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Older patients having a fractured neck of the femur are usually discussed within a risk category because of high rates of morbidity and mortality associated with their condition. These patients are often proposed to undergo a total hip replacement to improve health outcomes and increase their functional mobility, but the problem is that negative outcomes associated with surgery are also possible (Bagaria, 2018). In this context, much attention should be paid to proper and effective pre-operative and post-operative management. The focus should be on decreasing risks for older patients that are related to their comorbidities associated with femoral fracture. The early and appropriate surgical fixation of the fracture along with necessary post-operative treatment and rehabilitation are required for addressing the health issue (Farrell, 2016). In this paper, appropriate pre-operative and post-operative management strategies and techniques will be discussed in the context of addressing the case of a nursing home patient who needs to undergo a total hip replacement.
Pre-operative management for an older patient includes several stages to complete to prevent any complications related to the surgery. When patients come to the emergency department, nurses are responsible for making primary observations and providing analgesia to relieve severe pain (paracetamol given every six hours or opioids when prescribed) (Spasovski, 2017). If opioids do not work to relieve pain, nerve blocks can be prescribed depending on a patient’s assessment (Farrell, 2016). Nurses also provide nutritional screening for a patient and control a diet and fluids consumption 24 hours before the surgery. Furthermore, a patient will be starved for 6 hours before the surgery (Boddaert, Raux, Khiami, & Riou, 2014). The abbreviated mental test score (AMTS) is applied to assess a patient for a possible cognitive impairment (“Abbreviated mental test score,” n.d.). In this context, the capacity assessment is realized to receive informed consent from a patient.
One of the first steps is the assessment by orthogeriatric and orthopedics who conduct evaluations of a patient’s state with the help of nurses and several tools. At this stage, a surgical suitability assessment is also completed based on the results of x-rays. Additionally, the selection of a fitting implant should be completed (Ikpeze, Mohney, & Elfar, 2017). The Nottingham hip fracture score (NHFS) is applied as a specific risk prediction tool for identifying potential risks of the postoperative mortality of a patient (“Risk prediction in surgery,” 2019). The results of the test depend on a patient’s comorbidities, age, gender, preoperative cognitive function, and other factors.
Investigations that are important to be conducted during the pre-operative stage include the full blood analysis, the urea analysis, screening for delirium, the measurement of electrolytes, the cardiovascular assessment using an electrocardiogram, and the dental evaluation. The coagulation status of a patient and risks of venous thromboembolism should be determined (Shah et al., 2017). At this stage, healthcare professionals can determine possible anemia, renal dysfunction, or problems with hydration in older patients and prescribe the related therapy (“Surgical risk calculator,” 2019). Intravenous fluids should be prescribed for older patients (“Hip replacement,” 2019). Investigations are also critical for determining additional therapies for patients having such conditions as atrial fibrillation, chest infection, diabetes, and a heart murmur (Bagaria, 2018). Therefore, the chest x-ray analysis is also conducted by healthcare professionals (Spasovski, 2017). Nurses also provide the results of assessments associated with the patient’s socio-economic status, living conditions, exercising, and weight status that can affect the results of the surgery and post-operative management.
The next step is the assessment provided by an anesthetist to choose working anesthetic techniques and prevent perioperative risks for a patient. A patient should be informed regarding the risks and benefits associated with using general and spinal anesthesia. Complications of spinal anesthesia include haematologic complications associated with spinal hematoma, infectious complications (S. aureus), and neurologic complications (Rodriguez, Barraco, & Ivatury, 2018). General anesthesia can cause temporary soreness, memory loss, confusion, vomiting, and dizziness among other issues (Farrell, 2016; Spasovski, 2017). The choice of the technique depends on a patient’s decision informed by an anesthetist’s assessment.
Another important component of pre-operative management is education provided to patients. Thus, a patient needs to be fully informed regarding the details of the surgery, associated limitations, his or her risk status, effects of the surgery, and outcomes. The patient in this case should be educated regarding the prognosis and strategies to reduce all possible risks during the surgery and a postoperative period (Levinger et al., 2017). As a result, a patient will be able to avoid harmful behaviors during the pre-and post-operative periods while focusing on the activities contributing to quicker recovery.
The next step in the pre-operative management is the organization of the theatre team and the environment for conducting the surgery to make it safe for a patient. The focus is on conducting routines to avoid wound infection and guarantee access to sterile instruments (Farrell, 2016; Ikpeze, Mohney, & Elfar, 2017). Along with preparing the setting for the surgery, nurses assist in conducting pre-operative showering and washing for patients before the surgery.
Post-operative management can be divided into two stages, including the immediate post-operative period and the longer post-operative treatment. During the first 24 hours after the completed surgery, an orthopedic surgeon and a nurse should conduct a medical assessment (Maceroli et al., 2016). This review usually involves the assessment of the appropriateness of the provided pain management, the inspection of wounds, and the evaluation of given anti-microbial prophylaxis (Mani, Raj, Acharya, & Pangeni, 2015). Nurses are also responsible for regular observations and assessments in this case that include the neurovascular analysis, the vital sign assessment, and the pain score assessment (Soffin & YaDeau, 2016; Spasovski, 2017). Depending on their state and the results of the surgery, patients should be informed that only a minimal movement is possible or that early mobilization is required. In any case, the hip should be stabilized in a specific correct position to avoid complications.
In addition, during this short period, it is important to provide wound and pressure area care and required analgesia management. Nurses also fill in fluid balance charts and determine the cognitive (CAT) score. The assessment of the cognitive function is critical for older patients because of the high risks of observing this problem during a post-operative period (Bagaria, 2018). The effective management of this medical issue includes providing required nutrition and hydration, the stabilization of an electrolyte balance, analgesia, and the prevention of infections.
It is also important to monitor the levels of hemoglobin and electrolytes to control a patient’s state. The assessment of a patient’s ability to swallow is conducted to decide a way of providing a meal during a short period after the surgery (Miller, Buerba, & Leslie, 2014). Complications that can be noticed during this period may include adverse effects of anesthesia and individual negative effects associated with an overall health state of an older patient (Abdel & Della Valle, 2017). In the first 24 hours after the surgery, the urinary catheter should be removed (Farrell, 2016; Spasovski, 2017). It was also important to note that all the listed efforts contribute to preventing such complications as possible delirium and venous thromboembolism (Abdel & Della Valle, 2017; Farrell, 2016). They work to predict infections, cardiovascular problems, and pressure ulcers typical of older patients who are more susceptible to developing these conditions during the post-operative period.
Long-term care guaranteed to patients after the surgery includes nurses’ observations. They are associated with cognitive and neurovascular assessments, regular pain management, and wound care depending on a schedule and a patient’s needs. Nurses also evaluate patients’ abilities regarding oral intake, functioning, and mobility (Abdel & Della Valle, 2017; Bagaria, 2018). Additional delirium screening is also required at this stage, and it is usually conducted by nurses. Complications that can be determined at this stage include the lack of mobility, would infections, changes in bone health, severe pain that is difficult to be managed, and problems caused by patients’ chronic conditions. The routine examination of a patient’s bowel function is also required to predict any problems associated with the effects of the surgery and used medications.
Post-operative management involves the continuous assessment of the state of a patient’s bones and the education on fall prevention techniques. Secondary fracture prevention techniques should also be explained to patients. At this stage, a discharge management plan should be prepared along with a rehabilitation care plan to be followed by an older patient at home or in a nursing home (Abdel & Della Valle, 2017). Additionally, older patients are also recommended to continue taking nutritional supplements and monitor their hydration status (Bagaria, 2018). As a result, such negative long-term outcomes as functional disability and mortality can be avoided.
To guarantee that the surgery related to a total hip replacement in an older patient is conducted without further complications and adverse effects, it is necessary to focus on pre-and post-operative management. In completing pre-and post-operative procedures and activities, much attention is paid to the role of a nurse in the process because of the necessity to conduct regular monitoring and assessment. As a result, it is possible to achieve the realization of positive health outcomes for older patients who are usually regarded within a high-risk category. Therefore, routine assessments and monitoring performed for older patients are necessary to prepare surgery most appropriately. This paper has presented the discussion of activities and steps that need to be performed in the context of pre-and post-operative management to reach positive effects for patients belonging to the senior age category. As a result, the listed pre-and post-operative techniques and strategies can be discussed as required to be realized by healthcare professionals working with older patients who need a hip total replacement to improve mobility.
Abbreviated mental test score. (n.d.). Web.
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