Hip fractures refer to a fracture or break in the proximal or upper third of the femur, extending to 5 cm below the lesser trochanter. This is common in older adults and usually results from direct trauma or a fall.
Hip fractures are classified into different types:
- Intracapsular fractures occur within the hip joint capsule and are often associated with minor trauma and osteoporosis.
- Capital – fractures occurring at the head of the femur
- Subcapital – fractures occurring just below the head of the femur
- Transcervical – fractures occurring on the femoral neck
- Extracapsular fractures occur outside the hip joint capsule and are commonly caused by severe trauma or fall.
- Intertrochanteric – fractures occurring between the lesser and greater trochanter
- Subtrochanteric – fractures occurring below the lesser trochanter
Signs and symptoms of hip fractures include muscle spasms, external rotation, severe pain, shortening of the affected extremity, and tenderness and bruising around the fractured site. Necrosis of the femoral head can also occur due to fractures in the femoral neck that impair the supply of blood to the femoral head.
Physical examination and imaging studies including x-rays, MRI scans, and CT scans are often used to diagnose hip fractures.
The Nursing Process
Hip fractures will typically require surgery within 1 to 2 days after injury, as surgical intervention will help relieve acute pain and lessen possible complications as well as restore mobility.
The nurse is responsible for preparing and caring for the patient before, during, and after the surgery. 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 rehab or home health care is required to promote further healing and recovery.
Nursing Care Plans Related to Hip Fractures
Acute Pain Care Plan
One of the clinical manifestations of hip fractures is pain along with tenderness in the affected area.
Nursing Diagnosis: Acute Pain
- Surgical intervention
As evidenced by:
- Expression of pain
- Expressive behavior
- Guarding behavior
- Positioning to ease pain
- Limited mobility
- The patient will express pain relief from the administration of pain medication
- The patient will implement nonpharmacologic pain relief measures
Acute Pain 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.
Acute Pain 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 Care Plan
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
- 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
- The patient will demonstrate effective transfer ability with minimal supervision
- The patient will transfer safely using assistive devices
Impaired Transfer Ability 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.
Impaired Transfer Ability 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.
Risk for Infection Care Plan
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
- 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.
- The patient will remain free of symptoms of infection and demonstrate strategies to effectively prevent infection
Risk for 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.
Risk for Infection 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 and Sources
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- 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/
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.