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Diploma in Nursing
Integrated Nursing Sciences 2.1

Hip Fracture and Deep Vein Thrombosis

Learning Objectives
1. Remember and recollect important principles of fractures and deep vein thrombosis.
2. Identify patient’s issue (or problems) from the case study, integrating evidences gathered
from patient’s history and investigative results to the patient’s diagnosis.
3. Identify the possible risk factors that could have predispose the patient to developing the
disease.
4. Briefly explain the relationship between the risk factors and the development of DVT.
5. Develop and prioritize an individualized plan of care for the patient in the case scenario.
Include at least 2 important nursing diagnoses and describe 5 nursing interventions with
rationale for each nursing diagnosis
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LECTURE Vascular and Musculoskeletal System: Key Points and Concepts

Types of fractures (#)

Type of fracture: Transverse Type of fracture: Open/ Compound

Type of fracture:
Greenstick
Type of fracture: Comminuted
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Neurovascular assessment – 5 P’s

Perform the Neurovascular assessment comprising of the 5 P’s on your partner (To monitor for
disruption to the blood supply to the affected limb).

5Ps Approach Aspects of Assessment

Pain Assess patient’s level of pain (pain scale) before and after pain
medication administration or any intervention.

Paralysis Ask patient to flex and move the ankle; inability of pointing the toe
upward indicates peroneal nerve damage; immobility of the ankle
indicates ligament damage.

Paranesthesia Check for any altered sensation on the leg; followed by touching each
areas of the affected limb to assess sensation.

Pulse Palpate dorsalis pedis pulse on the right foot, then left foot. Note any
difference in rate and quality of the pulse. Weak or absent pulse indicates
tibia artery damage.

Pallor Observe the colour of the left leg in comparison to the right, noting any
pale, cyanosis or mottled appearance. These indicated altered tissue
perfusion.
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Compartment Syndrome

Compartment syndrome occurs when _____excess pressure in a limited space ____ constricts
and entraps the structures within a compartment, _reducing circulation to muscles and
nerves__.

Deep Vein Thrombosis

Deep vein thrombosis is a condition in which a __blood clot (thrombus) forms on the wall of a
vein,_ causing ___inflammation of the vein wall ___ and a degree of obstruction to the venous
blood flow.

Risk factors for DVT

Age  60 years old

Prolonged bed Blood Clot can happen if calf muscles immobilized for a period of time.
rest of sitting

Injury or Injury to veins and surgery can increase the risk of blood clot.
surgery

Being Increases the pressure in the pelvis and legs.

overweight or
obese. 

Smoking Affects blood clotting and circulation.

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SBL of Hip Fracture with Deep Vein Thrombosis

ROLE-PLAY :Ann, 78-year-old, was admitted to the NUHS

Emergency Department for a fractured right hip after falling in
the bathroom.

Assessment findings:
Past medical history: Hypertension (HTN) × 20 years,
Social history: Ann is ambulant and lives with her only daughter
in an HDB flat

Physical Examination
Neurological: conscious, alert, pupils equally round and reactive
to light
Respiratory: RR 18 breaths per minute, SaO2 98% on room air,
Breath sounds=Clear
Cardiovascular: Pulse rate 92bpm, BP 160/100 mmHg,
temperature 37.4 C.
Gastrointestinal: abdomen soft, non-tender, bowel sounds present, BNO yesterday
Musculoskeletal:Right leg is shorter than left and externally rotated. Severe right hip pain score
of 8/10. Inability to move the right leg. Bruise at the outer part of the hip.
Others: Weight 48kg, Height 150cm.

Doctor’s Order
PO Amlodipine 5 mg OM
PO Hydrochlorothiazide 25 mg OM
PO Paracetamol 1g 6 hourly
IM Pethidine 50 mg 6 hourly/PRN
IM Metoclopramide 10 mg 6 hourly/PRN
PO Senna 2 tablets ON
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APPLICATION

1. Name the four areas of the upper femur that are commonly fractured and known
also as hip fracture.
Femoral Neck, Intertrochanteric area, Subtrochanteric area, Femoral head.

2. Each pair to discuss why Ann presented with a shorten leg at the affected side.
Broke leg bone can lead to a limb length discrepancy if it heals in a shortened position.
It may be due to the bone unable to produce the necessary bone tissue to heal the
broken bone especially with inadequate stability and blood flow.

Image 1:
AAOS. (2018). Hip Fractures. Retrieved from https://orthoinfo.aaos.org/en/diseases--
conditions/hip-fractures/
Shortening of the leg due to compression of the bone at the fracture site.
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3. Prioritise according to the importance patient’s issue (or problems) from the case study
integrating evidences gathered from patient’s history and investigative results to the patient’s
diagnosis.

Issue Evidence
Severe right hip pain Right hip pain score 8/10

Compression of bone due to Right leg appears to be shorter in length than the left
fracture side and is rotated externally.

High Blood Pressure BP: 160/ 100 mmhg

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4. Identify the investigation ordered (Image 2) to diagnose the condition. Compare image 2 with
image 1 to identify the site involved.

A _______X-ray_______ was ordered and Ann most likely sustained a right hip fracture at the
site of the ____femoral neck____-.

Image 2
AAOS. (2018). Hip Fractures Retrieved from https://orthoinfo.aaos.org/en/diseases--conditions/hip-fractures/
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Anne was optimised for surgery and was taken to the operating theatre for a right hemi-
arthroplasty, or partial hip replacement.

As

Post-operative medications
PO Amlodipine 5 mg OM
PO Hydrochlorothiazide 25 mg OM
PO Paracetamol 1g 6 hourly
IM Pethidine 50 mg 6 hourly/PRN
IM Metoclopramide 10 mg/PRN
PO Senna 2 tablets ON

5. Identify the immediate post-operative management for Anne after surgery. Provide a
rationale for your answer.

Immediate Management Rationale

Monitor for vital signs such as Blood Pressure, To establish baseline data and monitor for
Pulse Rate, Respiratory Rate, SpO2 hourly or as disease progression. To monitor for tachycardia
per ordered. and hypotension which may indicate bleeding.

Monitor for X-ray at the operative site. To monitor for bleeding at the operative site.

Assess for evidence of vascular, nervous or To monitor for disruption to the blood supply to
visceral injury. the affected limb. To inform the doctor
immediately if present to preserve the function
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of the extremity.

Administer IM Pethidine 50 mg 6 hourly/PRN

To inhibit the synthesis of prostaglandin in the
central nervous system, with blockage of the
pain impulse.

Drug binds with the opioid receptor sites (mu

and kappa) and alters the release of
neurotransmitters. This alters the perception and
tolerance of pain.

To encourage patient to wear a hip precaution

such as compression stocking. The hip precaution is to prevent hip dislocation
(hip from moving out of the joint)

To elevate right leg affected leg

To aid venous blood return and prevent stasis.

On the 2nd postoperative day (POD), the nurse noted an increased swelling of the right leg. The
doctor was informed and physical examination signs, as reported.

Physical Examination
Musculoskeletal: Right calf is warm to touch with slight oedema; Severe right calf pain with
pain score 8/10, Homans’ sign positive on right leg, Right leg feels cool to touch
Others: On anti-embolic stockings on. Right hip dressing –dry and intact.
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6.Prioritise according to the importance patient’s issue (or problems) from the case study
integrating evidences gathered from patient’s history and investigative results to the patient’s
diagnosis.

Issue Nursing Diagnosis Evidence

Severe right hip pain Acute Pain Right hip pain score 8/10

Compression of bone Risk for Peripheral Right leg appears to be shorter in length
due to fracture Neurovascular than the left side and is rotated
Dysfunction externally.

7. Briefly explain how is the Homans’ sign performed and the suggested assessment finding
when “Homans’ sign positive on right leg”?

The Homans’ sign is considered positive when ______there is a presence of

thrombosis________________________________.
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A venous doppler ultrasound of the right leg was ordered and Ann was diagnosed with Deep
Vein Thrombosis (DVT) over the right leg.

8. Identify the possible risk factors that could have predisposed Ann to developing the DVT. Fill
in the table below.

Risk Factors Evidence

Age (>60 years ) Ann’s Age 78 years old

Prolonged Rest In Bed Right Hip Fracture

9. Briefly explain the relationship between the risk factors and the development of DVT.

_____Veins and arteries are less elastic in older age, it alters the smooth flow of blood in
the bloodstream. Prolonged rest in bed ______

Thrombo (2015). Deep vein thrombosis. Retrieved

from https://trombo.info/venous-
thromboembolism/tromboinfo-deep-vein-
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The doctor prescribed

 PO Warfarin 4 mg stat, according to International normalized ratio (INR)
 SC Enoxaparin 40 mg BD

Resource: https://nurseslabs.com/5-deep-vein-thrombosis-nursing-care-plans/3/
You will need to adapt the NCP to the scenario

10. Formulate a nursing care plan with five (5) nursing interventions and rationale for the
nursing diagnosis: Ineffective tissue perfusion to right leg related to venous stasis and increased
coagulability of blood as evidenced by symptoms of right calf being warm to touch with slight
oedema; severe right calf pain with a pain score 8/10, positive Homans’ sign on right leg and
right leg is cool to touch.

Nursing intervention Rationale

Assessment
To assess and for the signs and symptoms of
progression or resolution of the deep vein
thrombosis (DVT) and alteration in tissue
perfusion

To assess pain, location, characteristics, and level As a baseline and subsequent

using a pain score. measurements provide a measure of
treatment effectiveness.

Treatment
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To prevent extension or recurrence of clots

To bridge the transition to therapeutic INR

levels of 2-3 before withdrawing SC
Enoxaparin to ensure adequate
anticoagulation

Monitor blood for: These are used to measure the effectiveness

of anticoagulant therapy and to adjust
warfarin dosage till therapeutic levels are
met.

is a marker for clot lysis. This test

can also be used to check the effectiveness
of treatment

Apply warm, moist heat compress to affected To increase venous return, reduce blood
extremity. stasis and venous pressure, and improve
lower extremity oedema

To prevent venous stasis

Hydration prevents an increased viscosity of

blood, which contributes to venous stasis
and clotting.
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11. Formulate a nursing care plan with five (5) nursing interventions and rationale for the
nursing diagnosis alteration in comfort: right leg pain related to diminished arterial circulation
and oxygenation of tissues with production and accumulation of lactic acid in tissues or
inflammatory response in affected vein as evidenced by Ann’s complaints of severe right calf
pain a pain score 8/10.

Nursing Intervention Rationale

Assessment
Monitor vital signs including To establish baseline data and monitor for disease
temperature, heart rate (HR), blood progression. To monitor for tachycardia and
pressure (BP) and respiratory rate (RR) hypotension which may indicate bleeding.

To assess pain, location,

characteristics, and level using a pain As a baseline and subsequent measurements
score. provide a measure of treatment effectiveness.

Intervention

Administer medications as ordered:

PO Paracetamol 1g 6 hourly

IM Pethidine 50 mg 6 hourly/PRN

Apply warm, moist heat compress to

affected extremity.
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To elevate right leg (/affected leg)

INDIVIDUAL
Case Study Summary for INS2.1

Patient’s Name

Diagnosis

Issues

Immediate Management

Health Education