The patient I worked with during my clinical placement was a sixty-seven-year-old obese woman. She was admitted because of reduced mobility following a fall. She fell two weeks prior to admission and a CT confirmed a Right Neck of Femur Fracture (R NOF) and GAMMA NAIL 3/3. She had pain in the right hip and knee. She had type two diabetes mellitus with unstable Blood Sugars Levels of 1.7. She weighed 102 kg preoperative and 106 kg postoperative and her Basal Metabolic Index was 44.2. She was incontinent of urine and bowel and moved with a walking frame.
Impact on the Patient
Fracture is common in postmenopausal women because of an increase in bone resorption due to a decrease in estrogen levels (Cummings, 2002). Bone resorption increases its fragility and in case of a fall, it can easily fracture. This is the reason why the patient sustained a R NOF after the fall. A positive correlation exists between an increase in age and fractures of the hips (Buchwald et al., 2004). Old people suffering from diabetes are at risk of falling because of poor vision, gait disorders and dementia. The patient is likely to have fallen because of poor vision and gait problems. Poor vision is because of diabetic retinopathy while gait problem is due to being overweight. According to research done, Kee (2002) explains that reduced mobility predisposes a patient to obesity because the body utilizes less food than the patient consumes. This is the reason why the patient gained four kilograms after the operation. Type II diabetes is associated with obesity, nerves damage and decreased immunity, which predisposes a patient to incontinence of urine and bowel (Abbatecola, 2009). In obesity, the Pelvic Floor muscles weaken because of excessive weight. The damage of the nerves supplying the bladder and the bowel are common in type II diabetes. Decreased immunity predisposes the patient to urinary tract infection with subsequent incontinence.
Nursing Care Needs
Specific Care Needs
The specific care of the client is the management of hypoglycemia. This is because hypoglycemia predisposes a patient to fall, fracture, pain and incontinence. The hypoglycemic patient can become fatigued, fall and get a fracture manifesting with pain (Drucqer, 2008). Scott (2005) explains that hypoglycemia is a cause of obesity because excess sugars are converted to fats. The excess fats exert pressure on the pelvic floor muscles and the patient presents with incontinence of urine and bowel (Satman, 2002). The management of hypoglycemia will decrease the chances of the patient falling, getting a fracture and having incontinence of urine and bowel.
The assessment involved measuring blood sugar levels. The rationale was to determine the specific blood sugar levels so that the nurse could choose appropriate interventions. The patient had Blood Sugars Levels of 1.7. This means that she was hypoglycemic and she needed a glucose supply. The diagnosis was hypoglycemia related to poor intake as evidenced by low blood sugar levels of 1.7.
The plan of care was regular BSL monitoring, educating the patient about BSL and encouraging her to eat a meal at the same time. The blood sugar levels were monitored at an interval of two hours. The rationale was to detect any deviation or improvement and act accordingly. For instance, Abbatecola (2009) states that in case the blood sugar levels do not increase, the patient should be given intravenous dextrose because it goes directly to the bloodstream. The patient was educated about the types of food that she should eat to elevate her blood sugar levels and the frequency of meals. The rationale was to empower her with knowledge about blood sugar levels so that she can take care of herself. According to research done, Miller (2002) explains that diabetic patients who have knowledge about blood sugar levels are less likely to suffer from hypoglycemic attacks.
The evaluation criteria entailed an assessment of the documented blood sugar levels to determine the trend and a patient interview to know her knowledge level on BSL. Upon evaluation, the blood sugar levels had increased and the patient knew the type of food to consume, amount and frequency.
Self-care /independence in ADLs: prevention of functional decline
The assessment of the Activities of the Daily Living (ADL) involved the use of a KATZ index. It is an assessment tool that evaluates the ability of a patient to bath, dress, go to the toilet, eat, move and remain incontinent (Narayan, Boyle & Thompson, 2007). The patient is given a score depending on the number of activities that she can perform. The patient had a score of two out of six because she could eat and dress up.
The diagnosis was limited activities related to the fracture as evidenced by the patient not being able to go to the toilet, take a bath and move. The goal of the interventions was to prevent functional decline and assist the patient to perform activities of daily living. The patient was given an assisted bath. The rationale is that Arthur (2007) states that a patient who is given an assisted bath becomes independent as she learns the technique during the bathing process. The nurse assisted the patient with toileting activities by placing the urine bottle and bedpan near her bed. The rationale is that when the urine bottle and bedpan are within the patient’s reach, she can easily pick them thus preventing incontinence (Perri et al., 2003). The patient was educated on what to do when she wants to go to the toilet or to have a bath. The rationale was to assist the patient to be an active participant in care. For instance, she should always ask for help when she wants to have a bath or pass urine. Lastly, the patient was advised to exercise by walking. The rationale is that walking is one of the exercises that strengthen the muscles and facilitate quick recovery thus free movement.
The evaluation criteria were assessed by the use of the KATZ index, interview and walking analysis. Upon assessment by the use of a KATZ index, the patient scored four out of six. She could eat, bath, dress and perform the toileting activities. The nurse assisted her by placing the required materials and equipment within reach. The patient was interviewed and she knew what to do in case the needed materials and equipment were out of reach. The walking analysis revealed that the patient could move with the frame for a longer distance.
The fall risk assessment was done through interviewing the patient and investigative procedures. The patient was asked if she had a history of falls, a balance problem or was unable to rise from a chair. The investigative procedures included the determination of visual acuity by use of a snellen chart and diabetic retinopathy from the database. According to research done, most patients with diabetes are at risk of falls due to impaired vision (Wallace et al., 2002). The assessment of neuromuscular functions involved standing on the toes for approximately thirty seconds and walking five steps.
The assessment revealed a history of falling and a balance problem. The diagnosis of the patient was a risk of falling related to history and gait problem. The patient fell two weeks prior to admission and fractured the right neck of the femur. As a result, she had problems with her gait and moved with a walking frame. She did not have statistical and dynamic balance because she could neither stand on her toes for thirty seconds nor move five steps without the walking frame. The goal of the intervention was to prevent further falls.
The factors precipitating falls were reviewed. The rationale was to prevent their occurrences. Lindsay (2006) explains that if the patient usually falls because of hypoglycemia, the nurse should control it to prevent further occurrences. The nurse educated the patient about the causes and prevention of falls. The rationale was to empower the patient with knowledge about fall preventive measures. In a prospective study about the incidence of falling in older women with type II diabetes, the fall rates decreased by 40% after the patients were educated about preventive measures (Lee, 2004).
In order to address the problem of balance, the patient was trained how to move safely using the walking frame. The rationale was to help her walk effectively and efficiently without fear of falling. In a study done, patients who use walking frames are at risk of falling because of the fear in them and not the ineffectiveness of the device (Hofbauer, 2007). The nurse modified the environment by placing the necessary materials within the patient’s reach. The rationale was to prevent bending or stooping because it put the patient at risk of a fall. Modification of the environment compensates for the patient’s disability and maximizes safety (Dunning & Manias, 2005).
The evaluation criteria were interviewing the patient to assess her knowledge about fall prevention and balance assessment. Upon interviewing the patient, she could explain how to prevent falls. Balance assessment involved observation for swaying and neuromuscular tests. The patient was able to walk steadily using a walking frame.
The assessment of pain involved the use of a pain score. The patient was given a scale to rate the degree of pain. The scale starts from zero to ten and it depends on the behavioural and physiological changes because of pain. The rating is 0-pain free:
- very minor irritation,
- minor irritation,
- irritating and distracting,
- ignored but distracting,
- cannot be ignored for more than thirty minutes,
- cannot be ignored but a person can still work,
- difficult to concentrate,
- limited activities,
- cannot speak and
- unconscious (Brown, 2003).
The patient reported a score of 6 out of ten.
The diagnosis was pain related to the fracture as evidenced by the patient’s complaint of pain in the right hip and knee. The goal of the intervention was to relieve pain and leave the patient comfortable. The patient was given the prescribed analgesia. The rationale is that analgesia blocks the transmission of pain impulses thus the patient cannot experience pain (Shwan & Jo, 2009). The patient was instructed to stop walking for long distances. The rationale is to relieve pressure on the knees and hips. Excessive pressure on a fractured bone presents as pain (Schwartz et al., 2002).
The evaluation criteria were the use of the pain score and analysis of the program of activities. Upon assessment of pain, the patient scored four out of ten. This shows that the pain had reduced. The program of activities analysis indicated that the patient’s activities had been reduced. This shows that there is a positive correlation between the movement of a person with a fractured neck of femur and pain (Christou, 2004).
Discharge planning involved patient evaluation, education and referral to a diabetic educator, physiotherapist and dietitian. The rationale for evaluation was to determine if the patient had benefitted from the interventions and was fit for discharge. The patient was evaluated for incontinence, pain and risk of falling. The incontinence and pain had decreased and the patient knew how to prevent falls. The patient was educated about the importance of follow-up clinics. In a survey done, Whittemore, Melkus & Grey, (2005) explain that diabetic patients who attended clinics suffered fewer episodes of hypoglycemic attacks than their counterparts who did not.
The patient was referred to a diabetic educator so that she could be taught about the management of blood sugar levels using diet. This is because when a patient knows the right type of diet, she will control her sugar levels and avoid either hypoglycemic or hyperglycemic attacks (Wing, 2004). The physiotherapist is important because he will train the patient how to mobilize without exerting too much pressure on the fractured site. Lastly, a dietitian is of significance because he will teach the patient the type of food to consume in order to lose weight.
Abbatecola, A. (2009). Diabetes Care Target in Older Persons. Diabetes Res Clin pract , 1 (35), 86-87.
Arthur, C. (2007). Diabetes Management: Complication risk assessment, Diagnosis and Therapeutic Actions. Oxford: Oxford Publishing Company.