A Fractured Neck of Femur - Case Study Example

Running Head: CASE STUDY: A FRACTURED NECK OF FEMUR, MRS DORIS JOHNSON. Case Study Student Name Institution Date A fractured neck of femur: Ccase study, Mrs Doris Johnson Introduction Doris is an 85 years old woman who has been admitted to hospital with a femoral neck fracture and is scheduled for open reduction, internal fixation of her hip. Femoral neck fractures are serious fractures that are connected with significant morbidity and high mortality in the elderly population. According to Wylde & Dieppe (2008, 100), the significant aspect with fractures of the femoral neck is the disruption of blood supply towards the fractured region of the bone. This case study reviews the clinical manifestations, path physiology of the disease and pharmacological and surgical management of the disease. Under the condition of pathophysiology, a fracture of femoral neck usually occurs after falls. The factors that raise the hazard of injuries are connected to conditions that raise the likelihood of falls and those which decrease the inherent capability of the individual to endure the trauma. Malnutrition, impaired balance and vision, slower reflexes and neurological problems raise the risks of osteoporosis in older people like Doris and is an important risk issue that leads to hip fractures and this condition decreases the strength of bone and its capability to defy trauma. Femoral neck fracture can be linked to chronic stress instead of a sole traumatic occurrence (Mickey, 2009). According to Mickey (2009) a hip joint is a big multiaxial ball and socket synovial joint which is enclosed by a wide articular capsule. A hip joint is meant for a variety of movement and stability. When a person is standing, the whole mass of the upper portion of the body is conveyed to the neck and head of the femur. Supply of blood towards the hip is tenuous. It comprises of perforating branches of the lateral and medial circumflex arteries of the femur, the superior and inferior gluteal arteries along with the posterior branch of obturatory artery. Brown (2009, 25) argues that these branches create the three major vascular constitutions that supply blood to the femoral head and neck. The medial circumflex which supplies majority of blood to femoral neck and head is torn when fracture of femoral neck occurs. When there is break of blood vessels, the section of the bone may not receive any blood which can result to a vascular necrosis (Brown, 2009, 202). Pharmacological management of femoral neck fracture is essential as it ensures that the patients suffering are taken care off accordingly. Before surgery Doris has required preoperative management. Control of pain is vital for quality care of Doris. Analgesics are used for Doris and they ensures her comfort, and sedating properties Bongiovanni (2005, 74) argues that femoral neck fracture requires tetanus prophylaxis, and administration of broad spectrum antibiotics such as aminoglycoside and cephalosporin. According to Walsh (2007), osteoporosis, which is a major risk factor in Doris, is caused by low bone mineral density. Inadequate intake of calcium by Doris promotes bone loss and leads to osteoporosis. Deficiency of vitamin D increases the hazard of osteoporosis (Frank, 2008). According to Brody, (2005, 246), vegetables and fruits which contain nutrients like Vitamin K, magnesium and potassium which plays a significant functions in the health of bones. High consumption of vegetables and fruits especially those contain potassium are connected with increased bone mineral density and reduced hazard of hip fracture in Doris Brody (2005, 247). Clinical Manifestation of Fractured Femoral Neck is yet an important factor to be put under consideration. A hip fracture causes pain which makes Doris unable to actively move her legs. It causes bruising or swelling and the hip can look deformed. It becomes hard to move the hip particularly turning the leg outwards or bending at the hip. Doris is limited in motion so as to prevent maximal hip extension since this position lessens capsular volume and increases intra articular pressure and places maximal strain on the femoral neck. This condition leads to impaired mobility and deterioration of mental and physical condition. This condition makes Doris lose her independent living because she cannot carry out daily activities on her own (Browner, 2009, 219). This condition has potential medical conditions on Doris such as urinary tract infection, myocardial infarction, wound infection, and deep vein thrombosis. Femoral neck fracture exposes the bone to infection which may be intractable. The fracture can release fat that embolise to lungs and results in respiratory complications such as pulmonary embolism. Femoral neck fracture normally interrupt articular cartilage and the misaligned cartilage is likely to be disfigured leading to impairment of joint motion and osteoarthritis. Other symptoms and signs include deformity, bone tenderness and crepitation (Brown, 2009, 105). Surgical Treatment of femoral neck fracture follows a given procedure which has to be strictly adhered to. Diagnostic testing along with pre anesthesia interview will be done on Doris before surgery. Doris will be given a careful explanation the procedure, any risks, its purpose and the anticipated outcome. Doris is then requested to sign an informed consent form, which affirms that she has understood everything that will be involved in the surgery. The consent should be carefully read before signing it. If Doris have any questions or requires more information she should ask her physician. Since Doris is traumatized by the fracture a guardian or close relative can assist Doris in reading through and signing the consent form (Wicker, 2006, 210). According to Blomfeldt (2009, 105-110), repair of a hip fracture using surgical means is usually indicated and carried out as soon as possible following the injury. A fracture without displacement is often treated by fixation of three or four screws which can be inserted via the skin. Brown & Edwards (2008, 102) argues that a displaced fracture is treated in order to restore the functioning of the hip and to preserve life. A displaced fracture is usually treated through open reduction and internal fixation Open reduction refers to open surgery to realign bones to their anatomically normal position and internal fixation is the fixation of plates or screws to facilitate or enable healing. Attention should be given to blood vessels and nerves in the fractured area as they may be damaged during reduction or during injury. Treatment of a dislocation or fracture can entail treatment of injured blood vessels and nerves (Young, 2009, 192). Open reduction internal fixation is an in-patient procedure that is carried out in an operating room. An opening is made on the fracture, the wound is cleaned, and the position of the fracture is corrected using pressure. The reduced site is maintained using orthopedic hardware like screws or plates placed around or through fracture fragments. An exterior fixator device can be used to sustain the position. The fixator enables early motion of joints below and above the fracture. The fixator is usually eventually removed while internal screws or plates are left (Mickey, 2009, 62). Nursing management after surgery is quite important. According to David, (2006, 217) the wound should be monitored for any accumulation of fluid or blood and if there is any fluid or blood accumulating on the wound it should used with portable suction such a Bellovac wound drain. The wound should be cleaned on a daily basis and a cotton tipped swab should be used to remove any blood dried blood or crust. The wound is then pat dried gently. A slim layer of Polysporin or Bacitracin ointment is applied on the wound and covered with a Telfa pad or bandage Ointments that contain neomycin should be avoided as they cause itching and redness of wound (White, 2006). Postoperative pain can raise body’s sympathetic response with subsequent increases in cardiac work, oxygen consumption and heart rate. Pain relievers like opoids (fentanyl or morphine) should be injected into Doris using the intravenous catheter. Medications that contain ibuprofen or aspirin should not be used as they can cause bleeding (Blomfeldt, & Vertilis, 2009, 96). After surgery Doris is immobilized and the immobilization can lead development of bed or pressure sores as a result of pressure against a portion of skin with bone underneath it. This limits the flow of blood to the area and the structures and skin underneath start to die Pressure area care entails moving Doris into another position regularly in order to relieve pressure and prevent development of a bed sore or pressure ulcer. This assists restore blood circulation to the body area that is compressed when Doris does not move. Doris is moved or rolled from side to and onto her back at regular intervals. Pressure area care also entails deep venous thrombosis screening along with prophylaxis until Doris is mobile. A Doppler duplex scan is taken within 36 hours after operation and thereafter on weekly basis until Doris is completely mobilized (Walsh, 2007, 220). Immobilization result to formation of blood clots as a result of disrupted venous return. Doris should therefore use Thrombo Embolic Deterrent stockings on the leg to prevent formation of blood clots. They are composed of elastic fibres that squeeze and insert pressure on leg muscles and promote venous return, prevent blood clots and reduces the likelihood of development of deep vein thrombosis and its common sequel pulmonary embolism in immobile Doris. If Doris has recent skin conditions like open sores, or dermatitis the Ted stockings cannot be used (Brown, & Edwards, 2008, 220). According to Hardy, (2008, 702), Doris movement is restricted after the surgery and this can damage blood vessels and nerves which a neurovascular deficit. Neurovascular observations include the assessment of the vascular and neurological integrity of the leg. When assessing symptoms and signs of neurovascular deficit paralysis, pain, pallor, pulses and paraesthesia must be considered. In addition, evaluation should consider any swelling and warmth of the leg. Ischaemic muscles are perceptive to elongating and extension of the joint can result to severe pain of the leg. If the pain does not stop when the toes are gripped in extension and movement has been restricted in Doris, the nurse must be alerted (Wylde, & Dieppe, 2008, 53). According to Pasero (2005, 45), Doris must be requested to report changes in sensation to the operated leg, which can result from pressure on relevant nerves.). Documentation must note where Doris reports altered feeling and the type of sensation so that the medical staff may be able to identify the affected nerve. Capillary refill must be applied to evaluate arterial perfusion. In regard to temperature the warmth of the leg distally and proximally to the surgery must be assessed. Any changes in colour and temperature must be noted (Wilson & Giddens, 2009, 103). Even though, inflammation is not essentially a sign of neurovascular deficit, if there is not increase in swelling it should be reported and documented. Documentation of neurovascular observations is significant in identification of symptom patterns after Doris has undergone surgery. A neurovascular chart must be used in assessing Doris and results must be documented together with every action undertaken by a nurse. Morrison (2006, 216) argues that If a difficulty emerges and documentation fails then the assumption will be that no any action was taken on the observation. If there is suspicion of neurovascular deficit, the acting nurse is supposed to report it to the medical team urgently in order for it to be reviewed. Ice instigation and elevation after surgery is useful in reducing swelling. Nevertheless, elevation must be reduced to below the level of heart and ice eliminated if there is suspicion of neurovascular deficit to avoid further impediment of circulation. Any constraining bandages must be loosened to lessen restriction of the leg. There is loss of body fluids following surgery. When managing fluid balance, physical abilities or mobility of Doris must be considered as a feature in loss of body fluids. Fluid balance should be recorded on a detailed fluid balance chart and the nursing evaluation of fluid balance must include the medical history of Doris, clinical observation, physical examination along with analysis of laboratory outcomes. A detailed report of Doris history must be taken particularly her fluid output and input (Mickey, 2009, 75). A clinical evaluation of Doris must be undertaken including crucial observations like measuring blood pressure, respiration, temperature and pulse. The physical appearance of Doris must be noted and attention must be given to the tongue, face and skin. The universal well being of Doris is a useful indicator of fluid gain and loss (Harris, Nagy, & Vardaxis 2010, 96). Central venous pressure must be conducted. A central venous pressure is useful in establishing the quantity of fluid in the body. The fluid output and input is recorded on a fluid balance chart and precise recording is vital for Doris well being. Fluid loss following surgery leads to electrolytes imbalance in the blood. Laboratory blood examinations like urea and electrolytes such as magnesium, calcium and glucose helps in determining disperancies and rule out the treatment needed to restore fluid balance (Browner, 2009, 152). Replacement of preoperative deficit should be considered because Doris might have been desiccated for numerous days prior to surgery. This will help in determining the amount of fluid to be administered postoperatively. A fluid balance sheet gauges Doris hourly fluid output and intake over duration of 24 hours. After 24 hours the total measured fluid output entailing the fluids lost through drains urine and nasogastric drainage is subtracted form the total measured fluid intake entailing oral intake and intravenous infusion (Wicker, 2006, 300). A positive fluid balance implies that intake exceeds output and there is accumulation of water in Doris body. Actually, appositive balance is not actually positive since there are particular outputs not measured very precisely like fluid lost in faeces and other fluids lost in respiration and sweat are not possible to measure. As a result, for the initial 24 hours, the fluid balance chart will often illustrate a great positive balance of about 10 litres. In the succeeding days, the chart must regress to the usual 1 to 1.5 litres positive for each day. Generally if Doris shows a consistent positive balance every day, it implies that her condition is not resolving. Loss of drip and inability to manage hypotension is the major cause of death after Doris surgery. Therefore she needs a post surgery infusion to manage any deficit along with maintenance. A placement of intravenous cannula is very crucial. A vein should be used in a position that will stay for a long duration in the ward. A tape that sticks the cannula to the skin should be used to ensure that it does not detach from the vein (Bongiovanni, 2005, 69). There are various ways that health is promoted by the person suffering from the disease. After the painful signs of a fixed femoral neck fracture have been controlled in the acute treatment phase, exercises in order to restore and improve hip motion. After the operation, the patient is supposed to rest until pain stops and then continues with full action as healing continues (Torres & Mittal, 2008, 78). Brody (2005) argues that universal conditioning of upper extremities and the uninvolved lower extremity can assist to facilitate early transfers and mobilization. Doris should be educated on how she prevent falls in future. Stairs act as a major risk of falls in Doris and she should use a walker, crutches, and handrails or have a person to assist her until her flexibility, strength and balance are improved According to McLaren, (2008, 209), Doris should be told not to close her legs or move them beyond 90 degrees so as to avoid tension of the fracture.Weight control exercise increases bone minerals density in Doris. Exercise increases bone mineral density gains and also strengthen muscles and strengthened muscles offer extra support to femoral neck that is vulnerable to rapture According t (Torres & Mittel, 2008, 192), Conclusion Femoral neck fractures can cause significant morbidity and high mortality in elderly people and therefore the condition should be treated as soon as possible. It is important to assess the fracture before determining the method of treatment to be used. Non dislocated fractures are treated by fixation of screw on the injured part while displaced fractures are treated by open reduction and internal fixation where the bones are realigned to their anatomical position and then the screws or pins are inserted. Post operative management is essential to ensure that Doris is able to recover and is not exposed complications that may result from surgery. References Blomfeldt, R., Vertilis A., & Jain N., (2009).Femoral neck fracture: treatment and medication. Retrieved August 2, 2010 from Bongiovanni, M. S.,(2005). Orthopaedic trauma: critical care nursing issues. Critical care nursing Quartery 28(1): 60-78. Brody, L., (2005). Therapeutic exercise: moving toward function. Australia: Lippincott Williams & Wilkins Publisher. Browner, L., (2009). Skeletal trauma: basic science, management, and reconstruction, 4th Edition. Texas: Elsevier Health Sciences Publisher. Brown, D., & Edwards, H., (2008). Lewis's medical surgical nursing: Assessment and management of clinical problems, 2nd Edition. Sydney, Australia: Mosby Elsevier. Brown, T., (2009). Arthritis & arthroplasty: The hip. Retrieved on August 3 2010 from David, J., ( 2006). Hip fractures: a practical guide to management. New York: Springer Publisher. Hardy, J., (2008). Complications in surgery and their management. Michigan: University of Michigan Press. Farrell, M., (2005). Smeltzer and Bare's textbook of medical-surgical nursing: Australian and New Zealand edition. Broadway, NSW, Australia: Lippincott Williams & Wilkins. Harris, P., Nagy,S., & Vardaxis N., (2010). Mosby's dictionary of medicine, nursing and health professions, 2nd Edition. Sydney, Australia: Mosby Elsevier. Mickey, J. (2009). The clinical practice of neurological and neurosurgical nursing. 6th Edition Philadelphia: Lippincott Williams and Wilkins. Morrison, M., (2006). A colour Guide to the Nursing management of Chronic Wounds. 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