Collaborative Nursing Practice
An important aspect of patient care has been the assessment system inside the
healthcare sector, and it is the primary source for identifying specific requirements and
effectively address those needs. Specialists may not be confident that a person is
obtaining the most suitable care without precise, planned, and systematic assessment.
The assessment has become a holistic method for nurses that reflects on all aspects of
human life, taking into account the sociological, psychological, and physical factors that
interact to create the patient and the living setting. The clinical method determines how
nurses interpret and prepare treatment; the nurses require the individual's person-
centered assessment to formulate a health action care approach and then analyze the
results of the therapy. Effective nursing assessment and treatment management will be
addressed in this essay. To every question, it would define acceptable assessment
instruments, pursue the role of the nurse, and address how this could guide the delivery
of care.
According to Davis et al., (2018), Assessment, planning, implementation, and evaluation
are the four phases of the nursing practice. By keeping records of the assessments, it
helps the medical staff to improve the delivery of care. The core factors of clinical
treatment in patients suffering from a hip fracture from admissions to surgery and
discharge also are illustrated in this essay. The National Tariff Payment System is used
to promote aspects of treatment recognized as essential in maintaining and improving
patient health conditions after such a hip fracture of fragility.
The scenario is about Mary who seems to be of average height and weight. She has
been brought to the hospital due to immense pain around her hip region, which is a
consequence of tripping. Upon being brought to the hospital, Mary’s baseline
observations were taken according to which, Mary had a normal respiration rate which
was 19 breaths/mins. her oxygen saturation was falling within normal range i.e 96%, her
radial pulse was in normal range i.e 80 beats/min. Upon checking with the help of a
thermometer, the temperature of the patient was 36.5 degrees Celsius, her blood
pressure is low at 70/60 mmHg indicating hypotension. Hypotension should be treated
as a medical emergency. Assure that patients have a clear airway and can respire
properly; a high concentration of oxygen should be given, pulse rate, bp and refill period
of capillary should be checked as well. patients should be positioned in a prostrate
posture, lifting the legs by adjusting the bed will help improve the flow of cerebral blood.
Appropriate monitoring devices such as the cardiovascular monitor and pulse oximeter
should be attached. It should however be kept in mind that keeping track of pulsatile
fluids or oxygen saturation reading is difficult if peripheral perfusion is poor. A large IV
cannula (14 or 16 G) should be implanted since it has an optimum flux rate which
enables fast injection of medications and fluids. An alternative route for the
administration of medicines and IV fluids may include inserting another large cannula.
According to Gordon et al., (2017), In England, the number of hip fractures caused by
inpatient falls declined from 5.4% in 2013 to 3.8% in 2015, which has been reasonably
stable ever since. In Northern Ireland, the rate stayed very small (<0.5 percent) until the
start of the rise in 2014, hitting a high prevalence of 2.8 percent in 2017. Hip dislocation
has been a common occurrence that takes place postoperatively following complete hip
replacement or in response to elevated trauma. Many people who have fractures and
are over 60 years of age were found to have reduced bone strength from osteopenia or
osteoporosis, diseases that are mostly unnoticed and silenced before a fracture
happens, while the prevalent bone disorder is osteoporosis. Osteoporosis has become
a metabolic bone condition characterized by micro-architectural bone tissue
degradation, and by low bone density and resulting in enhanced fragility of the bone and
a subsequent rise in the likelihood of fracture. While bone density is an essential
element of the disorder, the balance of bone consistency and mass contributes to the
total strength and capacity of bones to withstand fracture. People who are above 60,
mostly experience these fractures. For many people, It is their first osteoporotic fracture.
The absence of care usually accompanied by a major osteoporotic fracture is troubling.
Recorded recovery results following hip fracture are now in the range of approximately
15 percent to 25 percent. Prevention of Primary fracture due to osteopenia is important.
To strengthen the health and wellbeing of adults throughout the future, advances in
algorithms to classify people at high risk of fracture would be critical. If the individual
with a bone fracture receives the best level of treatment, the individual not only
recovers, but it also leads to cost reductions.
Traumatic hip dislocations have become an orthopedic emergency for patients. The
major reason is elevated blunt force trauma, while prosthetic hip joints can dislocate
with far less strength. For the person, treatment must be of high quality. Patient
wellbeing is the avoidance of complications and negative impacts on individuals related
to health services, as per the World Health Organisation (WHO). For instance, adverse
effects may include malnutrition, falls, PU (pressure ulcer), and UTI (urinary tract
infection). It is necessary to include patients throughout the process of treatment, from
the beginning (admission) to end (discharge), to maximise the safety of individuals.
Sufferers must be interested in how their treatment is organized and handled, and
compassion and appreciation must be given to all people. When treating an individual
with a hip injury, a nurse needs to increase patient care at the bedside. It is possible to
avoid pressure ulcers easily by increasing energy/caloric consumption (Waddell et al.,
2018).
Hip fractures need hospitalization and surgical treatment. They are correlated with high
mortality and morbidity rates, however to maximize performance, skilled nursing
management, and assessment, together with interprofessional collaboration, are
necessary. For Mary's case, a meeting of a multi-disciplinary team was called when the
nurse informed senior doctors about Mary's condition. The members of the team
included nurses who in delivering care to these complex patients, play a crucial and
fundamental role. The nurses are perfect for understanding the pre-injury condition of a
patient. It included accident and emergency staff, orthopedic surgeons, general
practitioners. The physiotherapist works on the quality of movement and gait practice
activities. Occupational Therapists in unit work together with their physiotherapist
partners to evaluate and advise patients on transition, maintenance, and self-care
safety. Dieticians are a mandatory part of the team since the nutritional condition of hip
fracture patients may also be low at the time of admission and can worsen for different
reasons. It is thus important that patients with hip fractures be tested on admission
using a simple tool such as the Malnutrition Universal Screening Tool (MUST score)
and that program should be provided to increase their nutritional intake. Issues such as
osteoporosis, drug review, and accident prevention should be tackled early and used in
recovery planning when orthogeriatricians participate in the treatment of acute trauma
patients. Radiologists are also a part of the team since, without the help of radiology, it
is impossible to locate the exact location of the injury. According to Coughlin, (2010),
When hip fractures are suspected, lateral hip and anterior-posterior pelvic X-rays are
needed. Shenton's line would be used to determine the location of the femoral head
regarding the acetabulum (it is the smooth curve created by the inferior aspect of the
superior pubic ramus and medial portion of the femur). A fracture can be suggested by
damage to the cortical surface or this line. It is practicable to use the Garden
classification to classify which patients are at increased risk of acquiring femoral head
avascular necrosis. Nevertheless, precaution is recommended, as the anterior/posterior
view will not recognize a displacement that could only be noticeable on lateral X-ray.
Blood flow to the head of the femoral is more likely to be interrupted by Garden Stages
3 and 4 fractures. The latest NICE guidelines advise either a complete hip replacement
or hemiarthroplasty for those patients who have a displaced intracapsular hip fracture.
Displaced extracapsular fractures are far less prone to cause vascular damage and can
thus be controlled by surgical procedures including hip screws.
Other members of the team include ambulance staff, accident and emergency staff,
theatre staff, etc, The challenges encountered by the MDT involved in Mary's case were
threats of injury to the nerve. If the thighbone is pulled out of the socket, particularly in
posterior dislocations, the nerves in the hip may be crushed and stretched. The team
also discussed the risk of osteonecrosis that cuts out nerves and vessels when the
bone of the thigh is separated from the joint. When blood flow is disrupted, the
bone ends up dying, resulting in osteonecrosis. This is a debilitating disease which will
eventually cause the demise of joints of the hip and arthritis. The National Tariff
Payment System encourages main treatment aspects to optimize medical conditions
following a hip fracture with fragility. Fracture treatment must provide the secondary
prevention of fracture risk by assessing and controlling the osteoporosis risk of injury
and falls.
Beginning of anesthesia to perform a surgical procedure within 36 hours of arriving at
the emergency room or within the 36 hours of admission when the person is already
being admitted constitute characteristics of hip fracture treatment specified in the
National Tariff. An individual was examined by a geriatrician during the perioperative
time which is around 72 hours of admission. An abbreviated mental examination was
conducted before the surgical procedure and a National Hip Fracture Database ranking
was carried out. The nutritional evaluation was carried out after admission. Evaluation of
delirium by using 4AT monitoring instrument conducted after admission. The individual
is examined by a physiotherapist after or on a surgical day. Assessment of fracture
prevention (fall and bone health) conducted by NHS England and NHS Improvement
(2017) after admission.
A 'fast-track' protocol would allow quick and easy access to analgesia, scanning, and
confirmation of a bed on an orthopedic ward within an emergency room. There can be
comorbidities in certain individuals with reported hip fracture, like dementia, progressive
kidney disease, arthritis, and ischaemic heart failure (Shah et al, 2014). Mary was
found to be hypertensive. Electrocardiography and basic blood testing which includes
coagulation screening, urea, and electrolytes, full blood count, must be performed and
those patients must be cannulated before they appear in an emergency room. To
estimate one-year and 30-day mortality and help in treatment preparation, the
Nottingham Hip Fracture Score could be used. The cognition of individuals must be
tested on admissions, because possible cognitive disability may have implications for
their treatment. Tools like the MMSE (Mini-Mental State Examination) or the MOCA
(Montreal Cognitive Assessment) may be used to assess cognition. Capability to
consent to therapy should be systematically evaluated and registered, and checked if
there is an improvement in the individual's health. Frequently used as a staffing
proforma that uses a shortened MMSE. The 4AT accelerated clinical test for psychosis
can be utilized to evaluate people at arrival and if there is a drop in intellectual
performance. as individuals with hip fractures would be at greater risk of delirium
(Moppett et al, 2012).
Mary's pain must be measured and analgesia should be issued immediately upon
admission to the hospital due to diagnosis of hip fracture; it should be reassessed within
thirty minutes after preliminary pain relief and again after one hour after the person has
stabilized in the hospital. (NCGC, 2011). Self-reporting pain or using a standardized
assessment scale can be challenging for people with cognitive dysfunction, which may
contribute to Misreporting and substandard services when these individuals need
special attention. Paracetamol must be given daily until contraindicated, extra opioids
like oxycodone or codeine can also be administered for relieving severe pain, it is also
believed that using nerve blockers offer effective pre-operative pain control. Non-
steroidal anti-inflammatory drugs are not prescribed (NCGC, 2011).
According to Muren et al, (2017), It is necessary to recognize the needs of Mary and her
family when considering diagnosis and recovery and answer their questions. Cautionary
and conservative treatment should be provided to patients at the end of their lifespan or
for which the risks of surgery exceed the advantages. It is important to precisely record
and reconsiders the options in choosing conservative treatment, to improve Mary's
health. It is essential to highlight the complications of surgery directly with Mary or her
family members; While successful care decreases death rates, the hip fracture remains
associated with a high mortality rate in the initial year after trauma. Throughout the stay
in the hospital, nearly 20 percent of hip fracture individuals suffer severe adverse
outcomes. In mitigating risks, time for a surgical procedure is recognized as a crucial
factor. Adults must have surgery on a scheduled emergency registry after or on the day
of diagnosis (NICE, 2016). This includes inter-professional cooperation and teamwork to
facilitate prompt optimization of clients for surgical procedures. This is achieved through
a trauma management service of most major hospital trusts that can prioritize cases.
Mary should have routinely monitored physiological signs during her hospital stay by
using NEWS (National Early Warning Score). The assessment of neurological status,
heart rate, respiration rate, blood pressure, temperature, and oxygen saturation are
included. The electrolytes and fluid balance require care, as complications are
widespread, and around one-third of hip fracture individuals are hospitalized with renal
failure. Fluid balance must be thoroughly examined and, before the injury and following
surgery, people are often in danger of blood loss. Among many individuals, an average
blood pressure of 120/80mmHg could be sufficient, this may represent a substantial
decrease among those who, like Mary, are typically hypertensive. Upon admission,
certain people can be dehydrated and require intravenous fluids.
Dietary screening is a crucial aspect in the preliminary evaluation since the frequency of
malnutrition is high in people with fractures of the hip. People with reduced food
resources will be more prone to infectious diseases and their maximum rehabilitation
potential could take longer. Monitoring for malnutrition can classify those at risk for
instance, by using the Malnutrition Universal Screening Tool (MUST). Oral
supplementation provided before surgical procedure or shortly thereafter can help avoid
complications. It is necessary to reduce obstacles to people so they can eat well, and
also provide dietary supplements and extra snacks. For instance, it could be
problematic for those who are immovable in bed to access food; make sure that people
are in a comfortable place for eating when the food arrives and food trays are within
reach would help (Avenell et al, 2016).
The integrity of the skin and the risk of pressure ulcers must be checked on diagnosis
and periodically afterward since individuals are at elevated risk of pressure injury as a
result of immobilization. Every patient-reported pain or disturbance must be included in
the analysis and the skin must be checked for variations in colour, purity, temperature,
and heat. For instance, the assessment could show inflamed, or dry skin, oedema, and
incontinence (NICE, 2014). To complement professional judgment and evaluate
effective pressure-relieving equipment and procedures, risk-assessment tools like the
Braden Scale can be used. Treatment of the pressure region must be checked
periodically as the status of the patient varies. Whether they are willing or not, Mary
must be motivated to change her place frequently. Comprehensive geriatric
coordination and assessment with orthogeriatricians were crucial to optimizing
performance, ensuring optimum rehabilitation, and immediately raising the number of
patients discharged from the hospital (Gray et al, 2017).
A structured multidisciplinary strategy is needed after surgeries to make sure that Mary
has the best opportunities to reclaim movement and come back to her independence
before the fracture and return her to the community where she came from (NCGC,
2011). According to Shadmi and Zisberg, (2011), Just 10% of patients identified
themselves as 'freely mobile without aids' during a 120-day mobility follow-up, in
comparison with 37% before the hip fracture (NHFD, 2017). Earlier movement lowers
the risk of problems after surgery and raises the chance of improvement. Likewise, a
shorter period of stay is correlated with increased degrees of mobility. A history of falls
throughout the previous year has been the main indicator of more falls (NICE, 2015), so
measuring Mary's risk of falls and determining modifiable risk factors is essential. This
includes multidisciplinary assessment and probably referring her to an evaluation team
for expert falls. Potential dangers in the house, like bad lighting, ill-fitting boots, and rugs
are issues to remember. Easy equipment like perch stools, rails, or mobility aids will
encourage autonomous life and reduce the risk of slipping. Community analysis and
follow-up can be scheduled if needed.
According to Smith et al, (2013), It is necessary to recognize the potential psychological
effects of the fall when many people suffer a hip fracture from a fall. The dread of falling
is a good indicator of a low standard of living, so measures to reduce the fear will
increase the quality of life effectively. Elderly people who survive a hip injury may have
substantial social and clinical care needs. An occupational therapist may determine their
preferences following discharge for extra care to help them recover and regain function.
After a hip fracture, the estimated duration of stay in NHS care is 21 days and 17
percent of people are discharged into "ongoing care" (NHFD, 2017). Proactive
discharge planning would allow the detection of people who are at risk of discharge to
several other treatment centers, which may in turn further maximize the number of
people who could be discharged immediately. There are periods when intermediate
care is required to cross the difference between home and hospital. If persons are
clinically fit but still haven't reached their full healing potential, early aided discharge with
continuing community intervention can be recommended. (Salar et al, 2017).
According to McLellan et al (2011), the Hip fracture is usually due to an underlying
condition like osteoporosis after low-intensity trauma. An essential component of
treatment is preventing the secondary fragility fractures, which can also require the
prognosis and control of osteoporosis. Fracture liaison programs recognize people at
increased risk of osteoporosis who experienced a fragility fracture and are suitable for
further examination. To assess the bone mineral density and detect osteoporosis, dual-
energy X-ray absorptiometry could be utilized. To improve their bone density,
individuals presenting with osteoporosis may need medicine. Details on dietary changes
that may enhance general bone health must be followed by this. Bisphosphonates can
originally be administered to individuals to reduce bone turnover or increase bone
density, but various bone-stimulating and anti-resorptive drugs could also be used
(NHFD, 2017).
In conclusion, it is not possible to overstate the value of a detailed, thoughtful, and
organized assessment. The great way to maximize comprehensive comprehension is
through a detailed analysis of the individual's concerns and the identification,
preparation, execution, and appraisal process. Intervention methods conducted without
the aid of proper assessment are far less likely to have a meaningful long-term impact
on individuals. A typical injury seen mostly in elderly adults is hip fractures. To offer
prompt and appropriate treatment during admissions, maximize results during a surgical
procedure, and enhance the quality of life after discharge, a multidisciplinary strategy is
necessary. In the treatment and care of individuals with hip dislocations, and in
minimizing the risks correlated with malnutrition and immobility, nursing personnel plays
a vital role. Patients with hip dislocations should undergo a thorough diagnostic
checkup, and the practicing specialist (nurses) should be well knowledgeable in the
various approaches to treat the condition and future complications. Timely diagnosis
and recovery, particularly identifying the possible risks, are important to offer the optimal
result for the individual. Effective nursing interactions motivate individuals to be more
engaged and active.
The case study looks at Mary, an 81-year old female. She is a widow, living in a care
home. Mary seems to be of average height and weight, height being around 1.62m and
weight around 64kg which falls within the normal BMI range. She was brought into A
and E by an ambulance after tripping and falling down the stairs in the early hours of the
morning. Mary has no known allergies and is currently taking amlodipine as she has a
past medical history of hypertension. Other than hypertension, Mary has no previous
significant medical history. On reaching A and E, the patient mentioned that she felt
severe pain around the region of her left hip. A physical examination and an order
imaging of the hip by using an X-ray machine confirmed that she had broken her left hip
as a result of the fall. The nurses looking after the patient, as well as other health
professionals, confirmed that the ball of the hip joint had been pushed out of the socket.
Mary typically had discomfort, pain, and also a limitation of movement. She was unable
to walk properly. Any movement could be possible, based on the type of injury, but it
would be painful. Usually, pain is present in the outer upper thigh or groin. Mary is
diagnosed with hip dislocation in which the affected limb may seem to be rotated,
shortened, or abducted. Acutely after progressive reduction icing and resting the hip
and using narcotic or/and anti-inflammatory drugs to alleviate pain are effective.
Mary’s baseline observations were taken according to which her blood pressure is low
at 70/60 mmHg indicating hypotension. Her vital signs were taken 10 minutes ago are
as seen below.
Conscious level Alert but in discomfort
Respiration 19 bpm
Spo2 96%
Capillary refill time 2seconds
Blood Pressure 70/60 mmHg
Pulse 80 beats per minute
Glucose 6.2mmol
Temperature 36.5 degree Celsius
Urine output Not catherised- last past urine 3hrs ago
References
Avenell, A., Smith, T.O., Curtain, J.P., Mak, J.C. and Myint, P.K., 2016. Nutritional
supplementation for hip fracture aftercare in older people. Cochrane database of
systematic reviews, (11).
Dawson-Amoah, K., Raszewski, J., Duplantier, N., and Waddell, B.S., 2018. Dislocation
of the hip: A review of types, causes, and treatment. Ochsner Journal, 18(3), pp.242-
252.
Fiset, S., 2016. Validation of the Radiographic Union Score for Tibial Fractures (RUST)
using Medical Imaging and Biomechanical Testing in an In-Vivo Rat Model (Doctoral
dissertation, University of Toronto (Canada)).
Huang, R., Southall, N., Wang, Y., Yasgar, A., Shinn, P., Jadhav, A., Nguyen, D.T., and
Austin, C.P., 2011. The NCGC pharmaceutical collection: a comprehensive resource of
clinically approved drugs enabling repurposing and chemical genomics. Science
translational medicine, 3(80), pp.80ps16-80ps16.
Kelly-Pettersson, P., Samuelsson, B., Muren, O., Unblock, M., Gordon, M., Stark, A.,
and Sköldenberg, O., 2017. Waiting time to surgery is correlated with an increased risk
of serious adverse events during the hospital stay in patients with hip fracture: a cohort
study. International Journal of Nursing Studies, 69, pp.91-97.
Leal, J., Gray, A.M., Hawley, S., Prieto‐Alhambra, D., Delmestri, A., Arden, N.K.,
Cooper, C., Javaid, M.K., Judge, A. and REFReSH Study Group, 2017. Cost‐
effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture
patients: a population‐based study. Journal of Bone and Mineral Research, 32(2),
pp.203-211.
McDonald, E.W., Boulton, J.L., and Davis, J.L., 2018. E-learning and nursing
assessment skills and knowledge–An integrative review. Nurse education today, 66,
pp.166-174.
Mclellan, A.R., Wolowacz, S.E., Zimovetz, E.A., Beard, S.M., Lock, S., McCrink, L.,
Adekunle, F., and Roberts, D., 2011. Fracture liaison services for the evaluation and
management of patients with osteoporotic fracture: a cost-effectiveness evaluation
based on data collected over 8 years of service provision. Osteoporosis
International, 22(7), p.2083.
Moppett, I.K., Parker, M., Griffiths, R., Bowers, T., White, S.M. and Moran, C.G., 2012.
Nottingham Hip Fracture Score: longitudinal and multi-center assessment. British
journal of anesthesia, 109(4), pp.546-550.
Salar, O., Baker, P.N., Forward, D.P., Ollivere, B.J., Weerasuriya, N., Moppett, I.K. and
Moran, C.G., 2017. Predictors of direct home discharge following fractured neck of
femur. The Annals of The Royal College of Surgeons of England, 99(6), pp.444-451.
Shadmi, E., and Zisberg, A., 2011. In-hospital mobility and length of stay. Archives of
internal medicine, 171(14), pp.1298-1299.
Smith, P., Ariti, C., and Bardsley, M., 2013. Focus on hip fracture. Trends in emergency
admissions for fractured neck of femur, 2001 to 2011. The Health Foundation/Nuffield
Trust.
Tsang, C., Boulton, C., Burgon, V., Johansen, A., Wakeman, R., and Cromwell, D.A.,
2017. Predicting 30-day mortality after hip fracture surgery: Evaluation of the National
Hip Fracture Database case-mix adjustment model. Bone & joint research, 6(9), pp.550-
556.
