Barbados Community College

Division of Health Sciences

Nursing Department

Bachelor of Science Nursing: Year Three (3) Group Three (3)

Course: Geriatrics
Title: Hip Fracture and Osteoporosis
Tutor: Ms. Fay Parris
Group Members: Rhea Depieza 0089165
Michaela Inniss 0082827
Nicole Mathurin 0089553
Katrina Randall 0006903
Shanice Scantlebury 0007022
Kevin St. Pierre 0082802
Date: November 17th, 2017
WHAT IS A HIP FRACTURE?

Hip Fracture: a hip fracture is a break in the upper quarter off the femur (thigh) bone. The extent
of the break depends on the forces that are involved. Hip fractures are said to be common in
women who are susceptible to osteoporosis.

WHAT IS OSTEOPOROSIS?

A condition of fragile bone with an increase susceptibility to a fracture. Osteoporosis weakens

bones and increases the risk bone breaking.

Identify possible causes for the condition in the scenario

Hip fractures mostly occurs from: a fall, a direct blow to the side of the hip, osteoporosis (a
condition of fragile bone which weakens the bone and increases the risk of a bone fracture),
cancer or stress injuries which can weaken the bone and make the hip more susceptible to
breaking, blunt trauma to the hip, obesity which leads to too much pressure on the hip bones.

Causes of Osteoporosis: osteoporosis occurs when there is an imbalance between the new bone
formation and the old bone re-absorption. This may be that the body may fail to form enough
new bone, or too much old bone may be re-absorbed or both. Other possible causes are oestrogen
in women and androgen in men, inadequate intake of vitamin D, lack of weight bearing
exercises, changes in the endocrine functions (in addition to the lack of oestrogen), over use of
corticosteroids, thyroid problems, lack of muscle use, generic disorders, age, lack of calcium
intake in the body, lifestyle choices, medications, high phosphate intake

Clinical manifestations associated with hip fractures

• Inability to move immediately after a fall

• Severe pain in the groin

• Inability to put weight on the injured hip

• Stiffness, swelling and bruises around the hip area

• The leg is shorter on the injured side

• Inflammation in the hip

Osteoporosis

Excruciate pain
Stooped posture- caused by vertebrae fractures, when the vertebrae is fracture the bone
compresses. The vertebra bones are like cubes; they are not long bones, therefore they do not
snap

Loss of height over time -caused by spinal fractures

Fractures that occur much more easily – even by a simple sneeze.

Explain how the process of ageing impacts on the development of four (4) clinical
manifestations for the client in the scenario

The aging process impacts the development of osteoporosis, hip fractures, impaired mobility and
increases the risk for infection because as the body ages the bone density decreases causing
osteoporosis and osteoporosis then raises the susceptibility of getting fractures and fractures then
leading to impaired mobility which decreases the patient’s ability to function independently and
preform daily task by themselves. The aging process also increases the risk for infection because
of the impaired immune function as well as anatomic and functional changes all which increase
the risk for infection for the patient especially after a surgical procedure such as internal fixation
with the insertion of a pin as in the client in the scenario.

Treatment and Management

Bone- Healthy lifestyle

Exercise, fall prevention and smoking cessation in the elderly with osteoporosis should be
encouraged whenever possible to help preserve bone mineral density and reduce fracture risk.
Weight bearing and resistance exercise increases bone mineral density of the spine, walking
alone increases bone mineral density of both the hip and the spine in postmenopausal women
however. A medical examination is recommended to make sure the patient is safe to exercise and
to assess muscle strength, range of motion, level of physical activity, fitness, gait and identify
balance problems.

Exercise regimens should be tailored to individual patient abilities. Loading exercises that can
be beneficial to the hip can result in compression fractures of the spine, so the intensity/
resistance of exercise might need to be adjusted to Bone mineral density, for example a 5 to 10
minute warm-up session of walking or stretching.

Other methods of preventing falls includes home environment modifications, for example
Removing loose rugs or extension cords, repairing rickety stairs, adding grab bars in the
bathroom, increasing lighting, assessing vision and treating any remedial visual abnormalities,
assessing need for ambulation-assistive devices such as canes and walkers.

Hip Protectors
These are specialized undergarments which are designed to pad the area surrounding the hip
decreasing the force of impact from falls.

Calcium and Vitamin D

All patients with osteoporosis, regardless of age, should receive adequate calcium and vitamin D.
Diet alone is usually not adequate to maintain recommended intakes of calcium and vitamin D,
and supplementation is almost always necessary.

Drug Therapy

• Bisphosphonates which can be given orally and intravenously.

• Raloxifene, and estrogen agonist-antagonist, is considered a second line option for the
management of osteoporosis in older seniors.

• Teriparatide and parathyroid hormones are administered by subcutaneous injection once

daily. They are an option for patients that are at high risk for fractures or who cannot tolerate or
fail other therapies.

• Administer Opioids for pain management e.g. Morphine.

Diagnostic Test

The diagnostic tests used are:

• MRI

• BONE SCAN

• X-RAY

Describe two (2) complications of the condition

Two complications of hip fractures due to immobility;

Blood clots in your legs or lungs and further loss of muscle mass which can increase your risk of
falls and injuries
Interventions:

Nutrition

1. Encourage the patient to add calcium and vitamin D to their diet – calcium strengthens
the bones and vitamin D aids with the absorption of calcium, and improves muscle strength

2. Advice patient to limit alcohol intake – alcohol decreases bone formation and reduces the
body’s ability to absorb calcium

3. Encourage the patient drink 1500 to 2000mls of water daily– to lubricate joints and aid in
the calcium absorption

4. Encourage the patient to add protein to their diet such as eggs and chicken - protein aids
with building and repairing tissues

5. Encourage the patient to increase the intake of dairy products such as cheese, cream,
yogurt, milk – to increase the calcium intake

6. Advice patient to get at least 15 minutes of sun exposure – the sunlight is an excellent
source of vitamin D

7. Encourage the patient to add vegetables such as kale and broccoli- theses vegetables
contain large amounts of calcium

8. Administer estrogen as prescribed – to decrease the rate of bone reabsorption and lower
the risk of osteoporosis.

Precautions when taking estrogen pill; this pill can increase the risk of strokes, blood clots,
breast cancer and heart attacks. The estrogen pill is also harsh on the liver; and persons who have
liver problems should choose a different way to get estrogen.
The patient can use estrogen skin patches; which has a combination of estrogen and progestin.
The estrogen patches lower the risk of osteoporosis and is not harsh on the liver. The estrogen
skin patches bypass the liver and goes directly in the blood stream.

Take into consideration

Estrogen patches should not be exposed to high heat or sunlight. Heat can make the patches
release estrogen too quickly; giving you a high dosage first and a low dosage later

Elimination

Nursing diagnosis

Functional urinary incontinence related to limited physical mobility manifested by hip fracture.

Goals

Patient uses adaptive equipment to reduce or eliminate incontinence related to impaired mobility.

Interventions

Interventions & Rationales

1. Set a toileting schedule: - A toileting schedule guarantees the patient of a designated time
for voiding and reduces episodes of functional incontinence.

2. Eliminate environmental barriers to toileting: - Loose rugs and inadequate lighting can be
a barrier to functional continence.

3. Place an appropriate, safe urinary receptacle such as a 3-in-1 commode, female or male
hand-held urinal, no-spill urinal, or containment device when toileting access is limited
by immobility or environmental barriers: - The patient must take this alternative toileting.

4. Assist the person to change their clothing to maximize toileting access. Select loose-
fitting clothing with stretch waistbands rather than buttoned or zippered waist; minimize
buttons, snaps, and multi-layered clothing; and substitute Velcro or other easily loosened
systems for buttons, hooks, and zippers in existing clothing.: - Clothing can be a barrier
to functional continence if it takes time to remove before voiding. Pants with elastic
waistband may be easier for men to remove for toileting.
 5. Tell the patient to limit fluid intake 2 to 3 hours before bedtime and to void just before
bedtime: - Restricting fluid intake and voiding before bedtime reduces the need to disrupt
sleep for voiding.

6. Manage any existing perineal skin excoriation with a vitamin-enriched cream, followed
by a moisture barrier: - Moisture barrier ointments are beneficial in protecting perineal
skin from urine.

7. Monitor elderly patients for dehydration in the long-term care facility, acute care facility,
or home: - Dehydration can intensify urine loss, produce acute confusion, and increase
the risk of morbidity and mortality, especially in the frail elderly patient.

Activity Rest and Comfort

Diagnostic Tests:

X-ray

MRI (Magnetic Resonance Imaging)

Bone Scan

Assessment:

Fracture to right hip

Diagnosis:

Impaired physical mobility related to right hip fracture manifested by limited range of motion
evidenced by being on complete bed rest

Interventions:

1. Assess degree of immobility produced by injury or treatment and note patient’s

perception of immobility.

Rationale: Patient may be restricted by self-view or self-perception out of proportion with actual
physical limitations, requiring information or interventions to promote progress toward wellness.

2. Encourage participation in diversional or recreational activities. Maintain stimulating

environment (radio, TV, newspapers, personal possessions, pictures, clock, calendar, visits from
family and friends).
Rationale: Provides opportunity for release of energy, refocuses attention, enhances patient’s
sense of self-control and self-worth, and aids in reducing social isolation.

3. Instruct patient or assist with active and passive ROM exercises of affected and
unaffected extremities.

Rationale: Increases blood flow to muscles and bone to improve muscle tone, maintain joint
mobility; prevent contractures or atrophy and calcium resorption from disuse.

4. Encourage use of isometric exercises starting with the unaffected limb.

Rationale: Isometrics contract muscles without bending joints or moving limbs and help maintain
muscle strength and mass. These are not to be done if bleeding or swelling is present.

5. Provide footboard, wrist splints, trochanter or hand rolls as appropriate.

Rationale: Useful in maintaining functional position of extremities, hands and feet, and
preventing complications (contractures, foot drop).

6. Place in supine position periodically if possible, when traction is used to stabilize lower
limb fractures.

Rationale: Reduces risk of flexion contracture of hip.

7. Assist with self-care activities (bathing, shaving).

Rationale: Improves muscle strength and circulation, enhances patient control in situation, and
promotes self-directed wellness.

8. Reposition periodically and encourage coughing and deep-breathing exercises.

Rationale: Prevents or reduces incidence of skin and respiratory complications (decubitus,

atelectasis, pneumonia).

9. Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel
routine. Place on bedside commode, if feasible, or use fracture pan. Provide privacy.

Rationale: Bed rest, use of analgesics, and changes in dietary habits can slow peristalsis and
produce constipation. Nursing measures that facilitate elimination may prevent or limit
complications. Fracture pan limits flexion of hips and lessens pressure on lumbar region and
lower extremity cast.

10. Encourage increased fluid intake to 2000–3000 mL per day (within cardiac tolerance),
including acid or ash juices.
Rationale: Keeps the body well hydrated, decreasing risk of urinary infection, stone formation,
and constipation

11. Consult with physical, occupational therapist or rehabilitation specialist.

Rationale: Useful in creating individualized activity and exercise program. Patient may require
long-term assistance with movement, strengthening, and weight-bearing activities, as well as use
of adjuncts (walkers, crutches, canes); elevated toilet seats; pickup sticks or reachers; special
eating utensils. When the client reaches this stage in recovery.

SAFETY AND PROTECTION

DIADNOSTIC TEST FOR HIP FRACTURE AND OSTEOPOROSIS

Hip fracture: x-ray, CT-scan, MRI (magnetic resonance imaging)

Osteoporosis: Dual-energy X-ray Absorptiometry (DXA). Osteoporosis is diagnosed by DXA,

which provides information about BMD at the spine and hip.

BMD testing. BMD testing is useful in identifying osteopenia and osteoporotic bone and in
assessing response to therapy.

Laboratory studies. Laboratory studies such as serum calcium, serum phosphate, serum alkaline
phosphatise, urine calcium excretion, hematocrit, erythrocyte sedimentation rate, and x-ray
studies

Nursing Interventions:

- Assess general status of the patient; this is to determine the patient’s condition that may
cause injury

- Avoid use of restraints. Obtain a physician’s order if restraints are needed, if patients are
restrained, they can sustain injuries.

- Provide medical identification bracelet for patients at risk for injury, signs are vital for
patients at risk for injury to promote patient safety.
- If patient is notably disturbed, consider using a special safety bed that surrounds patient,
special beds can be an efficient and useful alternative to restraints and can help keep the patient
safe during periods of confusion and anxiety

- Limit the use of wheelchairs as much as possible because the patient can move the
wheels, stand up from the chair and cause severe harm to the body

- Secure the bed board under the mattress or place the patient on an orthopedic bed because
a soft mattress may obstruct the traction which could disrupt the place of internal fixation and
pin.

- Support the fracture site with pillows and maintain a neutral position of the affected hip
to prevent unnecessary movement and disruption of the alignment and prevent pressure
deformities.

- Provide support above and below the hip fracture site to reduce the possibility of
disturbing the alignment and muscle spasms.

- Observe and elevate the hip for resolution of oedema.

- Maintain the position of integrity of the traction

- Keep ropes unobstructed with hanging free; avoid lifting or releasing the weights, this
may cause sudden excess pull on the fracture with associated pain and any possible muscle
spasms.
- Position the patient so that appropriate pull is maintained on the long bone of the axis.
This would promote bone alignment and reduces the risk of complications.

- Ensure that the traction setup is functioning properly to avoid interruption of the fracture

- Administer anticoagulants (heparin, warfarin) to prevent to reduce coagulation of the

blood by lying in bed and not having much mobility

- Administer antibiotics as prescribed to prevent or treat any possible infections

- Use an abductor pillow when turning the patient to prevent abduction of the hip joint
which could cause the femoral head to dislocate and also make sure that the patient body is
maintained in proper alignment.

Psychology

Interventions

1. Interview family regarding patient’s orientation and cognitive abilities before injury: -
This provides data for evaluation of current finding.

2. Assess patient orientation status:- evaluate presenting orientation of patient confusion

may result from stress of fracture

3. Give simple explanation of procedures and plan of care: - This promotes understanding
and active participation.

4. Explain treatment regimen and routines to facilitate positive attitude in relation to

rehabilitation:- Understanding the plan of care helps to diminish fears of the unknown

5. Encourage patient to participate in planning of care: - Provides for some control of self.
6. Encourage participation in hygiene: - Participation in routine activities increases awareness of
self.

7. Encourage patient to express concerns and to discuss the possible impact of fractured hip:-
Verbalization helps patient deal with problems and feeling, clarification of thoughts and feeling
promotes problem solving.

8. Teach patient about nutrition and calcium intake: - Adequate calcium helps to prevent
osteoporosis.

9. Monitor for signs of anxiety: - Patient may be concern that finances may not be enough for
continuing care. They will be referred to social services.

10. Involve significant others and support services: - Sharing concerns lessens the burden and
facilitates necessary modification.
 Bibliography

Charlotte Eliopoulos (2010) Gerontology Nursing 7th Edition Lippincott Raven Philadelphia

Nurseslab.com

Orthoinfo.aaos.org

www.medicinenet.com

https://www.ncbi.nlm.gov/pmc/articles/pmc4133447/

mayoclinic.org