Clinical Scenario: Helen Maroney, an 81-year-old woman presentsto the emergency department after slipping on the ice in herdriveway. She reports right hip pain and an inability to bearweight. She has no prior history of hip pain and is ambulatory withthe use of a cane. She lives with her husband and performs allactivities of daily living independently. Her medical historyincludes mild dementia, hypertension, and osteoarthritis. She iscurrently on metoprolol, Lisinopril, and acetaminophen. Physicalexamination of the right hip demonstrates pain with range ofmotion, external rotation of the right root, shortening of theright leg and then leg is adducted. The leg is neurovascularlyintact with good sensation, capillary refill, and pulses in thefoot. Radiographs demonstrate a displaced sub-capital femoral neckfracture of the right hip. The client receives an ultrasound guidedregional nerve block in the emergency department for pain controland is admitted to the hospital for treatment of her hip fracture.Preoperative traction is not used but the client is placed on bedrest with use of intermittent pneumatic compression devices.Adequate pain relief is achieved with acetaminophen following theadministration of a regional block, which was used to minimize therisk of delirium. The orthopedic surgeon had a discussion with theclient and family regarding the overall long-term prognosis ofpossible decreased mobility and independence as a result of the hipfracture. The discussion also includes the possibility ofmortality. After considering nonsurgical treatment measures, theclient makes an informed decision to proceed with surgery based onthe quality of life and mobility benefits associated with thismethod of treatment. The surgeon also discusses with the client theoption of a total hip arthroplasty for the benefit of improvedfunction and long-term results. After careful consideration, theclient decided to move forward with surgery. Postoperative OrdersMedications Hip precautions cefazolin 500mg q 8 hr. X2 doses Diet:DAT metoprolol ER 25 mg q day IV: D5 ½ NS KVO Lisinopril 10 mg qday Activity: out of bed as tolerated with physical therapy heparin5000 units SC bid Weight-bearing as tolerated per physical andoccupational therapy calcium carbonate 600 mg TID Continuousintermittent pneumatic compression device Vitamin D 1000 IU bidNutrition consultation Metamucil 1 Tbsp. q AM Ensure with meals,TID acetaminophen 500 mg q 6hr AM Labs; CBC, WBC, albumin, calcium,vitamin D celecoxib 100 mg bid tramadol 50 mg q 6 hr.Postoperatively, the client is mobilized. The client is placed onHip Precautions. Weight-bearing exercises are introduced astolerated with physical and occupational therapy. She is placed onlow-molecular-weight heparin and continues on intermittentpneumatic compression devices because of the high risk of venousthromboembolic events in this client population. Her admissionalbumin level was low; the nutrition service is consulted. Theclient is started on nutritional supplements following surgery toimprove her protein levels and caloric intake. In addition, she isfound to be vitamin D deficient, calcium and vitamin Dsupplementation are initiated. Pain is initially well controlledafter surgery because of the long-acting regional nerve block. Amultimodal pain regimen is also used, including celecoxib,acetaminophen, and tramadol, thus minimizing narcotic use to avoiddelirium. The client’s hemoglobin level decreases to 8.1 g/dLpostoperatively; however, her blood pressure is stable. Althoughshe experiences some transient lightheadedness and tachycardia,this improves with hydration.
Teaching Plan Directions: Think about the learning/educationalneeds of this client. Make sure to include physical/sensorylimitations & learning barriers. 1. Create a teaching outlinefor educating the client. The outline must include: Assessment oflearning readiness, expected learning outcomes, content outline,teaching strategies/resources, expected outcomes.
