovascular problems. Pain must be assessed
comfort with
periodically to gauge effectiveness of
position changes
continuing analgesic therapy.
• Expresses
2 Acknowledge existence 2 Reduces stress experienced by the patient by
comfort when leg
. of pain; inform patient of . communicating concern and availability of help
is positioned and
available analgesics;
in dealing with pain. Documentation provides
immobilized
record patient's baseline baseline data.
• Minimizes
discomfort.
movement of
extremity before
3 Handle the affected
3 Movement of bone fragments is painful;
reduction and
. extremity gently,
. muscle spasms occur with movement; adequate
fixation
supporting it with hands support diminishes soft tissue tension.
or pillow.
• Uses physical,
psychological,
4 Apply Buck's traction if 4 Immobilizes fracture to decrease pain, muscle
and
. prescribed. Use
. spasm, and external rotation of hip.
pharmacologic
trochanter roll.
measures to
5 Use pain-modifying
5 Pain perception can be diminished by
reduce discomfort
. strategies.
. distraction and refocusing of attention.
• Describes a
decrease in pain
a. Modify the
a. Interaction with others, distraction, and
in 24 to 48 hours
environment.
environmental stimuli may modify pain
after surgery
b. Administer
experiences.
• Requests pain
prescribed
b. Analgesics reduce the pain; muscle
medications and
analgesics as
relaxants may be prescribed to decrease
uses pain relief
needed.
discomfort associated with muscle
measures early in
c. Encourage
spasm.
pain cycle
patient to use
c. Mild pain is easier to control than
• States that
pain relief
severe pain.
positioning
measures to
d. Assessment of effectiveness of
provides comfort
relieve pain.
measures provides basis for future
•
Appears
d. Evaluate patient's
management interventions; early
comfortable and
response to
identification of adverse reactions is
relaxed
medications and
necessary for corrective measures and
other paincare plan modifications.
• Moves with
reduction
techniques.
e. Consult with
physician if relief
of pain is not
obtained.
e. Change in treatment plan may be
necessary.
increasing
comfort as
healing
progresses
6 Position for comfort and 6 Alignment of body facilitates comfort;
. function.
. positioning for function diminishes stress on
musculoskeletal system.
7 Assist with frequent
7 Change of position relieves pressure and
. changes in position.
. associated discomfort.
Nursing Diagnosis: Impaired physical mobility related to fractured hip
Goal: Achieves pain-free, functional, stable hip
Nursing Interventions
1 Maintain neutral positioning
. of hip.
2 Use trochanter roll; roll to
. uninjured side.
3 Place pillow between legs
. when turning.
4 Instruct and assist in position
. changes and transfers.
Rationale
Expected Outcomes
1 Prevents stress at the site of fixation.
• Patient engages in
.
therapeutic
positioning
2 Minimizes external rotation.
• Uses pillow
.
between legs when
3 Supports leg; prevents adduction.
turning
.
• Assists in position
4 Encourages patient's active
changes; shows
. participation while preventing stress on
increased
hip fixation.
independence in
5 Instruct in and supervise
5 Strengthens muscles needed for
transfers
. isometric, quadriceps-setting, . walking.
• Exercises every 2
and gluteal-setting exercises.
hours while awake
6 Encourage use of trapeze.
6 Strengthens shoulder and arm muscles
• Uses trapeze
.
. necessary for use of ambulatory aids.
• Participates in
7 In consultation with physical 7 Amount of weight bearing depends on
progressive
. therapist, instruct in and
. the patient's condition, fracture
ambulation program
supervise progressive safe
stability, and fixation device;
• Actively
ambulation within limitations ambulatory aids are used to assist the
participates in
of weight-bearing prescription. patient with non–weight-bearing and
exercise regimen
partial-weight-bearing ambulation.
• Uses ambulatory
8 Offer encouragement and
8 Reconditioning exercises can be
aids correctly and
. support exercise regimen.
. uncomfortable and fatiguing;
safely
encouragement helps patient comply
with the program.
9 Instruct in and supervise safe 9 Prevents injury from unsafe use.
. use of ambulatory aids.
.
Nursing Diagnosis: Risk for infection related to surgical incision
Goal: Maintains asepsis
Nursing Interventions
1 Monitor vital signs.
.
Rationale
Expected Outcomes
1 Temperature, pulse, and respiration
• Patient maintains vital signs
. increase in response to infection.
within normal range
(Magnitude of response may be
• Exhibits well-approximated
minimal in elderly patients.)
incision without drainage or
excessive inflammatory
2 Perform aseptic dressing 2 Avoids introducing infectious
response
. changes.
. organisms.
• Relates minimal discomfort;
3 Assess wound
3 Red, swollen, draining incision is
demonstrates no hematoma
. appearance and character . indicative of infection.
• Tolerates antibiotics;
of drainage.
exhibits no evidence of
4 Assess report of pain.
4 Pain may be due to wound
osteomyelitis
.
. hematoma, a possible locus of
infection, which needs to be
surgically evacuated.
5 Administer prophylactic 5 Antibiotics reduce the risk for
. antibiotic if prescribed, . infection.
and observe for side
effects.
Nursing Diagnosis: Readiness for enhanced urinary elimination related to immobility
Goal: Maintains normal urinary elimination patterns
Nursing Interventions
Rationale
Expected Outcomes
1 Monitor intake and output. 1 Adequate fluid intake ensures
• Intake and output are
.
. hydration; adequate urinary
adequate; patient exhibits
output minimizes urinary stasis.
normal voiding patterns
• Demonstrates no evidence of
2 Avoid/minimize use of
2 Source of bladder infection.
urinary tract infection
. indwelling catheter.
.
3 Perform intermittent
3 Empties bladder; reduces urinary
. catheterization for urinary . tract infections.
retention.
Nursing Diagnosis: Readiness for enhanced coping related to injury, anticipated surgery, and
dependence
Goal: Uses effective coping mechanisms to modify stress
Nursing Interventions
Rationale
1 Encourage patient to express 1 Verbalization helps patient deal
. concerns and to discuss the
. with problems and feelings.
possible impact of fractured
Clarification of thoughts and
hip.
feelings promotes problem
Expected Outcomes
• Patient describes feelings
concerning fractured hip
and implications for
solving.
2 Support use of coping
2 Coping mechanisms modify
. mechanisms. Involve
. disabling effects of stress; sharing
significant others and support concerns lessens the burden and
services as needed.
facilitates necessary modification.
3 Contact social services, if
3 Anxiety may be related to
. needed.
. financial or social problems;
facilitates management of
problems associated with
continuing care.
4 Explain anticipated treatment 4 Understanding of plan of care
. regimen and routines to
. helps to diminish fears of the
facilitate positive attitude in
unknown.
relation to rehabilitation.
5 Encourage patient to
5 Participating in care provides for
. participate in planning.
. some control of self and
environment.
lifestyle
• Uses available resources
and coping mechanisms;
develops health
promotion strategies
• Uses community
resources as needed
• Participates in
development of health
care plan
Nursing Diagnosis: Risk for disturbed thought process related to age, stress of trauma, unfamiliar
surroundings, and medication therapy
Goal: Remains oriented and participates in decision making
Nursing Interventions
1 Assess orientation status.
.
Rationale
Expected Outcomes
1 Evaluate presenting orientation of patient;
• Patient establishes
. confusion may result from stress of fracture,
effective
unfamiliar surroundings, coexisting
communication
systemic disease, cerebral ischemia,
• Demonstrates
hypoxemia, or other factors. Baseline data
orientation to
are important for determining change.
time, place, and
person
2 Interview family regarding 2 Provides data for evaluation of current
. patient's orientation and
. findings.
• Participates in
cognitive abilities before
self-care activities
injury.
• Remains mentally
alert
3 Assess patient for auditory 3 Diminished vision and auditory acuity
• Avoids episodes
. and visual deficits.
. frequently occur with aging; glasses and
of confusion
hearing aid may increase patient's ability to
interact with environment.
a. Assist patient with
use of sensory aids
(eg, glasses, hearing
a. Aids must be in good working order
aid)
and available for use.
b. Control
b. Facilitates communication.
environmental
distractors
4 Orient to and stabilize
. environment.
a. Use orientation
activities and aids
(eg, clock, calendar,
pictures,
introduction of self).
b. Minimize number of
staff working with
patient.
4
.
a. Short-term memory may be faulty in
the elderly; frequent reorientation
helps.
b. Consistency of caregivers promotes
trust.
5 Give simple explanations of 5 Promotes understanding and active
. procedures and plan of care. . participation.
6 Encourage participation in 6 Participation in routine activities promotes
. hygiene and nutritional
. orientation, increases awareness of self.
activities.
7 Provide for safety.
7 Mechanism for securing assistance is
.
. available to patient; independent activities
based on faulty judgment may result in
a. Keep light on at
injury.
night.
b. Have call bell
available.
c. Provide prompt
response to requests
for assistance.
8 Assess mental responses to 8 Elderly people tend to be more sensitive to
. medications, especially
. medications; abnormal responses (eg,
sedatives and analgesics.
hallucinations, depression) may occur.
Collaborative Problems: Hemorrhage; pulmonary complications; peripheral neurovascular
dysfunction; deep vein thrombosis; pressure ulcers related to surgery and immobility
Goal: Absence of complications
Nursing Interventions
Hemorrhage
1. Monitor vital signs,
observing for shock.
Rationale
1. Changes in pulse, blood pressure, and
respirations may indicate development
of shock; blood loss and stress may
contribute to development of shock.
2. Consider preinjury
2. Necessary for interpretation of current
blood pressure values
blood pressure determinations.
and management of
coexisting
hypertension, if
present.
3. Note character and
3. Excessive drainage and bright red
amount of drainage.
drainage may indicate active bleeding.
4. Notify surgeon if
4. Corrective measures need to be
patient develops shock
instituted.
or excessive bleeding.
5. Note hemoglobin and 5. Anemia due to blood loss may develop;
hematocrit values, and
bleeding into tissues after hip fracture
report decreases in
may be extensive; blood replacement
values.
may be needed.
Pulmonary Complications
1. Assess respiratory
1. Anesthesia and bed rest diminish
status: respiratory rate,
respiratory effort and cause pooling of
depth, and duration,
respiratory secretions. Adventitious
breath sounds,
breath sounds, pain on respiration,
sputum. Monitor
shortness of breath, blood tinged
temperature.
sputum, cough, etc., indicate pulmonary
dysfunction.
2. Report adventitious
2. Elevated temperature in the early
and diminished breath
postoperative period may be due to
sounds and elevated
atelectasis or pneumonia.
temperature.
3. Supervise deep
3. Promote optimal ventilation. Coexisting
breathing and
respiratory conditions diminish lung
coughing exercises.
expansion.
Encourage use of
incentive spirometer if
prescribed.
4. Administer oxygen as 4. Reduced ventilatory efforts may
prescribed.
diminish PaO2 when patient is
breathing room air.
Expected Outcomes
• Vital signs are
stabilized within
normal limits
• Experiences no
excessive or bright
red drainage
• Exhibits stable
postoperative
hemoglobin and
hematocrit values
• Patient has clear
breath sounds
• Breath sounds present
in all fields
• Exhibits no shortness
of breath, chest pain,
or elevated
temperature
• Vital signs are
stabilized within
normal limits
• Patient has clear
breath sounds
• Breath sounds present
in all fields
• Exhibits no shortness
of breath, chest pain,
or elevated
temperature
• PaO2 on room air
within normal limits
• Performs respiratory
exercises; uses
incentive spirometer
as instructed
• Changes position
frequently
5. Turn and reposition
5. Promotes optimal ventilation.
patient at least every 2
Diminishes pooling of respiratory
hours. Mobilize
secretions.
patient (assist patient
out of bed) as soon as
possible.
6. Ensure adequate
6. Liquefies respiratory secretions.
hydration.
Facilitates expectoration.
Peripheral Neurovascular Dysfunction
• Consumes adequate
fluids
1. Assess affected
extremity for color
and temperature.
2. Assess toes for
capillary refill
response.
3. Assess affected
extremity for edema
and swelling.
• Patient has normal
color and the
extremity is warm
• Demonstrates normal
capillary refill
response
• Exhibits moderate
swelling; tissue not
palpably tense
• States pain is
tolerable
• Reports no pain with
passive dorsiflexion
• Reports normal
sensations and no
paresthesia
• Demonstrates normal
motor abilities and no
paresis or paralysis
• Has strong and equal
pulses
1. The skin becomes pale and feels cool
with decreased tissue perfusion. Venous
congestion may cause cyanosis.
2. After compression of the nail, rapid
return of pink color indicates good
capillary perfusion.
3. The trauma of surgery will cause
swelling; excessive swelling and
hematoma formation can compromise
circulation and function; edema may be
due to coexisting cardiovascular
disease.
4. Minimizes dependent edema.
4. Elevate affected
extremity.
5. Assess for deep,
5. Surgical pain can be controlled; pain
throbbing, unrelenting
due to neurovascular compromise is
pain.
refractory to treatment with analgesics.
6. Assess for pain on
6. With nerve ischemia, there will be pain
passive flexion of
on passive stretch.
foot.
7. Assess for sensations 7. Diminished pain and paresthesia may
and numbness.
indicate nerve damage. Sensation in
web between great and second toeperoneal nerve; sensation on sole of
foot-tibial nerve.
8. Assess ability to move 8. Dorsiflexion of ankle and extension of
foot and toes.
toes indicate function of peroneal nerve.
Plantar flexion of ankle and flexion of
toes indicate functioning of tibial nerve.
9. Assess pedal pulses in 9. Indicates circulatory status of
both feet.
extremities.
10. Notify surgeon if
10. Function of extremity needs to be
diminished
preserved.
neurovascular status
occurs.
Deep Vein Thrombosis
1. Apply thigh-high anti- 1. Compression aids venous blood return
embolism stockings
and prevents stasis.
and/or sequential
compression device as
prescribed.
2. Remove stockings for 2. Skin care is necessary to avoid skin
20 minutes twice a
breakdown. Extended removal of
day, and provide skin
stocking or device defeats purpose.
care.
3. Assess popliteal,
3. Pulses indicate arterial perfusion of
dorsalis pedis, and
extremity. With coexisting
posterior tibial pulses.
arteriosclerotic vascular disease, pulses
may be diminished or absent.
4. Assess skin
4. Local inflammation increases local skin
temperature of legs.
temperature.
5. Assess calf every 4
5. Unilateral calf tenderness, warmth,
hours for tenderness,
redness, and swelling may indicate deep
warmth, redness, and
vein thrombosis.
swelling.
6. Measure calf
6. Increased calf circumference indicates
circumference twice
edema or altered perfusion.
daily.
7. Avoid pressure on
7. Compression of blood vessels
popliteal blood vessels
diminishes blood flow.
from appliances or
pillows.
8. Change patient's
8. Activity promotes circulation and
position and increase
diminishes venous stasis.
activity as prescribed.
9. Supervise ankle
9. Muscle exercise promotes circulation.
exercises hourly while
patient is awake.
10. Ensure adequate
10. Elderly people may become dehydrated
hydration.
because of low fluid intake, resulting in
hemoconcentration.
11. Monitor body
11. Body temperature increases with
temperature.
inflammation (magnitude of response
minimal in elderly people).
Pressure Ulcers
1. Monitor condition of 1. Elderly patients are subject to skin
skin at pressure points
breakdown at points of pressure
(eg, heels, sacrum,
because of diminished subcutaneous
shoulders); inspect
tissue.
heels at least twice a
day.
2. Reposition patient at 2. Avoids prolonged pressure and trauma
• Wears thigh-high
anti-embolism
stockings
• Uses sequential
compression device
• Experiences no more
warmth than usual in
skin areas
• Exhibits no increase
in calf circumference
• Demonstrates no
evidence of calf
tenderness, warmth,
redness, or swelling
• Changes position
with assistance and
supervision
• Participates in
exercise regimen
• Experiences no chest
pain; has lungs clear
to auscultation;
presents no evidence
of pulmonary emboli
• Exhibits no signs of
dehydration; has
normal hematocrit
• Maintains normal
body temperature
• Patient exhibits no
signs of skin
breakdown
• Skin remains intact
• Repositions self
frequently
least every 2 hours.
to the skin.
Avoid skin shearing.
3. Administer skin care, 3. Immobility causes pressure at bony
especially to pressure
prominences; position changes relieve
points.
pressure.
4. Use special care
4. Devices minimize pressure on skin at
mattress and other
bony prominences.
protective devices (eg,
heel protectors);
support heel off the
mattress.
5. Institute care
5. Early interventions prevent tissue
according to protocol
destruction and prolonged
at first indication of
rehabilitation.
potential skin
breakdown.
• Uses protective
devices
Nursing Diagnosis: Risk for ineffective health maintenance related to fractured hip and impaired
mobility
Goal: Exhibits health maintenance/promotion behaviors
Nursing Interventions
1 Assess home environment for
. discharge planning.
Rationale
Expected Outcomes
1 Physical barriers (especially
• Home is accessible for
. stairs, bathrooms) may limit
patient at time of
patient's ability to ambulate and
discharge
care for self at home.
• Patient appears relaxed
and develops strategies
2 Encourage patient to express
2 Patient may have special
to deal with identified
. concerns about care at home;
. problems that need to be
problems
explore with patient possible
identified so that solutions might
solutions to problems.
be identified.
• Has personal assistance
available
3 Assess availability of physical
3 Because of limitation of
• Demonstrates ability to
. assistance for ADLs and health . mobility, patient requires some
use necessary assistive
care activities.
assistance in ADLs and routine
devices within
health care.
therapeutic prescription
4 Teach caregiver the home health 4 Understanding of rehabilitative
• Complies with home
. care regimen.
. regimen is necessary for
care program; keeps
compliance.
follow-up health care
5 Instruct patient in posthospital
5 Lack of knowledge and poor
appointments
. care:
. preparation for care at home
contribute to patient anxiety,
insecurity, and nonadherence to
a. Activity limitations.
therapeutic regimen.
b. Reinforce exercise
instructions.
c. Safe use of ambulatory
aids.
d. Wound care.
e. Measures to promote
healing (nutrition, wound
care).
f. Medications.
g. Potential problems.
h. Continuing health care
supervision.