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

Journal of
Orthopaedic Nursing

www.elsevierhealth.com/journals/joon

A critical study of a 100-year-old patient receiving

a 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

KEYWORDS Summary This care study critically examines the care given to one elderly female
Fracture of the patient on an orthopaedic trauma unit following a dynamic hip screw insertion for a
neck of femur; fracture of the neck of femur. It examines the patient history, mode of injury,
Dynamic hip screw; choice of and delivery of both medical and nursing care. Issues include the choice
Nursing care; of nursing model and the influence of government policy on care delivery, stemming
Model of nursing from the National Service Framework for Older People and Essence of Care. The
work 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 comments
As busy health care practitioners, we rarely give time to step back and consider the way we think about patients and the care we
provide. This study does just that, through the eyes of a staff nurse, and suggests how changing the way we perceive our care can
dramatically affect how we nurse. PD

Introduction A brief patient history, a description of the

The objective of this paper is to review the care
delivery of an individual female patient, admitted
to 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 of
femur following a fall. The author of this paper was
directly involved in the care delivery of this patient.
mode of injury and a diary of care is provided.
The choice of surgical procedure, the use of the
particular nursing model used within the clinical
area and the influence of relevant government
policy are discussed. The paper provides some
thoughts on the future of trauma and orthopaedic
nursing.
Patient history

* Tel.: +44 7754724213. The patient was 100 years young at the time of
E-mail address: bran.griffith@yahoo.co.uk. admission and of East European origin. Avoiding


1361-3111/$ - see front matter c 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.joon.2007.08.001
178
the invading German army during the Second World
War, she settled in England. The patient was a wo-
man of some determination and for the sake of this
paper, we name her Emily. She had rheumatoid
arthritis, 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 Unit
of 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 that
morning. She was not believed to have been left on
the floor for any length of time.
The patient had sustained injury to the right hip
and 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 mild
confusion. X-ray identified a fractured neck of fe-
mur but no fracture to the forearm.
Nursing assessment on the trauma unit identified
her as being occasionally doubly incontinent and as
having red heels. She also had a skin break to her
sacral region, to which ‘Granuflex’ was applied.
Her normal mobility was identified as independent
with a walking frame. Due to urinary retention, she
was 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 at
08.00 and 18.00 h, Adcal D3 (i) at 08.00 and
18.00. It was also found that she was being pre-
scribed prior to admission; olanzapine 2.5 nocte,
usually used in the treatment of schizophrenia or
mania, and this was continued.
Morphine and cyclizine as subcutaneous injec-
tions, procholorperazine as an intramuscular injec-
tion and Lacri-lube and Hypermellose for the eyes
was 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 through
the 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, she
underwent surgery. She required a four hole 135
DHS plate with an 85 mm dynamic hip screw lag
screw under general anaesthetic. No drains were
inserted.
D. Griffith
One unit of blood was given pre-operatively, fol-
lowed by 20 mg of frusemide. Emily’s blood glucose
pre-operatively was 3.5 mmol (06.45 h) rising to
8.3 post operatively (11.00 h). Intravenous dex-
trose saline had been administered during the
operation.
At the patient’s hospital the majority of trauma
patients, those not destined for intensive care or
high dependency, are admitted to the Trauma
Assessment Unit (TAU). The ward of thirty beds is
split into pre and postoperative areas. Patients
returning to TAU post operatively are expected to
stay on the unit only two or three nights before
transfer to an orthopaedic ward.
The alternative Extended Recovery Unit takes pa-
tients post operatively, for usually no more than one
overnight stay before transfer to an orthopaedic
ward. Although primarily caring for the elective
orthopaedic theatre lists, trauma cases are taken
when necessary. The objective of both units is to
provide specialist nursing care and close monitoring.
On the first postoperative day the patient was
seen by the medical team and prescribed 500 mcg
of Digoxin with a further 250 mcg to follow 6 h later
and was also transfused one unit of blood. That
evening Emily was transferred from the recovery
unit to a general ward and had an X-ray of her
hip taken. An X-ray of the surgical area is generally
required to confirm weight-bearing status, prior to
full mobilisation. On the second postoperative day,
she was seen by the physiotherapists and sat out of
bed. Her wound dressing had been changed and re-
dressed with a dry dressing for protection. She had
her bowels well open. Unfortunately, her skin was
judged 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 short
distances with a walking frame. The skin tear to
the right forearm was redressed on alternate days.
The surgical incision was dry and left exposed on
the 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, it
was observed that the patient’s right arm appeared
deformed and moved in an abnormal manner. On
checking the original X-ray no fracture of either
the radius or ulna was visible. However, the X-ray
was only of the distal forearm. Suspecting a missed
fracture, this was reported by the author to the
nurse in charge and on to the team. A second X-
ray showed a fracture to the proximal ulna and
the patient had a plaster of Paris back slab fitted
later that day. A ‘‘collar and cuff’’ was provided
for comfort and support.
A critical study of a 100-year-old patient receiving a dynamic hip screw
Over the next few days, the patient’s pressure
areas remained a concern. ‘Duoderm’ was applied
to her sacrum and a foam dressing to her left heel.
A pressure-relieving mattress had been in use from
admission and she remained able to walk to the toi-
let but was occasionally doubly incontinent.
On the twelfth day post operation the patient
had a complete lightweight cast fitted to her right
forearm and was discharged back to her residential
home on the fourteenth day post operation.
Hip screws
Fractures of the femoral neck are generally divided
into two categories, intracapsular or extracapsular
(Walsh, 1997). Intracapsular fractures occur
through the capsule at the base of the femoral
head. Extracapsular pass through either of the tro-
chanters or the intertrochanteric area (Walsh,
1997).
Fractures to the intracapsular region are likely
to damage the blood vessels supplying that region,
so causing avascular necrosis (Schoen, 2000a). This
is particularly so if there is displacement and the
choice 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) and
the choice of fixation is either dynamic hip screw
or an intramedullary nail (Kunkler, 2002).
Jenson et al. (1980) have concluded that with
stable 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 general
consensus that the DHS is the implant of choice
for stable trochanteric fractures (Harrington
et al., 2002; Lorich et al., 2004). This is considered
to 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 and
Jones, 1995; Schoen, 2000b). The general opinion
is that two views at right angles, are the minimum
number required to evaluate a suspected fracture
and that the X-rays should include the joints above
and below (Kunkler, 2002). Although it is not the
role of the nurse to check an X-ray, a working
179
knowledge of the fracture and the basic anatomical
structures involved can provide guidance in care
delivery. The first X-ray of Emily’s right forearm
was not from joint to joint and this is why the ulna
fracture was originally not detected.
The implications of a fracture are many but the
primary ones include; risk of compartment syn-
drome, risk of fat embolism syndrome, risk of deep
vein thrombosis (Pellino et al., 2002), wound infec-
tion, chest infection, elimination difficulties, tis-
sue breakdown, pain, the patient’s psychological
state and an adverse effect on the ability to self-
care (Santy, 2005a). The factor that many of these
nursing issues have in common is the detrimental
influence of immobility. Within orthopaedic nurs-
ing recovery is very often measured by the assis-
tance a patient requires (Santy, 2005a). With
mobility in particular, comparison is made with
the patient’s pre-fracture existence (Williams
et al., 1994). The role of the orthopaedic nurse
goes well beyond the prevention, detection and
monitoring of any deterioration in a patient’s con-
dition. The role of the orthopaedic nurse includes
active rehabilitation and the restoration of self-
care wherever possible.
Nursing models and nursing process
To assess a patient and identify potential or actual
problems some form of framework on which to
base and develop the nursing process is required.
Fawcett (1984) writes that concepts, theories and
models are linked in a hierarchical structure with
concepts as a base and models being the result.
Nursing models are not physical representations
of an idea, concept or theory. It can be argued that
nursing models are conceptual in their own right
(Riehl and Roy, 1980) and that they are based upon
a theory of nursing, such as self-care (Orem, 1971)
or activities of living (Roper et al., 1980).
A nursing model is an abstract and conceptual
framework from which we are able to assemble a
nursing process. The patient’s current condition is
compared with before admission, allowing prob-
lems and goals to be identified. These factors are
used to formulate a care plan and together they
will form the nursing process.
The nursing process is often regarded as having
distinct stages (Walsh, 1997; Andrews and Smith,
1992):
Assessment of the patient.
Identification or diagnosis of problems.
Establishment of goals and the writing of the
care plan.
180
Implementation of the identified nursing care.
The ongoing evaluation and final conclusion of
the care given.
The Roper, Logan and Tierney model
The Roper et al. (1980) nursing model is used at
the patient’s hospital as it is regarded as a general
model, adaptable to many areas and needs. The
starting point for this model is the work of Abra-
ham Maslow (1954) and his hierarchy of human
needs, from the most basic to the most sophisti-
cated. Maslow suggests that our basic biological
requirements (such as nutrition) must be met, be-
fore we are able to satisfy higher psychological
needs.
The model is based on the theory that people
are best understood by the activities of their lives
(Aggleton and Chalmers, 2000), biological, social
and cultural. Some activities are essential and pri-
marily biological in nature, while others are non-
essential but enhance the quality of life. These
needs are therefore primarily social and psycholog-
ical. This is a holistic view of the person and repre-
sents a move away from the mechanistic
perspective, of the traditional biologically centred
medical 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, working
and playing, expressing sexuality, sleeping and fi-
nally dying. Added to this concept are three com-
ponents of nursing care based upon a balance
between 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 new
problems. The second component is that of the
comforting component, the object to provide and
assist in physical, emotional and spiritual comfort.
This component is difficult to define as it is highly
individualised relying heavily on the nurse’s inter-
personal skills. The third and final component is
the dependent component, this component recog-
nises that the patient will be dependent upon the
nursing staff for aid and it is this component that
represents the implementation of nursing care.
Although intended as a framework for care
delivery nursing models are often used as an assess-
ment aid, with little influence on the later stages
of the nursing process. The model is popular with
D. Griffith
nurses and it is suggested this is because of its
resemblance to the medical systems model (Archi-
bald, 2000). There is a danger that any model used
mechanistically becomes mechanistic, as does
eventual care delivery.
The model is relevant to orthopaedic nursing as
it recognises how injury can affect the patient’s
self-care ability (Santy, 2005b) in addition to the
many serious medical complications. How the mod-
el influences care delivery, is best illustrated by a
brief review of the care given. The factors that
they influence and are influenced by, are broad in
concept and overlap.
Maintaining a safe environment
Due to the patient’s mild and intermittent confu-
sion, an awareness of potential dangers to her
wellbeing is vital. Care was taken that she could
manage a hot drink and was supervised when
mobilising in the early stages of her stay. A falls
risk assessment is carried out on all patients
within this particular clinical area. She was
judged to be of a high risk but was later reas-
sessed as medium as her ability to mobilise
increased.
Communicating
A two-way process in which the healthcare staff
must identify the patient’s needs using both verbal
and non-verbal cues. Roper, Logan and Tierney
place pain in this activity as the patient must ex-
press their discomfort. Therefore, the alleviation
of pain or the introduction of a coping mechanism
is a nursing issue. Her pain was well controlled dur-
ing her stay with no particular complaints being
made post-operation, even with an unidentified
broken arm.
Breathing
This also includes the cardiovascular system as a
whole 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 the
choice of correct menu was required. Her diabetes
was remarkably stable post-operation.
A critical study of a 100-year-old patient receiving a dynamic hip screw
Eliminating
The patient was occasionally incontinent, some-
times doubly. Prior to her operation, she required
catheterisation but this was removed on the fourth
day post-operation and incontinence pads pro-
vided. She was by this time walking to the toilet
with a walking frame and the catheter’s removal
gave her greater independence.
Personal cleansing and dressing
Due to her advanced age and her injury, the patient
required assistance. Over a few short days how-
ever, she was able to progress to washing her upper
body with less help. When assisting a patient with
hygiene healthcare staff are in a privileged position
of intimacy, raising many issues regarding privacy
and dignity. This time also affords an opportunity
to inspect the patient’s skin integrity. It was whilst
assisting with her morning wash that a suspicion of
the 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’s
temperature is necessary. The patient also re-
ceived a blood transfusion peri-operatively and
therefore required close monitoring at that time.
Mobilising
The patient was able to walk on the second day
post-operation. Her walking distance and indepen-
dence increased until she was able to walk to the
toilet without assistance, although she could not
get in or out of bed or raise herself from a sitting
position without assistance. Increased mobility is
desirable, as it lessens the risk of complications
such as venous thromboembolism and aids the
recovery of pressure areas.
Working and playing
Her leisure interests centred around reading and
watching 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 context
causes some confusion. This activity includes both
181
sexuality and gender issues relating to hygiene,
self-image and self-awareness. Patient’s need to
express individual and self-perceived needs relat-
ing to hair, make up, washing and shaving (facial
if male and lower limb if female). On one occasion
after bathing, her hair was put in curlers.
Sleeping
Lack of sleep and sleeping in a strange environment
can have detrimental effects upon an individual’s
mental state. Promoting good quality sleep and
rest in hospital is difficult as the wards are always
busy and very often noisy. Limiting the number of
visitors to each bedside and monitoring noise levels
can help. Providing comfortable and the right num-
ber of pillows may help. Unfortunately, there are
still difficulties and, although necessary from a
health and safety position, ward night lights do
not promote rest.
Dying
People die everyday but an individual does not.
However, a patient and his or her relatives may
have concerns about the possible worsening of an
illness. Patients with a terminal illness or the el-
derly may ‘‘live with the prospect of death’’ and
the nurse should handle these concerns with care.
The documentation of who to contact if the need
arises should be made. In dealing with anxiety,
the nurse may need to contact distant friends, a
spiritual advisor or even a neighbour.
Roper, Logan and Tierney model within
orthopaedics
Many nursing models are unnecessarily compli-
cated, yet the Roper Logan and Tierney nursing
model may be regarded by some nurses as being
simplistic. This is a mistaken view as the model
has depth that will only become apparent with reg-
ular use by the practitioner. This is particularly
true when exploring the component factors related
to dependency. Here it is for the practitioner to
use their own judgement, as to when to step back
and allow the patient to do more.
There is no ideal nursing model and in practice,
the nurse may subconsciously use a combination of
models. Each nurse may carry their own nursing
theory or philosophy, in their head. The model
has the balance of being relatively easy to become
familiar with, together with the depth to allow
adaptation in variable settings.
182
Balcombe (1994) with Davis and Lim attempted
to adapt the model to orthopaedics by placing
the patient’s desired health state at the centre of
nursing care; giving eleven areas for consideration
within 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 and
aspirations.
Davis (2005a) takes this one-step further by
adapting the activities of living model (Roper
et al., 1990) to orthopaedics. By centralising mobil-
ising, the ‘‘Davis model’’ shares some characteris-
tics of the Balcombe model. Incorporated into the
Davis model are the activities of living from Roper,
Logan and Tierney, together with the lifespan and
the dependence–independence concepts from
the same model.
The possible advantage of the Davis model is
that it recognises the value of other models and
builds upon them. Added to the above is a self-
empowerment framework, an area representing
individualised nursing that includes assessment
and finally an ‘‘other’’ category. This area called
‘‘factors influencing’’ is the framework for factors
not 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 the
importance of pain as a factor in its own right
and not merely as a sub-factor. Davis is honest en-
ough to have an ‘‘other’’ category and links pain to
mobilising, as it is on movement that orthopaedic
patients tend to have most pain.
One possible way of combining all that is best
from the above models would be the continued
use 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 use
of the integrated care pathway as having significant
benefits to patient care (Davis, 2005b). However,
less than fifty percent of trusts actually use them
(House of Commons, 2004). Each care pathway
should be tailored around the unique needs of each
clinical area (Bayliss and Salter, 2004), so recognis-
ing their inherent speciality. A key feature of the
Davis model, in being different from the Balcombe
model, is the recognition that orthopaedic nursing
is a speciality and therefore deserves a specialised
nursing model.
D. Griffith
UK policy
There is today a wide spread professional and gov-
ernment support for the concept of patient centred
care (Price, 2004). Current thinking has a focus on
benchmarking and clinical governance. The aim is
to provide a structured approach to the comparison
and improvement of clinical practice (Bayliss and
Salter, 2004; Burton, 2004).
UK government policy directives provide the
structure for future planning in healthcare (Martin,
2001). There are a number that influence current
thinking, including The NHS Plan (DOH, 2000), var-
ious National Service Frameworks and The Essence
of Care (Parkin and Bullock, 2005).
It is generally accepted by many that age discrim-
ination can and does exist within the UK National
Health Service (DOH/SNMAC, 2001; Coombes, 2001
and Kmietowicz, 2001). There is however, some dif-
ference of opinion as to whether age discrimination
is endemic or an aberration from normal practice.
Forster (1993) quoted Eric Midwinter the former
director of the Centre for Policy on Ageing as saying,
‘‘Discrimination by age is as vicious as discrimination
by race or sex and is not borne out by medical evi-
dence’’. The suggestion is made that discrimination
may 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 plan
to end age discrimination within the National
Health Service (Kmietowicz, 2001). The objective
of the NSF is to guarantee fair and equal care for
the older person. Concerns as to the differences
in care across the country were summed up by
Bowling (1999), who wrote of evidence of age being
used as a factor in health care provision and in the
invitation of joining screening programmes. All pa-
tients have the right to be treated with dignity and
respect (Williams et al., 1999) and this includes the
right to privacy.
Standard six of the NSF is of relevance within
orthopaedic nursing, as it highlights preventative
measures regarding falls. Research suggests that
the strongest predictor of having an osteoporotic
fracture, is having had a previous one (Minns
et al., 2004). Although it is important to prevent
the first fall, we must recognise that once a fall
has taken place, prevention of further falls is
equally important.
Although it may be tempting to think that where
the NSF for older people ends, the Essence of Care
(DOH, 2001a,b) begins, this is not strictly true. For
example, both publications share the same original
year of publication.
A critical study of a 100-year-old patient receiving a dynamic hip screw
Originally, the Essence of Care consisted of eight
core aspects considered crucial to the quality of
the patient’s experience of care (Bayliss and Salt-
er, 2004). A ninth aspect was later added focusing
on communication (Burton, 2004; Modernisation
Agency/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 in
acute mental health and general hospital
settings.
Principles of self-care.
Communication between patients, carers and
healthcare personnel.
Conclusion
The patient was well cared for and she made a
remarkable recovery and was discharged, pain free
and mobile. The introduction of a change of
emphasis, such as a greater focus on mobilising
within the framework of care delivery, coupled
with the clearly set standards of the Essence of
Care, may yet prove beneficial to our patients.
The time has come for orthopaedic nursing to have
its own nursing model.
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