1.

Disease Comparison
Medical Diagnose: Hip Dislocation

Theory Patient

Meaning:
Traumatic hip dislocation is a specific term Patient have diagnosed hip
used to describe complete loss of contact dislocation because of she have
between the articular surface of the femoral ever falling accident.
head and that of the acetabulum. The hip joint
is of “ball and socket” type.
Under physiological circumstances, the head of
the femuris constrained within the
acetabulum.When no contact exists between
these two structures, dislocation is said to have
occurred.

Factors:
Patient came to the Hospital
1. Road traffic injuries, fall, impact sports after fall
2. Osteoporosis is the biggest risk factor, weakens the
upper femur (Hip) breaks, and then causes the
person to fall

Sign and Symptoms

- inability the move immediately after a fall Patient have severe pain scale
- severe pain in hip or groin
records
- inability to put weight on leg on the side of
injured hip
- stiffness, brising and swelling in and around
your hip area
- shorter leg on the side of your injured hip
- turning outward of your leg on the side of
your injured hip
- inflammation of the hip
- bruising

Patology
Hip dislocation is usually unilateral; very In the CT-scan examination
 rarely it may be bilateral. After results looks asymmetrical hip
dislocation, the femoral head can either lie
dislocation in the right side.
anterior (10%) to the acetabulum or posterior
(90%) to it. The hip is commonly held in
adduction and either internal rotation (in
posterior dislocations) or external rotation (in
anterior dislocations). Anterior dislocations
may be associated with a palpable lump in
the groin. In either case, the leg is usually
shortened. The patient experiences extreme
pain when any attempt is made to move the
affected leg.
Dislocations can be of simple type or
associated with fractures of the femoral head,
the femoral neck, or the acetabulum.A fracture
is a break or disruption in the continuity of a
bone that often affects mobility and sensation,
it can occur any where in the body and at any
age.

Treatment

1. Resuscitation and deal with ABC priorities first 1. Provide Morphine medicine
2. Provide analgesia 2. Elevating the limb
3. Closed reduction under general anaesthetic
4. Applying a cold pack to reduce pain and edema
5. Elevating the limb to reduce pain and edema.
6. Treatment for a fracture in the first 24 hours
R- Rest
I-Ice
C-Compression
E-Elevation

Procedure

1. CT-Scan 1. CT-Scan
2. X-Ray 2. Prosthetic Hip Dislocation
3. Replacement of the femoral head with a prosthesis Surgery
4. Surgical repair (open reduction, internal fixation, or 3. Simple Traction (Skin
 Orif) when possible, to reduce pain and allow the Traction)
order patient to be out of bed and ambulatory
7. Skin (Buck’s) traction may be applied before
surgery to help decrease pain associated with
muscle spasm.
Laboratory

1. Check leukocytes: if high alert for infection occur. 1. Complex Hematology check,
2. Hemoglobin check:if abnormal do transfusion
consist of Hb, HCT, RBC, LY
because patient finish operation
%, NE%, MO%, RDW%
3. Examination to search for osteoporosis secondry
2. Chemistry lab consist of BUN,
etiology
Creatinine, Sodium, Potassium,
4. Check Hyperthyroidism: TSHs, Ft4,
Calcium, Phosphorus,
Hyperparathyroid: PTH, Cushing's syndrome:
Bicarbonate, Chloride,
cortisol. DM (Diabetes melitus): Glucose N / PP,
Magnesium, Cholesterol, Total
Meiloma: Regular hematolodies, SPE
Protein, Albumin, Globulin,
Total Bilirubin, Direct
Bilirubin, ALT, AST, Alkaline
Phos, HBA1c
Nursing Care
- monitoring pain level
- provide semi fowler position 1. Pain level monitoring
- teach technique relax and distraksi 2. Provide semi fowler position
- provide a comfortable position 3. Provide breath exercise with
-provides morphine if pain is excessive Triflow
4. Provide a comfortable position
5. Provide Morphine

References:

Ignatavicius, D., & Workman, M. (2013).Medical Sirgical Nursing Patient-Centered

Collaborative Care. Elsevier Saunders. 7thEdition.ISBN: 978-1-4377-2801-9

Evans, S., et al. (2008). Synopsis of Causation Traumatic Hip Dislocation. Ministry of Defence
2. Patient Introduction:
a. Gender : Female
b. Age : 81 years old
c. Disease : Hip Dislocation
d. Operation : Prosthetic Hip
e. Date of Admission : 27/02/2018
f. Date of Operation : 05/03/2018
g. Sources of Information : Medical record, and nurses information.
3. Treatment

One Day Continuation

27/02/2018
Simple Traction (Closed reduction) Morphine 4 mg

05/03/2018
Order Prosthetic hip dislocation surgery Ceftriaxone 2 g IV line, one/day
Omeprazole 2 g, one/day
Paracetamol 1 tab, 4 hour
Celtub (Calsium) 1500 mg, one/day
Metfromin 500, ½ /day, 4 Unit

07/03/2018
HCT status = 25 Morphine 4 mg, IV line
PRC IV drip in 3 hour Follow up HCT every 6 hour
Stool occur blood (Melena)
CBC (tomorrow)

08/03/2018
Breathing exercise (Triflow breathing) Off ceftriaxone
Semifowler position Fortum 2 g

09/03/2018
Morphine 3 mg, IV line, 4 hour
 FANCAS Assessment

Assessor: Nely Qomarun Nisa and Rozi Date of assessment: 9th March 2018

Hospital Number: HS7801 Admission Number: Admission Date:

Chief Complaints: Patient feel severe pain in right side of hip location

History of present illness:

Patient came to Hospital in February 27th 2018 after experienced fall then diagnosed Hip
Dislocation. Then, got the Prosthetic Hip Dislocation surgery in February 27 th 2018, and removal
Prosthetic in March 5th 2018.

History of past illness:

Patient with Diabetic Melitus type II came to Hospital in January 26 th 2018 after experienced fall
then diagnosed Neck Fracture. Then, got the Arthroplasty treatment in February 3rd 2018.

Diagnoses: Hip Dislocation in the Right side

Operation (if any): Prosthetic hip dislocation

Date of Operation: next week

Allergies: None

Vital sign

Temperature: 37.8 °C Pulse: 80 times Respiratory Rate: 16 times Blood

Pressure: 139/84 mmHg

Patient general information

Age: 81 years old Sex: Female Nationality: None Height (cm): None

Weight (kg): None BMI: None

Developmental Status: None

Nutrition Status: None

Severity of illness:

Because of falling accident patient have dislocation in hip location, then got traction treatment
before prosthetic hip dislocation surgery. Because of that, patient always feel severe pain until
the scale is 10 in the right side of hip
 1. Fluid Balance

1.1 Cardiovascular system

1. History: Patient doesn’t have any history of cardiovascular system diseases
2. Physical examination
a. Inspection/ Palpation – Blood vessels
Skin: Color: Brown Temperature: 37.8 °C
Changes
Abnormality of blood vessels : None
Tenderness location : None
Edema: In the right foot
Pulse rate: Carotid : None Brachial: None Radial: None
Femoral: None Poplitheal: None
Posterior tibialis: None Dorsalis pedis: 80 times
Apical Pulse: None
Pulse quality (Rhythm, amplitude, laterally): Normal
Capillary refill time (in second): < 2 second (normal)
b. Auscultation – Blood vessels
Blood Pressure: 139/ 84 mmHg
Bruit: None Hum: None
c. Neck vein: None
d. Inspection Palpation – Heart
Point of maximum impuls (PMI): Normal
Precordial movement: None
Epigastrium: None
Heaving: None
Thrilling: None
e. Auscultation - Heart
Heart sound: S1: None S2: None
S3: None S4: None
Heart valves: aortic: None Pulmonic: None
Tricuspid: None Mitral: None
Murmur: None Rub: None
3. Laboratory result and another examination: None
3.1 Laboratory result
a. CBC: RBC : 3.38 10^6/ul Hemoglobin: 9.4 g/dl Hematocrit: 28.7 %
WBC: 24.9 10^3/ul Platelets: 3.38 10^6/ul
Differential WBC: Neutrophils: 91.4 % Lymphocytes: 3.2 %
Eosinophil: 0.3 % Basophils: None
b. Cloting time: PT: None PTT: None INR: None
c. Enzymes: None
d. EKG: None
e. X-ray (heart/lung): None
f. Echocardiogram (if any): None
g. Cardiac catheter: None
h. CVP: None
 i. Other test: None
3.2 Other relevant information: None

1.2 Kidney system

1. History: Patient doesn’t have any history of kidney system diseases
2. Physical examination: None
3. Laboratory results
a. Urine: Volume: 1360 ml Specific gravity: None
Color: None Clarity: None pH: None
RBC: 3.38 10^6/ul WBC: 24.9 10^3/ul Protein: 0.8 g/dl
Bacteria: None Yeast: None Crystals: None
Casts: None BUN: 11.2 mg/dl Creatinine:0.53 mg/dl
Glucose: 6.0 %
b. Other relevant information: Albumin: 2.8 g/dl
1.3 Fluid and electrolyte balance
1. History: Patient have risk of fluid and electrolyte imbalance
2. Physical examination:
skin texture is rough, dry, have bruise in the left arm and wrist hand caused by skin
deformity for blood test injection intervention, and have swelling in right foot.
3. Laboratory results and record
a. Intake – output (24 hour): Intake: 650 ml (Lack) Output: 1360 ml
b. Blood sugar: 102 mg/dl
c. Osmolality: Serum: None Urine: None
+
d. Electrolytes: Serum: Na : None K+:4.9 mEq/L (Normal)
Cl: 101 mEq/L (Normal)

HCO3: 20.1 mEq/L (Normal)

Mg2+: 1.9 mg/dl (Normal)

Ca2+: 8.0 mg/dl (Normal)

Others:

Urine Na+: None K+: None Cl: None

Others: Albumin: 2.8 g/dl
e. Other relevant information: None
1.4 Acid – base balance
Arterial blood gas: pH: None PaO2: 98% (Normal) PaCO2: None
HCO3: None Be: None Anion gap: None
A-a gradient: None
Analysis of problem for fluid balance
 Patient have lack of body fluid intake that is just 650 ml in a day, in the other side patient
have active fluid output until 1360 ml a day. And physical examination showed that skin
texture were rough and dry.
Nursing diagnoses for fluid balance
Risk for deficient fluid volume related to active fluid volume loss

2. Aeration
1. History: Physician stated that patient’s lungs can not expand normally, so the physician
order breathing exercise Triflow
2. Physical examination
a. Inspection:
Shape: None
Respiration: rate: 16 times Rhythm: Normal Depth: Normal
Ap-Lateral ratio: None
b. Palpation
Trachea position: None
Tactile fremitus : Front: None Back: None
Chest Expansion : Front: None Back: None
Tenderness (if present, specifiy location): None
Subcutaneous emphysema: None
Mass: None
c. Percussion
Front: None
Back: None
Lateral Left: None Right: None
d. Auscultation (specify breath sounds, adventitious sounds)
Front : None
Back : None
Lateral Left: None Right: None
3. Other symptoms
a. Cyanosis: No
b. Use of accessory muscles: No
c. Dyspnea/shortness of breath: No
d. Clubbing finger: No
4. Laboratory results and other tests
a. Chest x-ray: None
b. Lung function
Tidal volume: None Spontaneous: None
Minute volume: None Spontaneous: None
Vital capacity: None
 c. Oxygen saturation: 98%
d. PaO2/FiO2 ratio: None
e. sputum culture/gram satin: None
f. arterial blood gas : pH: None PaO2: 98% PaCO2: None
HCO3: None BE: None
Anion gap: None A-a gradient: None
g. other relevant information: None

Analysis of problem for aeration

There is no any aeration problem for patient

Nursing Diagnoses for Aeration: None

3. Nutrition
1. History: Patient doesn’t complaint any difficulties when eating. But, patient looks skinny.
2. Physical examination
a. General appearance
b. Oral cavity : Teeth: Normal Tongue: Redness (Normal)
Oral hygiene: Clean
Gag reflex: Normal
 Swallowing reflex: Normal
c. Abdomen
Inspection:
Skin color, lesion, scar:
Skin color same with the other body parts that is brown-yellow (Normal),
no lesion or scar in patient’s abdomen

Size, shape, symmetry:

Have normal size and shape (no acites) and symmetrical

Abdominal movements: Normal

Umbilicus / hernia: Umbilicus location in the middle of abdomen
Superficial veins: None
Abdominal aorta: None
Cullens’s sign: None
Grey Turner’s sign: None
Ascites: No Abdominal circumference: None
Auscultation :
Gurgling sound: Normal
Bowel sound: Normal
Bruits : None
Venous hum (liver): None
Friction rubs (organs): None
Percussion :
Sound : None
Tenderness: None
Liver span (cm): None
Splenic span (cm): None
Shifting dullness: None
Costovertebral angle: None
Palpation :
Surface characteristics: Normal
Tenderness / guarding: Normal
Liver : None
Spleen : None
Rebound tenderness: None
Murphy’s sign: None
Rectum and anus: None
3. Nourishment condition
a. History Eating pattern: Little
Usual Food: Rice
Elimination pattern: Irregular
Factors that limit nutritional intake: None
Factors that increases nutritional demand: None
b. Physical examination
Weight: None Height: None BMI: None
 Ideal body weight: None
Mid –arm circumference: None
Triceps skin fold: None
Total energy expenditure/day (TEE): None
4. Laboratory results
a. Serum Albumin: 2.8 g/dl Pre-albumin: None
Transferring WBC: 28.7 10^3/ul (High) RBC: 3.38 10^6/ul (Low)
Hemoglobin: 9.4 g/dl (Low) Hematocrit: 28.7 % (Low)
b. Urine UUN (urine urea nitrogen): None
5. Other relevant information: None

Analiysis of problems for nutrition

Patient 81 years old looks have lack of nutritional intake, because of little nutrition intake and
according to physical examination, patient body looks so skinny. Additionally, patient have
imbalance blood components of WBC (high), RBC (Low), Hb (Low), and HCT (Low).

Nursing diagnoses for nutrition

Imbalanced nutrition: less than body requirements related to biological factors and insufficient
dietary intake.
 4 Communication

1. Communication process
1.1 History : Patient doesn’t have any difficulties in communication with the other
1.2 Physical examination
a. Vision : Normal
b. Ability to read : Normal
c. Hearing : Normal
d. Sensory/perception: Normal
e. Ability to speak/speech: Normal
f. Ability to gesture/non-verbal communication: Normal
2. Communication content
2.1 History
a. Ethnic background : None
b. Religion: None Level of education: None Occupation: None
C. Coping
When in pain: None
When upset/anger: None
Use of medicine/illicit drugs: None
c. Emotional/mental issues: None
2.2 Information at present (at the time of assessment)
a. Emotional expression: Normal
b. Expectation for this admission: Normal
c. Patient’s significant others: None
d. Adaptation stage at present: None
3. Other tests: None
4. Other relevant information: None

Analysis of problem for communication

Patient doesn’t have problem in communication, still able to understand when someone speak
with her, and able to give responses in verbally and body gesture.
Nursing Diagnoses for communication: None
5. Activity
1. History : Level of past activity: Able to move to everywhere by her self
Level of activity at present as directed by doctor (specify time):
Patient came to Hospital on 27th February 2018 after fall, then the doctor do
laboratory examination and found that patient’s have hip dislocation in the right
side. After that, patient got traction on her right side traction before the
Prosthetic Hip surgery in the next week.

Actual patient’s activity:

Patient just have bed-rest, and can’t move to everywhere because of the right leg
simple traction (skin traction) treatment.
2. Physical examination
 a. Sensory (normal or decrease): Normal
b. Glasgow coma scale : E: 4 M: 6 V: 5 (GCS: 15)
c. Muscle tone: Have hypertonia in the elbow (can not contration)
d. Muscle strength (motor power ): 5
e. Range of motion: Have limitation in right leg movement
f. Deep tendon reflexes: 1+ ( a slight byt definitely present response: may be normal)
g. Skin integrity: Normal
h. Factors that inhibit activity
Cast: None ventilator: None IV Lines: Applied
Decrease ROM: Yes Activity intolerance: None Others : None

3. Other tests/examinations:
Pain Scale:
P: Hip dislocation and traction
Q: None
R: Right leg
S: 10
T: None
4. Other relevant information : None
Analysis of problems for activity:
Patient have limitation of activity due to hip dislocation because of fall accident, and the
skin traction treatment. Beside that, patient also feel severe pain in the right leg, and the
pain scale is 10.

Nursing diagnosis for activity:

1. Acute pain related to physical injury agent (dislocation of joint)
2. Impaired physical mobility related to alteration in cognitive functioning,
musculoskeletal impairment, and pain
 5. Stimulation
1. History : Patient have low response of stimulation, but still in normal range
2. Physical examination
Level of consciousness: GCS= 15 (E: 4 M: 6 V: 5)
Emotion and behavior: Patient looks calm
Head and neck
Eye : Cornea reaction: Normal VA: Normal VF : Normal
Pupil size : Normal Pupil reaction: Have reflex to the light
Extremities : Sensory : low response (3)
Ability to move:
Unable to move in the right leg. For the other part, patient able to move
Deep tendon reflexes: 4
Babinski sign: Normal
Posturing and balance: None
Coordination : None
3. Other tests: None
4. Other relevant information: None

Analysis of problems for stimulation:

Patient have low responses of sensory, but that is still in normal range according to her age.
Nursing diagnoses for stimulation:
None
Conclusion of problems ( Mark all that apply)

Fluid balance Aeration Nutrition

√ Communication Activity √ Stimulation

Relevant pathophysiology √
The mechanism of dislocation of the hip most commonly secondary to impact with a
dashboard in a motor vehicle crash, but falls from height are also a significant cause, whereas
sport injuries are a less common cause. The direction of the dislocation is dependent on the
position of the hip at impact and the direction of the force vector applied. The impact on the knee
with the hip in an adducted position leads to a posteriorly-directed force, causing a posterior
dislocation. In contrast, an anterior dislocation occurs when the hip is abducted and externally
rotated. With hip dislocations, the capsule and the ligamentum are usually disrupted. Patients
presenting with dislocations of the hip typically are unable to move the lower extremity and are
in severe discomfort. The classic appearance of an individual with a posterior hip dislocation is
a patient in severe pain, with the hip in a position of flexion, internal rotation, and adduction.

List of nursing diagnoses (priority)

1. Acute pain related to physical injury agent: dislocation of joint (Priority)
2. Impaired physical mobility related to alteration in cognitive functioning, musculoskeletal
impairment, and pain
3. Imbalanced nutrition: less than body requirements related to biological factors and
insufficient dietary intake
4. Risk for deficient fluid volume related to active fluid volume loss

Nursing Care Plans

NOC NIC Rational Evaluation

Dx: Acute pain

√ Goal: - Perform a - Identifying these S: None
The patient’s pain is comprehensive will assist in O:
relieved or reduced assessment of accurate diagnosis - pain as
√ result criteria: pain to include and treatment; impaled
- The patient will location, most patients who - Pain level is 0
verbalize that pain has characteristics, experience
 been relieved 30 onset/duration, dislocations - Vital sign:
minutes after frequency, experience some BP: 126/88
intervention. quality, intensity pain, especially mmHg
- The patient will or severity of while movement. T: 37ºC
verbalize an pain and RR: 16 times
understanding of what precipitating P: 60 times
causes pain factors - Helps to determine A: the problem
- The patient is able to - assist patient and whether is resolve.
identify factors that family to seek interventions have P : intervention
precipitate pain and and provide been effective in continued.
understands how to support relieving pain or
modify behaviors principles of pain whether new
accordingly management strategies need to
be employed
- Educate patient - Ice reduces
and families to swelling through
apply ice packs, vasoconstriction
20 minutes on, and reduces pain
20 minutes off
for the first 48
hours of falling,
especially to the - NSAIDs work in
injured hip peripheral tissues
- Collaborate with some block the
other health synthesis of
professionals to prostaglandins,
select and they are effective
implement in managing mild
pharmacological to moderate pain
pain relief
(analgesic), as
appropriate

Dx: Impaired physical - Check or - These exam S:-

mobility related to observed result confirm the O:
alteration in cognitive of diagnostic diagnosis, exact - hip dislocation
functioning test, x –rays, Ct- location, and in right foot
√ Goal: scan, MRI, etc. severity of injury - Have skin
The patient obtain - Assist with - Prompt treatment traction
physical mobility to the immediate is require to - Able to do
highest permissible relocation by prevent vascular ROM on the
level assisting with damage to the normal
√ results criteria: manual traction head of the femur, extremities
- Body positioning, (closed reduction also A : the problem
coordination, joint reduction), as decrease pain and solved partially
movement restores range of
 performance ordered motion P : intervention
- The patient - Educate and - Early mobilization resumed
verbalizes a encourage early will prevent
willingness to ambulation and complication of
participation in mobility as immobility in hip
physical exercise to directed by the dislocation.
all extremities as physical
prescribed therapist and
- The patient reduce length of - exercise enhances
demonstrate gradual bedrest increases venous
improvement in - Help the patient return, prevents
movement in the to exercise the stiffness and
extremities. unaffected maintains muscle
extremities by strength and
doing the range stamina
of motion
exercise as - some dislocation
directed by may require
physical surgical repair due
therapist to the extent of
- Collaboration soft tissue damage
with the
physician in
operative
procedures as
ordered
(Prosthetic Hip
dislocation
surgery)

Dx: Imbalanced - Observation - For calculation S: None

patient nutrition patient nutritional O:
nutrition: less than
intake-output balance - Patient looks
body requirements - Encourage patient - To elevate skinny
to eat regularly, nutritional intake for - Patient able to
related to biological
and small snacks body balanced eat by oral
factors and based on body - Patient still
needs - Help the family and have teeth and
insufficient dietary
- Education patient patient to able to
intake and patient’s understand the chewing
√ results criteria: family about the health meal to - Patient need
- Reached normal body important to take encourage patient’s assistant for
the health meal body nutrition take the food
weight
(many variants - Patient have
- BMI in the normal
food example little intake of
veggies, fruits, and
 base line 18 – 22 meats) and eat in - The patient’s meals food
- Increased nutritional the on time with portion for A: problem
appropriate nutritional intake solved partially
intake
portions will be more P: intervention
- Collaboration with sufficient and order resume
nutritionist for the menu that can
order patient’s motivate patient to
meals. eat.

Dx: Risk for deficient - Observation - For calculation S: None

patient body fluid patient nutritional O:
fluid volume related to
intake-output balance - Patient have
active fluid volume - Encourage patient - To elevate fluid administer
to have sufficient balance. normal saline
loss
fluid intake, 100ml every
√ results criteria:
minimal 5 glass - Help the patient and day
- Skin integrity is
250 ml of drinks families to - Patient skin
normal (moistured) per day understand how to still dry
- There is no dry skin - Education the prevent dryness in - Patient unable
- Normal body fluid patient and patient skin and for to drink by her
families the blood circulation self (need
balance intake (1500-
important of - To prevent active assistant)
2000 ml) regular drinks in a fluid loss cause by - Patient able to
- Normal fluid output day urine elimination drink trough
- Collaboration with oral
physician in order A: problem
and administer of solved partially
anti diuretic P: continued
medicine or intervention
crystalloid fluid
(e.g NaCl, Normal
saline) to patient