Pathophysiology of subtrochanteric hip fracture - Essay Example

Task: QUESTION Explain the underlying pathophysiology of subtrochanteric hip fracture and bone healing following ORIF. Use current literature to support/justify. (Approximately 400 words). Hip fracture refers to a breakage in the hip bone which is very common in the elderly people caused by falls – even a slight fall can cause it to fracture. For instance, Mr. Smith tripped and fel on the pavement outside his home meaning that his cause of the fracture was falling. In young individuals who still have stronger bones; things like car accidents (Handoll and Parker 81) mainly cause hip fractures. The ORIF, on the other hand is the surgery done by a surgeon to put up the fractured parts of femur bone back together using particular metal hardware. It also encompasses putting the hip back together. Hip fracture is mostly detected through the nervous system. For example, Mr. Smith grumbled of agonizing pain in his right leg and hip. He employed IV infusion where Patient Controlled Analgesia (PCA) for pain management using Morphine 1mg bolus dose with a 5-minute lockout. Therefore, he had to undergo postoperative care following an open reduction and internal fixation (ORIF) with compression plate and bone screws of the right femur. This means that as a caregiver, it is important to understand him and take his condition seriously. This is because, in elderly people like him who are above 80 years, complications can turn out to be life threatening (Handoll, Cameron, Mak and Finnegan 42). This means that there is the need to ensure hospitalization and intensive post surgery care in order for him to recover well and to be able to walk again. However, before that, it is important to understand his medication history and his response to treatment. After assessing him well, I noticed that his vital signs were stable, BSL was within normal restrains, IVTD/saline was running 8 hourly and had been ordered to use low molecular weight heparin. I also learned that he was on supplement oxygen to maintain his oxygen saturations above 95 percent, he had a Bellovac drain in situ that was to be removed in 24 hours time as well as TED stockings in situ on both legs (Chi-Chuan et al. 340). I also learned that Mr. Smith had a history of type 2 diabetes and has a 60 pack-year smoking history. This means he used one full packet of cigarettes every day for 60 years. With this information, it is easy to take good care of him since as a nurse, have sufficient information concerning hip fractures and with the addition information concerning his health history, it is now easy to take care of him. What I need to ensure is that he takes all his medications well and in time in order to recover quickly (Keene, Parker and Pryor 307). QUESTION 2 Discuss the immediate prioritized post operative care for Mr. Smith using current evidence and literature to support/justify your reasoning: A. Identify Nursing Problem/Diagnosis - Priority 1 The problematic nature of curing hip fracture sterns in part since fracture is anatomically different from other proximal femoral peritrochanteric breakages as well as tricky characteristics of femoral shaft breakages (Doherty and Lyden 141). This means that it must be cured with particularly modeled implants that can endure massive muscular forces for lengthened periods of curative. It is not strange to note that this breakage has considerably higher rates of malunion and nonunion than other femoral fractures. Successful outcomes can be attained incase there is an advanced comprehension of the breakage and the precise treatment alternatives. o Identify four (4) key pieces of assessment data to support this problem The process of nursing assessment is very critical in nursing process to both the patient and the nurse because it helps the nurse know and understand the patient well and helps the patient to feel free and share important information with the nurse (World Health Organization pp19). Therefore, the four key pieces of assessments in nursing diagnosis include assessing the history of the patient or the damage, assess presence of signs of breakages, assess presence of signs and symptoms and assess the severity of the open breakage and extreme external hemorrhage. It is very important for the nurse to examine the history of the damage, especially the presence of the factors that may have led pathologic breakages such as osteomyelitis, osteoporosis, and neoplastic diseases among others (French and Tornetta 218). For example, Mr. Smith’s damage history is as follows. Stan Smith is an elderly male person with 82 years of age admitted to hospital through the emergency department. He had a damage, which was caused by tripping and falling down on the pavement exterior to his home. He also had a history of type 2 diabetes and has a 60 pack-years (1 pack each day for 60 years) smoking history. He stays alone in his home though he has a daughter in the next village and a son who lives interstate. Mr. Smith had been complaining of agonizing pain in his right leg and hip and was issued IVI Morphine with effect. There was certain bruising and skin staining to his right higher thigh. His right leg was outwardly turned around and partially shorter than the left (Seinsheimer 410). Therefore, he was discovered to have subtrochanteric breakage of the right hip and has just come back to the ward post operatively following an open reduction and internal fixation (ORIF) with compression plate and bone screws of the right femur. Therefore, as a nurse, being aware of this information concerning Mr. Smith is very important because I am aware what he is going through and what he needs in order to recover faster. Moreover, there is the need to assess presence of signs of fracture. As a nurse taking care of Mr. Smith, I must be in a position to be able to notice any changes occurring on Mr. Smith’s fracture. In most cases, people with hip fractures normally experience some sorts of pain, edema, loss of motion, abnormal positioning crepitus or extremity disproportion. Mr. Smith is an elderly person and the most common breakage signs are likely to experience is pain and loss of motion. This means that I have to ensure that pain relieving drugs are present and make sure I visit him after every like five or ten minutes (Trafton 62). This is to ensure that I move him or change his sleeping position because if he looses motion, he cannot be able to perform that. Besides, I should also be in a position to assess presence of signs and symptoms of soft tissues involvement. Since he is an elderly person, he might experience swelling, hemorrhage and impaired sensation in the extremity. The last aspect to assess is the vital signs, fluid balance and urine output. This ar every dangerous signs because they symbolize some sort of complications. If for example, Mr. Smith experiences vital signs such as presence of malunion, then it means that his fracture has taken another dangerous course. However, with good care and keen observation of all the requirements, I believe that Mr. Smith will definitely heal up without any further complications (Chi-Chuan et al. 351). o Discuss two (2) relevant Interventions and justify your clinical reasoning there are several interventions for Mr. Smith’s subtrochanteric breakage but the two major ones are provide emergency care if requires prevention of shock, respiratory care and hemostasis, and providing fracture fixation to prevent following injury of tissues. Incase Mr. Smith requires emergency care due to some emerging complication, I can always provide for him respiratory care if he develops breathing difficulties due to loss of motion (Wiss and Brien 234). I should also be ready to issue him with fracture fixation to prevent following injury of tissues. o Outline two (2) specific evaluation criteria that would indicate that the interventions were successful The two specific evaluation criteria that would indicate that the interventions are successful are better response to stimuli and quick healing. Better response to stimuli refers to the appropriate response to medication meaning that the medication is effective and functions properly in Mr. Smith’s body (Bose, Corces and Anderson 239). This may only occur if my nursing operation is efficient and effective. If there is god response to stimuli then it means there will be quick healing and recovering process. For example, if he was to take 9 weeks to recover, he may end up healing in 6 or 7 weeks. B. Identify Nursing Problem/Diagnosis - Priority 2 The second major nursing problem that may arise is when the patient develops some complications such as infection and Thromboembolism. These are very dangerous complications, which may make an individual to remain crippling for life (Milne, Potter, Vivanti and Avenell 181). o Identify four (4) key pieces of assessment data to support this problem Post operative care and rehabilitation for Mr. Smith Mr. Smith is an elderly person who need to be treated like a young child in order to recover faster. There are four main concepts to consider during his postoperative care. These are weight bearing, physical rehabilitation, total hip precautions and occupational rehabilitation. The surgeon who undertakes the surgery determines weight bearing. It also depends on steadiness of bone, reduction, the fixation technique since cement allows immediate weight bearing but related threats of intra operative fat embolism, and hypotension since it is injected under pressure. Physical rehabilitation is all about early mobilization, which is very safe. Therefore, as the nurse looking after him, I must ensure that he receives early mobilization, which will help him heal up faster. Good care enables a patient to be stress free and to recover quickly. Moreover, there are the total hip precautions. The first precation that I should make sure Mr. Smith adapts is no abduction beyond midline. I should ensure that Mr. Smith uses abduction pillow when he is in bed. This will enable him to have a comfortable sleeping position that will help him recover. Another precaution is that Mr. Smith must ensure that no hip flexion past 90 degrees. This encompasses bending trunk forward. He should also note that there is no internal rotation meaning that he has to keep toes upright when on bed. Occupational rehabilitation is the last concept whereby Mr. Smith may require occupational therapy for help with actions of everyday living while obeying the hip precautions. Infection is the most devastating difficulty and is providential uncommon (1 – 2 percent of patients. If antibiotics cannot eliminate infection, removal of the components may be needed. The incidence of infection is augmented in patients with rheumatoid arthritis, an obtainable infection, diabetes, obesity, alcoholism and patients with immunosuppressive drugs and steroids (Raj and Coleman 101). Infection presents with pain and uneasiness limited to a small area of the affected hip. The most ordinary organisms engross Staphylococcus aureus, streptococcus, staphylococcus epidermidis, Pseudomonas aeruginosa and Escherichia (Crotty, Unroe, Cameron, Miller, Ramirez and Couzner 222). The recurrence of infection following revision hip surgery is common and still takes place in 5- 10 percent of cases. The curing of the infected hip joint may be conducted in one operation or it may be done in two levels. Thromboembolism, on the other hand, is the blood clots and migration of the clot to the lungs. As with any key surgery a blood clot can structure in the veins of the legs. Deep vein thrombosis (DVT), or blood clots are normally safe but in about 3 percent of patients, they can cause difficulties (Rao, Kumar and Venket 129). They can take place at any time in the initial weeks after operation. Patients undergo difficulties like pain and swelling in the affected leg. This does not influence the hip replacement and does not cause revision surgery, but they may engage lengthened hospital stay and prolonged post operative care until the condition is efficiently managed. o Outline two (2) specific evaluation criteria that would indicate that the Interventions were successful the specific evaluation criteria are same to those in first problem. These are better response to stimulus and medicine, and quick recovery. Better response to stimuli refers to the appropriate response to medication meaning that the medication is effective and functions properly in Mr. Smith’s body (Coleman et al. 84). This may only occur if my nursing operation is efficient and effective. If there is god response to stimuli then it means there will be quick healing and recovering process. For example, if he was to take 9 weeks to recover, he may end up healing in 6 or 7 weeks. QUESTION 3 Briefly discuss the two (2) most likely complications that Mr. Smith may develop post operatively. Before examining the two main complications related to hip fractures, it is important to note that complications for intertrochanteric breakages are alike to those for femoral neck fractures and encompass thromboembolism, infection, nonunion and pressure sores (Garnavos, Peterman and Howard 408). Infection and thromboembolism as well as malunion and nonunion are possibly life-threatening complications whereby prophylaxis should be undertaken. Therefore, the two most likely complications that Mr. Smith may develop are malunion and nonunion of fractures due to his age. A mulunion is a fractured bone that has cured in an intolerable position that leads to considerable impairment. A nonunion, on the other hand, is a breakage that has not been unsuccessful in getting better after a long period (Trafton 68). In malunion, the bone may cure up at a bent angle (angulated), may be turned around and move out of position, or the broken ends may be extend beyond each other leading to bone shortening. Malunion is therefore, dangerous and may occur because of insufficient immobilization of the breakage, premature removal of the cast or misalignment during immobilization time. Nonunion has numerous causes. The fractured ends of bone may be divided too much (overdistraction), which can take place if surplus grip was applied. There could have been extreme motion at the breakage site, from inefficient immobilization either after the wound or from having a cast removed prematurely (Seinsheimer 310). Muscle or other tissue caught between the breakage wreckage also can stop curative, as can the presence of illness or inefficient blood distribution to the breakage site. Other bone diseases such as bone cancer can as well alter the curative. Nonunion is in two types namely, fibrous nonunion and false joint (pseudartrosis). Fibrous nonunion are breakages that have cured up through forming fibrous tissue other than new bone. Pseudarthosis, on the other hand, is a nonunion where recurrent movement of the breakage fragments has caused the development of a false joint. Particular types of breakages are related to high risks of nonunion, like breakages of the wrist (carpus), encompassing scaphoid bone, some food breakages like navicula breakages and jones (diaphyseal) among others (Milne, Potter, Vivanti and Avenell 181). The harshness of the damage is a strong factor in the curative procedure. People who have had a harsh traumatic breakage, huge displacement between fracture fragments, and breakages whre the bone was fractured into several pieces (comminuted fracture) are at an augmented threat of nonunion. Open or compound breakages also are at a threat of malunion or nonunion. A condition termed as compartment syndrome can take place when harsh trauma causes such an intensity of swelling that the blood distribution is compromised. The consequence is death of muscle around the breakage site and insufficient bone repair. However, through the four main postoperative care and rehabilitations which include weight bearing, physical rehabilitation, total hip precautions and occupational rehabilitation, Mr. Smith can recover without the above mentioned complications. The most important thing is that, as a nurse looking after him, I need to ensure that all the four concepts are respected and followed to the fullest in order to avoid any further complications. Works Cited Trafton PG. Subtrochantric-intertrochantric femoral fractures. Orthop Clin North Am, 2000; 18:59-71. Chi-Chuan Wu, Chun-Hsiung Shih, Zhon-Liau Lee. Subtrochantric fractures treated with interlocking nailing. Journal of Trauma.2001; 31:326-333. Doherty JH, Lyden JP. Intertrochantric fractures of the hip. Clin Orthop 1999; 141:184. Seinsheimer F III: Subtrochantric fractures of the femur. J Bone Joint Surg. 2002; 60-A, 300. Garnavos C, Peterman A, Howard PW. 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Milne AC, Potter J, Vivanti A, Avenell A. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database of Systematic Reviews 2009, Issue 2. Read More