Hip fractures refer to a fracture or break in the femur near the hip joint. They are most common in older adults and are frequently caused by falls. Younger patients can also experience hip fractures, most likely from trauma such as a motor vehicle accident. Pathological fractures are caused by a disease process, such as cancer, instead of trauma.
In this article:
- Overview
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Impaired Transfer Ability
- Ineffective Tissue Perfusion
- Risk for Falls
- Risk for Infection
Overview
The hip is a ball-and-socket joint with the head of the femur (ball) tucked into the acetabulum (socket) of the pelvis. The most common locations for hip fractures are the femoral neck (just below the femoral head) and the intertrochanteric area, which is below the neck of the femur and between the greater and lesser trochanter.
Hip fractures carry a high rate of mortality within the first year after the fracture, and only 40 to 60% of patients regain their baseline level of mobility. Many patients who were previously independent require some level of assistance after a hip fracture. Preventing falls and screening for and managing osteoporosis are important strategies to reduce the incidence of hip fractures.
Nursing Process
Hip fractures will typically require surgery within 1 to 2 days after injury to lessen complications and preserve mobility.
The nurse is responsible for prepping the patient prior to surgery and monitoring them after the procedure. For optimal recovery, nurses are involved in pain management, infection prevention, and encouraging ambulation as prescribed. Nurses are also part of the collaborative approach if rehabilitation is required to promote further healing and recovery.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to hip fractures.
Review of Health History
1. Assess the patient’s general symptoms.
Signs and symptoms of hip fractures include severe pain, deformity, immobility, tenderness, and bruising around the fractured site.
2. Investigate the nature of injury.
Hip fractures can happen to anyone at any age due to severe impact, like car accidents and falls. Stress fractures are another possibility from repeated use, such as in marathon runners.
3. Determine the patient’s risk factors.
Note the following risk factors that can place a patient at risk for hip fractures, such as:
- Advancing age
- Vision/hearing problems
- Poor balance
- Female gender (due to low estrogen levels post-menopause)
- Low bone density
- Low body weight
- Sedentary lifestyle
4. Review the patient’s medical history.
The patient may be at risk for hip fractures if they have the following medical conditions:
- Osteoporosis
- Hyperthyroidism
- Diabetes
- Gastrointestinal conditions interfering with vitamin D and calcium absorption
- Conditions that affect balance (such as Parkinson’s disease, stroke, and vertigo)
5. Note the patient’s medications.
Certain medications can increase the risk of hip fractures. Long-term use of corticosteroids, proton pump inhibitors, and dopaminergic drugs can damage bones. Sedatives, antidepressants, and pain medications can cause dizziness or a change in level of consciousness, increasing the risk for falls.
6. Assess the patient’s lifestyle.
The absence of regular weight-bearing activity can weaken bones and muscles, increasing the risk of fractures and falls. Additionally, alcohol and tobacco use have the potential to disrupt bone health.
Physical Assessment
1. Assess the fracture site.
Carefully inspect and palpate the hip joint. Hip fractures commonly present with an obvious deformity, with the affected leg appearing shorter and externally rotated. Note the presence of swelling and external or internal bleeding (such as ecchymosis).
2. Assess the pain.
A hip fracture typically causes severe pain. With a stress fracture, the pain may be subtle and exacerbated by activity. The patient may still be able to walk, though with a limp.
3. Assess the musculoskeletal status.
Immobility is expected with a hip fracture. Passive range of motion typically elicits a pain response.
4. Monitor the neurovascular status.
It’s essential to assess the circulation, sensation, and motor function of the injured site for possible complications. Assess peripheral pulses, capillary refill, skin temperature, color, and motor strength.
Diagnostic Procedures
1. Collect blood specimens for testing.
Laboratory tests are based on the patient’s status and anticipated surgery. Consider the following laboratory tests:
- Complete blood cell (CBC) count
- Serum electrolytes
- Renal panel
- Glucose level
- Urinalysis
- Coagulation profile
- Prothrombin time (PTT)
- Activated partial thromboplastin time (APTT)
- Arterial blood gas (ABG) analysis
2. Obtain an X-ray of the hip.
Prepare the patient for an X-ray to determine the type of fracture.
3. Anticipate other imaging scans.
If an X-ray fails to identify the fracture, anticipate further imaging scans:
- Magnetic resonance imaging (MRI)
- Computed tomography (CT) scan
- Bone scan
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions related to hip fractures.
1. Stabilize the patient.
In cases of trauma, such as a motor vehicle accident or falls from an extreme height, the nurse will be involved with stabilizing any bleeding or airway management as the first priority. Prepare to infuse IV fluids or blood products.
2. Anticipate surgery.
Anticipate surgical hip repair or replacement for hip fractures. Older adults with intracapsular hip fractures (occurring within the hip joint capsule) are best managed with arthroplasty or hemiarthroplasty, which entirely or partially replaces the joint. For extracapsular fractures (those occurring outside of the hip joint capsule), open reduction internal fixation (ORIF) using nails and screws is the recommended treatment.
3. Administer medications as ordered.
Oral and IV analgesics control pain, while NSAIDs manage inflammation. Nerve blocks may be used preoperatively to manage pain without causing systemic sedation. Antibiotics may be prescribed as prophylaxis to lower the risk of postoperative infection. Anticoagulants are anticipated to prevent venous thromboembolism.
4. Maintain hip alignment after surgery.
It’s imperative to maintain hip alignment following surgery to ensure proper bone healing. Instruct the patient to avoid flexing the hip, i.e., do not sit at a 90-degree angle. The knees must remain lower or at the same level as the hips. Patients should also avoid crossing their ankles. When turning the patient, place a pillow between the knees to maintain alignment. The patient may use a trapeze bar to assist with repositioning.
5. Follow activity restrictions.
The nurse must implement activity orders prescribed by the surgeon. This may include protected weight bearing with the use of devices such as crutches or walkers to limit weight on the joint. Activity restrictions will depend on each patient, the extent of injury, and the surgical intervention. Movement must not be avoided as it decreases the risk of complications, such as pneumonia, deep vein thrombosis, and skin breakdown.
6. Monitor for complications.
There are various complications that may arise following a hip fracture and surgery. The nurse must closely monitor for worsening pain, signs of infection, alterations in vital signs, changes in mental status, and poor wound healing that require prompt intervention.
7. Collaborate with physical therapy.
A physical therapist will tailor a program for the patient to help them regain their strength, flexibility, and mobility. Following hip replacement surgery, PTs can recommend specific exercises to increase the patient’s range of motion and weight-bearing ambulation. PT may continue once the patient returns home or in a rehabilitation facility.
8. Review fall prevention strategies and bone health preservation.
The nurse can offer education to the patient on preventing falls and increasing their bone strength by:
- Utilizing assistive devices as needed
- Installing grab bars for extra support
- Standing up or repositioning slowly to prevent dizziness
- Participating in weight-bearing activities
- Quitting smoking and limiting alcohol
- Eating foods high in calcium and vitamin D (or taking a supplement)
- Obtaining a bone density scan and treating osteoporosis
Nursing Care Plans
Once the nurse identifies nursing diagnoses for hip fractures, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for hip fractures.
Acute Pain
One of the clinical manifestations of hip fractures is pain along with tenderness in the affected area.
Nursing Diagnosis: Acute Pain
Related to:
- Surgical intervention
- Trauma
- Injury
As evidenced by:
- Expression of pain
- Expressive behavior
- Guarding behavior
- Positioning to ease pain
- Limited mobility
Expected outcomes:
- Patient will express pain relief from the administration of pain medication.
- Patient will implement nonpharmacologic pain relief measures.
Assessment:
1. Assess pain characteristics, location, intensity, and impact on function.
A comprehensive pain assessment is critical in successfully identifying the effects of pain, appropriate treatment regimens, and if pain management is effective.
2. Use pain scales and descriptors.
Have the patient describe pain on a numerical scale or using the FACES pain scale if unable to verbalize. Assess for pain that is described as “dull” or “burning” which can signal nerve pain and requires other types of medication.
Interventions:
1. Administer medications as ordered.
Severe muscle spasms in hip fractures may worsen pain. Nerve pain following surgery may require adjunctive treatment along with opioids and muscle relaxants to help reduce pain and promote comfort.
2. Assist to a comfortable position if not contraindicated.
Following hip surgery, the patient should not bend past 90 degrees and should not cross the ankles to keep the hip in alignment.
3. Properly apply traction.
Applying traction as ordered can help reduce muscle spasms and relieve pain.
4. Supplement with NSAIDs.
Nonsteroidal anti-inflammatory medications are very important following surgery and in conjunction with opioid analgesics to reduce swelling.
5. Implement nonpharmacologic interventions.
Ice packs can be applied in 15-minute increments to decrease swelling.
Impaired Transfer Ability
Patients with hip fractures have difficulty moving due to the loss of structural integrity to the femur and/or hip as well as from pain. This results in a decreased ability to ambulate and transfer.
Nursing Diagnosis: Impaired Transfer Ability
Related to:
- Pain
- Tenderness
- Insufficient muscle strength
- Musculoskeletal impairment
As evidenced by:
- Difficulty transferring between bed and chair
- Difficulty standing
- Difficulty transferring to the toilet
- Difficulty transferring into a vehicle
Expected outcomes:
- Patient will demonstrate effective transfer ability with minimal supervision.
- Patient will transfer safely using assistive devices.
Assessment:
1. Assess factors causing impaired transfer ability.
To determine how to best support transferring, assess if there are barriers related to pain, fear, or a lack of physical support or equipment.
Interventions:
1. Provide medications as ordered.
Analgesics are often indicated to help reduce pain so the patient is more inclined to attempt to transfer.
2. Encourage ADLs within limitations.
Depending on the patient’s individual activity orders, bed rest and traction may be required and limit mobility. Provide trapeze bars and items such as wash basins and toiletries so the patient can still participate and maintain independence.
3. Collaborate with PT or OT for rehabilitation.
Rehabilitation therapy is critical for patients recovering from hip fractures. The nurse can prepare the patient for their therapy sessions by premedicating and completing tasks before and after PT/OT visits.
4. Provide transfer aids and assist patients in moving.
Initially, patients with hip fractures may need assistive devices such as bedside commodes and walkers. Support safe transferring by using gait belts, non slip shoes, and remaining within arm’s reach.
Ineffective Tissue Perfusion
Intracapsular fractures of the femoral neck can disrupt the blood supply to the femoral head, causing avascular necrosis.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Vascular damage
- Delayed healing
As evidenced by:
- Absent or diminished pulses in the affected area
- Pain
- Edema
- Altered motor function
- Poor wound healing
Expected outcomes:
- Patient will maintain adequate tissue perfusion around the affected area, as evidenced by palpable pulses and warm and dry skin.
- Patient will not experience any complications in healing that require surgical revision.
Assessment:
1. Assess and palpate distal pulses.
Diminished or absent peripheral pulses indicate ineffective tissue perfusion and require immediate intervention.
2. Monitor for bleeding.
Hip and femoral fractures can result in severe bleeding. Monitor for bruising and swelling around the hip.
3. Monitor for pain.
Pain is expected with a hip fracture and following surgical intervention. Monitor for worsening pain or chronic pain that indicates an ongoing issue, such as delayed healing.
Interventions:
1. Prepare the patient for surgery.
Damage to the blood supply of the femoral head can impact surgical options. For displaced fractures, arthroplasty is often chosen, while undisplaced fractures can be managed with fixation (such as screws) or arthroplasty.
2. Initiate Buck’s traction and monitor closely.
Buck’s traction, a form of skin traction, is used to temporarily manage femoral and hip fractures. Traction helps relieve discomfort, immobilize the affected extremity, and prevent further damage by maintaining alignment. The nurse should closely monitor the patient’s peripheral pulses, capillary refill, sensations, and motor function to ensure adequate perfusion.
3. Assist with early ambulation.
Early ambulation is advised following hip surgery to promote circulation and prevent complications such as thromboembolism.
4. Advise against smoking.
Patients who smoke should be instructed to quit as smoking causes vasoconstriction and can impede blood flow, delaying the healing of the fracture and surrounding tissues.
Risk for Falls
Falls are a major cause of hip fractures, but the risk of falls also increases after a hip fracture due to reduced mobility and loss of muscle strength.
Nursing Diagnosis: Risk for Falls
Related to:
- Impaired physical mobility
- Impaired postural balance
- Decreased muscle strength
- Gait alterations
- Pain
- Delayed healing
- Prolonged recovery
- Visual or hearing impairment
- Advanced age
- Use of assistive devices
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free from falls.
- Patient will participate in physical rehabilitation to prevent falls after a hip fracture.
Assessment:
1. Assess the patient’s baseline level of mobility.
Inquire about the patient’s activity and mobility level prior to the hip fracture. Some patients are unable to regain their pre-fracture level of mobility, which increases their risk of falls and injuries. This often depends on the type of surgery required, the healing process, the patient’s chronic medical conditions, any complications that arise, and the patient’s adherence to recovery and rehabilitation.
2. Conduct a fall risk assessment.
Various factors like medications, pain, confusion, postural hypotension, dizziness, and a history of falls can further increase the risk of falls in addition to the patient’s hip fracture.
3. Monitor the patient’s mental status.
Older adults, in particular, are at risk for delirium in the inpatient setting due to surgery, medications, an unfamiliar environment, and more. Delirium can cause confusion, agitation, delusions, and changes in sleep habits that may cause the patient to attempt to get up without assistance, resulting in falls.
Interventions:
1. Encourage physical and occupational therapy.
Physical therapy is crucial to restoring mobility and any lost muscle strength and assisting the patient in returning to their pre-level of functioning. Some patients may also benefit from occupational therapy to overcome self-care deficits and prevent falls in their homes or other environments.
2. Encourage the use of assistive devices and mobility aids.
Mobility aids such as crutches and walkers are often utilized after hip fracture surgery to help compensate for reduced strength and balance and postoperative weight-bearing restrictions.
3. Instruct the patient to avoid using a rocking or swivel chair.
Chairs that rock or swivel should not be used by patients after a hip fracture as they are unstable and may increase the risk of falls and injuries. A power lift reclining chair is especially useful to help the patient stand from a seated position.
4. Educate the patient on fall prevention strategies.
The nurse should educate the patient on strategies to prevent future falls and a subsequent hip fracture, including:
- Installing grab bars in the home where needed
- Wearing nonskid footwear inside and outside the home
- Participating in balance exercises and regular physical activity
- Removing throw rugs and using non-slip mats in the shower
Risk for Infection
Infection of the surgical site is a potential complication following hip arthroplasty. Patients who develop infections require longer inpatient care and more aggressive management. Reduction of this risk is vital to promote an early and smooth recovery.
Nursing Diagnosis: Risk for Infection
Related to:
- Surgical interventions
- Long-term invasive devices (PICC line, urinary catheters, etc.)
- Difficulty managing wound care
- Other chronic nonhealing wounds and pressure ulcers
- Inadequate health literacy
- Inadequate hygiene
- Inadequate knowledge to avoid exposure to pathogens
- Impaired skin integrity
As evidenced by:
A risk diagnosis is not evidenced by any signs and symptoms, as the problem has not occurred yet and nursing interventions will be directed at the prevention of symptoms.
Expected outcomes:
- Patient will remain free of symptoms of infection and demonstrate strategies to effectively prevent infection.
Assessment:
1. Assess risk factors that predispose the patient to infection.
Older age, comorbidities, malnutrition, impaired skin integrity, and a compromised immune system are additional risk factors that predispose the patient to infection.
2. Assess for signs of infection at the surgical site.
Erythema, swelling, and the development of pus can indicate a surgical site infection. Changes in mental status, hypotension, fever, and chills can indicate sepsis.
3. Assess laboratory values.
Leukocytosis is a sign of infection and requires further assessment.
Interventions:
1. Provide wound care.
The surgical site must be kept clean and dry at all times. Educate the patient and family members on how to provide appropriate wound care at discharge.
2. Teach the patient about hand hygiene.
Infection prevention includes strict hand hygiene. Always wash hands when visibly soiled and use alcohol-based hand rubs before touching the patient.
3. Administer antibiotics as ordered.
Antibiotic therapy is often provided for patients following surgery to prevent infection and promote wound healing.
4. Remove invasive lines as soon as possible.
IV lines, urinary catheters, PICC lines, and more increase the risk of catheter-related bloodstream infections. Discontinue invasive lines as soon as they are no longer needed.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Auerbach, N., & Tadi, P. (2023, July 4). Antalgic gait in adults – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved February 2024, from https://www.ncbi.nlm.nih.gov/books/NBK559243/
- Bhatti, N. S. (2024, January 25). Hip Fracture Clinical Presentation. Diseases & Conditions – Medscape Reference. Retrieved February 2024, from https://emedicine.medscape.com/article/87043-clinical#showall
- Emmerson, B. R., Varacallo, M., & Inman, D. (2023, August 8). Hip fracture overview – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved February 2024, from https://www.ncbi.nlm.nih.gov/books/NBK557514/
- Hip Fracture. Mayo Clinic. Updated May 5, 2022. From: https://www.mayoclinic.org/diseases-conditions/hip-fracture/symptoms-causes/syc-20373468
- Hip Fracture. NHS. Reviewed: October 03, 2019. From: https://www.nhs.uk/conditions/hip-fracture/
- Hip Fractures. OrthoInfo. Stuart J. Fischer, MD, FAAOS, and Joshua L. Gray, MD, FAAOS. Reviewed November 2020. From: https://orthoinfo.aaos.org/en/diseases–conditions/hip-fractures/
- Hip fracture & broken hip. (2021, January 21). Cleveland Clinic. Retrieved February 2024, from https://my.clevelandclinic.org/health/diseases/17101-hip-fracture
- Hip fracture. (2022, May 5). Mayo Clinic. Retrieved February 2024, from https://www.mayoclinic.org/diseases-conditions/hip-fracture/symptoms-causes/syc-20373468
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Patient Information Fractured Hips. (2016, April). The Ottawa Hospital. Retrieved February 2024, from https://www.ottawahospital.on.ca/en/documents/2017/01/cp03b-fractured-hip-english-april-2016.pdf/
