Journal of Orthopaedic Nursing (2007) 11, 177–184

www.elsevierhealth.com/journals/joon

Journal ofOrthopaedic Nursing

A critical study of a 100-year-old patient receivinga dynamic hip screw

Daniel Griffith RNA, DN (Staff Nurse) *

Trauma and Orthopaedic Directorate, Derby Hospitals NHS Foundation Trust, Derby Royal Infirmary,London Road, Derby DE1 2QY, UK

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KEYWORDSFracture of theneck of femur;Dynamic hip screw;Nursing care;Model of nursing

61-3111/$ - see front mattei:10.1016/j.joon.2007.08.00

* Tel.: +44 7754724213.E-mail address: bran.griffi

r �c 2001

th@yaho

Summary This care study critically examines the care given to one elderly femalepatient on an orthopaedic trauma unit following a dynamic hip screw insertion for afracture of the neck of femur. It examines the patient history, mode of injury,choice of and delivery of both medical and nursing care. Issues include the choiceof nursing model and the influence of government policy on care delivery, stemmingfrom the National Service Framework for Older People and Essence of Care. Thework finally calls for the introduction of an adapted nursing model within the spe-ciality of orthopaedic trauma.

�c 2007 Elsevier Ltd. All rights reserved.

Editor’s commentsAs busy health care practitioners, we rarely give time to step back and consider the way we think about patients and the care weprovide. This study does just that, through the eyes of a staff nurse, and suggests how changing the way we perceive our care candramatically affect how we nurse. PD

Introduction

The objective of this paper is to review the caredelivery of an individual female patient, admittedto the Trauma and Orthopaedic Directorate of a hos-pital within the Midlands of the UK. The patient sus-tained an intertrochanteric fracture of the neck offemur following a fall. The author of this paper wasdirectly involved in the care delivery of this patient.

7 Elsevier Ltd. All rights rese

o.co.uk.

A brief patient history, a description of themode of injury and a diary of care is provided.The choice of surgical procedure, the use of theparticular nursing model used within the clinicalarea and the influence of relevant governmentpolicy are discussed. The paper provides somethoughts on the future of trauma and orthopaedicnursing.

Patient history

The patient was 100 years young at the time ofadmission and of East European origin. Avoiding

rved.

178 D. Griffith

the invading German army during the Second WorldWar, she settled in England. The patient was a wo-man of some determination and for the sake of thispaper, we name her Emily. She had rheumatoidarthritis, type II diabetes mellitus, atrial fibrilla-tion, hypertension and mild confusion or dementia.She was of small stature and weighed 45 kg.

She was admitted via the accident and emer-gency department to the Trauma Assessment Unitof a nearby hospital, arriving on the unit just be-fore lunchtime on a weekday. The patient had fall-en at her residential home and had been found thatmorning. She was not believed to have been left onthe floor for any length of time.

The patient had sustained injury to the right hipand a skin tear to the right forearm. Medical assess-ment in A& E did confirm atrial fibrillation, hyper-tension, hallucinations, osteoporosis, anaemia,type II diabetes mellitus, frequent falls and mildconfusion. X-ray identified a fractured neck of fe-mur but no fracture to the forearm.

Nursing assessment on the trauma unit identifiedher as being occasionally doubly incontinent and ashaving red heels. She also had a skin break to hersacral region, to which ‘Granuflex’ was applied.Her normal mobility was identified as independentwith a walking frame. Due to urinary retention, shewas catheterised on the day of admission.

Medication was prescribed on the ward; paracet-amol 1 g QDS, codeine phosphate 15 mg QDS, senna(ii) nocte, aspirin 75 mg mane, enalapril 5 mg at08.00 and 18.00 h, Adcal D3 (i) at 08.00 and18.00. It was also found that she was being pre-scribed prior to admission; olanzapine 2.5 nocte,usually used in the treatment of schizophrenia ormania, and this was continued.

Morphine and cyclizine as subcutaneous injec-tions, procholorperazine as an intramuscular injec-tion and Lacri-lube and Hypermellose for the eyeswas prescribed. During her entire hospital stay,she did not require any of these medications.

Cefuroxime 750 mg TDS intravenously was gi-ven. Starting from lunchtime on the day of admis-sion, she received seven doses running throughthe day of operation to the first day post opera-tively. Intravenous fluids were also begun pre-operatively as routine (normal saline and Hart-manns solution).

Surgery

Within 24 h of arrival on the trauma unit, sheunderwent surgery. She required a four hole 135DHS plate with an 85 mm dynamic hip screw lagscrew under general anaesthetic. No drains wereinserted.

One unit of blood was given pre-operatively, fol-lowed by 20 mg of frusemide. Emily’s blood glucosepre-operatively was 3.5 mmol (06.45 h) rising to8.3 post operatively (11.00 h). Intravenous dex-trose saline had been administered during theoperation.

At the patient’s hospital the majority of traumapatients, those not destined for intensive care orhigh dependency, are admitted to the TraumaAssessment Unit (TAU). The ward of thirty beds issplit into pre and postoperative areas. Patientsreturning to TAU post operatively are expected tostay on the unit only two or three nights beforetransfer to an orthopaedic ward.

The alternative Extended Recovery Unit takes pa-tients post operatively, for usually nomore than oneovernight stay before transfer to an orthopaedicward. Although primarily caring for the electiveorthopaedic theatre lists, trauma cases are takenwhen necessary. The objective of both units is toprovide specialist nursing care and closemonitoring.

On the first postoperative day the patient wasseen by the medical team and prescribed 500 mcgof Digoxin with a further 250 mcg to follow 6 h laterand was also transfused one unit of blood. Thatevening Emily was transferred from the recoveryunit to a general ward and had an X-ray of herhip taken. An X-ray of the surgical area is generallyrequired to confirm weight-bearing status, prior tofull mobilisation. On the second postoperative day,she was seen by the physiotherapists and sat out ofbed. Her wound dressing had been changed and re-dressed with a dry dressing for protection. She hadher bowels well open. Unfortunately, her skin wasjudged too fragile to tolerate the usual anti-throm-boembolism stockings.

On the following days, the patient began to be-come more independent and was able to walk shortdistances with a walking frame. The skin tear tothe right forearm was redressed on alternate days.The surgical incision was dry and left exposed onthe fourth day and the urinary catheter was also re-moved. Her pressure risk areas, although delicate,were showing signs of improvement.

On the sixth day, while washing the patient, itwas observed that the patient’s right arm appeareddeformed and moved in an abnormal manner. Onchecking the original X-ray no fracture of eitherthe radius or ulna was visible. However, the X-raywas only of the distal forearm. Suspecting a missedfracture, this was reported by the author to thenurse in charge and on to the team. A second X-ray showed a fracture to the proximal ulna andthe patient had a plaster of Paris back slab fittedlater that day. A ‘‘collar and cuff’’ was providedfor comfort and support.

A critical study of a 100-year-old patient receiving a dynamic hip screw 179

Over the next few days, the patient’s pressureareas remained a concern. ‘Duoderm’ was appliedto her sacrum and a foam dressing to her left heel.A pressure-relieving mattress had been in use fromadmission and she remained able to walk to the toi-let but was occasionally doubly incontinent.

On the twelfth day post operation the patienthad a complete lightweight cast fitted to her rightforearm and was discharged back to her residentialhome on the fourteenth day post operation.

Hip screws

Fractures of the femoral neck are generally dividedinto two categories, intracapsular or extracapsular(Walsh, 1997). Intracapsular fractures occurthrough the capsule at the base of the femoralhead. Extracapsular pass through either of the tro-chanters or the intertrochanteric area (Walsh,1997).

Fractures to the intracapsular region are likelyto damage the blood vessels supplying that region,so causing avascular necrosis (Schoen, 2000a). Thisis particularly so if there is displacement and thechoice of surgical intervention is hemiarthroplasty(Santy, 2005a). With extracapsular fractures how-ever, the viability of the blood supply to the femo-ral head is not usually an issue (Walsh, 1997) andthe choice of fixation is either dynamic hip screwor an intramedullary nail (Kunkler, 2002).

Jenson et al. (1980) have concluded that withstable trochanteric fractures, the choice of im-plant does not necessarily affect results. However,past studies of the DHS in this area (Doppelt, 1980)have put the reputation of the implant almost be-yond question. Besides allowing early mobilisation,the implant has good load bearing capability (Ja-cobs et al., 1980).

Twenty-five years later, it is still the generalconsensus that the DHS is the implant of choicefor stable trochanteric fractures (Harringtonet al., 2002; Lorich et al., 2004). This is consideredto be particularly so in the elderly (Koval and Zuck-erman, 1998).

Nursing implications

The diagnosis of a fracture is based on history,symptoms and on radiographic studies (Unwin andJones, 1995; Schoen, 2000b). The general opinionis that two views at right angles, are the minimumnumber required to evaluate a suspected fractureand that the X-rays should include the joints aboveand below (Kunkler, 2002). Although it is not therole of the nurse to check an X-ray, a working

knowledge of the fracture and the basic anatomicalstructures involved can provide guidance in caredelivery. The first X-ray of Emily’s right forearmwas not from joint to joint and this is why the ulnafracture was originally not detected.

The implications of a fracture are many but theprimary ones include; risk of compartment syn-drome, risk of fat embolism syndrome, risk of deepvein thrombosis (Pellino et al., 2002), wound infec-tion, chest infection, elimination difficulties, tis-sue breakdown, pain, the patient’s psychologicalstate and an adverse effect on the ability to self-care (Santy, 2005a). The factor that many of thesenursing issues have in common is the detrimentalinfluence of immobility. Within orthopaedic nurs-ing recovery is very often measured by the assis-tance a patient requires (Santy, 2005a). Withmobility in particular, comparison is made withthe patient’s pre-fracture existence (Williamset al., 1994). The role of the orthopaedic nursegoes well beyond the prevention, detection andmonitoring of any deterioration in a patient’s con-dition. The role of the orthopaedic nurse includesactive rehabilitation and the restoration of self-care wherever possible.

Nursing models and nursing process

To assess a patient and identify potential or actualproblems some form of framework on which tobase and develop the nursing process is required.Fawcett (1984) writes that concepts, theories andmodels are linked in a hierarchical structure withconcepts as a base and models being the result.

Nursing models are not physical representationsof an idea, concept or theory. It can be argued thatnursing models are conceptual in their own right(Riehl and Roy, 1980) and that they are based upona theory of nursing, such as self-care (Orem, 1971)or activities of living (Roper et al., 1980).

A nursing model is an abstract and conceptualframework from which we are able to assemble anursing process. The patient’s current condition iscompared with before admission, allowing prob-lems and goals to be identified. These factors areused to formulate a care plan and together theywill form the nursing process.

The nursing process is often regarded as havingdistinct stages (Walsh, 1997; Andrews and Smith,1992):

Assessment of the patient.Identification or diagnosis of problems.Establishment of goals and the writing of thecare plan.

180 D. Griffith

Implementation of the identified nursing care.The ongoing evaluation and final conclusion ofthe care given.

The Roper, Logan and Tierney model

The Roper et al. (1980) nursing model is used atthe patient’s hospital as it is regarded as a generalmodel, adaptable to many areas and needs. Thestarting point for this model is the work of Abra-ham Maslow (1954) and his hierarchy of humanneeds, from the most basic to the most sophisti-cated. Maslow suggests that our basic biologicalrequirements (such as nutrition) must be met, be-fore we are able to satisfy higher psychologicalneeds.

The model is based on the theory that peopleare best understood by the activities of their lives(Aggleton and Chalmers, 2000), biological, socialand cultural. Some activities are essential and pri-marily biological in nature, while others are non-essential but enhance the quality of life. Theseneeds are therefore primarily social and psycholog-ical. This is a holistic view of the person and repre-sents a move away from the mechanisticperspective, of the traditional biologically centredmedical model (Archibald, 2000).

The 12 activities of living identified by this mod-el are: maintaining a safe environment, communi-cating, breathing, eating and drinking,eliminating, personal cleansing and dressing, con-trolling body temperature, mobilising, workingand playing, expressing sexuality, sleeping and fi-nally dying. Added to this concept are three com-ponents of nursing care based upon a balancebetween dependence and independence (Kenwor-thy et al., 1996). The first is the preventing compo-nent, here the object of nursing care is to prevent(or assist in preventing) a worsening of the pa-tient’s condition and the development of newproblems. The second component is that of thecomforting component, the object to provide andassist in physical, emotional and spiritual comfort.This component is difficult to define as it is highlyindividualised relying heavily on the nurse’s inter-personal skills. The third and final component isthe dependent component, this component recog-nises that the patient will be dependent upon thenursing staff for aid and it is this component thatrepresents the implementation of nursing care.

Although intended as a framework for caredelivery nursing models are often used as an assess-ment aid, with little influence on the later stagesof the nursing process. The model is popular with

nurses and it is suggested this is because of itsresemblance to the medical systems model (Archi-bald, 2000). There is a danger that any model usedmechanistically becomes mechanistic, as doeseventual care delivery.

The model is relevant to orthopaedic nursing asit recognises how injury can affect the patient’sself-care ability (Santy, 2005b) in addition to themany serious medical complications. How the mod-el influences care delivery, is best illustrated by abrief review of the care given. The factors thatthey influence and are influenced by, are broad inconcept and overlap.

Maintaining a safe environment

Due to the patient’s mild and intermittent confu-sion, an awareness of potential dangers to herwellbeing is vital. Care was taken that she couldmanage a hot drink and was supervised whenmobilising in the early stages of her stay. A fallsrisk assessment is carried out on all patientswithin this particular clinical area. She wasjudged to be of a high risk but was later reas-sessed as medium as her ability to mobiliseincreased.

Communicating

A two-way process in which the healthcare staffmust identify the patient’s needs using both verbaland non-verbal cues. Roper, Logan and Tierneyplace pain in this activity as the patient must ex-press their discomfort. Therefore, the alleviationof pain or the introduction of a coping mechanismis a nursing issue. Her pain was well controlled dur-ing her stay with no particular complaints beingmade post-operation, even with an unidentifiedbroken arm.

Breathing

This also includes the cardiovascular system as awhole and several of the patient’s medical condi-tions fall within this activity, including hyperten-sion, atrial fibrillation, anaemia and diabetes.The necessity of close observation is clearly re-quired in the early stages of care to prevent com-plications developing.

Eating and drinking

The patient was type II diabetic and therefore thechoice of correct menu was required. Her diabeteswas remarkably stable post-operation.

A critical study of a 100-year-old patient receiving a dynamic hip screw 181

Eliminating

The patient was occasionally incontinent, some-times doubly. Prior to her operation, she requiredcatheterisation but this was removed on the fourthday post-operation and incontinence pads pro-vided. She was by this time walking to the toiletwith a walking frame and the catheter’s removalgave her greater independence.

Personal cleansing and dressing

Due to her advanced age and her injury, the patientrequired assistance. Over a few short days how-ever, she was able to progress to washing her upperbody with less help. When assisting a patient withhygiene healthcare staff are in a privileged positionof intimacy, raising many issues regarding privacyand dignity. This time also affords an opportunityto inspect the patient’s skin integrity. It was whilstassisting with her morning wash that a suspicion ofthe injury to her right forearm came about.

Controlling body temperature

There is always a risk of potential infection follow-ing an operation and monitoring of the patient’stemperature is necessary. The patient also re-ceived a blood transfusion peri-operatively andtherefore required close monitoring at that time.

Mobilising

The patient was able to walk on the second daypost-operation. Her walking distance and indepen-dence increased until she was able to walk to thetoilet without assistance, although she could notget in or out of bed or raise herself from a sittingposition without assistance. Increased mobility isdesirable, as it lessens the risk of complicationssuch as venous thromboembolism and aids therecovery of pressure areas.

Working and playing

Her leisure interests centred around reading andwatching television. Her family, who visited daily,provided books and newspapers as necessary to re-lieve the boredom of her hospital stay.

Expressing sexuality

The use of the word sexuality within this contextcauses some confusion. This activity includes both

sexuality and gender issues relating to hygiene,self-image and self-awareness. Patient’s need toexpress individual and self-perceived needs relat-ing to hair, make up, washing and shaving (facialif male and lower limb if female). On one occasionafter bathing, her hair was put in curlers.

Sleeping

Lack of sleep and sleeping in a strange environmentcan have detrimental effects upon an individual’smental state. Promoting good quality sleep andrest in hospital is difficult as the wards are alwaysbusy and very often noisy. Limiting the number ofvisitors to each bedside and monitoring noise levelscan help. Providing comfortable and the right num-ber of pillows may help. Unfortunately, there arestill difficulties and, although necessary from ahealth and safety position, ward night lights donot promote rest.

Dying

People die everyday but an individual does not.However, a patient and his or her relatives mayhave concerns about the possible worsening of anillness. Patients with a terminal illness or the el-derly may ‘‘live with the prospect of death’’ andthe nurse should handle these concerns with care.The documentation of who to contact if the needarises should be made. In dealing with anxiety,the nurse may need to contact distant friends, aspiritual advisor or even a neighbour.

Roper, Logan and Tierney model withinorthopaedics

Many nursing models are unnecessarily compli-cated, yet the Roper Logan and Tierney nursingmodel may be regarded by some nurses as beingsimplistic. This is a mistaken view as the modelhas depth that will only become apparent with reg-ular use by the practitioner. This is particularlytrue when exploring the component factors relatedto dependency. Here it is for the practitioner touse their own judgement, as to when to step backand allow the patient to do more.

There is no ideal nursing model and in practice,the nurse may subconsciously use a combination ofmodels. Each nurse may carry their own nursingtheory or philosophy, in their head. The modelhas the balance of being relatively easy to becomefamiliar with, together with the depth to allowadaptation in variable settings.

182 D. Griffith

Balcombe (1994) with Davis and Lim attemptedto adapt the model to orthopaedics by placingthe patient’s desired health state at the centre ofnursing care; giving eleven areas for considerationwithin the assessment criteria; mental state, diet,self-concept, sleep and rest, breathing (and cardio-vascular state), home environment, pain, move-ment (and mobility), behaviour, hygiene andaspirations.

Davis (2005a) takes this one-step further byadapting the activities of living model (Roperet al., 1990) to orthopaedics. By centralising mobil-ising, the ‘‘Davis model’’ shares some characteris-tics of the Balcombe model. Incorporated into theDavis model are the activities of living from Roper,Logan and Tierney, together with the lifespan andthe dependence–independence concepts fromthe same model.

The possible advantage of the Davis model isthat it recognises the value of other models andbuilds upon them. Added to the above is a self-empowerment framework, an area representingindividualised nursing that includes assessmentand finally an ‘‘other’’ category. This area called‘‘factors influencing’’ is the framework for factorsnot necessarily covered by the others.

By placing pain within communicating Roper, Lo-gan and Tierney give the impression that the activ-ity of communicating is something of a catch-all.Balcombe has the advantage of recognising theimportance of pain as a factor in its own rightand not merely as a sub-factor. Davis is honest en-ough to have an ‘‘other’’ category and links pain tomobilising, as it is on movement that orthopaedicpatients tend to have most pain.

One possible way of combining all that is bestfrom the above models would be the continueduse and development of integrated care pathways.Care pathways are documentation and care plan-ning tools, following agreed guidelines and proto-cols while based upon evidence based practice(National Electronic Library for Health, 2004; San-ty, 2005b). Care can be documented and any devi-ations recorded as a variance (Bayliss and Salter,2004).The UK government has identified the useof the integrated care pathway as having significantbenefits to patient care (Davis, 2005b). However,less than fifty percent of trusts actually use them(House of Commons, 2004). Each care pathwayshould be tailored around the unique needs of eachclinical area (Bayliss and Salter, 2004), so recognis-ing their inherent speciality. A key feature of theDavis model, in being different from the Balcombemodel, is the recognition that orthopaedic nursingis a speciality and therefore deserves a specialisednursing model.

UK policy

There is today a wide spread professional and gov-ernment support for the concept of patient centredcare (Price, 2004). Current thinking has a focus onbenchmarking and clinical governance. The aim isto provide a structured approach to the comparisonand improvement of clinical practice (Bayliss andSalter, 2004; Burton, 2004).

UK government policy directives provide thestructure for future planning in healthcare (Martin,2001). There are a number that influence currentthinking, including The NHS Plan (DOH, 2000), var-ious National Service Frameworks and The Essenceof Care (Parkin and Bullock, 2005).

It is generally accepted bymany that age discrim-ination can and does exist within the UK NationalHealth Service (DOH/SNMAC, 2001; Coombes, 2001and Kmietowicz, 2001). There is however, some dif-ference of opinion as to whether age discriminationis endemic or an aberration from normal practice.Forster (1993) quoted Eric Midwinter the formerdirector of the Centre for Policy on Ageing as saying,‘‘Discrimination by age is as vicious as discriminationby race or sex and is not borne out by medical evi-dence’’. The suggestion is made that discriminationmay be unintentional and that health care profes-sionals are unaware that the older person can bene-fit from many procedures.

The National Service Framework for Older Peo-ple (DOH, 2001a,b) has been interpreted as a planto end age discrimination within the NationalHealth Service (Kmietowicz, 2001). The objectiveof the NSF is to guarantee fair and equal care forthe older person. Concerns as to the differencesin care across the country were summed up byBowling (1999), who wrote of evidence of age beingused as a factor in health care provision and in theinvitation of joining screening programmes. All pa-tients have the right to be treated with dignity andrespect (Williams et al., 1999) and this includes theright to privacy.

Standard six of the NSF is of relevance withinorthopaedic nursing, as it highlights preventativemeasures regarding falls. Research suggests thatthe strongest predictor of having an osteoporoticfracture, is having had a previous one (Minnset al., 2004). Although it is important to preventthe first fall, we must recognise that once a fallhas taken place, prevention of further falls isequally important.

Although it may be tempting to think that wherethe NSF for older people ends, the Essence of Care(DOH, 2001a,b) begins, this is not strictly true. Forexample, both publications share the same originalyear of publication.

A critical study of a 100-year-old patient receiving a dynamic hip screw 183

Originally, the Essence of Care consisted of eightcore aspects considered crucial to the quality ofthe patient’s experience of care (Bayliss and Salt-er, 2004). A ninth aspect was later added focusingon communication (Burton, 2004; ModernisationAgency/DOH, 2003).

The nine patient focused benchmarks are:

Continence, bladder and bowel care.Personal and oral hygiene.Food and nutrition.Pressure ulcers.Privacy and dignity.Record keeping.Safety of patients with mental health needs inacute mental health and general hospitalsettings.Principles of self-care.Communication between patients, carers andhealthcare personnel.

Conclusion

The patient was well cared for and she made aremarkable recovery and was discharged, pain freeand mobile. The introduction of a change ofemphasis, such as a greater focus on mobilisingwithin the framework of care delivery, coupledwith the clearly set standards of the Essence ofCare, may yet prove beneficial to our patients.The time has come for orthopaedic nursing to haveits own nursing model.

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