International Journal of Orthopaedic and Trauma Nursing (2013) 17, 4–18

www.elsevier.com/locate/ijotn

Acute nursing care of the older adult with fragility hip

fracture: An international perspective (Part 2)
a,*,1
Ann Butler Maher RN, MS, FNP-BC, ONC (Family Nurse Practitioner) , Anita
J Meehan RN-BC, MSN, ONC (Clinical Nurse Specialist, Gerontology/Director)
b,1
, Karen Hertz RN, BSc(Hons), MSc
c,2
(Advanced Nurse Practitioner T&O) , Ami Hommel RN, CNS, PhD (Associate
d,3
Professor) , Valerie MacDonald RN, BSN, MSN, ONC (Clinical Nurse Specialist)
e,4
, Mary P O’Sullivan RGN, RM, BNS/RNT, MSc Nursing (Clinical Development
f,5
Co-ordinator) ,
g,6
Kirsten Specht RN, MPH (PhD Student/Research Nurse) , Anita
Taylor RN, OrthoNCert, GradDipOrtho, MNSc (Orthopaedic Nurse
h,7
Practitioner)

a Long Branch, NJ, USA

b NICHE Program, Akron General Medical Center, Akron, OH, USA
c University Hospital of North Staffordshire, UK
dDept. of Orthopaedics, Skane University Hospital, Lund/Dept. of Health Sciences Lund University, Sweden
e Fraser Health Authority, BC, Canada
f Cork University Hospital, Wilton, Cork, Ireland
g Dept. of Orthopaedics, Vejle Hospital, Vejle, Denmark
h Royal Adelaide Hospital, Adelaide, SA, Australia

* Corresponding author. Address: 35 Pavilion Avenue, Long Branch, NJ 07740, USA. Tel.: +1 732 571 1218. E-mail address:
[email protected] (A.B. Maher).
1 International Collaboration of Orthopaedic Nurses.
2 Royal College of Nursing Society of Orthopaedic and Trauma Nursing.
3 Swedish Orthopaedic Nurses Association.
4 Canadian Orthopaedic Nurses Association.
5 Irish Orthopaedic Nurses Section.
6 Danish Orthopaedic Nurses Association.
7 Australian and New Zealand Orthopaedic Nurses Association.
 c
1878-1241/$ - see front matter 2012 Elsevier Ltd All rights reserved.
http://dx.doi.org/10.1016/j.ijotn.2012.09.002
Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 5

Editor’s comment
We are proud to announce the publication of this important international document that provides a clinical review for
the care of the older person with a fracture of the hip. This important and ground breaking clinical review document
is published in full online at: http://dx.doi.org/10.1016/j.ijotn.2012.09.002. and in two parts in print format; the
second part here and the first part in an earlier edition of the Inter-national Journal of Orthopaedic and Trauma
Nursing. In many countries hip fracture is the most important issue facing trauma services in the 21st century and this
document will help to provide those caring for this vulnerable group of older people with sound, evidence-based
advice on the best ways to ensure that care is as sensitive and effective as possible. It is our fervent hope that the
clinical review will be used around the globe to ensure care is sensitive to the complex needs of this group of patients.
JS-T.

Keywords Summary The second part of this paper provides those who care for orthopaedic patients with
Hip fracture; evidence-supported international perspectives about acute nursing care of the older adult with
Clinical review; fragility hip fracture. Developed by an international group of nurse experts and guided by a range
Nursing of information from research and clin-ical practice, it focuses on nurse sensitive quality indicators
during the acute hospi-talisation for fragility hip fracture. Optimal care for the patient who has
experienced such a fracture is the focus. This includes (in the first, earlier, part):

Pain
Delirium
and in this part
Pressure Ulcers
Fluid Balance/Nutrition
Constipation/Catheter Associated Urinary Tract Infection
Vigilant nursing assessment and prompt intervention may prevent the develop-ment of
the complications we discuss. If they do occur and are identified early on, they may resolve
with appropriate and timely nursing management.
This ‘‘tool kit’’ has been developed under the auspices of the International Collaboration
of Orthopaedic Nursing (ICON) a coalition of national associations of orthopaedic nursing
(www.orthopaedicnursing.org).
c
2012 Elsevier Ltd All rights reserved.

Pressure ulcers tolerance for pressure. Inability to reposition the body –

often present in the elderly – is an additional risk factor
Significance of problem/risk factors (Moore and Cowman, 2009).

A pressure ulcer is localised injury to the skin and/ or Following hip fracture, pressure injury resulting in
underlying tissue usually – over a bony prominence – as skin breakdown is devastating for the patient and costly
a result of pressure or pressure in combination with in terms of resources needed to treat the wound(s)
shear (EPUAP and NPUAP, 2009). Pressure ulcers are (Chaves et al., 2010; Remaley and Jaeblon, 2010).
common and present a major challenge for patients with Lindholm et al. (2008) reported pressure ulcer
hip fracture (Baath et al., 2010). While pressure and prevalence as 10% on admission and 22% at discharge
shearing force are the causative factors in pressure ulcer in a Pan-European study of hospitalised hip fracture
development, tissue tolerance is a key variable (DeFloor patients while Campbell et al. (2010) reported
and Grypdonck, 2004). The probability of pressure ulcer prevalence rates of 16–55% in hip fracture patients in
development increases with the duration and magnitude Canada. In the United States, Baumgarten et al. (2009)
of the force acting on the tissue. Shear greatly increases found the highest incidence of acquired pressure ulcer
the risk of pressure ulcer development because it occurs in the hospital setting. Assessment of risk factors
produces tissue ischemia that further reduces tissue
and strategies to prevent pressure ulcer formation
among older patients serves to avoid unnecessary
6 A.B. Maher et al.

Document any disruption in skin integrity pres-ent on

suffering, improve outcomes and control resource admission. This is helpful in developing a
consumption.
Houwing et al. (2004) showed that advanced age and
time on the operating table were risk factors for patients
with hip fractures. More recently, Ha-leem et al. (2008)
found, in their review of 4654 consecutive patients with
hip fractures, that the important factor in pressure ulcer
development was delay to surgery. Specifically, delay
between admission to hospital and time of surgery was
the most important risk factor. Patients operated on
within 24 h of admission develop significantly fewer
pressure ulcers compared to those whose surgery was
delayed longer than 24 h (Al-Ani et al., 2008; Hommel
et al., 2007a).

A predisposition to pressure ulcer development exists

in older patients, particularly in orthopaedic settings, and
those with co-morbidities such as dia-betes, respiratory
disease, low hemoglobin, low sys-tolic blood pressure
and altered mental status (Lindholm et al., 2008; Moore
and Cowman, 2008; Campbell et al. 2010). The
European Pressure Ulcer Advisory Panel (EPUAP) and
the US National Pressure Ulcer Advisory Panel
(NPUAP), in their 2009 joint document, recognise a
number of contributing fac-tors associated with the
development of pressure ul-cers. This also includes
cardiovascular instability, oxygen use, nutritional status
and skin moisture le-vel. However, the significance and
exact relation-ship between these factors has yet to be
established.

Assessment/detection

Pressure ulcer risk assessment is a nurse-sensitive

quality indicator (https://www.nursingquali-ty.org/).
Pressure ulcers can develop rapidly in the vulnerable
patient, so a skin assessment is important within six
hours of admission (Riordan and Voegeli, 2009) and
may be repeated as needed based on changes in the
patient’s condition.

Skin assessment
Skin assessment is a process that examines every body
surface of the individual for abnormalities. The nurse
looks at and touches the skin from head to toe,
particularly over bony prominences and any tissue
subjected to prolonged pressure such as the buttocks.
During this assessment the nurse uses techniques for
identifying blanching response, localised heat, oedema,
and induration (hardness). Blanching may not be visible
in darkly pigmented skin but its colour may be different
from the sur-rounding tissue.
plan of care to treat ulcers and to monitor their status.
Ask the patient about any areas that are painful or
uncomfortable as sensory changes may precede tissue
breakdown (EPUAP and NPUAP, 2009).

A comprehensive skin assessment includes five

elements:

Temperature
Color/discoloration
Moisture level
Turgor
Skin integrity (skin is intact or there are open areas,
rashes, wounds, etc. present).

Specifics about checking each of these compo-nents

can be found at: http://www.ahrq.gov/
research/ltc/pressureulcertoolkit/putool7b.htm. Scroll
down to Tool 3B, Elements of a Comprehen-sive Skin
Assessment. Helpful photos for assessing darkly
pigmented skin can be found at: http://
www.puclas.ugent.be/puclas/e/.

Pressure ulcer risk assessment

The goal of pressure ulcer risk assessment is to identify
those individuals who are at risk for the development of
pressure ulcers so that preventive care can be planned
and implemented. The process of assessing risk is
multifaceted and includes the use of a validated risk
assessment scale. A pressure ulcer risk assessment scale
is a tool for establishing a risk score based on a series of
risk factor criteria. Hospital policy or protocol identifies
the frequency with which risk assessment is to be
performed. Any change in the patient’s condition
requires reassess-ment of risk for pressure ulcer
(EPUAP and NPUAP, 2009).

Moore and Cowman (2008) found that despite

widespread use of risk assessment tools, no ran-domised
trials exist that compare them with un-aided clinical
judgment or no risk assessment in terms of pressure
ulceration. Pancorbo-Hidalgo et al. (2006) compare
various risk assessment tools with unaided clinical
judgment in a systematic analysis of studies of
predictive validity and find that the Braden Scale offers
the best predictive validity and notes that both the
Braden Scale and the Norton Scale are superior to
clinical judgment. The Braden Scale is most frequently
used in re-search and, along with the Norton Scale, is
recom-mended by the Agency for Health Care Research
and Quality (AHRQ) (Berlowitz et al., 2011).

The Braden Scale (http://www.braden-scale.com)

consists of six subscales (sensory per-ception, moisture,
activity, mobility, nutrition,
Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 7

and friction/shear) scored from 1–4 or 1–3 (1 for low tioning). The subscales are added together for a to-tal
level of function and 4 for highest level or no score that ranges from 5–20. Scores of 14 or less
impairment). Total scores range from 6–23. A low-er generally indicate at-risk status. Go to:
score indicates higher levels of risk for pressure ulcer http://www.ahrq.gov/research/Itc/pressureulcer-
development. Scores of 18 or less indicate at-risk status. toolkit/putool17b.htm and scroll down to Tool 3E.
This threshold may need to be adjusted for specific
patient populations (Berlowitz et al., 2011). Pressure ulcer description
EPUAP and NPUAP (2009) describe pressure ulcers by
The Norton Scale consists of five subscales (physical category/stage according to the appearance of the tissue
condition, mental condition, activity, mobility, involved. The terms unclassified/unsta-geable and deep
incontinence) scored from 1–4 (1 for low level of tissue injury used in the US are generally graded as
function and 4 for highest level of func- Category IV in Europe. Most
Table 6 International Pressure Ulcer Classification System. Source: European Pressure Ulcer Advisory Panel and National
Pressure Ulcer Advisory Panel. 2009. Prevention and treatment of pressure ulcers: quick reference guide. Washington, DC:
National Pressure Ulcer Advisory Panel.
Category/Stage Description
I: Non-blanchable Intact skin with non-blanchable redness of a localised area usually over a bony
erythema prominence. Darkly pigmented skin may not have visible blanching; its colour may
differ from the surrounding area. The area may be painful, firm, soft, warmer or
colder as compared to adjacent tissue. Category I may be difficult to detect in
individuals with dark skin tones. May indicate ‘‘at risk’’ persons.
II: Partial thickness Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink
wound bed, without slough. May also present as an intact or open/ruptured serum-
filled or serosanguinous-filled blister. Presents as a shiny or dry shallow ulcer without
slough or bruising*. This category should not be used to describe skin tears,
tape burns, incontinence-associated dermatitis, maceration or excoriation.
*
Bruising indicates deep tissue injury.
III: Full thickness skin Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle
loss are not exposed. Slough may be present but does not obscure the depth of tissue loss.
May include undermining and tunneling. The depth of a Category/Stage III pressure
ulcer varies by anatomical location. The bridge of the nose, ear, occiput and
malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can
be shallow. In contrast, areas of significant adiposity can develop extremely deep
Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
IV: Full thickness tissue Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar
loss may be present. Often includes undermining and tunneling. The depth of a Category/
Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear,
occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can
be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting
structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis
likely to occur. Exposed bone/muscle is visible or directly palpable.
Additional Categories/Stages for the USA
Unstageable/ Full thickness tissue loss, in which actual depth of the ulcer is completely obscured
unclassified: by slough (yellow, tan, gray, green, or brown), and/or eschar (tan, brown, or black)
Full thickness skin in the wound bed. Until enough slough and/or eschar are removed to expose the base
or tissue loss – of the wound, the true depth of the wound cannot be determined, but it will be
depth unknown either a Category III or IV. Stable (dry, adherent, intact without erythema or
fluctuance) eschar on the heels serves as ‘‘the body’s natural (biological) cover’’
and should not be removed.
Suspected deep Purple or maroon localised area of discoloured intact skin or blood-filled blister due
tissue injury – to damage of underlying soft tissue from pressure and/or shear. The area may be
depth unknown preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as
compared to adjacent tissue. Deep tissue injury may be difficult to detect in
individuals with dark skin tones. Evolution may include a thin blister over a dark
wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be
rapid exposing additional layers of tissue even with optimal treatment.
8 A.B. Maher et al.

Older patients with hip fracture may have poor

important is that the actual definition of pressure ulcer nutritional status. Patients who
and the level of skin/tissue injury are the same,
regardless of term used. For definitions of the
categories/stages, refer to Table 6. Go to
http://www.logicalimages.com/publicHealthRe-
sources/pressureUlcer.htm to view photos of pres-sure
ulcers with illustrations of the depth of the wound; or to
http://www.nursingquality.org and click on Pressure
Ulcer Training to view Module One.

Prevention strategies

It is universally agreed that pressure ulcers are best

prevented. Samuriwo (2010) suggests that nurses who
place a high value on pressure ulcer preven-tion appear
to be more proactive and determined to deliver care that
protects their patients’ skin. Carson et al. (2012)
describe the development and implementation of an
evidence based pressure ulcer prevention initiative. An
underlying focus of the framework for this initiative was
to improve the knowledge of clinical staff and to
strengthen the staff-nurse skin care champion model.
Harrison et al. (2008) report on a proactive program to
implement practice guideline recommendations on
pressure ulcer prevention. This program also created
unit-based skin care champions who use a peer to peer
learning approach to enhance the knowledge of clinical
staff and develop a unit based nurse resource model.
Both programs dem-onstrated a decrease in pressure
ulcer prevalence in their respective health care settings.

Pressure ulcers can develop at any time during

hospitalisation. Prolonged periods in the supine po-
sition may contribute to the development of such an
injury. Organisations should use some form of pressure
relieving surface for high risk patients on nursing units,
in the operating theatre, and in the emergency
department (Beckett, 2010; Pham et al., 2011a; Pham et
al., 2011b). Despite best ef-forts in some instances,
pressure ulcer develop-ment is an unavoidable
consequence of multiple organ failure or pre-admission
circumstances, such as a patient who has fallen and was
lying on a hard surface for many hours prior to hospital
admission.
Nutrition, skin care, appropriate support sur-faces
and repositioning all contribute to prevention efforts.

Nutritional status
Malnutrition is a common problem in hospital pa-tients
and often goes unrecognised (Somanchi et al., 2011).
are malnourished on admission to the hospital are twice
as likely as well-nourished patients to devel-op pressure
ulcers (Thomas, 2006). However, it is possible to reduce
the development of hospital-ac-quired pressure ulcers
among elderly patients with a hip fracture even though
they have poor pre-frac-ture nutritional status (Hommel
et al., 2007b). Re-fer to the section on
Nutrition/Malnutrition in this document for more
information on nutritional assessment and intervention.

Skin care and treatment

Appropriate preventive care for skin may minimise
progression to actual pressure ulcer. Normal age related
changes result in older adults having dry skin. Use skin
emollients for hydration as dry skin is a significant risk
factor on its own. Protect skin from excessive moisture
using a barrier product as needed. When deciding on
treatment plans, dis-tinguish skin excoriation due to
incontinence (incontinence associated dermatitis) from
pressure ulcer. Photos that demonstrate skin excoriation
can be found at: http://www.tissueviabilityon-
line.com/pu. Click on Grading and Tools, then on
Excoriation Tool.

Pressure reducing support surfaces

Reducing the amount, duration and intensity of pressure
exerted on the skin is the most effective strategy for
pressure ulcer prevention (Sakai et al., 2009). Place
individuals at high risk of devel-oping pressure ulcers on
pressure relieving surfaces rather than a standard
hospital mattress. However, it is not clear if an
alternating-pressure mattress or a constant low pressure
mattress provides a supe-rior benefit (McInnes et al.,
2011). Medical grade sheepskins are associated with a
decrease in pres-sure ulcer development (McInnes et al.,
2011). EPUAP/NPUAP Consensus Guidelines (2009)
recom-mend avoiding cutouts, rings or donut devices as
these increase pressure.

Repositioning
Repositioning is an essential aspect of prevention.
Repositioning encourages reperfusion to tissues and
reduces the risk of developing pressure related ischemia.
Repositioning schedules and technique incorporate the
patient’s medical condition, func-tional ability and
support surface used. The patient with a hip fracture
may present unique reposition-ing challenges.
Preoperatively, consider the frac-ture stabilisation
technique being used and postoperatively consider
fracture fixation tech-nique and limitations on motion
prescribed by the physician.
Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 9

When repositioning a patient it is important to lift, who are allowed postoperative hip flexion, raise the
not drag, the patient across the support sur-face. knees first, then the head of the bed (no more than 30
Transfer aids such as overhead lift equip-ment, if degrees). Roll the patient slightly to one side to release
available, help reduce friction and shear forces. The use shear, then settle back down so that the patient’s hips
of these devices must be made with consideration of the and knees are in alignment with the bends in the bed
type of fracture and postoper-ative limitations imposed. (Mimura et al., 2009) A 30-de-gree lateral position is
Repositioning a patient with a hip fracture may require often recommended. Even if the patient is lying on a
more than one caregiver. pressure-reducing mat-tress, assisting the patient with
scheduled reposi-tioning decreases the risk of pressure
In general, do not turn a patient onto a body sur-face ulcers (DeFloor et al., 2005). When the patient is able to
that remains reddened after previous reposi-tioning as sit in a chair, limit the time and use a pressure
this indicates the skin on that surface has not recovered redistribution surface to avoid pressure ulcer
from pressure loading. Massaging or vigorously rubbing development.
at-risk skin surfaces can be painful and may cause tissue
damage. Maintain the patient’s heels off the bed surface
by using heel-protection devices, e.g. a waffle boot or a Self-management strategies
pil-low under the calf. Placing a pillow under the calves
and keeping the knee in slight flexion may help to With your guidance, patients and their families can
minimise risk of deep vein thrombosis. participate in preserving intact skin. Some guide-lines
recommended by Nurses Improving Care for
When repositioning the patient on their side after Healthsystem Elders NICHE (2010) include:
surgery, consider any postoperative restric-tions. Place a
pillow or padding between the legs to prevent tissue 1. Change position at least every 2 h to relieve pressure
trauma at the knees and ankles. When raising the head
of the bed for patients
10 A.B. Maher et al.

2. If you cannot move yourself, ask for help chang-ing tions are likely to worsen with the stress of surgery and
your position the hospital experience. These are serious conditions that
3. Moisturise dry skin may lead to organ damage, delirium, functional decline
4. Tell your nurse if you develop reddened, purple, or and mortality. Fluid balance monitoring and
sore areas optimisation is a clinical imperative for this population.
5. Tell your nurse if you have a problem with leak-ing
urine or stool
Dehydration
6. Clean your skin immediately if you get urine or stool
on it
7. Use pillows to pad areas between knees and ankles. Dehydration is highly prevalent among the hospita-lised
Elevate heels off the bed or foot rest on chairs older adult with significant adverse conse-quences.
Institutionalised older adults admitted to acute care from
8. Do not lie directly on your hip bone residential facilities tend to present with dehydration due
9. Eat a well-balanced diet to pre-existing re-stricted fluid intakes. It is highly
probable the older adult is dehydrated on presentation to
hospital with hip fracture (Hodgkinson et al., 2001).
For the complete list, you can view the entire
Hospi-talisation may compound pre-existing
brochure at http://nicheprogram.org/need_to_-know.
Click on Skin Care: Pressure Ulcers. dehydration or increase the risk of dehydration.
Dehydration decreases circulatory volume resulting in
dimin-ished perfusion to organs and tissues and is impli-
Fluid balance and nutrition and cated in the development of delirium, renal failure,
elimination pressure ulcers, falls, venous thromboem-bolism,
impaired mobility, catheter associated uri-nary tract
Significance of the problem infection (CAUTI) and cystitis.

When older adults present with an acute hip fracture Dementia, delirium and decreased manual dex-terity
they do so in the context of frailty, often with pre- and immobility as well as communication and sensory
existing medical co-morbidity and other functional and impairments may all contribute to dehy-dration,
psychological issues. Older adults following hip fracture particularly if a delay to hospital presenta-tion has
repair may experience one or more com-mon post- occurred. The hip fracture and surgery may result in
operative complications including delir-ium, CCF, significant blood loss. Normal age related changes result
pneumonia, DVT, PE, pressure ulcer, arrhythmia, in a diminished thirst reflex and sub-sequent diminished
myocardial infarct, anaemia and mor-tality’’ (Agency fluid intake. Those patients who suffer from
for Clinical Innovation, 2010). These ‘common’ incontinence may limit fluid intake as a measure to
complications can impact the fluid bal-ance, nutrition reduce the risk of incontinence due to perceived lack of
and elimination status of the older adult with hip timely access to toileting. Limited mobility, unfamiliar
fracture and rarely occur in isolation. This section environment, concerns that re-quests for assistance will
addresses those aspects of care that benefit most from not be prompt enough to meet their need and the desire
nurse-initiated intervention: dehydration, malnutrition, to preserve dignity are factors that may influence this
constipation and cathe-ter associated urinary tract decision. Since hip fracture occurs in an emergency
infections. context, delay to surgery with an extended period of pre-
operative fasting is also a risk factor.
Fluid balance

Scope of the problem Assessment/detection

Age related changes in homeostatic mechanisms and Evidence supports taking a thorough clinical history that
underlying co-morbidities increase the vulner-ability of includes identifying the patient’s average dai-ly fluid
older people to the physiological stresses associated intake. The following signs and symptoms may indicate
with the hip fracture and surgery. White et al. (2009) dehydration:
found renal dysfunction in 36% of pa-tients admitted
with hip fracture and Carbone et al. (2010) reported the Diminished urine output
incidence of heart failure as 21% in this population. Hypotension, tachycardia
Frail older hospitalised patients are at risk for iatrogenic Dry lips, mucous membranes, diminished skin turgor
dehydration, fluid overload, heart failure, and electrolyte
distur-bances. Pre-existing heart failure or renal condi-
Muscle weakness, dizziness, restlessness, headache
Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 11

series provides added recom-mendations for hydration

Delirium which may be hypoactive management. http://

Upon presentation there are a range of strate-gies the

nurse can employ including clinical and biochemical
analysis (urine and blood markers) to assist in
assessment of dehydration.

Prevention and management strategies

Fluid and electrolyte management begins in the
Emergency Department with an accurate assess-ment
and formal recording of the patient’s fluid status
including documentation of the time (approximate) the
fracture occurred. Once a re-view of the patient’s
coexisting medical problems is correlated against their
likely fluid balance, pa-tients should have clinical and
laboratory assess-ment for possible hypo or
hypervolaemia, electrolyte balance and any identified
deficiencies appropriately and promptly corrected
(Scottish Intercollegiate Guidelines Network, 2009).

Where delay to surgery occurs and extended periods

of fasting ensue, nursing staff must ensure the patient
receives adequate hydration. Wherever possible,
attempts must be made to minimise peri-ods of fasting
from oral food and fluids in accor-dance with local
guidelines and policies that reflect best evidence. Mouth
care is important at all times but it is especially
important when oral fluids are restricted.

Nursing staff must continually assess the patient for

signs and symptoms of dehydration and fluid overload
as clinically indicated and in response to the patient’s
condition. Strategies include: ensur-ing regular vital
sign observations, maintaining accurate documentation
of fluid balance and prompt reporting of alterations to
the patient’s status. A nursing assessment of swallow
and/or referral for formal swallow screen should occur
where there is concern about the safety of the pa-tient’s
ability to swallow. Early resumption of oral intake in the
post-operative period is preferable, with intravenous or
subcutaneous supplementation secondary.

Patients’ access to fluids in the hospital setting is

often limited. Drinking containers should be
ergonomically suited to be manipulated by older
patients and placement of the container made in
consideration of any visual limitations. Nurses should
proactively offer fluids with each visit rather than
inquiring about the patient’s desire for a drink.
Intentional hourly nursing rounds (‘rounding’) should
include hydration needs. The following link to the
Hartford Institute for Geriatric Nursing’s ‘‘Try This’’
www.consultgerirn.org/topics/hydration_manage-
ment/want_to_know_more.

Fluid overload/heart failure

Certain populations of older adults with hip fracture

require more careful monitoring for fluid overload/ heart
failure. Diminished cardiac and renal function renders
the frail older adult susceptible to fluid overload i.e.
more fluid than the heart can effec-tively pump. (See
Scottish Intercollegiate Guide-lines Network SIGN 95,
2007 http://www.
sign.ac.uk/guidelines/fulltext/95/index.html & National
Heart Foundation of Australia, Cardiac Society of
Australia and New Zealand, Chronic Heart Failure
Guidelines Expert Writing Panel. Guidelines for the
prevention, detection and management of chronic heart
failure in Australia, 2006).

Assessment/detection
Risk factors include cardiac or renal disease, large or
rapid infusions of fluids and intravenous infusion with
sodium solution. Heart failure manifests with pulmonary
and peripheral oedema (Hartree, 2010).

The stress of surgery leads to an increased secretion

of the antidiuretic hormone (ADH) which impairs the
ability to excrete sodium and water. Symptoms to
monitor include:

urinary output less than 30 cc per hour

increasing blood pressure
shortness of breath
moist breath sounds
dependent edema

Prevention and management strategies

Carefully monitor fluid intake and output. Titrate fluids,
administer diuretics and/or restrict sodium in
consultation with physician or advanced practice nurse.

Electrolyte disturbances

Scope of the problem

Renal and cardiac decline, dehydration and fluid
administration and fluid losses during surgery in-crease
the risk of electrolyte disturbances. Hypo-natremia is
the most common electrolyte imbalance in the older
population and is associated with delirium and falls
(Gankam Kengne et al., 2008). Elevated serum urea
nitrogen and hyper or hyponatremia are associated with
significantly
12 A.B. Maher et al.

Malnutrition is often associated with ageing and is

higher mortality rates when left untreated (Lewis et al., characterised by ‘‘diminished hunger & thirst, chronic
2006). illness patterns, dentition issues and so-

Assessment/detection
Risk factors include cardiac or renal dysfunction,
dehydration or fluid overload and the use of diuret-ics.
Consult with the physician or advanced practice nurse to
ensure that lab tests are ordered for appro-priate patients.
Blood electrolytes and renal func-tion should be
regularly monitored until returned to baseline (Agency
for Clinical Innovation, 2010).

Prevention and management strategies

Monitor and manage fluid balance as described

above.
Consult with physician or advanced practice nurse for
clinical interventions to address imbal-ances. For
example, an accurate haemoglobin assessment is
needed to prevent impaired func-tional ability,
dizziness, delirium and risk of fall. In that case the
nurse consults with the physi-cian to ensure iron
supplementation and blood transfusion is ordered if
indicated.

Self-management strategies
Engage patient and family in learning about the:

Importance of hydration and how dehydration and

overhydration adversely affects health and personal
goals (e.g. decreased energy, falls etc.).
Strategies for facilitating hydration e.g. readily
available water – hot or cold, flavoured or not,
decaffeinated drinks, in easily manipulated
containers, drink offered with each interaction,
written and verbal reminders.
Strategies to mitigate incontinence e.g. timing of
fluids earlier in the day, limiting of fluids throughout
the day as appropriate, regularly scheduled toileting.

Chronic illness/Medications and their impact on fluid

balance. Importance of adhering to dietary and fluid
restrictions/guidelines.
Warning signs of dehydration, overload and what to
do.

Malnutrition

Scope of problem
cial isolation’’ (MacDonald, 2011). Studies show that
30–50% of patients admitted to an orthopae-dic unit
suffer from malnutrition (Ponzer et al., 1999; Eneroth et
al., 2005). Fry et al. (2010) re-ported that patients with
pre-existing malnutri-tion have a 2.5 times greater risk
of developing a surgical site infection, a 5.1 times
greater risk of developing a catheter associated urinary
tract infection and are 3.8 times more likely to devel-op
a pressure ulcer than those without malnutri-tion. Koren-
Hakim et al. (2012) found that poor nutritional status
was associated with ‘‘higher co-morbidity indices,
mortality and readmissions’’.

While hospitalised, it is estimated that hip frac-ture

patients consume only half their recom-mended daily
energy, protein and other nutritional requirements
(British Orthopaedic Asso-ciation, 2007) and despite the
development of fast-ing guidelines patients continue to
be kept without food or water for too long prior to
surgery.

Assessment/detection
The nurse is best placed to assess and monitor a
patient’s nutritional status particularly when the need for
nutrition support in an acute care set-ting often exceeds
the dietetic resources avail-able. The nurse can play a
critical role in identifying the ‘at risk’ patient, assess
nutritional status and initiate nutritional care that will aid
recovery and prevent functional decline, includ-ing an
assessment of mental capacity to consent (Jackson et al.,
2011). Nutrition for this patient population is an inter-
disciplinary concern (British Orthopaedic Association,
2007) requiring constant vigilance and liaison.
Examples of nursing inter-ventions to ensure timely
nutrition support include:

Nutrition history.
Weigh on admission; weight history (recent loss/
gain) and observe for lack of body fat, dry skin &
skin turgor.
Nutrition Assessment & Screening (such as MUST
by BAPEN (2003) (British Association of Paren-teral
Nutrition see http://www.bapen.org.uk/
musttoolkit.html).
Speech pathology review/consult for swallow
evaluation, when symptoms present and as
appropriate.
Minimise the period of preoperative fasting, in
accordance with policies and anesthesia protocols.

Where concern exists document food & fluid intake

(Food Diary).
Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 13

Encourage early resumption of oral intake par- may need more time to complete meals and may need
ticularly oral protein and energy supplementa-tion as more help, and plan for this reality. Does the patient
a strategy to minimise postoperative complication wear dentures? Are there adequate teeth for chewing
rate. foods? Does the patient have an oral fungal infection?
Initiate appropriate multi-nutrient supplements that Ensure that communica-tion is facilitated by having
are high energy and high protein containing hearing aids in place and eyeglasses on or available.
appropriate levels of vitamins and minerals at the Encourage patients to be out of bed for meals and
earliest convenience in the pre-operative period provide assistance as needed.
where possible; Dietician review/consult for
additional nutrition support. Several interventional studies suggest nutri-tional
Initiate nourishing fluids/mid-meal snacks. supplementation, specifically for the older adult hip
Optimise oral intake at meals: dentures, posi-tioning fracture patient, has a positive effect on quality of life
for meals, assisting feeding as necessary. and the reduction of hospital re-lated complications
(Gunnarsson et al., 2009; Volk-ert et al., 2006; Milne et
Where extended periods of inadequate oral in-take al., 2006). Interventions should be patient-focused, and
occur, consideration must be given to avoid ‘re-feeding aimed to minimise further nutritional decline throughout
syndrome’. This is a condition of meta-bolic and the recovery period (Dieticians Association of Australia,
electrolyte disturbance which occurs when nutrients are 2009).
replaced too quickly following a period of inadequate
nutritional intake for 5 days or more (National Institute Self-management strategies
for Health and Clinical Excellence, 2006). Every effort
Self-care strategies address both in-hospital and out-of-
should be made to avoid this syndrome through
hospital care and may include: the social as-pects of
appropriate and timely renourishment as potentially
eating and drinking in hospital in which el-derly patients
fatal shifts in fluids and electrolytes can occur
can benefit from eating together with other persons in a
(Mehanna et al., 2008). A systematic review by Skipper
dining room setting in the hospital (Gordge et al., 2009),
(2012) noted that although ‘‘there is no widely accepted
strategies to estab-lish a normal routine, supporting
or uni-formly applied set of defining characteristics for
people with dementia, help with opening containers and
diagnosing refeeding syndrome, hypophosphatemia was
pack-ets, use of strategies such as red trays and other
a consistent finding’’.
methods to prioritise high risk patients and inclu-sion of
informal carers appropriately in supporting good
For those patients where a high index of suspi-cion nutrition in hospital as an adjunct to profes-sional
exists for poor nutrition, consider early die-tary consult nursing care. Engage patient and family in learning
with the goal of optimizing nutritional status. A number about the:
of studies demon-strate positive benefits of early
nutritional supple-mentation (Volkert et al., 2006 &
Milne et al., 2006). In the event of an inability of the
Importance of nutrition in preserving health and
patient to take food orally, consideration should be
personal goals e.g. preventing hospitalisation, re-
given to temporary naso-gastric feeding. This decision
hospitalisation, falls, post-operative infec-tion etc.
should be made in full consultation with the pa-tient and
family and with full consideration of men-tal capacity,
the prognosis, advanced care planning and end-of-life Consult with dietician to develop specialised menus
and meal planning strategies at home.
decision making. The issue of sup-plementary feeding,
treatment escalation and palliation and the timing of Need for families to monitor: ability to obtain food,
such may need to be explored. prepare meals and the tendency to regu-larly skip
meals, especially if living alone.
Community resources for meals and dietary
assessment/services.
Strategies to mitigate incontinence e.g. timing of
Prevention and management strategies fluids earlier in the day, regularly scheduled toileting.
Be mindful that older patients are at risk for malnu-
trition and be vigilant at monitoring intake and out-put. Chronic illness/Medications and their impact on fluid
Complete a nutrition screening assessment such as the balance. Importance of adhering to dietary and fluid
MUST (BAPEN, 2003) tool calculation where restrictions/guidelines.
appropriate. Recognise the older person with Warning signs of dehydration, overload and what to
impairments (cognitive, sensory or motor) do.
14 A.B. Maher et al.

drug-induced constipation (Scottish Intercollegiate

Continence Guidelines Network, 2009) or con-

An assessment of continence should be made on

admission as part of the comprehensive assess-ment.
Early resumption of baseline bowel & blad-der habits
must remain the priority for the older adult hospitalised
with hip fracture. This section addresses two common
complications related to elimination: constipation and
catheter-associated urinary tract infection (CAUTI).

Constipation

Risk factors
Prevention of constipation should be considered in the
early management of hip fracture patients. Constipation
is made worse by dehydration, immo-bility, poor fluid
intake, decreased dietary fibre and general changes to
normal dietary routines. Opioid analgesics, even in low
doses also cause constipation (Scottish Intercollegiate
Guidelines Network, 2009). Constipation is an under-
appreci-ated cause of delirium in the older patient.

Assessment/detection
Constipation can manifest at any point along a con-
tinuum that ranges from general gut discomfort, nausea
and vomiting, abdominal or rectal pain to abdominal
distension and bowel obstruction. Agita-tion and
delirium may accompany any or all of these symptoms
The Joanna Briggs Institute (JBI) (2008) best practice
guidelines suggest the following:

Document baseline [on admission to hospital] and

usual bowel patterns.
Evaluate and document severity of constipation.
Document improvements or progression of con-
stipation &/or response to management of
constipation.

Prevention and management strategies

An emphasis on privacy, dignity, good accessibility to
toilet facilities (especially for people with
dementia/delirium), orientation and signage are
strategies the nurse can initiate to minimise consti-
pation. Wherever possible the impact of constipa-tion
should be minimised and at best avoided altogether
through the implementation of an evi-dence based
bowel protocol that incorporates pre-emptive
aperients/laxatives, a high fibre diet and fluids as
recommended in the British National Formulary for
sideration given to using a standardised grading tool
such as the Bristol Stool Scale (Lewis and Hea-ton,
1997). Conversely, overuse of laxatives or inadequate
drinking should not be underestimated as a problem
surrounding the management of constipation.

Some recommendations for practice include:

Delay to surgery and extended periods of fasting for

surgery can affect bowel function and should be
avoided wherever possible or proactively managed as
appropriate.
Unless otherwise restricted, fluids should be
encouraged to a minimum of 1500 mL of oral fluid
daily.
A regular toileting regime (every 2 h) that encourages
ambulation and discourages the use of bedpans
should be adopted.
Close monitoring of bowel habit should be recorded
including description of, frequency and amount of
bowel movement daily (SIGN 2009).

Aim for a bowel movement by post op day 2 then 48

hourly thereafter (Auron-Gomez and Michota, 2008).

Efforts should be made using the above strategies to

prevent secondary fecal impaction (Western
Australian Department of Health, 2008).

Catheter associated urinary tract infection

(CAUTI)

Scope of problem
Reportedly 40% of all nosocomial infections are
attributed to infections of the urinary tract (UTI) and
80% of these infections are associated with the use of an
indwelling urinary catheter (IUC) (Joanna Briggs
Institute, 2010; Centre for Disease Control, 2009).
Asymptomatic bacteriuria is a common occurrence in
older adults with hip fracture (SIGN, 2009) and the use
of an indwelling urinary catheter (IUC) increases the
risk for developing a UTI. Care providers may see
indwelling urinary catheters as beneficial, helping to
prevent falls and to address urinary incontinence and
patients will sometimes request them or refuse
discontinuation. It is impor-tant to remember that IUC’s
are not innocuous de-vices. In addition to increasing the
risk for CAUTI, indwelling catheters are associated with
local trau-ma to the urinary meatus, restriction of
mobility, pain, encrustation, delirium and increased risk
for mortality. A high index of suspicion for urinary tract
infection (UTI) should be ever present in the older adult
with hip fracture.
Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 15

Assessment and risk factors Close monitoring of cardiac or renal function in

The most significant risk factors for the develop-ment of critically ill patients.
catheter associated urinary tract infec-tions include; Comfort care measure in terminal illness.
insertion technique, inadequate cleansing with soap and Prolonged surgical intervention or surgery requiring
water, prolonged ‘dwell time’ and failure to maintain a decompression of the bladder.
‘closed’ system of drainage (Centre for Disease Control,
2009). Admis-sion assessment should include
information regard-ing the nature of the patient’s usual Prevention and management strategies
bladder function. Ongoing vigilance for and The presence of a catheter predisposes the patient to
documentation of the signs and symptoms of UTI must acquiring a urinary tract infection. When an indwelling
continue throughout hospitalisation. An indwelling urinary catheter is deemed necessary, incorporate
urinary catheter should be used in operative patients as maintaining adequate fluid balance with accurate
an exception rather than as a routine. recording of input and output, effec-tive analgesia and
routine catheter care into daily nursing care. There is
The Centre for Disease Control (2009) supports the unanimous support for the removal of the catheter at the
following indications for indwelling urinary catheter earliest conve-nience, preferably within the first 24 h, to
use: minimise infection, (CDC, 2009; Wald et al., 2005; Lo
et al., 2008). If there is a need to retain the catheter after
Urinary retention or obstruction unrelieved by 24 h, the clinical indication should be documented and
straight catheterisation. continual monitoring for removal when clini-cally
Stage 3 or 4 pressure ulcer in perineal area, sacrum appropriate. After removal, monitoring the
or ischial tuberosity.
16 A.B. Maher et al.

patient for retention/incontinence is required (Auron- Acknowledgements

Gomez and Michota, 2008).
Further research is recommended regarding the We would like to acknowledge the support of ICON
benefits of antimicrobial (silver and antibiotic constituents during the development of this paper,
impregnated) catheters to reduce CAUTI (Schumm and particularly Joyce Lai of AADO, Hong Kong, and
Lam, 2008; CDC, 2009). Inserting the smallest lu-men Reggie Aquilina of AMON, Malta.
catheter possible (CDC, 2009:12) and instilling 5 mL in We are grateful to the nurse experts whose input
the balloon minimises bladder irritation and trauma to guided and strengthened the paper. Those who re-
bladder neck and urethra. It is impor-tant to secure the viewed the entire document were Marie Boltz, PhD, RN,
catheter, avoid dependent loops in the drainage tube and GNP-BC (USA), Peter Davis MBE (UK), Sue Baird
position the collection bag below the level of the bladder Holmes, MS RN (USA).
(CDC, 2009). Nurses play a significant role in reducing Pain section reviewers were: Donna Sipos Cox,
the incidence of CAUTI by advocating for use only MSN, RN, ONC, CCRC (USA) Keela Herr, PhD, RN,
when clinically nec-essary and discontinuing as soon as AGSF, FAAN (USA), Alan Pearson AM (Australia),
possible. Brenda Poulton, RN, MN, NP (Canada).
Self-management strategies Delirium section reviewers were Marcia Carr, RN,
BN, MS, GNC(C) (Canada), Donna Fick, PhD, RN,
Engage patient and family in learning about:
FGSA, FAAN (USA), Lorraine Mion, PhD, RN, FAAN
(USA), Manuela Pretto, MNS, RN (Switzerland).
Risk factors, prevention and management of
constipation (e.g. high fibre diet, fluids, mobility). Pressure Ulcer section reviewers were Joyce M.
Black, PhD, RN, CSPN, CWCN, FAAN (USA), Chris-
Risks for and strategies to prevent urinary tract tina Lindholm, PhD, RN (Sweden), Zena Moore, PhD,
infection. MSc, PG Dip, FFNMRCSI (Ireland).
Perineal hygiene, adequate hydration, avoid Fluid Balance/Nutrition/Elimination reviewers were
indwelling catheter use/alternative strategies to Joanne Alderman, APRN-CNS, RN-BC, FNGNA
manage urinary incontinence. http://consult- (USA), Merete Gregersen, MHSc (Denmark), Nicky
gerirn.org/topics/urinary_incontinence/ Hayes, RGN, BA(Hons), MSc, PGCert (HE) (UK), Alan
want_to_know_more Pearson AM (Australia).
We thank Jennifer Gibson for her editorial expertise
Disclaimer and meticulous attention to detail and Judy Knight MLS,
AHIP, coordinator, library ser-vices for her valuable
This article was developed using a range of litera-ture assistance.
which included evidence-based research, con-sensus
documents, guideline statements, systematic reviews and
peer reviewed publications and also was informed by
best practice and content expert commentary. The References
information presented in this article is to educate and
inform the reader about common complications of Agency for Clinical Innovation (ACI), The orthogeriatric model of
fragility hip frac-ture in older adults. The decision to use care: summary of Evidence 2010 New South Wales agency for
clinical innovation, NSW.
specific assessment methods and interventions must be
Al-Ani, A., Samuelsson, B., Tidermark, J., Norling, ., Ekstro¨m, W.,
made by the individual practitioner/health care Cederholm, T., Hedstro¨m, M., 2008. Early operation on patients
organisation relative to the individual patient, available with a hip fracture improved the ability to return to independent
resources and other relevant factors. living. Journal of Bone and Joint Surgery Am 90, 1436–1442.

Auron-Gomez, M., Michota, F., 2008. Medical management of hip

fracture. Clinics in Geriatric Medicine 24, 7010719.
Conflict of interest statement Baath, C., Wilde-Larsson, B., Idvall, E., Hall-Lord, M.L., 2010.
Registered nurses’ and enrolled nurses’ assessments of
postoperative pain and risk for malnutrition and pressure ulcers in
There are no conflicts of interest for the authors of this patients with hip fracture. International Journal of Orthopaedic and
manuscript. Trauma Nursing 14, 30–39.
Baumgarten, M., Margolis, D.J., Orwig, D.L., Shardell, M.D.,
Hawkes, W.G., Langenberg, P., Palmer, M.H., Jones, P.S.,
McArdle, P.F., Sterling, R., Kinosian, B.P., Rich, S.E., Sowinski,
Role of funding source J., Magaziner, J., 2009. Pressure ulcers in elderly patients with hip
fracture across the continuum of care. Journal of American
No funding was obtained for this study. Geriatrics Society 57, 863–870.
Acute nursing care of the older adult with fragility hip fracture: An international perspective (Part 2) 17
Beckett, A.E., 2010. Are we doing enough to prevent patient injury Gordge, L., De Young, J., Wiechula, R., 2009. Reducing functional
caused by positioning for surgery. Journal of Periop-erative decline of older people in an acute-care setting: are we providing
Practice 20 (1), 26–29. adequate care to maintain/optimise the functional status of our
Berlowitz, D., VanDeusen Lukas, C., Parker, V., Neiderhauser, A., elder patients? International Journal of Evidence Based Healthcare
Silver, J., Logan, C., Ayello, El, Zulkowski, K., 2011. Preventing 7, 181–186.
pressure ulcers in hospitals: a Toolkit for improv-ing quality of Gunnarsson, A., Lonn, K., Gunningberg, L., 2009. Does nutri-tional
care. Agency for Healthcare Research and Quality, Rockville, MD. intervention for patients with hip fracture reduce postoperative
http://www.ahrq.gov/researchItc/ pressureulcertoolkit/. complications and improve rehabilitation? Journal of Clinical
Nursing 18, 1325–1333.
British Association of Parenteral Nutrition (BAPEN) 2003. The Haleem, S., Heinert, G., Parker, M.J., 2008. Pressure sores and hip
‘MUST’ Report: a Guide to the ‘Malnutrition Universal Screening fractures. Injury 39, 219–223.
Tool’ for Adults by Members of the Malnutrition Action Group Harrison, M.B., Mackey, M., Friedberg, E., 2008. Pressure ulcer
(MAG), a Standing Committee of the British Association for monitoring: a process of evidence-based practice, quality, and
Parenteral and Enteral Nutrition (BAPEN). Accessed via research. Joint Commission Journal of Quality and Patient Safety
http://www.bapen.org.uk/musttoolkit.html). 34 (6), 355–359.
British Orthopaedic Association (BOA), 2007. The Care of Patients Hartree, N. (2010). Fluid overload. In Patient.CO.UK. Retrieved Dec
with Fragility Fracture. British Orthopaedic Associ-ation, London, 2011 <http://www.patient.co.uk/doctor/Fluid-Overload.htm>.
England.
Campbell, K.E., Woodbury, G., Houghton, P., 2010. Heel pressure Hodgkinson, B., Evans, D., Wood, J., 2001. Maintaining oral
ulcers in orthopaedic patients: a prospective study of incidence and hydration in older adults: a systematic review. Joanna Briggs
risk factors in an acute care hospital. Ostomy Wound Management, Institute Library of Systematic Reviews.
44–45 (www.o-wm.com). Hommel, A., Bjo¨rkelund, K.B., Thorngren, K.-G., Ulander, K.,
Carbone, L., Buzkova, P., Fink, H.A., Lee, J.S., Chen, Z., Ahmed, A., 2007a. A study of a pathway to reduce pressure ulcers for patients
Robbins, J.R., 2010. Hip fractures and heart failure: findings from with a hip fracture. Journal of Orthopaedic Nursing 11, 151–159.
the cardiovascular health study. Euro-pean Heart Journal 3 (1), 77–
84, Retrieved from http:// search.ebscohost.com/login.aspx? Hommel, A., Bjo¨rkelund, K.B., Thorngren, K.-G., Ulander, K.,
direct=true&db=mn-h&AN=19892715&site=ehost-live. 2007b. Nutritional status among patients with hip fracture in
Carson, D., Emmons, K., Falone, W., Preston, A.M., 2012. relation to pressure ulcer. Clinical Nutrition 26 (5), 589–596.
Development of pressure ulcer program across a university health Houwing, R., Rozendaal, M., Wouters-Wesseling, W., Buskens, E.,
system. Journal of Nursing Care Quality 27 (1), 220– 227. Keller, P., Haalboom, J., 2004. Pressure ulcer risk in hip fracture
patients. Acta Orthopedica Scandinavica 75 (4), 390–393.
Chaves, L.M., Grypdonck, M., DeFloor, T., 2010. Protocols for
pressure ulcer prevention: are they evidence-based? Journal of Jackson, J., Currie, K., Graham, C., Robb, Y., 2011. The effectiveness
Advanced Nursing 66, 562–572. of interventions to reduce undernutrition and promote eating in
Centre for Disease Control (CDC) (2009) Guideline for Prevention of older adults with dementia: a systematic review. JBI Library of
Catheter Associated Urinary Tract Infections. http:// Systematic Reviews, JBL000306 9 (37), 1509–1550.
www.cdc.gov/hicpac/cauti/001_cauti.html.
DeFloor, T., Grypdonck, M., 2004. Validation of pressure ulcer risk Joanna Briggs Institute, 2008. Management of constipation in older
assessment scales: a critique. Journal of Advanced Nursing 48, adults. Best Practice Information Sheet 12 (7), 1–4.
613–621. Joanna Briggs Institute, 2010. Management of short term indwelling
DeFloor, T., DeBacquer, D., Grypdonck, M.H., 2005. The effect of urinary catheters. Best Practice Information Sheet 14 (12), 1–4.
various combinations of turning and pressure reducing devices on
the incidence of pressure ulcers. International Journal of Nursing Koren-Hakim, T., Weiss, A., Hershkovits, A., Otzateni, I., Grosman,
Studies 42 (1), 37–46. B., Frishman, S., Salai, M., Beloosesky, Y., 2012. The relationship
Dieticians Association of Australia (DAA), 2009. Evidence based between nutritional status of hip fracture operated elderly patients
practice guidelines for the nutritional management of mal-nutrition and their functioning, co-morbidity and outcome. Clinical
in adult patients across the continuum of care. Nutrition and Nutrition. April 19 (Epub ahead of print).
Dietetics 66, S1–S34.
Eneroth, M., Olsson, U.B., Thorngren, K.G., 2005. Insufficient fluid Lewis, J.R., Hassan, S.K., Wenn, R.T., Moran, C.T., 2006. Mortality
and energy intake in hospitalised patients with hip fracture. A and serum urea and electrolytes on admission for hip fracture
prospective randomised study of 80 patients. Clinical Nutrition 24, patients. Injury 37 (8), 698–704.
297–303. Lewis, S.J., Heaton, K.W., 1997. Stool form scale as a useful guide to
European Pressure Ulcer Advisory Panel and National Pressure Ulcer intestinal transit time. Scand Journal Gastroenterol 32 (9), 920–
Advisory Panel, 2009. Prevention and Treatment of Pressure 924, doi: 10.3109/00365529709011203. PMID‘ 9299672.
Ulcers: Quick Reference Guide. National Pressure Ulcer Advisory Retrieved from http://en.wikipedia.org/wiki/ Bristol_Stool_Scale.
Panel, Washington DC.
Fry, D.E., Pine, M., Jones, B., Meimban, R., 2010. Patient Lindholm, C., Sterner, E., Romanelli, M., Pina, E., Torray Bou, J.,
characteristics and the occurrence of never events. Archives of Hitenen, H., Iivananien, A., Gunningberg, L., Hommel, A., Klang,
Surgery 145 (2), 148–151. B., Dealey, C., 2008. Hip fracture and pressure ulcers – the Pan-
Gankam Kengne, F., Andres, C., Sattar, L., Melot, C., Decaux, G., European pressure ulcer study – intrinsic and extrinsic risk factors.
2008. Mild hyponatremia and risk of fracture in ambula-tory International Wound Journal 5 (2), 315–328.
elderly. QJM: Monthly Journal of the Association of Physicians
101 (7), 583–588, Retrieved from http:// Lo, E., Nicolle, L., Classen, D., Arias, K.M., Podgorny, K., Anderson,
search.ebscohost.com/login.aspx?direct=true&db=mn- D.J., 2008. SHEA/ISSA practice recommendations: strategies to
h&AN=18477645&site=ehost-live. prevent catheter associated urinary tract
18 A.B. Maher et al.
 infections in acute care hospitals. Infection Control and Hospital Remaley, D.T., Jaeblon, T., 2010. Pressure ulcers in orthopae-dics.
Epidemiology 29 (1), S41–S50. Journal of the American Academy of Orthopaedic Surgeons 18 (9),
MacDonald, V., 2011. Immediate postoperative management. In J. 568–575.
Waddel (Ed.), National Hip Fracture Tool Kit, p. 39. Riordan, J., Voegeli, D., 2009. Prevention and treatment of pressure
http://www.boneandjointcanada.com. ulcers. British Journal of Nursing. Tissue Viability Supplement 18
McInnes, E., Jammali-Blasi, A., Bell-Syer, S.E.M., Dumville, J.C., (20), S20–S27.
Cullum, N., 2011. Support surfaces for pressure ulcer prevention. Sakai, K., Sanada, H., Matsui, N., Nakagami, G., Sugama, J.,
Cochrane Database of Systematic Reviews Apr 13 (4), CD001735. Komiyama, C., Yahagi, N., 2009. Continuous monitoring of
interface pressure distribution in intensive care patients for
Mehanna, H.M., Moledina, J., Travis, J., 2008. Refeeding syndrome: pressure ulcer prevention. Journal of Advanced Nursing 65 (4),
what it is and how to prevent and treat it. British Medical Journal 809–817.
336 (7659), 1495–1498. http://dx.doi.org/ 10.1136/bmj.a301. Samuriwo, R., 2010. The impact of nurses’ values on the prevention of
pressure ulcers. British Journal of Nursing 19 (15), S4–S8.
Milne, A.C., Avenell, A., Potter, J., 2006. Meta-analysis: protein and
energy supplementation. Annals of Internal Medicine 144 (1), 37– Schumm, K., Lam, T.B., 2008. Types of urethral catheters for
48, Erratum in, Annals of Internal Medicine 2006 Apr management of short-term voiding problems in hospitalized adults.
4;144(7):538. The Cochrane Database of Systematic Reviews April 16 2 (15),
Mimura, M., Ohura, T., Takahashi, M., Kajiwara, R., Ohura Jr., N., CD00413.
2009. Mechanism leading to the development of pressure ulcers Scottish Intercollegiate Guidelines Network, SIGN 111, 2009.
based on shear force and pressures during a bed operation: Management of Hip Fracture in Older People –: A National
influence of body types, body positions, and knee positions. Clinical Guideline. SIGN, Edinburgh, Scotland.
Wound Repair and Regeneration 17 (6), 789–796. Scottish Intercollegiate Guidelines Network SIGN 95, 2007.
Moore, Z.E.H., Cowman, S., 2009. Repositioning for treating pressure Management of Chronic Heart Failure: A National Clinical
ulcers. Cochrane Database of Systematic Reviews Apr 15 (2), Guideline. SIGN, Edinburgh, Scotland, http://www.sign.a-
CD006898. c.uk/guidelines/fulltext/95/index.html.
Moore, Z.E.H., Cowman, S., 2008. Risk assessment tools for the Skipper, A., 2012. Refeeding syndrome or refeeding hypophos-
prevention of pressure ulcers. Cochrane Database Systematic phatemia: a systematic review of cases. Nutrition in Clinical
Reviews July 16 (3), CD006471. Practice 27 (1), 34–40.
National Heart Foundation of Australia, Cardiac Society of Australia Somanchi, M., Tao, X., Mullin, G.E., 2011. The facilitated early
and New Zealand, 2006. Chronic Heart Failure Guidelines Expert enteral and dietary management effectiveness trial in hospitalized
Writing Panel. Guidelines for the Preven-tion, Detection and patients with malnutrition. JPEN Journal of Parenteral and Enteral
Management of Chronic Heart Failure in Australia. National Heart Nutrition 35, 209–216.
Foundation of Australia, Sydney (Australia), pp. 76. Thomas, D.R., 2006. Prevention and treatment of pressure ulcers.
Journal of American Medical Directors Association 7 (1), 46–59.
National Institute for Health and Clinical Excellence, 2006. Nutrition
Support in Adults. Quick Reference Guide. Clinical Guideline 32. Volkert, D., Berner, Y.N., Berry, E., Cederholm, T., Coti, B.P., Milne,
A., Palmblad, J., Schneider, S., Sobotka, L., Stanga, Z., Lenzen-
NICHE, Nurses Improving Care for Healthsystem Elders, 2010. Need Grossimlinghaus, R., Krys, U., Pirlich, M., Herbst, B., Schu¨tz, T.,
To Know Skin Care: Pressure Ulcers. Hartford Institute for Schro¨er, W., Weinrebe, W., Ockenga, J., LochsEspen, H., 2006.
Geriatric Nursing, Division of Nursing, New York University. ESPEN Guidelines on Enteral Nutrition: Geriatrics. Clinical
Nutrition 25 (2), 330–360, http://
Pancorbo-Hidalgo, P.L., Garcia-Fernandez, F.P., Lopez-Medina, I.M., www.espen.org/documents/ENGeriatrics.pdf.
Alvarez-Nieto, C., 2006. Risk assessment scales for pressure ulcer Wald, H., Epstein, A., Kramer, A., 2005. Extended use of indwelling
preventions: a systematic review. Journal of Advanced Nursing 54 urinary catheters in postoperative hip fracture patients. Medical
(1), 94–110. Care 43 (10), 1009–1017.
Ponzer, S., Tidermark, J., Brismar, K., Soderqvist, A., Ceder-holm, T., Western Australian Department of Health, Aged Care Net-work.2008.
1999. Nutritional status, insulin-like growth factor-1 and quality of ‘Orthogeriatric Model of Care’/ Govt. of Western Australia, Dept.
life in elderly women with hip fractures. Clinical Nutrition 18, of Health, Perth. Available from http://
241–246. www.healthnetworks.health.wa.gov.au/modelsofcare/
Pham, B., Teague, L., Mahoney, J., Goodman, L., Paulden, M., Poss, docs/Orthogeriatric_Model_of_Care.pdf.
J., Li, J., Ierachi., L., Carcone, S., Krahn, M., 2011a. Early White, S.M., Rashid, N., Chakladar, A., 2009. An analysis of renal
prevention of pressure ulcers among elderly patients admitted dysfunction in 1511 patients with fractured neck of femur: the
through emergency departments: a cost-effective-ness analysis. implications for perioperative analgesia. Anaesthesia 64 (10),
Annals of Emergency Medicine 58 (5), 468–478. 1061–1065. http://dx.doi.org/10.1111/j.1365-2044.2009.06012x.
Pham, B., Teague, L., Mahoney, J., Goodman, L., Paulden, M., Poss,
J., Sikich, N.J., Lourenco, R., Ieraci, L., Carcone, S., Krahn, M.,
2011b. Support surfaces for intra-operative prevention of pressure
ulcers in patients undergoing surgery: a cost-effectiveness analysis.
Surgery 150 (1), 122–132.