1. Risk factors:
1. Rheumatoid arthritis.
2. Osteoarthritis.
3. Complications of femoral neck fractures— avascular necrosis and malunion (Table 7-40).
4. Congenital hip disease.

Fractures of the Hip

2. Analysis/nursing diagnosis:
   1. Risk for injury related to implant surgery.
   2. Knowledge deficit regarding joint replacement surgery.
   3. Impaired physical mobility related to major hip surgery.
   4. Pain related to surgical incision.
   5. Risk for impaired skin integrity related to immobility.
3. Nursing care plan/implementation:
   1. Preoperative:
      1. Goal: prevent thrombophlebitis or pulmonary emboli
         1. Antiembolic stockings.
         2. Increase fluid intake.
      2. Goal: prevent infection: antibiotics as ordered, given prophylactically.
      3. Goal: health teaching
         1. Isometric exercises - gluteal, abdominal, and quadricep setting; dorsiflexion and plantarflexion of the feet.
         2. Use of trapeze.
         3. Explain position of operative leg and hip postoperatively to prevent adduction and flexion.
         4. Transfer techniques - bed to chair and chair to crutches; dangle at bedside first time out of bed.
         5. Assist patient with skin scrubs with antibacterial soap.
   2. Postoperative:
      1. Goal: prevent respiratory complications.
         1. Turn, cough, and deep breathe.
         2. Incentive spirometry.
      2. Goal: prevent complications of shock or infection.
         1. Check dressings for drainage qlh for first 4 hr; then q4h and pm; may have Hemovac or other drainage tubes inserted in wound to keep dressing dry.
         2. Monitor I&O and vital signs hourly for 4 hr, then q4h and prn.
      3. Goal: prevent contractures, muscle atrophy: initiate exercises as soon as allowed: isometric quadriceps, dorsiflexion and plantarflexion of foot, and flexion and extension of the ankle.
      4. Goal: promote early ambulation and movement.
         1. Use trapeze.
         2. Transfer technique (pivot on unaffected leg); crutches/walker.
         3. Initiate progressive ambulation as ordered; ensure maximum extension of leg when walking.
         4. Administer anticoagulation therapy as ordered prophylactically to prevent thromboemboli.
         5. Recognize early side effects of medications and report appropriately.
      5. Goal: prevent constipation.
         1. Increase fluid intake.
         2. Use fracture bed pan.
      6. Goal: prevent dislocation of prosthesis.
         1. Maintain abduction of the affected joint (prevent external rotation); elevate head of bed, turn according to physician’s order. When turning to unaffected side, turn with abduction pillow between legs to maintain abduction.
         2. Buck’s extension or Russell’s traction may be applied (temporary skin traction).
         3. Plaster booties with an abduction bar may be used.
         4. Wedge Charnley (triangle-shaped) pillow to maintain abduction between knees and lower legs.
         5. Provide periods throughout day when patient lies flat in bed to prevent hip flexion and strengthen hip muscles.
         6. Report signs of dislocation: anteriorly - knee flexes, leg turns outward, leg looks longer than other, femur head may be felt in groin area; posteriorly - leg turns inward, appears shorter than other, greater trochanter elevated.
      7. Goal: promote comfort.
         1. Initiate skin care; monitor pressure points for redness; back care q2h.
         2. Alternating pressure mattress; sheepskin when sitting in chair.
      8. Goal: health teaching.
         1. Exercise program with written list of activity restrictions.
         2. Methods to prevent hip adduction.
         3. Avoid sitting for more than 1 hr: stand, stretch, and walk frequently to prevent hip flexion contractures.
         4. Advise not to exceed 90 degrees of hip flexion (dislocation can occur, particularly with posterior incisions); avoid low chairs.
         5. Teach alternative methods of usual self-care activities to prevent hip dislocation—, avoid: bending from waist to tie shoes, sitting up straight in a low chair, using a low toilet seat.
         6. Avoid crossing legs, driving a car for 6 wk.
         7. Wear support hose for 6 wk to enhance venous return and avoid thrombus formation.
4. Evaluation/outcome criteria:
   1. Participates in postoperative nursing care plan to prevent complications.
   2. Reports pain has decreased.
   3. Ambulates with assistive devices.
   4. Complications of immobility avoided.
   5. Able to resume self-care activities.