Case study - Left hip fracture: Nursing

Nurse Kenji works on a rehabilitation unit and is caring for Sharon, a 74-year-old female with a history of osteoporosis who was admitted post-surgery for a left hip fracture requiring an open reduction and internal fixation, or ORIF. In collaboration with the registered nurse, RN Betty, Nurse Kenji goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Sharon’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Kenji recognizes important cues, including Sharon’s vital signs, which are temperature 98.6 F or 37 C, heart rate 90 beats per minute, respirations 19 breaths per minute, and blood pressure 123/88 mmHg. During the bedside report, Nurse Kenji learned that Sharon declined repositioning during the night shift. Upon inspection, he notes that her hip appears mildly swollen and her surgical dressing is clean and dry. Nurse Kenji also notices that Sharon’s left foot is warm with intact sensation, 2+ palpable pulses, and she can wiggle her toes, which is consistent with RN Betty’s earlier assessment.

Nurse Kenji asks Sharon about her comfort.

Nurse Kenji: I see that you stayed in the same position throughout the night. Would you tell me your current pain level?

Sharon: I don’t have pain right now, but I don’t want to move because I know it'll hurt my hip.

Nurse Kenji: I understand. Have you considered taking the prescribed medications to manage your pain?

Sharon: I really don’t like pain medicine because I’m worried about becoming addicted.

Next, Nurse Kenji analyzes these cues. He reviews the electronic health record, or EHR, and notes that Sharon is scheduled for physical therapy today. He also notes that Sharon is prescribed ice packs to reduce hip swelling, as well as oxycodone and acetaminophen every four hours as needed for pain management but hasn’t taken any medication since early yesterday evening.

Nurse Kenji understands that hip fractures are fractures that occur in the upper third of the thigh bone, called the femur. He knows that Sharon is at risk for hip fractures due to her older age, which increases the risk for falls; being assigned female at birth, due to an increased loss of bone density as estrogen levels fall after menopause; and her history of osteoporosis, which causes bones to become brittle and fragile.

Nurse Kenji is aware that patients who’ve undergone surgery to repair hip fractures typically experience pain and tenderness around the affected area, due to tissue trauma and inflammation, which makes it difficult to bear weight on the affected leg. He also knows that if Sharon doesn't ambulate, she can develop complications of prolonged inactivity, like skin breakdown, deep vein thrombosis, or DVT, and pneumonia, as well as experience a delayed recovery. Nurse Kenji realizes that Sharon needs effective management to promote mobility.