Fractured Hip with Postoperative Complications Case Study (Harding & Snyder Case Study 46): Nursing Guide

How to use this guide: the textbook case and its questions are copyrighted, so they are not reproduced here. Instead, this guide explains the clinical content the case tests and walks through an original practice case with model answers. Use it to study and to check your reasoning, then answer the questions in your textbook in your own words. It is not an answer key.

Hip fracture: what the case tests

Hip fractures are common, serious injuries in older adults. Most result from a fall from standing height in a person with osteoporosis. They are classified as intracapsular (femoral neck, inside the joint capsule, where the blood supply to the femoral head can be disrupted) or extracapsular (intertrochanteric or subtrochanteric, below the capsule). Femoral neck fractures are often treated with hemiarthroplasty or total hip arthroplasty, and extracapsular fractures with internal fixation such as a nail or plate and screws (Harding et al., 2023).

A hip fracture is often a turning point in an older adult’s life. Many patients never regain their previous mobility, and complications after surgery, such as delirium, venous thromboembolism, pneumonia, pressure injuries and infection, are a major cause of death and disability. Clinical reasoning cases on this topic test whether the nurse can recognize these complications early and act on them.

Original practice case

Clinical reasoning questions and model answers

1. Which assessment findings are typical of a hip fracture, and what should the nurse assess first?

Classic signs are severe pain in the hip or groin, inability to bear weight, and a shortened, externally rotated leg caused by muscle spasm pulling the fractured bone. The nurse should assess pain and perform neurovascular checks of the affected leg (color, temperature, capillary refill, pulses, sensation and movement), compared with the other leg. Because Mrs. Kim lay on the floor for hours, the nurse should also check for dehydration, pressure injury, hypothermia and rhabdomyolysis (muscle breakdown that raises creatine kinase and can injure the kidneys), and find out why she fell.

2. What are the preoperative priorities?

• Pain control: scheduled acetaminophen, careful opioid dosing, and regional nerve blocks (such as a fascia iliaca block) where available, which reduce opioid needs and delirium risk.
• Early surgery: the American Academy of Orthopaedic Surgeons (AAOS, 2021) strongly recommends surgery within 24–48 hours of admission, which is linked to fewer complications.
• Medical optimization: fluids, labs, ECG, review of anticoagulants and blood pressure medications.
• Interdisciplinary care: orthopedics, geriatrics, nursing, nutrition and rehabilitation working together reduces complications and mortality (AAOS, 2021).
• Delirium prevention from admission (see question 4).

3. What precautions follow a posterior-approach hemiarthroplasty?

Until the soft tissues heal, the prosthesis can dislocate. Typical posterior precautions (always follow the surgeon’s orders) are:

• No hip flexion beyond 90 degrees (no low chairs or bending forward to reach the feet).
• No crossing the legs or bringing the operated leg past the midline (adduction); use an abduction pillow or a pillow between the legs.
• No inward turning of the foot or leg (internal rotation).

Signs of dislocation include sudden severe pain, a popping sensation, shortening and rotation of the leg and inability to move it. The nurse keeps the leg still and notifies the surgeon immediately. Raised toilet seats, reachers and sock aids help patients follow precautions at home.

4. On day 2 Mrs. Kim is disoriented and pulling at her IV. Is this dementia? What should the nurse do?

The sudden onset, fluctuating course and disorientation suggest delirium, an acute brain dysfunction. Dementia develops slowly over months to years. Delirium is common after hip fracture and is linked to longer stays, functional decline and death, so it is a medical problem, not “normal aging” (Inouye et al., 2014). A screening tool such as the Confusion Assessment Method (CAM) helps confirm it: acute onset and fluctuating course, inattention, and either disorganized thinking or altered level of consciousness.

The nurse should notify the provider and look for causes: hypoxia, infection (urinary tract, pneumonia, wound), pain, urinary retention, constipation, dehydration, electrolyte imbalance, anemia, low blood glucose and medications such as opioids, sedatives, anticholinergics and her nightly sleeping pill. Management is mainly nonpharmacologic (Inouye et al., 2014):

• Frequent reorientation with clocks, calendars and familiar people.
• Glasses and hearing aids in place (she has hearing loss).
• Normal sleep-wake cycle: daylight in the day, quiet and dark at night, no sleeping pills.
• Early mobility, hydration, nutrition and good pain control.
• Avoid physical restraints, which increase agitation and injury. Remove unnecessary lines and catheters.

Antipsychotics are reserved for severe agitation that puts the patient or others at risk.

5. On day 3 she is suddenly short of breath and hypoxic with chest pain. What is the likely cause, and what are the priority actions?

Sudden dyspnea, tachypnea, tachycardia, hypoxemia and pleuritic chest pain after hip surgery strongly suggest a pulmonary embolism (PE). Hip fracture surgery is one of the highest-risk situations for venous thromboembolism because of venous stasis from immobility, vessel injury and a hypercoagulable state. Fat embolism is another possibility after long-bone fractures, usually within 72 hours, with confusion and a petechial rash.

Priority actions:

1. Stay with the patient and call the rapid response team.
2. Raise the head of the bed and give oxygen to correct hypoxemia.
3. Assess vital signs, lung sounds and the legs for signs of deep vein thrombosis (swelling, warmth, tenderness).
4. Prepare for diagnostic tests such as CT pulmonary angiography, ABG and ECG, and ensure IV access.
5. Anticipate anticoagulation (for example, heparin) as ordered, balancing the risk of surgical bleeding.

6. How could VTE have been prevented?

Prevention includes pharmacologic prophylaxis (such as low-molecular-weight heparin) as ordered, mechanical devices (sequential compression devices), early mobilization on the first postoperative day when possible, leg and ankle exercises and hydration. The nurse should check that prophylaxis was not missed during the transition through surgery.

7. Her hemoglobin dropped from 11.8 to 9.1 g/dL. Is this a concern?

Some blood loss is expected from the fracture and surgery. The nurse monitors for signs of significant anemia or ongoing bleeding: hypotension, tachycardia, dizziness, fatigue, a swollen or tense thigh and wound drainage. Anemia can worsen delirium, fatigue and fall risk. Transfusion decisions depend on symptoms and the provider’s threshold.

8. What else should the plan include before discharge?

• Rehabilitation: physical and occupational therapy, walking with a walker, safe transfers and likely a short stay in inpatient rehabilitation or a skilled nursing facility.
• Bowel and bladder: opioids cause constipation, so give a bowel regimen. Remove urinary catheters early to prevent UTI and check for retention.
• Skin: reposition, use a pressure-redistributing mattress and keep heels off the bed.
• Bone health: evaluation and treatment for osteoporosis, vitamin D and calcium, to prevent another fracture.
• Fall prevention: remove rugs, add night lights and grab bars, review sedating medications and consider a medical alert device since she lives alone.

Sample nursing care plan

Frequently asked questions

Related reading: ageism in the care of older adults, musculoskeletal assessment guide, using data to solve a falls problem and neurological assessment guide.

Conclusion

Hip fracture cases are really about the older adult as a whole. Early surgery and good pain control matter, but the nurse’s main contribution is preventing and catching complications: delirium, pulmonary embolism, dislocation, bleeding, infection and further falls. Careful assessment, early mobility and a safe discharge plan give older patients the best chance of returning home.

References

American Academy of Orthopaedic Surgeons. (2021). Management of hip fractures in older adults: Evidence-based clinical practice guideline. https://www.aaos.org/aaos-home/newsroom/press-releases/aaos-updates-clinical-practice-guideline-for-management-of-hip-fractures-in-older-adults/

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis’s medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Harding, M. M., & Snyder, J. S. (2019). Clinical reasoning cases in nursing (7th ed.). Elsevier Mosby.

Inouye, S. K., Westendorp, R. G. J., & Saczynski, J. S. (2014). Delirium in elderly people. The Lancet, 383(9920), 911–922. https://doi.org/10.1016/S0140-6736(13)60688-1