International Journal of Orthopaedic and Trauma Nursing (2013) 17, 4–18

www.elsevier.com/locate/ijotn

Acute nursing care of the older adult with fragilityhip fracture: An international perspective (Part 2)

Ann Butler Maher RN, MS, FNP-BC, ONC (Family Nurse Practitioner) a,*,1,Anita J Meehan RN-BC, MSN, ONC (Clinical Nurse Specialist,Gerontology/Director) b,1, Karen Hertz RN, BSc(Hons), MSc(Advanced Nurse Practitioner T&O) c,2, Ami Hommel RN, CNS, PhD(Associate Professor) d,3, Valerie MacDonald RN, BSN, MSN, ONC(Clinical Nurse Specialist) e,4, Mary P O’Sullivan RGN, RM, BNS/RNT, MScNursing (Clinical Development Co-ordinator) f,5,Kirsten Specht RN, MPH (PhD Student/Research Nurse) g,6,Anita Taylor RN, OrthoNCert, GradDipOrtho, MNSc(Orthopaedic Nurse Practitioner) h,7

a Long Branch, NJ, USAb NICHE Program, Akron General Medical Center, Akron, OH, USAc University Hospital of North Staffordshire, UKd Dept. of Orthopaedics, Skane University Hospital, Lund/Dept. of Health Sciences Lund University,Swedene Fraser Health Authority, BC, Canadaf Cork University Hospital, Wilton, Cork, Irelandg Dept. of Orthopaedics, Vejle Hospital, Vejle, Denmarkh Royal Adelaide Hospital, Adelaide, SA, Australia

1878-1241/$ - see front matter �c 2012 Elsevier Ltd All rights reserved.http://dx.doi.org/10.1016/j.ijotn.2012.09.002

* Corresponding author. Address: 35 Pavilion Avenue, Long Branch, NJ 07740, USA. Tel.: +1 732 571 1218.E-mail address: annmaher@verizon.net (A.B. Maher).

1 International Collaboration of Orthopaedic Nurses.2 Royal College of Nursing Society of Orthopaedic and Trauma Nursing.3 Swedish Orthopaedic Nurses Association.4 Canadian Orthopaedic Nurses Association.5 Irish Orthopaedic Nurses Section.6 Danish Orthopaedic Nurses Association.7 Australian and New Zealand Orthopaedic Nurses Association.

Editor’s commentWe are proud to announce the publication of this important international document that provides a clinicalreview for the care of the older person with a fracture of the hip. This important and ground breakingclinical review document is published in full online at: http://dx.doi.org/10.1016/j.ijotn.2012.09.002.and in two parts in print format; the second part here and the first part in an earlier edition of the Inter-national Journal of Orthopaedic and Trauma Nursing. In many countries hip fracture is the most importantissue facing trauma services in the 21st century and this document will help to provide those caring for thisvulnerable group of older people with sound, evidence-based advice on the best ways to ensure that care isas sensitive and effective as possible. It is our fervent hope that the clinical review will be used around theglobe to ensure care is sensitive to the complex needs of this group of patients. JS-T.

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 5

KeywordsHip fracture;Clinical review;Nursing

Summary The second part of this paper provides those who care for orthopaedicpatients with evidence-supported international perspectives about acute nursingcare of the older adult with fragility hip fracture. Developed by an internationalgroup of nurse experts and guided by a range of information from research and clin-ical practice, it focuses on nurse sensitive quality indicators during the acute hospi-talisation for fragility hip fracture. Optimal care for the patient who hasexperienced such a fracture is the focus. This includes (in the first, earlier, part):

PainDelirium

and in this partPressure UlcersFluid Balance/NutritionConstipation/Catheter Associated Urinary Tract InfectionVigilant nursing assessment and prompt intervention may prevent the develop-

ment of the complications we discuss. If they do occur and are identified earlyon, they may resolve with appropriate and timely nursing management.

This ‘‘tool kit’’ has been developed under the auspices of the InternationalCollaboration of Orthopaedic Nursing (ICON) a coalition of national associations oforthopaedic nursing (www.orthopaedicnursing.org).

�c 2012 Elsevier Ltd All rights reserved.

Pressure ulcers

Significance of problem/risk factors

A pressure ulcer is localised injury to the skin and/or underlying tissue usually – over a bonyprominence – as a result of pressure or pressurein combination with shear (EPUAP and NPUAP,2009). Pressure ulcers are common and present amajor challenge for patients with hip fracture(Baath et al., 2010). While pressure and shearingforce are the causative factors in pressure ulcerdevelopment, tissue tolerance is a key variable(DeFloor and Grypdonck, 2004). The probabilityof pressure ulcer development increases withthe duration and magnitude of the force actingon the tissue. Shear greatly increases the risk ofpressure ulcer development because it producestissue ischemia that further reduces tissue

tolerance for pressure. Inability to repositionthe body – often present in the elderly – is anadditional risk factor (Moore and Cowman,2009).

Following hip fracture, pressure injury resultingin skin breakdown is devastating for the patientand costly in terms of resources needed to treatthe wound(s) (Chaves et al., 2010; Remaley andJaeblon, 2010). Lindholm et al. (2008) reportedpressure ulcer prevalence as 10% on admissionand 22% at discharge in a Pan-European study ofhospitalised hip fracture patients while Campbellet al. (2010) reported prevalence rates of 16–55%in hip fracture patients in Canada. In the UnitedStates, Baumgarten et al. (2009) found the highestincidence of acquired pressure ulcer occurs in thehospital setting. Assessment of risk factors andstrategies to prevent pressure ulcer formationamong older patients serves to avoid unnecessary

6 A.B. Maher et al.

suffering, improve outcomes and control resourceconsumption.

Houwing et al. (2004) showed that advanced ageand time on the operating table were risk factorsfor patients with hip fractures. More recently, Ha-leem et al. (2008) found, in their review of 4654consecutive patients with hip fractures, that theimportant factor in pressure ulcer developmentwas delay to surgery. Specifically, delay betweenadmission to hospital and time of surgery was themost important risk factor. Patients operated onwithin 24 h of admission develop significantly fewerpressure ulcers compared to those whose surgerywas delayed longer than 24 h (Al-Ani et al., 2008;Hommel et al., 2007a).

A predisposition to pressure ulcer developmentexists in older patients, particularly in orthopaedicsettings, and those with co-morbidities such as dia-betes, respiratory disease, low hemoglobin, low sys-tolic blood pressure and altered mental status(Lindholm et al., 2008; Moore and Cowman, 2008;Campbell et al. 2010). The European Pressure UlcerAdvisory Panel (EPUAP) and the US National PressureUlcer Advisory Panel (NPUAP), in their 2009 jointdocument, recognise a number of contributing fac-tors associatedwith the development of pressure ul-cers. This also includes cardiovascular instability,oxygen use, nutritional status and skin moisture le-vel. However, the significance and exact relation-ship between these factors has yet to be established.

Assessment/detection

Pressure ulcer risk assessment is a nurse-sensitivequality indicator (https://www.nursingquali-ty.org/). Pressure ulcers can develop rapidly inthe vulnerable patient, so a skin assessment isimportant within six hours of admission (Riordanand Voegeli, 2009) and may be repeated as neededbased on changes in the patient’s condition.

Skin assessment

Skin assessment is a process that examines everybody surface of the individual for abnormalities.The nurse looks at and touches the skin from headto toe, particularly over bony prominences and anytissue subjected to prolonged pressure such as thebuttocks. During this assessment the nurse usestechniques for identifying blanching response,localised heat, oedema, and induration (hardness).Blanching may not be visible in darkly pigmentedskin but its colour may be different from the sur-rounding tissue.

Document any disruption in skin integrity pres-ent on admission. This is helpful in developing a

plan of care to treat ulcers and to monitor theirstatus. Ask the patient about any areas that arepainful or uncomfortable as sensory changes mayprecede tissue breakdown (EPUAP and NPUAP,2009).

A comprehensive skin assessment includes fiveelements:

� Temperature� Color/discoloration� Moisture level� Turgor� Skin integrity (skin is intact or there are openareas, rashes, wounds, etc. present).

Specifics about checking each of these compo-nents can be found at: http://www.ahrq.gov/research/ltc/pressureulcertoolkit/putool7b.htm.Scroll down to Tool 3B, Elements of a Comprehen-sive Skin Assessment. Helpful photos for assessingdarkly pigmented skin can be found at: http://www.puclas.ugent.be/puclas/e/.

Pressure ulcer risk assessment

The goal of pressure ulcer risk assessment is toidentify those individuals who are at risk for thedevelopment of pressure ulcers so that preventivecare can be planned and implemented. The processof assessing risk is multifaceted and includes theuse of a validated risk assessment scale. A pressureulcer risk assessment scale is a tool for establishinga risk score based on a series of risk factor criteria.Hospital policy or protocol identifies the frequencywith which risk assessment is to be performed. Anychange in the patient’s condition requires reassess-ment of risk for pressure ulcer (EPUAP and NPUAP,2009).

Moore and Cowman (2008) found that despitewidespread use of risk assessment tools, no ran-domised trials exist that compare them with un-aided clinical judgment or no risk assessment interms of pressure ulceration. Pancorbo-Hidalgoet al. (2006) compare various risk assessment toolswith unaided clinical judgment in a systematicanalysis of studies of predictive validity and findthat the Braden Scale offers the best predictivevalidity and notes that both the Braden Scale andthe Norton Scale are superior to clinical judgment.The Braden Scale is most frequently used in re-search and, along with the Norton Scale, is recom-mended by the Agency for Health Care Researchand Quality (AHRQ) (Berlowitz et al., 2011).

The Braden Scale (http://www.braden-scale.com) consists of six subscales (sensory per-ception, moisture, activity, mobility, nutrition,

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 7

and friction/shear) scored from 1–4 or 1–3 (1 forlow level of function and 4 for highest level or noimpairment). Total scores range from 6–23. A low-er score indicates higher levels of risk for pressureulcer development. Scores of 18 or less indicate at-risk status. This threshold may need to be adjustedfor specific patient populations (Berlowitz et al.,2011).

The Norton Scale consists of five subscales(physical condition, mental condition, activity,mobility, incontinence) scored from 1–4 (1 forlow level of function and 4 for highest level of func-

Table 6 International Pressure Ulcer Classification SystemNational Pressure Ulcer Advisory Panel. 2009. Prevention anWashington, DC: National Pressure Ulcer Advisory Panel.

Category/Stage Description

I: Non-blanchableerythema

Intact skin with non-blanchable rprominence. Darkly pigmented skdiffer from the surrounding area.colder as compared to adjacent tindividuals with dark skin tones. M

II: Partial thickness Partial thickness loss of dermis pwound bed, without slough. Mayfilled or serosanguinous-filled blisslough or bruising*. This categorytape burns, incontinence-associat*Bruising indicates deep tissue inj

III: Full thickness skinloss

Full thickness tissue loss. Subcutaare not exposed. Slough may be pMay include undermining and tunulcer varies by anatomical locatiomalleolus do not have (adipose) sbe shallow. In contrast, areas ofCategory/Stage III pressure ulcers

IV: Full thickness tissueloss

Full thickness tissue loss with expmay be present. Often includes uStage IV pressure ulcer varies byocciput and malleolus do not havbe shallow. Category/Stage IV ulcstructures (e.g., fascia, tendon olikely to occur. Exposed bone/mu

Additional Categories/Stages for the USAUnstageable/unclassified:Full thickness skinor tissue loss –depth unknown

Full thickness tissue loss, in whicby slough (yellow, tan, gray, greein the wound bed. Until enough sof the wound, the true depth of teither a Category III or IV. Stablefluctuance) eschar on the heels sand should not be removed.

Suspected deeptissue injury –depth unknown

Purple or maroon localised area oto damage of underlying soft tisspreceded by tissue that is painfulcompared to adjacent tissue. Deeindividuals with dark skin tones. Ewound bed. The wound may furthEvolution may be rapid exposing

tioning). The subscales are added together for a to-tal score that ranges from 5–20. Scores of 14 orless generally indicate at-risk status. Go to:http://www.ahrq.gov/research/Itc/pressureulcer-toolkit/putool17b.htm and scroll down to Tool 3E.

Pressure ulcer description

EPUAP and NPUAP (2009) describe pressure ulcersby category/stage according to the appearance ofthe tissue involved. The terms unclassified/unsta-geable and deep tissue injury used in the US aregenerally graded as Category IV in Europe. Most

. Source: European Pressure Ulcer Advisory Panel andd treatment of pressure ulcers: quick reference guide.

edness of a localised area usually over a bonyin may not have visible blanching; its colour mayThe area may be painful, firm, soft, warmer orissue. Category I may be difficult to detect inay indicate ‘‘at risk’’ persons.

resenting as a shallow open ulcer with a red pinkalso present as an intact or open/ruptured serum-ter. Presents as a shiny or dry shallow ulcer withoutshould not be used to describe skin tears,ed dermatitis, maceration or excoriation.ury.neous fat may be visible but bone, tendon or muscleresent but does not obscure the depth of tissue loss.neling. The depth of a Category/Stage III pressuren. The bridge of the nose, ear, occiput andubcutaneous tissue and Category/Stage III ulcers cansignificant adiposity can develop extremely deep. Bone/tendon is not visible or directly palpable.osed bone, tendon or muscle. Slough or escharndermining and tunneling. The depth of a Category/anatomical location. The bridge of the nose, ear,e (adipose) subcutaneous tissue and these ulcers caners can extend into muscle and/or supportingr joint capsule) making osteomyelitis or osteitisscle is visible or directly palpable.

h actual depth of the ulcer is completely obscuredn, or brown), and/or eschar (tan, brown, or black)lough and/or eschar are removed to expose the basehe wound cannot be determined, but it will be(dry, adherent, intact without erythema orerves as ‘‘the body’s natural (biological) cover’’

f discoloured intact skin or blood-filled blister dueue from pressure and/or shear. The area may be, firm, mushy, boggy, warmer or cooler asp tissue injury may be difficult to detect involution may include a thin blister over a darker evolve and become covered by thin eschar.additional layers of tissue even with optimal treatment.

8 A.B. Maher et al.

important is that the actual definition of pressureulcer and the level of skin/tissue injury are thesame, regardless of term used. For definitions ofthe categories/stages, refer to Table 6. Go tohttp://www.logicalimages.com/publicHealthRe-sources/pressureUlcer.htm to view photos of pres-sure ulcers with illustrations of the depth of thewound; or to http://www.nursingquality.org andclick on Pressure Ulcer Training to view ModuleOne.

Prevention strategies

It is universally agreed that pressure ulcers are bestprevented. Samuriwo (2010) suggests that nurseswho place a high value on pressure ulcer preven-tion appear to be more proactive and determinedto deliver care that protects their patients’ skin.Carson et al. (2012) describe the developmentand implementation of an evidence based pressureulcer prevention initiative. An underlying focus ofthe framework for this initiative was to improvethe knowledge of clinical staff and to strengthenthe staff-nurse skin care champion model. Harrisonet al. (2008) report on a proactive program toimplement practice guideline recommendationson pressure ulcer prevention. This program alsocreated unit-based skin care champions who use apeer to peer learning approach to enhance theknowledge of clinical staff and develop a unitbased nurse resource model. Both programs dem-onstrated a decrease in pressure ulcer prevalencein their respective health care settings.

Pressure ulcers can develop at any time duringhospitalisation. Prolonged periods in the supine po-sition may contribute to the development of suchan injury. Organisations should use some form ofpressure relieving surface for high risk patients onnursing units, in the operating theatre, and in theemergency department (Beckett, 2010; Phamet al., 2011a; Pham et al., 2011b). Despite best ef-forts in some instances, pressure ulcer develop-ment is an unavoidable consequence of multipleorgan failure or pre-admission circumstances, suchas a patient who has fallen and was lying on a hardsurface for many hours prior to hospital admission.

Nutrition, skin care, appropriate support sur-faces and repositioning all contribute to preventionefforts.

Nutritional status

Malnutrition is a common problem in hospital pa-tients and often goes unrecognised (Somanchiet al., 2011). Older patients with hip fracturemay have poor nutritional status. Patients who

are malnourished on admission to the hospital aretwice as likely as well-nourished patients to devel-op pressure ulcers (Thomas, 2006). However, it ispossible to reduce the development of hospital-ac-quired pressure ulcers among elderly patients witha hip fracture even though they have poor pre-frac-ture nutritional status (Hommel et al., 2007b). Re-fer to the section on Nutrition/Malnutrition in thisdocument for more information on nutritionalassessment and intervention.

Skin care and treatment

Appropriate preventive care for skin may minimiseprogression to actual pressure ulcer. Normal agerelated changes result in older adults having dryskin. Use skin emollients for hydration as dry skinis a significant risk factor on its own. Protect skinfrom excessive moisture using a barrier productas needed. When deciding on treatment plans, dis-tinguish skin excoriation due to incontinence(incontinence associated dermatitis) from pressureulcer. Photos that demonstrate skin excoriationcan be found at: http://www.tissueviabilityon-line.com/pu. Click on Grading and Tools, then onExcoriation Tool.

Pressure reducing support surfaces

Reducing the amount, duration and intensity ofpressure exerted on the skin is the most effectivestrategy for pressure ulcer prevention (Sakaiet al., 2009). Place individuals at high risk of devel-oping pressure ulcers on pressure relieving surfacesrather than a standard hospital mattress. However,it is not clear if an alternating-pressure mattress ora constant low pressure mattress provides a supe-rior benefit (McInnes et al., 2011). Medical gradesheepskins are associated with a decrease in pres-sure ulcer development (McInnes et al., 2011).EPUAP/NPUAP Consensus Guidelines (2009) recom-mend avoiding cutouts, rings or donut devices asthese increase pressure.

Repositioning

Repositioning is an essential aspect of prevention.Repositioning encourages reperfusion to tissuesand reduces the risk of developing pressure relatedischemia. Repositioning schedules and techniqueincorporate the patient’s medical condition, func-tional ability and support surface used. The patientwith a hip fracture may present unique reposition-ing challenges. Preoperatively, consider the frac-ture stabilisation technique being used andpostoperatively consider fracture fixation tech-nique and limitations on motion prescribed by thephysician.

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 9

When repositioning a patient it is important tolift, not drag, the patient across the support sur-face. Transfer aids such as overhead lift equip-ment, if available, help reduce friction and shearforces. The use of these devices must be made withconsideration of the type of fracture and postoper-ative limitations imposed. Repositioning a patientwith a hip fracture may require more than onecaregiver.

In general, do not turn a patient onto a body sur-face that remains reddened after previous reposi-tioning as this indicates the skin on that surfacehas not recovered from pressure loading. Massagingor vigorously rubbing at-risk skin surfaces can bepainful and may cause tissue damage. Maintainthe patient’s heels off the bed surface by usingheel-protection devices, e.g. a waffle boot or a pil-low under the calf. Placing a pillow under thecalves and keeping the knee in slight flexion mayhelp to minimise risk of deep vein thrombosis.

When repositioning the patient on their sideafter surgery, consider any postoperative restric-tions. Place a pillow or padding between the legsto prevent tissue trauma at the knees and ankles.When raising the head of the bed for patients

who are allowed postoperative hip flexion, raisethe knees first, then the head of the bed (no morethan 30 degrees). Roll the patient slightly to oneside to release shear, then settle back down so thatthe patient’s hips and knees are in alignment withthe bends in the bed (Mimura et al., 2009) A 30-de-gree lateral position is often recommended. Even ifthe patient is lying on a pressure-reducing mat-tress, assisting the patient with scheduled reposi-tioning decreases the risk of pressure ulcers(DeFloor et al., 2005). When the patient is ableto sit in a chair, limit the time and use a pressureredistribution surface to avoid pressure ulcerdevelopment.

Self-management strategies

With your guidance, patients and their families canparticipate in preserving intact skin. Some guide-lines recommended by Nurses Improving Care forHealthsystem Elders NICHE (2010) include:

1. Change position at least every 2 h to relievepressure

10 A.B. Maher et al.

2. If you cannot move yourself, ask for help chang-ing your position

3. Moisturise dry skin4. Tell your nurse if you develop reddened, purple,

or sore areas5. Tell your nurse if you have a problem with leak-

ing urine or stool6. Clean your skin immediately if you get urine or

stool on it7. Use pillows to pad areas between knees and

ankles. Elevate heels off the bed or foot reston chairs

8. Do not lie directly on your hip bone9. Eat a well-balanced diet

For the complete list, you can view the entirebrochure at http://nicheprogram.org/need_to_-know. Click on Skin Care: Pressure Ulcers.

Fluid balance and nutrition andelimination

Significance of the problem

When older adults presentwith an acute hip fracturethey do so in the context of frailty, often with pre-existing medical co-morbidity and other functionaland psychological issues. Older adults following hipfracture repair may experience one or more com-mon post-operative complications including delir-ium, CCF, pneumonia, DVT, PE, pressure ulcer,arrhythmia, myocardial infarct, anaemia and mor-tality’’ (Agency for Clinical Innovation, 2010). These‘common’ complications can impact the fluid bal-ance, nutrition and elimination status of the olderadult with hip fracture and rarely occur in isolation.This section addresses those aspects of care thatbenefit most from nurse-initiated intervention:dehydration, malnutrition, constipation and cathe-ter associated urinary tract infections.

Fluid balance

Scope of the problem

Age related changes in homeostatic mechanismsand underlying co-morbidities increase the vulner-ability of older people to the physiological stressesassociated with the hip fracture and surgery. Whiteet al. (2009) found renal dysfunction in 36% of pa-tients admitted with hip fracture and Carboneet al. (2010) reported the incidence of heart failureas 21% in this population. Frail older hospitalisedpatients are at risk for iatrogenic dehydration, fluidoverload, heart failure, and electrolyte distur-bances. Pre-existing heart failure or renal condi-

tions are likely to worsen with the stress ofsurgery and the hospital experience. These areserious conditions that may lead to organ damage,delirium, functional decline and mortality. Fluidbalance monitoring and optimisation is a clinicalimperative for this population.

Dehydration

Dehydration is highly prevalent among the hospita-lised older adult with significant adverse conse-quences. Institutionalised older adults admittedto acute care from residential facilities tend topresent with dehydration due to pre-existing re-stricted fluid intakes. It is highly probable the olderadult is dehydrated on presentation to hospitalwith hip fracture (Hodgkinson et al., 2001). Hospi-talisation may compound pre-existing dehydrationor increase the risk of dehydration. Dehydrationdecreases circulatory volume resulting in dimin-ished perfusion to organs and tissues and is impli-cated in the development of delirium, renalfailure, pressure ulcers, falls, venous thromboem-bolism, impaired mobility, catheter associated uri-nary tract infection (CAUTI) and cystitis.

Dementia, delirium and decreased manual dex-terity and immobility as well as communicationand sensory impairmentsmay all contribute to dehy-dration, particularly if a delay to hospital presenta-tion has occurred. The hip fracture and surgery mayresult in significant blood loss. Normal age relatedchanges result in a diminished thirst reflex and sub-sequent diminished fluid intake. Those patients whosuffer from incontinence may limit fluid intake as ameasure to reduce the risk of incontinence due toperceived lack of timely access to toileting. Limitedmobility, unfamiliar environment, concerns that re-quests for assistance will not be prompt enough tomeet their need and the desire to preserve dignityare factors that may influence this decision. Sincehip fracture occurs in an emergency context, delayto surgery with an extended period of pre-operativefasting is also a risk factor.

Assessment/detection

Evidence supports taking a thorough clinical historythat includes identifying the patient’s average dai-ly fluid intake. The following signs and symptomsmay indicate dehydration:

� Diminished urine output� Hypotension, tachycardia� Dry lips, mucous membranes, diminished skinturgor� Muscle weakness, dizziness, restlessness,headache

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 11

� Delirium which may be hypoactive

Upon presentation there are a range of strate-gies the nurse can employ including clinical andbiochemical analysis (urine and blood markers) toassist in assessment of dehydration.

Prevention and management strategies

Fluid and electrolyte management begins in theEmergency Department with an accurate assess-ment and formal recording of the patient’s fluidstatus including documentation of the time(approximate) the fracture occurred. Once a re-view of the patient’s coexisting medical problemsis correlated against their likely fluid balance, pa-tients should have clinical and laboratory assess-ment for possible hypo or hypervolaemia,electrolyte balance and any identified deficienciesappropriately and promptly corrected (ScottishIntercollegiate Guidelines Network, 2009).

Where delay to surgery occurs and extendedperiods of fasting ensue, nursing staff must ensurethe patient receives adequate hydration. Whereverpossible, attempts must be made to minimise peri-ods of fasting from oral food and fluids in accor-dance with local guidelines and policies thatreflect best evidence. Mouth care is important atall times but it is especially important when oralfluids are restricted.

Nursing staff must continually assess the patientfor signs and symptoms of dehydration and fluidoverload as clinically indicated and in response tothe patient’s condition. Strategies include: ensur-ing regular vital sign observations, maintainingaccurate documentation of fluid balance andprompt reporting of alterations to the patient’sstatus. A nursing assessment of swallow and/orreferral for formal swallow screen should occurwhere there is concern about the safety of the pa-tient’s ability to swallow. Early resumption of oralintake in the post-operative period is preferable,with intravenous or subcutaneous supplementationsecondary.

Patients’ access to fluids in the hospital settingis often limited. Drinking containers should beergonomically suited to be manipulated by olderpatients and placement of the container made inconsideration of any visual limitations. Nursesshould proactively offer fluids with each visitrather than inquiring about the patient’s desirefor a drink. Intentional hourly nursing rounds(‘rounding’) should include hydration needs. Thefollowing link to the Hartford Institute for GeriatricNursing’s ‘‘Try This’’ series provides added recom-mendations for hydration management. http://

www.consultgerirn.org/topics/hydration_manage-ment/want_to_know_more.

Fluid overload/heart failure

Certain populations of older adults with hip fracturerequire more careful monitoring for fluid overload/heart failure. Diminished cardiac and renal functionrenders the frail older adult susceptible to fluidoverload i.e. more fluid than the heart can effec-tively pump. (See Scottish Intercollegiate Guide-lines Network SIGN 95, 2007 http://www.sign.ac.uk/guidelines/fulltext/95/index.html &National Heart Foundation of Australia, CardiacSociety of Australia and New Zealand, Chronic HeartFailure Guidelines Expert Writing Panel. Guidelinesfor the prevention, detection and management ofchronic heart failure in Australia, 2006).

Assessment/detection

Risk factors include cardiac or renal disease,large or rapid infusions of fluids and intravenousinfusion with sodium solution. Heart failuremanifests with pulmonary and peripheral oedema(Hartree, 2010).

The stress of surgery leads to an increasedsecretion of the antidiuretic hormone (ADH) whichimpairs the ability to excrete sodium and water.Symptoms to monitor include:

� urinary output less than 30 cc per hour� increasing blood pressure� shortness of breath� moist breath sounds� dependent edema

Prevention and management strategies

Carefully monitor fluid intake and output. Titratefluids, administer diuretics and/or restrict sodiumin consultation with physician or advanced practicenurse.

Electrolyte disturbances

Scope of the problem

Renal and cardiac decline, dehydration and fluidadministration and fluid losses during surgery in-crease the risk of electrolyte disturbances. Hypo-natremia is the most common electrolyteimbalance in the older population and is associatedwith delirium and falls (Gankam Kengne et al.,2008). Elevated serum urea nitrogen and hyper orhyponatremia are associated with significantly

12 A.B. Maher et al.

higher mortality rates when left untreated (Lewiset al., 2006).

Assessment/detection

Risk factors include cardiac or renal dysfunction,dehydration or fluid overload and the use of diuret-ics. Consult with the physician or advanced practicenurse to ensure that lab tests are ordered for appro-priate patients. Blood electrolytes and renal func-tion should be regularly monitored until returnedto baseline (Agency for Clinical Innovation, 2010).

Prevention and management strategies

� Monitor and manage fluid balance as describedabove.� Consult with physician or advanced practicenurse for clinical interventions to address imbal-ances. For example, an accurate haemoglobinassessment is needed to prevent impaired func-tional ability, dizziness, delirium and risk of fall.In that case the nurse consults with the physi-cian to ensure iron supplementation and bloodtransfusion is ordered if indicated.

Self-management strategies

Engage patient and family in learning about the:

� Importance of hydration and how dehydrationand overhydration adversely affects health andpersonal goals (e.g. decreased energy, falls etc.).� Strategies for facilitating hydration e.g. readilyavailable water – hot or cold, flavoured ornot, decaffeinated drinks, in easily manipulatedcontainers, drink offered with each interaction,written and verbal reminders.� Strategies to mitigate incontinence e.g. timingof fluids earlier in the day, limiting of fluidsthroughout the day as appropriate, regularlyscheduled toileting.� Chronic illness/Medications and their impact onfluid balance. Importance of adhering to dietaryand fluid restrictions/guidelines.� Warning signs of dehydration, overload and whatto do.

Malnutrition

Scope of problem

Malnutrition is often associated with ageing andis characterised by ‘‘diminished hunger & thirst,chronic illness patterns, dentition issues and so-

cial isolation’’ (MacDonald, 2011). Studies showthat 30–50% of patients admitted to an orthopae-dic unit suffer from malnutrition (Ponzer et al.,1999; Eneroth et al., 2005). Fry et al. (2010) re-ported that patients with pre-existing malnutri-tion have a 2.5 times greater risk of developinga surgical site infection, a 5.1 times greater riskof developing a catheter associated urinary tractinfection and are 3.8 times more likely to devel-op a pressure ulcer than those without malnutri-tion. Koren-Hakim et al. (2012) found that poornutritional status was associated with ‘‘higherco-morbidity indices, mortality andreadmissions’’.

While hospitalised, it is estimated that hip frac-ture patients consume only half their recom-mended daily energy, protein and othernutritional requirements (British Orthopaedic Asso-ciation, 2007) and despite the development of fast-ing guidelines patients continue to be kept withoutfood or water for too long prior to surgery.

Assessment/detection

The nurse is best placed to assess and monitor apatient’s nutritional status particularly when theneed for nutrition support in an acute care set-ting often exceeds the dietetic resources avail-able. The nurse can play a critical role inidentifying the ‘at risk’ patient, assess nutritionalstatus and initiate nutritional care that will aidrecovery and prevent functional decline, includ-ing an assessment of mental capacity to consent(Jackson et al., 2011). Nutrition for this patientpopulation is an inter-disciplinary concern (BritishOrthopaedic Association, 2007) requiring constantvigilance and liaison. Examples of nursing inter-ventions to ensure timely nutrition supportinclude:

� Nutrition history.� Weigh on admission; weight history (recent loss/gain) and observe for lack of body fat, dry skin &skin turgor.� Nutrition Assessment & Screening (such as MUSTby BAPEN (2003) (British Association of Paren-teral Nutrition see http://www.bapen.org.uk/musttoolkit.html).� Speech pathology review/consult for swallowevaluation, when symptoms present and asappropriate.� Minimise the period of preoperative fasting, inaccordance with policies and anesthesiaprotocols.� Where concern exists document food & fluidintake (Food Diary).

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 13

� Encourage early resumption of oral intake par-ticularly oral protein and energy supplementa-tion as a strategy to minimise postoperativecomplication rate.� Initiate appropriate multi-nutrient supplementsthat are high energy and high protein containingappropriate levels of vitamins and minerals atthe earliest convenience in the pre-operativeperiod where possible; Dietician review/consultfor additional nutrition support.� Initiate nourishing fluids/mid-meal snacks.� Optimise oral intake at meals: dentures, posi-tioning for meals, assisting feeding as necessary.

Where extended periods of inadequate oral in-take occur, consideration must be given to avoid‘re-feeding syndrome’. This is a condition of meta-bolic and electrolyte disturbance which occurswhen nutrients are replaced too quickly followinga period of inadequate nutritional intake for 5 daysor more (National Institute for Health and ClinicalExcellence, 2006). Every effort should be made toavoid this syndrome through appropriate andtimely renourishment as potentially fatal shifts influids and electrolytes can occur (Mehanna et al.,2008). A systematic review by Skipper (2012) notedthat although ‘‘there is no widely accepted or uni-formly applied set of defining characteristics fordiagnosing refeeding syndrome, hypophosphatemiawas a consistent finding’’.

For those patients where a high index of suspi-cion exists for poor nutrition, consider early die-tary consult with the goal of optimizingnutritional status. A number of studies demon-strate positive benefits of early nutritional supple-mentation (Volkert et al., 2006 & Milne et al.,2006). In the event of an inability of the patientto take food orally, consideration should be givento temporary naso-gastric feeding. This decisionshould be made in full consultation with the pa-tient and family and with full consideration of men-tal capacity, the prognosis, advanced care planningand end-of-life decision making. The issue of sup-plementary feeding, treatment escalation andpalliation and the timing of such may need to beexplored.

Prevention and management strategies

Be mindful that older patients are at risk for malnu-trition and be vigilant at monitoring intake and out-put. Complete a nutrition screening assessmentsuch as the MUST (BAPEN, 2003) tool calculationwhere appropriate. Recognise the older personwith impairments (cognitive, sensory or motor)

may need more time to complete meals and mayneed more help, and plan for this reality. Doesthe patient wear dentures? Are there adequateteeth for chewing foods? Does the patient havean oral fungal infection? Ensure that communica-tion is facilitated by having hearing aids in placeand eyeglasses on or available. Encourage patientsto be out of bed for meals and provide assistance asneeded.

Several interventional studies suggest nutri-tional supplementation, specifically for the olderadult hip fracture patient, has a positive effecton quality of life and the reduction of hospital re-lated complications (Gunnarsson et al., 2009; Volk-ert et al., 2006; Milne et al., 2006). Interventionsshould be patient-focused, and aimed to minimisefurther nutritional decline throughout the recoveryperiod (Dieticians Association of Australia, 2009).

Self-management strategies

Self-care strategies address both in-hospital andout-of-hospital care and may include: the social as-pects of eating and drinking in hospital in which el-derly patients can benefit from eating togetherwith other persons in a dining room setting in thehospital (Gordge et al., 2009), strategies to estab-lish a normal routine, supporting people withdementia, help with opening containers and pack-ets, use of strategies such as red trays and othermethods to prioritise high risk patients and inclu-sion of informal carers appropriately in supportinggood nutrition in hospital as an adjunct to profes-sional nursing care. Engage patient and family inlearning about the:

� Importance of nutrition in preserving health andpersonal goals e.g. preventing hospitalisation,re-hospitalisation, falls, post-operative infec-tion etc.� Consult with dietician to develop specialisedmenus and meal planning strategies at home.� Need for families to monitor: ability to obtainfood, prepare meals and the tendency to regu-larly skip meals, especially if living alone.� Community resources for meals and dietaryassessment/services.� Strategies to mitigate incontinence e.g. timingof fluids earlier in the day, regularly scheduledtoileting.� Chronic illness/Medications and their impact onfluid balance. Importance of adhering to dietaryand fluid restrictions/guidelines.� Warning signs of dehydration, overload and whatto do.

14 A.B. Maher et al.

Continence

An assessment of continence should be made onadmission as part of the comprehensive assess-ment. Early resumption of baseline bowel & blad-der habits must remain the priority for the olderadult hospitalised with hip fracture. This sectionaddresses two common complications related toelimination: constipation and catheter-associatedurinary tract infection (CAUTI).

Constipation

Risk factors

Prevention of constipation should be considered inthe early management of hip fracture patients.Constipation is made worse by dehydration, immo-bility, poor fluid intake, decreased dietary fibreand general changes to normal dietary routines.Opioid analgesics, even in low doses also causeconstipation (Scottish Intercollegiate GuidelinesNetwork, 2009). Constipation is an under-appreci-ated cause of delirium in the older patient.

Assessment/detection

Constipation can manifest at any point along a con-tinuum that ranges from general gut discomfort,nausea and vomiting, abdominal or rectal pain toabdominal distension and bowel obstruction. Agita-tion and deliriummay accompany any or all of thesesymptoms The Joanna Briggs Institute (JBI) (2008)best practice guidelines suggest the following:

� Document baseline [on admission to hospital]and usual bowel patterns.� Evaluate and document severity of constipation.� Document improvements or progression of con-stipation &/or response to management ofconstipation.

Prevention and management strategies

An emphasis on privacy, dignity, good accessibilityto toilet facilities (especially for people withdementia/delirium), orientation and signage arestrategies the nurse can initiate to minimise consti-pation. Wherever possible the impact of constipa-tion should be minimised and at best avoidedaltogether through the implementation of an evi-dence based bowel protocol that incorporatespre-emptive aperients/laxatives, a high fibre dietand fluids as recommended in the British NationalFormulary for drug-induced constipation (ScottishIntercollegiate Guidelines Network, 2009) or con-

sideration given to using a standardised gradingtool such as the Bristol Stool Scale (Lewis and Hea-ton, 1997). Conversely, overuse of laxatives orinadequate drinking should not be underestimatedas a problem surrounding the management ofconstipation.

Some recommendations for practice include:

� Delay to surgery and extended periods of fastingfor surgery can affect bowel function and shouldbe avoided wherever possible or proactivelymanaged as appropriate.� Unless otherwise restricted, fluids should beencouraged to a minimum of 1500 mL of oralfluid daily.� A regular toileting regime (every 2 h) thatencourages ambulation and discourages the useof bedpans should be adopted.� Close monitoring of bowel habit should berecorded including description of, frequencyand amount of bowel movement daily (SIGN2009).� Aim for a bowel movement by post op day 2 then48 hourly thereafter (Auron-Gomez and Michota,2008).� Efforts should be made using the above strategiesto prevent secondary fecal impaction (WesternAustralian Department of Health, 2008).

Catheter associated urinary tract infection(CAUTI)

Scope of problem

Reportedly 40% of all nosocomial infections areattributed to infections of the urinary tract (UTI)and 80% of these infections are associated with theuse of an indwelling urinary catheter (IUC) (JoannaBriggs Institute, 2010; Centre for Disease Control,2009). Asymptomatic bacteriuria is a commonoccurrence in older adults with hip fracture (SIGN,2009) and the use of an indwelling urinary catheter(IUC) increases the risk for developing a UTI. Careproviders may see indwelling urinary catheters asbeneficial, helping to prevent falls and to addressurinary incontinence and patients will sometimesrequest them or refuse discontinuation. It is impor-tant to remember that IUC’s are not innocuous de-vices. In addition to increasing the risk for CAUTI,indwelling catheters are associated with local trau-ma to the urinary meatus, restriction of mobility,pain, encrustation, delirium and increased risk formortality. A high index of suspicion for urinary tractinfection (UTI) should be ever present in the olderadult with hip fracture.

Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 15

Assessment and risk factors

The most significant risk factors for the develop-ment of catheter associated urinary tract infec-tions include; insertion technique, inadequatecleansing with soap and water, prolonged ‘dwelltime’ and failure to maintain a ‘closed’ system ofdrainage (Centre for Disease Control, 2009). Admis-sion assessment should include information regard-ing the nature of the patient’s usual bladderfunction. Ongoing vigilance for and documentationof the signs and symptoms of UTI must continuethroughout hospitalisation. An indwelling urinarycatheter should be used in operative patients asan exception rather than as a routine.

The Centre for Disease Control (2009) supportsthe following indications for indwelling urinarycatheter use:

� Urinary retention or obstruction unrelieved bystraight catheterisation.� Stage 3 or 4 pressure ulcer in perineal area,sacrum or ischial tuberosity.

� Close monitoring of cardiac or renal function incritically ill patients.� Comfort care measure in terminal illness.� Prolonged surgical intervention or surgeryrequiring decompression of the bladder.

Prevention and management strategies

The presence of a catheter predisposes the patientto acquiring a urinary tract infection. When anindwelling urinary catheter is deemed necessary,incorporate maintaining adequate fluid balancewith accurate recording of input and output, effec-tive analgesia and routine catheter care into dailynursing care. There is unanimous support for theremoval of the catheter at the earliest conve-nience, preferably within the first 24 h, to minimiseinfection, (CDC, 2009; Wald et al., 2005; Lo et al.,2008). If there is a need to retain the catheter after24 h, the clinical indication should be documentedand continual monitoring for removal when clini-cally appropriate. After removal, monitoring the

16 A.B. Maher et al.

patient for retention/incontinence is required(Auron-Gomez and Michota, 2008).

Further research is recommended regarding thebenefits of antimicrobial (silver and antibioticimpregnated) catheters to reduce CAUTI (Schummand Lam, 2008; CDC, 2009). Inserting the smallest lu-men catheter possible (CDC, 2009:12) and instilling5 mL in the balloon minimises bladder irritationand trauma to bladder neck and urethra. It is impor-tant to secure the catheter, avoid dependent loopsin the drainage tube and position the collection bagbelow the level of the bladder (CDC, 2009). Nursesplay a significant role in reducing the incidence ofCAUTI by advocating for use onlywhen clinically nec-essary and discontinuing as soon as possible.

Self-management strategies

Engage patient and family in learning about:

� Risk factors, prevention and management ofconstipation (e.g. high fibre diet, fluids,mobility).� Risks for and strategies to prevent urinary tractinfection.� Perineal hygiene, adequate hydration, avoidindwelling catheter use/alternative strategiesto manage urinary incontinence. http://consult-gerirn.org/topics/urinary_incontinence/want_to_know_more

Disclaimer

This article was developed using a range of litera-ture which included evidence-based research, con-sensus documents, guideline statements,systematic reviews and peer reviewed publicationsand also was informed by best practice and contentexpert commentary. The information presented inthis article is to educate and inform the readerabout common complications of fragility hip frac-ture in older adults. The decision to use specificassessment methods and interventions must bemade by the individual practitioner/health careorganisation relative to the individual patient,available resources and other relevant factors.

Conflict of interest statement

There are no conflicts of interest for the authors ofthis manuscript.

Role of funding source

No funding was obtained for this study.

Acknowledgements

We would like to acknowledge the support ofICON constituents during the development of thispaper, particularly Joyce Lai of AADO, Hong Kong,and Reggie Aquilina of AMON, Malta.

We are grateful to the nurse experts whose inputguided and strengthened the paper. Those who re-viewed the entire document were Marie Boltz, PhD,RN, GNP-BC (USA), Peter Davis MBE (UK), Sue BairdHolmes, MS RN (USA).

Pain section reviewers were: Donna Sipos Cox,MSN, RN, ONC, CCRC (USA) Keela Herr, PhD, RN,AGSF, FAAN (USA), Alan Pearson AM (Australia),Brenda Poulton, RN, MN, NP (Canada).

Delirium section reviewers were Marcia Carr,RN, BN, MS, GNC(C) (Canada), Donna Fick, PhD,RN, FGSA, FAAN (USA), Lorraine Mion, PhD, RN,FAAN (USA), Manuela Pretto, MNS, RN(Switzerland).

Pressure Ulcer section reviewers were Joyce M.Black, PhD, RN, CSPN, CWCN, FAAN (USA), Chris-tina Lindholm, PhD, RN (Sweden), Zena Moore,PhD, MSc, PG Dip, FFNMRCSI (Ireland).

Fluid Balance/Nutrition/Elimination reviewerswere Joanne Alderman, APRN-CNS, RN-BC, FNGNA(USA), Merete Gregersen, MHSc (Denmark), NickyHayes, RGN, BA(Hons), MSc, PGCert (HE) (UK), AlanPearson AM (Australia).

We thank Jennifer Gibson for her editorialexpertise and meticulous attention to detail andJudy Knight MLS, AHIP, coordinator, library ser-vices for her valuable assistance.

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