Chronic and Acute Ortho Care PDF

Chronic and acute ortho care ============================ Fragility fractures, particularly hip fractures, are the most common orthopedic trauma among elderly, frail patients and present a significant challenge globally. Care for such patients occurs across diverse settings, including pre-hospital...

Chronic and acute ortho care ============================ Fragility fractures, particularly hip fractures, are the most common orthopedic trauma among elderly, frail patients and present a significant challenge globally. Care for such patients occurs across diverse settings, including pre-hospital care, emergency departments, outpatient clinics, hospital units, and community settings. However, nurses often lack formal training in managing this vulnerable group. This book and its associated educational program aim to address this gap by enhancing nursing knowledge and skills for fragility fracture care. **Key Themes** 1. **Fragility Fracture Characteristics**: - Typically caused by osteoporosis and falls. - Hip fractures, a common type, require major surgery and intensive care, often leading to loss of function, independence, and potentially life-threatening complications if not managed optimally. 2. **Care Models**: - While general orthopedic trauma units are common, specialized **orthogeriatric units** or hip fracture wards with multidisciplinary teams (MDTs) are increasingly recognized for addressing the complex needs of these patients. - MDTs, including geriatricians, surgeons, and nurses, are critical for patient optimization before and after surgery. 3. **Nursing Role**: - Nurses play a central role in managing fragility fractures due to their continuous patient interaction. - Their responsibilities span acute orthopedic and geriatric care, rehabilitation, and sometimes palliative care. - Advanced skills in pain management, complication prevention, nutrition, hydration, wound care, and cognitive impairment management are crucial. 4. **Challenges and Opportunities**: - Variability in care models globally due to social, cultural, and resource differences. - Importance of shared learning and collaboration through networks like the **Fragility Fracture Network (FFN)** and the **International Collaboration of Orthopaedic Nurses (ICON)**. Osteoporosis Osteoporosis leads to reduced bone mass and structural deterioration, making bones fragile and prone to fractures. These fragility fractures cause significant pain, disability, and even death, alongside high societal costs. Osteoporosis and its complications are complex and require a multidisciplinary approach. A first fragility fracture often signals the onset of osteoporosis, highlighting the need for **secondary prevention**. ### Summary: Bone Biology, Osteoporosis, and Fragility Fractures The human skeleton provides structure, mobility, and protection, while also storing minerals and producing blood cells. The two types of bone, cortical (80%) and trabecular (20%), undergo continuous remodeling through osteoblasts, osteoclasts, and osteocytes. Bone mass peaks between ages 20-25, and by age 80, bone mass declines to about 50% of its peak due to resorption exceeding formation, leading to osteopenia and eventually osteoporosis. **Osteoporosis** is a systemic skeletal disease characterized by low bone mass and deterioration of bone structure, increasing fragility and fracture risk. It progresses silently until fractures occur, often from minimal trauma (\"fragility fractures\"). Common fractures include the hip, spine, wrist, and humerus, with hip fractures being the most severe, leading to high morbidity, mortality, and long-term care needs. Vertebral fractures, often undiagnosed, contribute to chronic pain, spinal deformities, and reduced pulmonary function, further increasing future fracture risks. **Nursing Role**: Nurses are pivotal in identifying fracture risk, assessing medical history, and educating patients on lifestyle changes to modify risk factors. Early recognition and treatment of fragility fractures can reduce future fracture risk by 50%, improving outcomes and preventing the decline in quality of life associated with fractures. - Equip nurses with evidence-based knowledge and skills for holistic patient care. - Foster understanding of frailty, osteoporosis, and fracture prevention. - Promote continuous professional development through structured learning and international collaboration. 5. **Vision for the Future**: - Enhanced nursing practice through shared expertise and multidisciplinary collaboration. - Improved patient outcomes by reducing pain, complications, and mortality while promoting independence and quality of life. further fractures. Nurses play a vital role in educating and guiding patients about osteoporosis management and fracture prevention. **Risk Factors, Prevention, and Management of Osteoporosis** **Risk Factors for Osteoporosis and Fractures** Risk factors are categorized as fixed and modifiable: **Fixed Risk Factors** (Non-modifiable): - **Age**: Risk doubles every decade after age 50. - **Gender**: Women are at higher risk due to lower peak bone mass and postmenopausal estrogen decline. - **Family History**: Parental history of hip fractures increases risk. - **Ethnicity**: Higher prevalence among Caucasian and Asian populations. - **Previous Fractures**: Doubles risk of subsequent fractures. - **Medical Conditions**: Rheumatoid arthritis, hypogonadism, long-term glucocorticoid use, and secondary disorders like endocrine or inflammatory bowel diseases. - **Low Bone Mineral Density (BMD)**: Influenced by genetics and lifestyle, a critical indicator of fracture risk. **Modifiable Risk Factors**: - **Lifestyle**: Smoking, excessive alcohol consumption, sedentary lifestyle, low calcium and vitamin D intake, and poor nutrition. - **BMI**: Low BMI (\ T \> -2.5: Low bone mass (osteopenia). - T ≤ -2.5: Osteoporosis. - T ≤ -2.5 with fractures: Severe osteoporosis. - A 1 SD decrease doubles fracture risk. 2. **Vertebral Fracture Assessment (VFA)**: - Identifies vertebral fractures often missed by DXA alone. - Fractures graded using **Genant Classification**: - Grade 0: Normal. - Grade 1--3: Mild to severe fracture, indicating increasing bone impairment. 3. **FRAX© Tool**: - Web-based calculator estimates 10-year fracture risk based on risk factors, with or without BMD. - Integrated into many national guidelines for identifying high-risk patients. **Differential Diagnosis of Secondary Osteoporosis** - **Secondary Causes** (30% in women, 50% in men): Often tied to underlying conditions. - Common disorders include diabetes mellitus, hyperthyroidism, rheumatoid arthritis, celiac disease, and anorexia nervosa. - Baseline tests: Evaluate bone metabolism, kidney/liver function, vitamin D levels, and thyroid-stimulating hormone. **Treatment** 1. **Medication and Lifestyle Interventions**: - Anti-osteoporosis medications (e.g., bisphosphonates) tailored through shared decision-making. - Calcium and vitamin D supplementation. - Address lifestyle factors (nutrition, exercise). - Fall prevention strategies. 2. **Follow-Up**: - Ensure patients understand their treatment plan and are monitored regularly to reduce fracture risk by \~50%. **Summary: Medication to Reduce Fracture Risk in Osteoporosis** **Medications** 1. **Bisphosphonates** (e.g., alendronate, ibandronate, risedronate, zoledronic acid): - Most commonly prescribed. - Suppress osteoclast activity, reducing bone turnover (\"anti-resorption therapy\"). - Must be taken with specific instructions for proper absorption (e.g., on an empty stomach, remain upright for 30 minutes). 2. **Selective Estrogen Receptor Modulators (SERMs)** (e.g., raloxifene): - Mimic estrogen in bones but block its effects in breast/uterus. 3. **Parathyroid Hormone (teriparatide)**: - Stimulates new bone formation. Administered via daily subcutaneous injection. 4. **Monoclonal Antibody (denosumab)**: - Inhibits osteoclast maturation. Given subcutaneously every six months. **Treatment Challenges** 1. **Adherence and Compliance**: - \~50% of patients discontinue treatment within the first year due to factors like gastrointestinal side effects or lack of perceived benefits. - Good education, clear communication, and regular follow-ups improve adherence. 2. **Side Effects**: - Gastrointestinal issues are common with oral medications. - Rare side effect: osteonecrosis of the jaw (ONJ). Prevented with good oral hygiene and dental care. 3. **Monitoring Treatment Efficacy**: - DXA scans show slow BMD changes, making them less suitable for short-term monitoring. - Biochemical markers of bone turnover provide quicker feedback. **Role of Nurses in Improving Treatment Outcomes** 1. **Education**: - Explain treatment goals, benefits, and medication instructions. - Highlight the chronic nature of osteoporosis but limited treatment duration (e.g., 3--5 years for bisphosphonates). 2. **Support and Monitoring**: - Encourage reporting of side effects. - Monitor compliance, adherence, and schedule regular re-evaluations of fracture risk. 3. **Lifestyle Guidance**: - Recommend dietary and exercise changes. - Provide advice on fall prevention and oral hygiene. 4. **Referrals**: - Direct patients to osteoporosis associations for additional support. **Summary: Frailty and Sarcopenia** **Frailty** Frailty is a clinical syndrome marked by increased vulnerability to stressors, diminished resistance, and heightened risks of functional impairment and adverse health outcomes (e.g., falls, disability, hospitalization, and death). - **Characteristics**: - Clinical syndrome - Increased vulnerability - Diminished resistance to stressors - Functional impairment risk - **Prevalence**: - Ranges from 4% to 59%, increasing with age and higher in women. **Assessment** - **Target Population**: Individuals over 70 or with significant weight loss (≥5%). - **Common Tools**: 1. **Physical Frailty Phenotype (PFP)**: Focuses on five criteria---weight loss, weakness, exhaustion, slowness, and low activity. 2. **Frailty Index**: Based on the number of accumulated deficits (illnesses, cognitive and functional decline). 3. **Other Tools**: Clinical Frailty Scale, FRAIL Scale, and SOF Frailty Tool. - **Selection Consideration**: Depends on context, validity, and feasibility. **Interventions** 1. **Exercise**: - Aerobic and resistance exercises enhance strength, physical performance, and mental well-being. - Programs of 30--45 minutes, three times a week for \~5 months, show positive outcomes. 2. **Nutritional Supplementation**: - Caloric and protein intake improves muscle strength and performance. - Example: 15g of protein twice daily for 24 weeks. 3. **Vitamin D**: - May support muscle strength and balance, though large-scale evidence is limited. 4. **Medication Review**: - Reducing polypharmacy lowers risks of falls, hospitalizations, and mortality. **Sarcopenia** Sarcopenia is the age-related loss of muscle mass and strength, significantly impairing physical function and increasing risks of disability, falls, and hospitalization. - **Prevalence**: Affects \~10% of the older population. - **Muscle Loss Rates**: - 8% per decade (ages 50--70). - 15% per decade after 70. - **Causes**: - Muscle disuse - Hormonal changes (e.g., reduced testosterone and estrogen) - Chronic diseases, inflammation, insulin resistance, and nutritional deficiencies. **Summary: Screening, Assessment, and Management of Sarcopenia** **Screening and Assessment** - **Challenges**: Sarcopenia is asymptomatic in early stages, and routine screening is not yet established. Effective screening tests should be cost-effective, easy to implement, and require minimal training. - **Diagnostic Criteria (EWGSOP)**:\ Sarcopenia is diagnosed based on: 1. **Low muscle mass** (e.g., DXA or BIA measurements). - DXA thresholds: - Men \ - A **comprehensive history** should be taken, considering comorbidities, medication, and previous functional abilities. Family members or caregivers should provide additional information when necessary. **2. Intraoperative Care:** - **Goal**: Manage the pathophysiological effects of surgery while preserving patient physiology, considering the frailty, comorbidities, and cognitive dysfunction commonly found in older adults. **3. Postoperative Care:** - **Goal**: Promote early remobilization, re-enable the patient, and prepare for discharge, ideally back to their residence. Delayed remobilization is linked to prolonged hospital stays. - **Key Elements**: - Early mobilization - Pain management - Postoperative hypotension and fluid management - Anemia management - Delirium assessment - Nutritional optimization **Summary**: Effective perioperative care for hip fracture in older adults involves a multidisciplinary approach with a focus on timely, individualized, and comprehensive care. Care should address not only physical health but also psychosocial and functional considerations, aiming for optimal recovery and independence post-surgery. **Hip Fracture Diagnosis, Surgery, and Pain Management** **Diagnosis and Surgery:** - **Diagnosis**: Hip fractures are diagnosed based on symptoms and confirmed with X-rays, often supplemented with MRI or CT scans. The two main types of hip fractures are: - **Femoral Neck Fracture**: Occurs within the hip joint capsule, risking disruption of the blood supply to the femoral head, which may lead to necrosis. Displaced fractures typically require **hemi-arthroplasty**, while undisplaced fractures may be treated with parallel implants. - **Intertrochanteric Fracture**: Occurs outside the joint capsule and is less likely to disrupt blood flow. These fractures are treated with internal fixation (nails, screws, plates). - **Surgery**: Surgery is the preferred treatment to stabilize the fracture, manage pain, and enable early remobilization. The type of surgery depends on the fracture location and displacement. **Pain Management:** - **Importance**: Pain management is critical but often overlooked. Inadequate pain relief can worsen outcomes, especially for older adults with cognitive decline, who may struggle to communicate pain. - **Pain Assessment**: Pain should be continuously assessed upon presentation, after initial analgesia, and regularly thereafter. Tools like the **Verbal Rating Scale (VRS)** and **Visual Analog Scale (VAS)** are useful, particularly for those with cognitive impairment. Nurses should be vigilant for non-verbal signs of pain, especially in older adults. - **Pain Relief Options**: - **Pharmacological**: Paracetamol (every 6 hours) and opioids are commonly used, but opioids should be administered cautiously due to the risk of side effects like sedation and respiratory depression. Nonsteroidal anti-inflammatory drugs (NSAIDs) are typically avoided in older adults. - **Non-pharmacological**: Strategies include ice packs, warm blankets, massage, cognitive-behavioral approaches (e.g., relaxation, music therapy), and physical therapy. - **Nerve Blocks**: Preoperative nerve blocks reduce opioid use and improve pain management outcomes. - **Multimodal Analgesia**: A combination of medications and non-pharmacological therapies is recommended to enhance pain relief while minimizing adverse effects. - **Side Effects of Medications**: Opioids, while effective, can cause side effects such as sedation, constipation, and nausea, which should be anticipated and managed. Close monitoring is essential, particularly for respiratory depression in older adults. **Postoperative Care:** - **Early Mobilization**: Early mobilization (within 24 hours post-surgery, unless contraindicated) helps prevent complications of immobility and promotes recovery. However, patients may initially resist weight-bearing due to pain, so motivation and effective pain management are key. - **Postoperative Pain**: Pain management remains critical post-surgery, as poorly controlled pain delays mobilization, increases the risk of complications (e.g., immobility, delirium), and impacts recovery. Pain assessment and management should continue through the postoperative period, with special attention to cognitively impaired or confused patients. - **Tools for Pain Management**: The **\"This is Me\" tool** can help staff understand the pain needs of patients with dementia by gathering personal insights from family and carers. In summary, hip fracture management involves careful diagnosis, timely surgery, and comprehensive pain management to ensure recovery and prevent complications, particularly in frail older patients. **Fundamental Nursing Care for Older Adults with Hip Fractures** **Maintaining Mobility and Independence:** - **Key Goal**: Preserving mobility, energy, and participation in self-care is crucial to maintaining independence, reducing falls, and boosting confidence. - **Empathy**: Providing care with empathy involves understanding patients\' needs, fears, and perspectives, especially for those with cognitive decline. **Core Aspects of Nursing Care:** - **Comfort and Hygiene**: Ensuring comfort, including addressing hunger, thirst, and dry mouth, with effective mouth care and regular hygiene routines. - **Cognitive Impairment**: Interaction with patients suffering from dementia or cognitive decline can be stressful, requiring sensitive care approaches. **Key Areas of Nursing Care:** 1. **Acute Delirium**: Early recognition of delirium signs by the nursing team (refer to Chapter 9). 2. **Pressure Injury Prevention**: Monitoring for and preventing pressure injuries, which are common in hip fracture patients (refer to Chapter 7). 3. **Hydration and Nutrition**: Proper fluid balance and nutrition are essential for recovery. Nurses should monitor fluid intake, especially since older adults may restrict fluids due to incontinence or other factors (refer to Chapter 8). 4. **Constipation Management**: Constipation is common in post-fracture patients and should be addressed with a high-fiber diet, regular assessment of bowel function, and timely use of aperients. 5. **Infection Prevention**: Preventing healthcare-associated infections, including pulmonary, urinary tract infections, and thromboembolism, is critical in the perioperative setting. 6. **Secondary Fracture Prevention**: Preventing future fractures through osteoporosis treatment and fall risk assessment is essential during the hospital stay and before discharge. **Preparation for Discharge:** - **Discharge Planning**: Begins as soon as the patient is admitted and should involve coordination between the patient, family, multidisciplinary team, and, if applicable, a new care facility. - **Education**: Ensuring patients and caregivers understand discharge instructions is vital. Due to factors like reduced visual and auditory acuity, a combination of oral, written, and pictorial information is recommended. - **Challenges**: Managing the emotional and physical challenges of patients, such as pain, anxiety, and limited cognitive capacity, can hinder their ability to absorb discharge instructions. **Summary of Key Points:** - **Complex Care Needs**: Caring for older patients after hip fractures involves multiple challenges, requiring evidence-based care. - **Nurses\' Role**: Nurses must understand the different types of hip fractures, their management, and the specific needs of each patient. - **Safety and Complication Prevention**: The primary goal throughout the perioperative period is to ensure patient safety, prevent complications, and prepare for discharge. - **Comprehensive Discharge Preparation**: Post-surgery recovery involves not just medical care but also thorough planning for the patient\'s continued well-being after leaving the hospital. **Mobility and Remobilisation After Hip Fracture** **Importance of Mobilisation:** - **Health and Recovery**: Early mobilisation is crucial for functional recovery and survival in older adults after a hip fracture. It helps prevent functional decline, muscle weakness, and complications from immobilisation. - **Pain Management**: Effective pain management is vital for facilitating rehabilitation and safe mobilization. Pain impacts mobility and is linked to complications like delirium and depression. - **Psychological Impact**: Fear of falling, loss of confidence, and the psychological stress of potential independence loss can affect recovery. It's important to manage these fears and help patients set realistic expectations. **Factors Affecting Mobilisation:** - **Age and Sarcopenia**: Age-related muscle loss and frailty can reduce a patient's ability to remobilise. Every day spent in bed requires 2.5 days to regain walking strength. - **Comorbidities and Cognitive Decline**: Depression, cognitive impairment, and delirium can all contribute to poor mobility outcomes. - **Holistic Approach**: An individualised approach considering each patient's physical, cognitive, and emotional state is essential for successful mobilisation. **Exercise and Rehabilitation:** - **Exercise Type and Timing**: Exercise regimens depend on fracture type and surgery, with weight-bearing restrictions based on surgical procedures. Early mobilisation generally improves functional outcomes. - **Basic and Functional Exercises**: Nurses should ensure patients practice basic exercises, such as ankle and knee movements, as well as functional tasks like sitting for meals and performing daily activities independently. - **Pain and Medication Management**: Coordinating pain relief with exercise schedules and using both pharmacological and non-pharmacological pain relief strategies are crucial for improving mobility. **Complications from Stasis:** 1. **Venous Thromboembolism (VTE)**: Immobilisation increases the risk of deep vein thrombosis (DVT) and pulmonary embolism. Risk factors include the fracture itself, surgery, and comorbidities like obesity and heart disease. 2. **Pulmonary and Urinary Tract Infections**: Hospital-acquired infections, including pneumonia and UTIs, are common and can increase hospital stay and mortality. Indwelling urinary catheters, though used for mobility limitations, increase UTI risk. 3. **Constipation**: A common postoperative issue due to limited activity, opioid analgesics, and changes in diet. Constipation can affect pain management and slow rehabilitation. **Managing Risks and Complications:** - **Prevention**: Early mobilisation, proper pain management, and preventing complications like infections and constipation are key to a successful recovery. - **Multidisciplinary Approach**: Nurses should actively involve patients in their care, ensuring they are engaged in mobilising exercises and activities to promote independence, reduce complications, and ensure timely discharge. **Assessment of Mobility and Remobilisation Potential** **Key Considerations for Mobility Assessment:** - **Health and Functional Status**: Includes musculoskeletal health, pain levels, cognitive status, pre-fracture mobility, and lifestyle. - **Psychosocial Factors**: The patient's willingness for remobilisation, support from family, and beliefs about their recovery. - **Tools for Assessment**: Various tools are used to evaluate mobility, such as the Timed Up and Go Test, the Berg Balance Scale, and the Barthel Index. While these tools help monitor progress, their reliability can vary. - **Safety and Walking Aids**: It's important to assess the risk of falls and determine appropriate walking aids, tailored to the patient's specific needs and fracture type. **Interventions for Mobility and Remobilisation:** - **Early Rehabilitation**: Mobilisation should begin as soon as the patient is stable. Nurses play a vital role in patient education, pain management, and motivating patients to engage in self-care. - **Collaboration**: Nurses work with the multidisciplinary team (MDT) and ensure patient involvement in goal-setting. Communication about patient progress and strategies is essential when transferring or discharging patients. - **Psychological Support**: Nurses provide encouragement, address patient anxieties, and support patients and families through rehabilitation. **Exercise: Assessment and Interventions:** - **Pre-Exercise Assessment**: Before starting exercise, assess the patient's functional level, ability to perform Activities of Daily Living (ADLs), and gait stability. - **Exercise Benefits**: Early mobilisation reduces hospital stay, improves walking, and enhances function. Exercises should focus on increasing muscle strength and range of motion. Even patients with cognitive impairments benefit from exercise. - **Progressive Exercise**: Exercise should begin with simple movements and progress in intensity. Resistance and balance training are beneficial for improving mobility. - **Factors for Successful Exercise**: Regular encouragement, pain management, a safe environment, adequate nutrition, and collaboration with the MDT enhance patient outcomes. **Key Evidence-Based Interventions:** - **Support for Independence**: Encourage patients to take part in self-care, use walking aids, and engage in rehabilitation exercises. - **Pain and Nutritional Management**: Effective pain control and adequate nutrition are essential for recovery. - **Multidisciplinary Team Involvement**: Nurses play a central role in the MDT, ensuring that individual care plans are followed and communicating any changes after discharge. These approaches help ensure a comprehensive, patient-centered strategy for mobilising and rehabilitating patients after a hip fracture, promoting better outcomes and quality of life. This section discusses the prevention of complications related to immobility, such as thromboembolism, pulmonary infections, urinary tract infections (UTIs), and constipation, emphasizing the importance of early mobilisation and specific interventions to mitigate these risks. **Key Points:** 1. **Thromboembolism**: Early mobilisation reduces the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Prophylactic measures include heparin, fondaparinux, and mechanical methods like pneumatic compression devices. Nurses should ensure hydration, avoid prolonged immobility, and support early mobilisation. 2. **Pulmonary Infections**: Early remobilisation and lung expansion techniques (e.g., deep breathing) are essential for preventing pneumonia. Additional measures include hydration, a high-calorie diet, oxygen therapy if needed, and positioning in semi-Fowler\'s position to aid breathing. 3. **Urinary Tract Infections (UTI)**: Preventing UTIs involves early removal of urinary catheters, good hydration, and monitoring for signs of infection. Catheters should be used only when necessary, and any urinary infection should be promptly addressed with appropriate antibiotics. 4. **Constipation**: Prevention includes maintaining hydration, a high-fiber diet, and encouraging mobility. Regular toileting routines and minimising the use of laxatives are recommended. **Summary:** - **Immobility** is linked to negative health outcomes, so **mobilisation and exercise** should be tailored to each patient\'s needs. - **Pain management and psychological support** are crucial for overcoming barriers to mobilisation. - Nurses play a significant role in **preventing complications** through vigilant assessment, mobilisation, and providing interventions like walking aids and education. - **Early mobilisation** is a key preventive strategy against thromboembolism, pulmonary infections, UTIs, and constipation. Pressure injuries are a significant patient safety concern, particularly following fragility fractures such as femoral and hip fractures. These injuries can lead to pain, distress, and are often seen as indicators of inadequate care, which can result in litigation. Nurses\' knowledge of pressure injury prevention is often inconsistent, contributing to the prevalence of these injuries in hospitals, care facilities, and home care settings. Proper education and adherence to evidence-based practices are crucial in reducing the incidence of pressure injuries. **Pathophysiology and Causes** Pressure injuries occur when skin and underlying tissues are subjected to prolonged pressure, friction, shear, or a combination of these forces. These forces impair blood flow, leading to tissue damage. Moisture, particularly from urinary incontinence, can exacerbate the problem, leading to conditions like incontinence-associated dermatitis (IAD). Factors such as age, limited mobility, impaired nutrition, and comorbidities like diabetes or cardiovascular disease reduce the skin\'s tolerance to these external forces. **Classification of Pressure Injuries** Pressure injuries are classified into four categories based on severity: 1. **Category 1**: Non-blanchable erythema of intact skin. 2. **Category 2**: Partial-thickness loss with exposed dermis. 3. **Category 3**: Full-thickness skin loss with visible adipose tissue. 4. **Category 4**: Full-thickness loss with exposed fascia, muscle, tendon, or bone. **Prevention Strategies** Prevention should follow evidence-based guidelines, and effective interventions require a coordinated, multidisciplinary approach. Key strategies include: - **Skin Care**: Maintain skin cleanliness and moisture balance with appropriate cleansers and moisturizers. Avoid massaging areas at risk for injury. - **Support Surfaces**: Use pressure-relieving mattresses and cushions for bedbound or immobile patients. - **Movement**: Encourage early mobilization and regular repositioning to reduce prolonged pressure. - **Incontinence Management**: Implement continence care plans to protect skin from moisture-related damage. - **Nutrition**: Ensure adequate nutritional support, particularly protein and vitamins, to maintain skin integrity. Assessment of patients should occur promptly after admission and be repeated regularly to identify risk factors and implement preventive measures effectively. The management of wounds following fragility fractures, particularly hip fractures, is essential for preventing complications like infection, hematoma, and wound dehiscence. Surgical wounds can heal predictably when care is well-executed, but elderly patients, often with multiple comorbidities, face challenges such as poor healing and infection. Proper wound care includes preoperative preparation, optimization of the patient's health, careful skin preparation, antibiotic prophylaxis, and aseptic techniques. Infection prevention is vital, with interventions such as hand hygiene, hospital environment cleanliness, timely drain removal, and careful monitoring of wound conditions. Nutrition plays a key role in promoting healing. Regular wound surveillance is essential to detect any early signs of infection, and immediate medical attention is required when complications arise. Evidence-based guidelines for pressure injury prevention focus on skin assessment, repositioning, maintaining mobility, managing moisture (especially incontinence), and ensuring proper nutrition. Proper intervention can reduce the risk of both surgical and pressure-related wounds. A healthy diet for older adults is essential for preventing malnutrition, supporting recovery, and managing chronic diseases. The diet should include at least 400g of fruits and vegetables daily, less than 10% of total energy intake from free sugars, less than 30% from fats (favoring unsaturated fats), and less than 5g of salt. Fluid intake should be around 2250ml per day, with adjustments based on health conditions like kidney or heart disease. Nutritional needs change with age, with a stable requirement for vitamins and minerals, while energy needs decrease. A nutrient-dense diet with adequate energy is vital for elderly individuals recovering from fractures or surgery. Calcium and vitamin D are crucial for bone health, especially in older adults. The recommended daily calcium intake for those over 65 is 1000mg, and vitamin D supplementation is advised (800--1000 IU daily) due to decreased natural production in older age. Vitamin D aids in calcium absorption, and sunlight exposure supports its production, though supplementation is often necessary, especially in less sunny regions. Regular physical activity also helps maintain bone density. Malnutrition and dehydration are common issues in older adults, with malnutrition defined by insufficient nutrient intake to meet metabolic needs (e.g., BMI \< 18.5 or significant weight loss). Dehydration is more complex, involving reduced body water or imbalanced fluid excretion. Nurses must identify and manage these conditions to improve patient health outcomes. **Symptoms of Malnutrition and Dehydration**\ Malnutrition symptoms include weight loss, low energy, lethargy, low mood, abdominal pain, reduced muscle tone (sarcopenia), and lack of interest in food or drink. Dehydration symptoms, which appear earlier, include increased heart rate, decreased urine output, nausea, dry lips, spasms, mental confusion, and pale mucosa. **Screening and Assessing Malnutrition**\ Validated screening tools for malnutrition include the 3-minute nutrition screening (3MinNS), Nutritional Risk Screening 2002 (NRS-2002), and the Malnutrition Universal Screening Tool (MUST). Patients should be screened within 24 hours of admission to identify risk factors and assessed comprehensively to enable appropriate interventions. Factors contributing to malnutrition include illness, medication, cognitive impairment, and eating difficulties, which vary by setting (hospital, outpatient care, or long-term care). **Interventions for Preventing and Treating Malnutrition**\ Malnutrition requires multifaceted intervention: 1. **Food and Meals**: Meals should be flavorful and customized to the patient\'s preferences. Nurses can assist with eating aids for those with physical or cognitive challenges. For swallowing issues or poor dentition, other healthcare professionals should be involved. 2. **Dietary Supplements**: High-protein, multi-nutrient supplements (0.9-1.2g/kg/day) can help patients who struggle to eat enough, especially post-surgery or during rehabilitation. Combining supplements with resistance training improves outcomes. 3. **Mealtime Interaction**: Nurses should provide calm, uninterrupted mealtime environments, offer adequate support, and encourage family involvement. 4. **Environment**: Creating a comfortable, pleasant mealtime atmosphere can help increase food intake. Involving families or volunteers can enhance the dining experience. 5. **Education and Guidance**: Providing individualized education about nutrition and hydration helps engage patients and their families. **Hydration and Dehydration**\ Dehydration is common in hospitalized older adults, with serious consequences. Screening for dehydration is difficult due to nonspecific symptoms and rapid progression. Key risk factors for dehydration include impaired fluid intake, excessive fluid loss, and underlying health conditions. **Summary of Key Points on Screening and Assessing Dehydration in Patients:** 1. **Screening for Dehydration:** - Nurses should screen all patients within 24 hours of admission for dehydration risks, similar to the approach for malnutrition. - No validated screening tools exist, so individualized assessments based on clinical knowledge are essential. - Key risk factors include low BMI, cognitive impairment, frailty, comorbidities, neurological deficits, dysphagia, and issues like constipation or incontinence. 2. **Criteria for Positive Risk Screening:** - Indicators may include fatigue, not drinking between meals, decreased fluid intake, diminished urine output, high urine osmolality, and low axilla moisture. 3. **Assessment and Further Action:** - If dehydration is identified, a comprehensive understanding of the issue is necessary. - Plan should include close monitoring of fluid intake and output (urine, vomiting, wound drainage). - Involve patients, families, and care teams in planning and encouraging hydration. - Ensure appropriate toilet access, and consider aids like commodes or urine bottles if needed. - Aim for around 2250 ml of daily fluid intake, if not contraindicated. 4. **Evidence-Based Interventions:** - Ensure constant availability of drinks and consider patient preferences (types, temperature, flavor). - Offer individualized support to help patients drink, using aids like straws or special cups. - Monitor fluid intake closely, understanding signs of dehydration such as concentrated urine, dry mucous membranes, and muscle weakness. 5. **Multidisciplinary Approach:** - Dehydration management should involve a team effort, including healthcare providers, family members, and caregivers. - Discuss hydration and nutrition during the discharge planning process, ensuring that the patient and family are informed and involved. 6. **Summary for Learning:** - Older hospitalized patients, particularly those with fractures, often struggle with nutrition and hydration. - Multidisciplinary assessment and involvement are crucial for addressing dehydration and malnutrition. - Monitoring of intake and output, along with patient and family involvement, are essential for effective care and prevention. **Summary of Assessment and Management of Delirium:** 1. **General Assessment:** - To recognize changes in a patient's function, a comprehensive baseline assessment is crucial. The **Comprehensive Geriatric Assessment (CGA)** is effective for identifying physical and mental health conditions, particularly in preoperative assessments. 2. **Delirium Overview:** - Delirium is a common, sudden onset of fluctuating altered consciousness with cognitive and perception changes. It is distressing for both the patient and caregivers and is associated with poor outcomes, such as increased complications, longer hospital stays, dementia, and higher mortality rates. - Delirium can occur post-surgery, particularly after hip fractures, with an incidence of up to 60%. 3. **Prevention and Early Intervention:** - Prevention is more effective than treatment. Early identification, especially in the preoperative period, is key to preventing delirium. There are rapid tools to identify risk, including predisposing and precipitating factors such as age, dementia, cognitive impairment, polypharmacy, and dehydration. - Cognitive impairment is a key risk factor for delirium. Simple screening tools should be used to assess cognitive function upon admission. 4. **Assessment Tools for Delirium:** - The **4AT** is a brief, easy-to-use tool to assess delirium and cognitive impairment. It includes questions on alertness, memory, attention, and fluctuating course. It can be used for initial screening and daily monitoring. - Detailed cognitive screening tools like the **Montreal Cognitive Assessment (MoCA)** and **Mini Mental State Examination (MMSE)** help assess cognitive decline and support care planning, though MoCA is preferred for its ease of use. 5. **Identifying and Diagnosing Delirium:** - Early identification is essential. The **Confusion Assessment Method (CAM)** is the gold standard for diagnosing delirium, requiring answers to four key questions about the patient\'s behavior and cognition. - Delirium is confirmed if the patient meets specific criteria (alertness, acute onset, and fluctuating behavior). The tool should be used frequently, especially if the patient's condition changes. 6. **Family Involvement:** - Family input is vital in identifying early signs of delirium. They can help recognize subtle cognitive changes and provide key information about the patient's baseline function. In conclusion, early recognition and intervention are essential to prevent and manage delirium, particularly in older patients, through regular cognitive screening, effective use of assessment tools, and close monitoring. **Summary of Prevention and Management of Delirium:** 1. **Prevention of Delirium:** - Delirium can be prevented by addressing modifiable risk factors through simple interventions: - Correcting acute issues like dehydration (e.g., IV fluids for kidney injury). - Managing pain (e.g., administering analgesia for hip fractures). - Ensuring patients have necessary aids (glasses, hearing aids). - Maintaining regular day/night routines and promoting sleep. - Encouraging daytime mobilization and frequent reorientation to time and place. - Structured protocols incorporating these strategies have been proven to reduce delirium incidence. - Educating patients and families about delirium risks is essential. 2. **Managing the Delirious Patient:** - Delirium diagnosis should be followed by detailed assessment and close monitoring to identify the underlying cause and initiate treatment. - **The Confusion Assessment Method (CAM)** is a useful diagnostic tool but does not provide information on delirium severity or duration. - **Four key actions should be performed within 4 hours of delirium diagnosis:** - **Medical Review:** Involves medical input but can be initiated by nurses. Identifying causes like medications or infections is crucial. - **Monitoring:** Close monitoring to assess changes in the patient's condition. - **Interventions:** Implement rapid interventions based on the identified cause. - **Patient Care:** Ensure that decisions are made based on the patient's capacity, which may be impaired during delirium. 3. **The Confusion Assessment Method (CAM):** - **CAM Tool Questions:** - **Acute Change in Mental Status:** Is there a noticeable shift from baseline (e.g., confusion, agitation)? - **Inattention:** Is the patient easily distracted or unable to follow a conversation? - **Disorganized Thinking:** Does the patient show disorientation or difficulty recalling time and place? - **Altered Level of Consciousness:** Is the patient excessively sleepy, agitated, or unresponsive? **Summary of Falls Risk, Delirium Management, and Dementia Care:** 1. **Falls Risk in Delirious Patients:** - Delirious patients are at a higher risk of falling, with those over 65 years having a 30% risk compared to 10% in non-delirious patients. - A falls risk assessment should be performed, emphasizing risk reduction strategies like: - Low beds, bed alarms, or enhanced observation. - Physical restraints should never be used in agitated patients; allowing mobility with support is safer. - Bed rails are discouraged as they can increase agitation and the risk of falls. 2. **Informing Family:** - Early contact with the family is key to managing delirium, as it reduces stress and helps with interventions. - Family presence can be calming and facilitate care but does not replace the need for regular observation and instruction. 3. **HELP (Hospital Elder Life Program):** - The HELP program is a multicomponent intervention aimed at maintaining cognitive and physical function during hospitalization. It includes: - Daily orientation (to time/place). - Early mobilization to maintain function. - Feeding assistance and therapeutic activities. - Non-pharmacological sleep management and adaptations for hearing/vision. - This program is most effective when combined with daily medical reviews and intentional rounding to promote patient interaction and comfort. 4. **Medication Management in Delirium:** - Sedation should be avoided, with medication considered only when necessary. - Antipsychotics and benzodiazepines should be used cautiously: - **Haloperidol** is often the first-line treatment. - **Lorazepam** is recommended for patients with Parkinson\'s disease, Lewy body dementia, seizures, or ECG changes. - A comprehensive medical review is needed to identify causes of delirium that could be treated to alleviate agitation. 5. **Dementia Care:** - **Dementia** is a group of degenerative brain diseases, including Alzheimer\'s, vascular dementia, and Lewy body dementia, affecting millions worldwide. - **Stages of dementia:** - **Early stage:** Characterized by subtle memory loss and personality changes, with preserved functional independence. - **Middle stage:** Difficulty with short-term memory, requiring support for daily tasks and safety. - **Late stage:** Full dependency with limited communication and motor function, possibly bed-bound. - No cure exists, but medications can manage symptoms. - As dementia becomes more prevalent in hospital patients, healthcare providers must consider its impact on health and decision-making. - **Dementia passports** (e.g., \"This is me\" document) are valuable for guiding care, providing insights into the patient's personality, preferences, and values to ensure individualized care planning. **Summary of Decision-Making Capacity, Advocacy, and Depression Care:** 1. **Capacity to Make Decisions:** - **Presumption of Capacity:** Patients are presumed to have capacity unless proven otherwise. - **Supporting Capacity:** Patients should be given information and time to make decisions, and are allowed to make unwise decisions without it implying lack of capacity. - **Best Interest:** Any treatment should prioritize the patient's best interest and be the least restrictive option. - **Decision-Specific Capacity:** Capacity must be assessed based on the specific decision at hand (e.g., surgery vs. taking medication). - **Two-Stage Assessment for Capacity:** - **Stage 1:** Check for disturbances in consciousness (e.g., delirium, impaired cognition). - **Stage 2:** Assess the patient's ability to understand, retain, weigh, and communicate the decision. - **Advocacy:** An advocate can help by providing information about the patient's preferences but cannot make decisions for them. In emergencies, treatment can proceed based on the information available. In non-emergencies, an Independent Mental Capacity Advocate (IMCA) may be appointed if necessary. 2. **Mental Health Framework:** - **Legal Framework:** In the UK, the **Mental Capacity Act** and **Human Rights Act** guide the treatment of patients lacking capacity, with safeguards like **Deprivation of Liberty Safeguards (DoLS)** to ensure decisions are in the patient's best interest. 3. **Depression in Healthcare:** - **Clinical Depression:** Different from normal sadness, clinical depression is persistent and affects all aspects of life. It is more common in adults but can affect older populations, often linked to chronic pain and health issues. - **Impact of Depression:** Depression slows recovery, especially post-surgery, and is associated with increased complication rates and long-term effects after discharge. - **Assessment of Depression:** Nurses should assess patients for depression using a comprehensive history and screening tools. Common tools include: - **Hospital Anxiety and Depression Scale (HADS):** A 14-question self-report tool, where scores of 8 or higher indicate likely depression or anxiety. - **Patient Health Questionnaire 9 (PHQ-9):** Used to monitor and assess the severity of depression. - **Factors Increasing Risk:** History of mental health issues, chronic illnesses, poor interpersonal relationships, and social isolation increase the risk of depression. Environmental factors can also influence screening results. In both decision-making and depression care, it\'s essential for healthcare practitioners to use structured assessments, respect the patient\'s autonomy, and apply best practice guidelines to ensure patient safety and well-being. **Summary of Interventions and Key Points for Cognitive Disorders and Depression Care:** 1. **Nursing Interventions for Depression:** - **Role of Nurses:** Nurses, with their presence at the bedside, are well-positioned to monitor subtle mood changes and provide emotional support. Compassionate care and strong communication skills are essential for helping patients with depression. - **Core Principles:** While nurses aren\'t expected to provide complex therapies, being empathetic, listening to patients, and offering time to talk or allowing them space to express themselves are key elements in promoting recovery. 2. **Key Learning Points:** - **Cognitive Disorders:** Cognitive disorders, including delirium and dementia, are common and can trigger acute confusion or delirium, which is a medical emergency requiring immediate investigation. - **Impact of Delirium:** Delirium increases both in-hospital and post-discharge complications and mortality, making early assessment critical. - **Assessment Tools:** Using simple tools for early assessment helps identify those at risk for delirium, dementia, or altered cognition. - **Multicomponent Interventions for Delirium:** A structured approach using simple interventions and involving family and carers can reduce delirium\'s duration and impact. - **Capacity Assessment:** Always assess capacity when altered cognition is present due to delirium or dementia. Background information about the patient is crucial for understanding their needs. - **Best Interest Decision:** A best-interest discussion should guide care decisions for patients with reduced capacity, with the least restrictive treatment being prioritized. - **Psychiatric Medication Continuation:** Ensure that usual psychiatric medications are maintained wherever possible. - **Team Consistency:** Consistent care from the same staff/team can help build rapport and foster trust with the patient. - **Regular Reassessment:** Regular reassessment of depression is important, allowing patients time to discuss their progress, setbacks, and feelings. Overall, a compassionate, structured, and individualized approach is crucial in caring for patients with cognitive disorders and depression. Nurses play an essential role in providing both emotional and clinical support. **Summary of Rehabilitation and Discharge Following Hip Fracture:** 1. **Rehabilitation Challenges:** - Patients with hip fractures face complex medical, surgical, social, and psychological challenges during rehabilitation. Fear of falling, self-efficacy, and coping strategies play a significant role in recovery. - A multidisciplinary approach is essential, involving collaboration between medical, nursing, physiotherapy, occupational therapy, and social care teams. Effective teamwork and communication are key to successful rehabilitation outcomes. 2. **Rehabilitation Goals:** - The primary goals are to restore independence in physical function and improve quality of life. - Poor outcomes include failure to return to independent living and hospital readmissions. - Early supported multidisciplinary rehabilitation can reduce hospital stays, improve function, and lower readmission rates. 3. **Rehabilitation Pathways:** - From admission, patients should be enrolled in a formal rehabilitation program, including: - Comprehensive geriatric/orthogeriatric assessment - Rapid preoperative fitness optimization - Early identification of rehabilitation goals - Integration with related services (e.g., mental health, falls prevention) - Following surgery, rehabilitation focuses on: - Frailty assessment - Mobilization and physical therapy - Occupational therapy for aids and daily living support - Medication management and secondary fracture prevention 4. **Mobility and Exercise:** - Early mobilization (within 48 hours post-surgery) is crucial for improving independence and strength. - Tailored exercise programs should be supervised by nurses but prescribed by physiotherapists. 5. **Patient Motivation:** - Rehabilitation is a challenging transition from helplessness to independence, requiring sustained effort and motivation. - Fear of falling and coping strategies are crucial factors. A positive and encouraging approach from healthcare providers can improve patient motivation. 6. **Discharge and Post-Hospital Care:** - Discharge planning should begin early to ensure continuity of care and reduce the risk of readmission. - Patients should be supported in understanding their health condition, self-care, and follow-up needs. - Factors influencing discharge planning include cognitive status, functional capacity, home suitability, and availability of caregiving support. 7. **Discharge Options:** - Discharge home is appropriate if patients can manage self-care and medications, with available support services. - If home discharge is not feasible, transfer to an inpatient rehabilitation facility or nursing home may be necessary. - Effective communication between hospital providers and other care facilities is essential to ensure smooth transitions and prevent complications. 8. **Post-Discharge Care:** - Discharge information should be clear and focused on critical self-care instructions. - A model like \"Ask Me 3\" ensures patients understand their condition, what they need to do at home, and why it is important. Successful rehabilitation and discharge depend on early planning, comprehensive multidisciplinary care, and effective communication with patients and caregivers. The discharge process for older patients, especially after hip fractures, involves careful planning, beginning at admission. It is divided into three phases: admission, hospitalization, and discharge. 1. **Admission Phase**: Within 48 hours of admission, tools like the Blaylock Risk Assessment Screening Score (BRASS) identify patients at risk of complicated discharge, allowing referral to discharge services. 2. **Hospitalization Phase**: The multidisciplinary team decides the discharge plan, whether to home, rehabilitation, or nursing facility, and assesses the patient's needs using tools like the Functional Independence Measure (FIM). Early education for patients and caregivers starts here. 3. **Discharge Phase**: A definitive care plan is implemented, addressing transportation, follow-up, equipment, and medication needs. Verification of the patient\'s safe arrival at home or the facility completes the process. **Continuity of Care** ensures the best patient outcomes and involves: - Transferring patient information to new care settings - Timely activation of necessary resources - Monitoring and follow-up - Addressing critical issues like delayed discharge, inadequate family preparation, and lack of services. Nurses play a vital role in ensuring smooth transitions. They act as coordinators, improving care integration, continuity, and coordination, especially when patients are transferred between settings. Nurses, with their clinical skills and ability to manage care, are crucial in reducing readmissions and supporting patients and caregivers throughout the discharge process. **Key Takeaways:** - Rehabilitation and discharge planning should start early. - Effective rehabilitation promotes independence and quality of life. - Multidisciplinary rehabilitation can reduce hospital stays and improve outcomes. - Nurses are central to discharge coordination, ensuring continuity of care across settings.