Introduction

Some patients you will care for during your clinical placement will have been admitted to hospital via the emergency services, usually through the accident and emergency (A&E) department or similar named units. This can be a traumatic experience not only for the patient but also for their families, carers, friends and sometimes even the nursing staff working in the department. This chapter focuses on a patient journey from the A&E department to the orthopaedic ward where you are undertaking your clinical placement experience.

Introduction to patient and clinical problem

Mrs Elsie Waters is an 80-year-old woman who lives on her own in a small bungalow that has been adapted to her needs. Her son and his family live close by and he or his wife call every day to see if she needs anything. He has also ensured she has a mobile phone in case she requires help and she uses it to call with any shopping or other needs.

On this particular day, her son let himself into the house, calling to his mother that he had arrived and asking where she was. Not getting any reply, he became worried and started to search the bungalow. He heard a weak call for help and found his mother on the floor of the bedroom with the mobile phone some distance away. It was clear she had fallen for some reason and articles from the bedside table were all over the floor. She was weak but was able to tell her son that her right hip hurt and she was unable to move that leg.

He immediately called an ambulance and placed a pillow underneath his mother's head but did not move her until they arrived. Within 10 minutes, the paramedic team arrived, assessed the situation and made a provisional diagnosis of a fractured neck of femur. They ensured a safe transfer from the floor onto a stretcher and informed her and her son that they would be taking her to the hospital. Her son told them he would sort out some clothes and other things for her, as it was clear she would be required to stay in hospital, and that he would follow them. He phoned his wife at work to let her know about his mother and that he would be going to the hospital with his mother and that he would phone back once she had been seen by the doctor in the A&E department.

Falls in the elderly population

Being mobile is very important to an older person like Mrs Waters and, like her, many live independent lives. However, Hindle (2011) states that, according to Help the Aged data, falls in the elderly ‘represent over half of hospital admissions for accidental injury – particularly hip fracture’ (Help the Aged 2005).

Admission to hospital

When Mrs Waters arrives at the A&E department, she is experiencing a great deal of pain in her right hip and side, she has a cut on her head (which is thought to have happened when she fell and hit her head on the corner of her bedside table), her pulse rate is raised and she is very pale. She is also worried about her cat and who is going to look after him. Her son arrives and reassures her about this latter concern.

Immediate care in the A&E department

The Scottish Intercollegiate Guidelines Network (SIGN) guidance (SIGN 2002) would be used to guide the perioperative period of care for Mrs Waters, including the immediate management in the A&E department. The guidelines (section 4) recommend early assessment and recording of the following, either in A&E or if admitted first prior to surgery on the ward (SIGN 2002):

They also suggest there should be immediate steps taken to prevent the development of pressure sores and that those at high risk of developing pressure sores should be assessed using appropriate assessment tools. They recommend that any patient admitted to A&E with a suspected hip fracture should also be managed as detailed in Box 13.1.

The triage nurse assesses Mrs Waters as someone who requires to be seen immediately by the doctor and who requires pain relief and an X-ray in order to make a diagnosis and also to make her more comfortable. Pain relief is ordered by the doctor and given by the staff nurse looking after Mrs Waters, prior to her being moved from the trolley to the X-ray table. The nurse accompanies her to the radiography unit which is next to the A&E department so that patients can easily be transported and returned.

Return from X-ray

Mrs Waters returns from X-ray and a diagnosis of a fracture of the femoral neck or an intracapsular fracture is made. This type of fracture involves an injury whereby the ‘ball’ or femoral head is broken off from the main shaft. Treatment will vary according to age, previous health and the condition of the bone and joint itself. Main treatments are either an internal fixation (of the broken off head and the femur shaft) or hemiarthroplasty (part hip replacement of the femoral head into the undamaged socket). Sometimes a total hip replacement of both head and socket may be required. As Mrs Waters is 80 years old, does not suffer from dementia and is normally very mobile, it is decided that a hemiarthroplasty will be undertaken.

Going to the operating theatre

Mrs Waters is taken to the orthopaedic ward from the A&E department to become familiar with staff and the surroundings on return from the operating theatre and also to enable the nursing staff on the ward to prepare her for surgery. Due to the timing of her fall, she has not eaten or drunk anything for some time, and an intravenous infusion has already been commenced in the A&E department. Her son has remained with her during admission and this has helped the nursing staff considerably, as she has someone familiar with her who has been able to contribute information regarding his her health and prior mobility.

The surgeon who is to carry out the surgery later that morning is on the ward when she arrives and is able to speak with her and her son. He also obtains consent for the surgery to take place and ensures that the right leg is marked ready for the surgery. She is prepared for theatre by the ward nurses and postoperative care is explained to her.

Immediate postoperative care: first 48 hours

Mrs Waters undergoes a hemiarthroplasty, with a new head of femur inserted. She is taken to the recovery ward for immediate observations and care. See Box 13.2 for the SIGN consensus statement on instructions for discharge from the recovery area, together with essential aspects of patient recovery criteria.

As soon as Mrs Waters meets the criteria for discharge from the recovery area, she is taken back to the ward by a recovery room nurse and a nurse from the ward. (If your mentor is one of these, take the opportunity to request that you go with her to collect the patient so that you can gain an understanding of the handover process in the recovery room, including what the anaesthetist and surgical team have written in relation to her care and treatment during surgery and in the recovery room.)

Postoperative care after return to the ward until discharge home

Mrs Waters made a good postoperative recovery and does not experience the confusion that many elderly patients experience following orthopaedic surgery. However, she was slightly disorientated during her first 2 nights postoperatively (see Rogers & Gibson's [2002] study of the experiences of nurses caring for elderly patients with acute confusion). She could also have experienced problems such as constipation, e.g. due to lack of mobility, opioid analgesics, different diet, or, if she had a catheter inserted, a urinary tract infection. This is normally avoided if at all possible (SIGN 2002, Guideline 8.6).

The physiotherapist linked to the ward visits Mrs Waters in the first 24 hours postoperatively to introduce herself and to assess her ability to move. She begins rehabilitation with the physiotherapist 48 hours after surgery.

Ryan (2008) identifies some standard protocols for early mobilisation after surgery for a fractured hip. These are listed in Box 13.3.

As mentioned, Mrs Waters did not experience any major post-operative confusion as described by Wong et al (2002:69) but she was disorientated at night and not during the day:

They also noted that ‘the incidence of post-operative confusion is greater in orthopaedic than in general surgery’ (Wong, 2002:69).

Discharge from hospital and rehabilitation following a fractured femur

Mrs Waters' postoperative recovery was good and her prior good health was of benefit in this. Her son and daughter-in-law came to the ward to discuss with the surgeon and the nursing staff what the best rehabilitation process would be for her, and she was actively involved in this discussion process. This was very important for her psychologically as well as recognising her individual views in decision making.

It was agreed that she would live with her family for the first 6 weeks post-discharge until her follow-up appointment at the orthopaedic clinic, then they would discuss whether she could go back home to live on her own again. Mrs Waters thought this was the best choice for her.

She was therefore discharged home with her postoperative instructions, including the importance of not dislocating the new head of femur.

An example of patient information discharge advice is given in Box 13.4.

Summary

Being admitted as an emergency has a major impact on what happens to patients on admission to hospital and any subsequent postoperative care pathways.

In this brief overview of one such patient, you can begin to understand the kind of care patients such as Mrs Waters experience. Not all patients have swift recoveries when they are 80 years old. During your clinical placement experience, it is important for you to be able to manage the care of older patients in any context. Due to the increasing ageing population, there will be many more elderly patients requiring acute or long-term care.