Nursing Care Plan - Femoral Fracture and Other Comorbidities - Case Study Example

Nursing Care Plan: Femoral Fracture and other Comorbidities Student’s Names Institutional Affiliation Nursing Care Plan: Femoral Fracture and other Comorbidities Introduction and Pathophysiology of Femoral Neck Fracture Mr. Peterson, a 78-year-old man, fall in his bathroom fracturing the neck of his right femur. His old age is a risk factor for fractures due to osteoporosis that is usually associated with bone loss (Syed & Ng, 2010). In addition, he only quit smoking five years ago which means his chronic smoking habit may have predisposed him to osteoporosis (Hattiholi & Gaude, 2013). The pathophysiology of femoral neck fracture (FNF) begins with weakening of part of the neck of femur. The weak points can be caused by an imbalance between bone resorption and bone formation through osteoblast mediated activity (Wildstein, 2013). As individuals age, the osteoblastic activity sometimes becomes insufficient to repair femoral bone areas that have undergone osteoclastic resorption. Weak points along the neck of femur increase the susceptibility to fractures. Therefore, Mr.Peterson’s fracture may have occurred along a weakness on the neck of femur. The narrow circumference, angle and length of the neck of femur predispose it to considerable shear forces during movements (Davenport, 2014). When these forces exceed the bone strength of an already weakened bone, a fracture may occur. Mr. Peterson’s fracture probably resulted from shearing forces overwhelming the strength of the femoral neck’s bone. His fracture, is intracapsular whose association with vascular supply disruption, especially affecting the circumflex artery, is high with a possible incident of avascular necrosis in the femoral head (Davenport, 2014). Healing of such kind of intracapsular fractures is complicated by a difficulty in callous formation due to the separation from capillaries and adjacent soft tissues by thick capsular surrounding on the femoral neck. Nursing Care Plan Nursing Diagnosis Expected Outcome Nursing Intervention Rationale References Preoperative Deficient knowledge related to the surgical process of total hip replacement (THR), and the postsurgical manifestations of anaesthesia evidenced by numerous questions and inaccurate instructions follow-through. *The patient will be able to demonstrate an understanding of the surgical process through verbalization of the pre and postoperative care and the possible postoperative sensations. * The patient will be capable of demonstrating that he can actively perform activities geared at precluding postoperative complications. * Review of the process of femur fracture in addition to the co-morbidities such as diabetes and hypertension, the whole surgical process, and the expected outcome of the procedure. * Explain the surgical process beginning with an incision on the right buttock that would be used to access, cut and remove a piece of the broken form to be replaced by a prosthetic one. * Demonstrate pre-rehabilitation technique such as those emphasizing on step training, resistance training and limb and body movement exercises geared to enhancing flexibility. * Explain to the patient instructions about preoperative testing such as routine blood count, coagulation tests, blood grouping and cross matching, and medications that will be administered preoperatively. Include the reason for the testing and the expected outcome. * This provides the patient a background of knowledge that would allow him to make informed decisions. * Knowledge of the procedure will allow him an insight on the expected outcome * Preoperative demonstration of physiotherapy effects has been shown to improve postsurgical functioning of patients after THR. * Various tests are performed on the patient prior to initiating the surgical process including basic vitals tests and some laboratory tests. This is meant to assess the suitability of the patient for the surgery and prevent any complications. (Louw, Diener, Butler & Puentedura, 2013) (McDonald, Page, Beringer, Wasiak & Sprowson, 2014). (Howard, Khaleel & Ellis, 2010). (Kumar & Srivastava, 2011). Anxiety associated with understanding the surgical procedure and its repercussions evidenced by trembling, sweating and hyperventilation prior to surgery. * Patient to understand the pros of the surgical procedure over the cons. * Patient will exhibit reduced anxiety before the procedure. * Acknowledge cognizant of the anxiety and assure and educate the patient calmly on the benefits of the procedure in addition to reassuring him that he will be safe during and after the procedure. * Demonstrate anxiety relieving tactics such as positive visualizations, deep breathing and use of reassuring self-statements. * Educating and reassuring the patient of his safety alleviates anxiety. * The techniques improve the patient’s sense of confidence, courage and personal mastery. (Myers & Gulanick, 2013) (Myers & Gulanick, 2013) Risk of infection associated with the invasive surgical procedure, insufficient primary defense due to broken skin and diabetes comorbidity * Patient will be free of any infection after the surgical procedure. * Normal pre-and post-operative blood sugars. * Ensure aseptic technique is applied when handling the patient, preparing him for surgery and during the surgical procedure. This includes implementing the required preoperative preparation of the skin that entails showering, utilization of shampoo and scrubbing of the skin with antibacterial disinfectants. * Administer the prescribed intravenous antibiotic correctly. * Discontinue or skip a dose of metformin on the day of the procedure. * Check blood ketones and if less than 3mmol/L administer 0.1 units/Kg of subcutaneous rapid acting insulin and monitor blood sugars after 1hr. If RBS remain above 12 mmol/L 2hrs later, consider the introduction of variable rate IV insulin infusion. * Such technique eliminates or decreases transient microorganisms that may accidentally get into the surgical site. * IV antibiotics are used prophylactically to prevent infection peri and postoperatively. * Metformin highly predisposes the surgical patient to lactic acidosis. * High RBS above 12mmol/L with more than 3mmol of capillary ketone may necessitate cancelation of surgery while hyperglycemia predisposes the patient to infection affecting prognosis after surgery. (Smeltzer, Bare, Hinkle & Cheeber, 2010). (Association for Professional in Infection Control and Epidemiology [APIC], 2010). (Loh-Trivedi, 2013; Richards, Kauffmann, Zuckerman, Obremskey & May, 2012). (Dhatayira et al., 2011) Preoperative comprehensive assessment of the patient as he is prepared for surgery. * Documented baseline parameters. * Undertake a comprehensive assessment including temperature, blood pressure, respiratory rate, pulse, oxygen saturation and RBS. In addition, complete the pre-op checklist and obtain consent. * To ensure safety and legibility of the patient for the surgical procedure (Chow, Rosenthal, Merkow, Ko, Esnaola, 2012). Post-operative Acute pain related to the injury after the surgical process evidenced by the patient’s guarding behavior, distraction, self-focusing and pain reports. * Patient to report relieved pain. * Patient able to relax, rest and sleep calmly. * Patient capable of demonstrating application of diversion activities and relaxation skills *Assess pain reports while noting the location, duration and intensity. The latter use the 0-10 scale. * Ensure the operated limb is properly positioned and comfortable through often repositioning of the limb. * Encourage the patient to employ techniques targeting the management of stress such as guided imagery, meditation, visualization and progressive relaxation. In addition, employ therapeutic touch appropriately. * Administer prescribed analgesic medication regularly and prior to physical activities. These medicine include the use of muscle relaxants and narcotics. The latter may incorporate patient-controlled analgesia (PCA) for which patient education regarding its use is necessary. * Pain report allows pain localization and is a basis for evaluating the success of the interventions. * Decreases muscle tension and spasms against the prosthetic joint. * Relieves the tension in the muscles, refocuses the patient’s attention enhancing control and coping ability over the pain. * Relieves tension in the muscles and enhances patient participation. Narcotics analgesics are appropriate in relieving severe pain (Gupta et al., 2010). (Callaghan, Rosenberg & Rubash, 2007). (Varvogli & Darvin, 2011). (Gillaspie, 2010; Botti et al., 2014). Impaired physical mobility associated with the surgery, pain and impairment of the musculoskeletal system evidenced by a reluctance to move, movement discomfort and limited muscle control. * Position of the limb and limb function maintained appropriately. * Patient to exhibit better function and increased strength of the right lower limb and hip joint. * Maintain function of unoperated limb and the whole body * Position the prosthetic hip joint as prescribed including maintaining the extremity in an abducted position using pillows in the first days after surgery. Explain position limitations such as maintaining the operated limb in appropriate alignment without so much moving it towards the unoperated limb. * Instruct patient on how to utilize overhead trapeze and the non-operated leg to facilitate his movement and assist the patient during turning. * Support and encourage the patient to participate in rehabilitative exercise routines targeting the knee, hip, and other joints while maintaining the prescribed limb movement limitations. * Allows stabilization of the prosthetic joint. * Improves movement with less discomfort and encourages patient independence. Staff support reduces falls, shearing and skin abrasions. * Improves patient’s confidence in movements, restores muscle strength and accustoms patient to new life with a prosthetic joint. (Smeltzer et al., 2010). (Callaghan, Rosenberg & Rubash, 2007). (Timby & Smith, 2014). Risk of metabolic disturbances related to diabetes and post-operative hypercatabolic state. * Normal levels of metabolic parameters and function. * Ensure control of blood sugars within accepted limits using insulin and oral antidiabetics, monitor and maintain normal electrolyte and fluid balance, optimize the control of pain, and facilitate resumption of the previous diabetic meal regimen. * Postoperative catabolic state predisposes patient to increased insulin resistance, hyperglycemia and electrolyte and fluid disturbances that would complicate wound healing, increase infection risk and slow the rehabilitation process. (Dhatariya et al., 2011). Risk of poor wound healing, development of pressure sores and peripheral neurovascular dysfunction related to immobilization, vascular obstruction and mechanical compression * Wound heals gradually as expected * Absence of pressure ulcers * Patient able to maintain sensation and movement functions. * Patient exhibit adequate perfusion of tissue as evidence by normal vitals. * Check vitals 4 hourly or more frequently and report any substantial changes to the GP and perform dressing reinforcement as required. Palpate pulses bilaterally and examine skin temperature and colour in comparison with the non-operated limb. * Help patient shift positions every 2 hrs and maintain the patient’s comfort level. Assess the sensation and movement of operated limb. * Position and confirm that stabilizing devices are not exerting too much pressure on the underlying tissues and the skin. * Routine assessment gives patient’s information regarding the cardiovascular status and perfusion to the limb that may indicate complication such as infection, excessive bleeding, vascular obstruction that may derail wound healing. * Position shifts aids in alleviating pressure ulcers and immobility complications while increasing numbness and difficulties performing expected movements may indicate nerve injury, prosthesis dislocation necessitating urgent interventions. * Lowers the risk of nerve compression and compromised circulation. (Timby & Smith, 2014). (Smeltzer et al., 2014). (Marya & Bawari, 2010). Depression associated with maladaptive coping evidenced by irritability and a sad look * Patient will live positively with the prosthesis and without a report of self-injury events. * Encourage the expression of feelings and advice on the significance of coping and other psychological interventions including cognitive behavioral therapy (CBT). * Speaking out feelings and employing CBT aids in altering unhelpful thoughts and behavior through cognitive distortion (Duivenvoorden et al., 2013). Summary of Care plan and Discharge Plan Mr. Petterson's care plan has been constructed putting into consideration the other comorbidities such as diabetes mellitus and hypertension that the patient suffers from. By controlling blood sugars keeping them within acceptable limits, the risk of infection is reduced. Metoprolol was maintained pre and post-operatively to keep the blood pressure within safe pre and post-surgical limits (Sear, 2010). The plan has incorporated interventions to reduce the patient’s anxiety including patient education about the hip replacement procedure and the roles the patient is expected to play postoperatively to enhance quicker recovery and resumption of normal mobility with the prosthesis hip joint. Patient education is instrumental in achieving better outcome especially post-operatively in limiting the variety of movements that the patient can perform to allow stabilization of the prosthesis. The nurse’s input in supporting the patient postoperatively has also been reiterated in the care plan considering that the prosthesis joint will not be ready for use immediately, and the patient will require supportive movement and flexion of limbs. Reassurance of the patient of an equally manageable life with the prosthesis limb is part of the care plan to enhance coping and relieve postoperative anxiety and depression. The patient's discharge plan would include instructions to continue taking the antidiabetic oral medications and antihypertensive as prescribed, instruction to redress the wound timely and appropriately, and suggestions for rehabilitative exercise program that the patient would participate in to enhance progressive but secure, strengthening of the operated limb. Other instructions provided in the discharge plan include sitting and sleeping instructions in addition to limb and body movement precautions and limits. References Association for Professionals in Infection Control and Epidemiology. (2010). Guide to elimination of orthopedic surgical site infections. Washington, DC: APIC. Botti, M., Kent, B., Bucknall, T., Duke, M., Johnstone, M., Considine, J., ... & Cohen, E.,. (2014). Development of a management algorithm for post-operative pain (MAPP) after total knee and total hip replacement: study rationale and design. Implementation Science, 9(110). 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