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rehabilitation

An overview of the rehabilitation process

hip fracture rehabilitation

In many respects, surgery for hip fractures is the easy part.  For the patient, the hardest part is the rehabilitation process.  The goal of hip fracture surgery is to restore the patient to walking, but if the rehabilitation process is neglected, a hip fracture will often result in a permanent loss of independence.  Rehabilitation typically takes a team approach which has many parts, but includes the following key components:

  • good nursing care to make sure that the patient is properly cared for after surgery
  • adequate pain control
  • physical therapy to mobilize the patient and teach the proper use of  a walker
  • discharge planning to facilitate transfer to a skilled nursing facility

Lets look at a few of these elements in depth.

Nursing care. Bed rest is terrible for the elderly.  Studies show that muscle mass decreases by about 1% for every day spent entirely in bed.  If often takes 6 to 8 weeks to build back the strength that is lost in just a few days of bed rest.  After a hip fracture surgery, the patient is often groggy, has a poor appetite, and little enthusiasm for getting out of bed.   However, it is very important that the patient is mobilized immediately.  This means that the patient is encouraged to sit up or sit in a chair for meals, start using the bathroom as rapidly as possible, and gets twice daily physical therapy.  Once the patient is able to take fluids and food by mouth the IV fluids can be discontinued which disconnects the patient from a tube that is “tethering” them to the bed.  Once the patient is able to get out of bed to a chair, they can use a bedside commode and the Foley catheter can be removed.  Removing the Foley catheter and the IV tubing makes it much easier to get in and out of bed because there are fewer tubes to get tangled up in.  Nursing care at this point should consist of gentle encouragement that a little pain is expected and can be treated, but the patient must work to get out of bed and back on their feet again.  Occasionally, especially in a an elderly and frail patient, the post-operative period after a hip fracture can be the beginnings of the “dwindles” where the patient loses interest in eating, getting out of bed, and walking.  If this happens, it can be very hard to rehabilitate the patient back to walking.

Pain Control.  Narcotic pain medications are a wonderful tool for alleviating post-operative pain.  However, if they are used too frequently or in too high of doses, they can have significant side effects that can do more harm than good.  Narcotics tend to suppress the appetite and also cause constipation and difficulty urinating.  If they are used sparingly, they will alleviate some (but not all) of the pain the patient is experiencing but not interfere with normal appetite, bowel and bladder function, or balance.  It is a good idea to transition to oral pain medication as quickly as possible and it is also a good idea to emphasize to the patient that COMPLETE pain relief to the point where the patient is functionally anesthetized is not the goal of post-operative pain control.  Pain medications are best used to help the patient sleep and tolerate physical therapy.  They should be used SPARINGLY!

Physical Therapy.  Studies have shown that most patients over the age of 70 are able to put only partial weight on the operated leg, usually because their balance and coordination have deteriorated with age.  Therefore, most surgeons urge patients toward “weight bearing, as tolerated” immediately after surgery.  This translates into instructions for the patient to put as much weight as needed on the operated limb.   After the operation, movements should be slow, controlled, and relatively pain free.  Typically a walker is used to help with the patient’s balance and make sure that they feel steady on their feet.

Discharge planning.  In most hospitals, a care coordinator called a discharge planner will facilitate the transition out of the hospital.  This person has the job of balancing the demands of the insurance program (Medicare in most cases) with the family’s requests and the patient’s ability to get back on their feet again.  As of 2011, Medicare requires that patient’s stay in a hospital for 3 days before they are eligible to be transferred to a skilled nursing facility or rehabilitation facility.  This has become standard of care — to expect a 3 to 4 day stay in the hospital after surgery and then a 1-2 week stay at a rehabilitation facility if the patient looks like they are going to be able to return to living independently.  If the patient is really having a hard time with rehabilitation and it looks like they are going to require close supervision and nursing care for much longer than 3 to 4 weeks the discharge planner will usually start looking for a longer term facility.  Typical criteria for discharge include the following:

  • the patient is on oral pain medications and is eating and drinking
  • the Foley catheter and IV fluids have been discontinued and the patient is able to urinate and is getting back to normal bowel function
  • the patient has been mobilized by physical therapy and is able to tolerate some PT
  • the other medical issues that existed prior to the hip fracture have been appropriately addressed

 

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