Question

She feels better and would like to participate in joint physical therapy? What would you assess for before she engages in activity?

Mrs. Jones a 93 year old female with a history of dementia, osteoarthritis and heart failure is admitted s/p fall. She sustained a fracture of her left hip and is 2 days postoperative hip arthroplasty who requires 2 units of packed red blood cells due to intraoperative blood loss. Her preoperative hemoglobin was 10.3 mg/dl and hct 35.1. Postoperative her hemoglobin dropped to 9.1 and 30.8 on day 1 postop and 6.9 and 21.9 on day 2 respectively.

The health care provider orders: 2 units of packed RBCs with 20 mg of IVP Furosemide in between transfusions. Administer each transfusion over 3 hours. During the transfusion, Mrs. Jones exhibits a febrile reaction to the blood transfusion. The following day, Mrs. Jones’s CBC is assessed and it demonstrates an increase in her hemoglobin to 8.9. She feels better and would like to participate in joint physical therapy? What would you assess for before she engages in activity?

Answer 1

Dementia and hip fractures are two conditions predominantly commonly seen in oldest old. The main concern to note here in the case is elderly patient with hip fractures are more vulnerable to delirium specially when patient already has dementia. Delirium superimposed on dementia adversely affects outcome.

• Rehabilitation training and use of walking aids is difficult for this patient due to his cognitive dysfunction (delirium and dementia). It increases risk of falls and injuries due to difficulty in following instructions and impaired decision making. Hence a gradual progression of rehabilitation program is of utmost importance after careful assessment of mental status.
• Anther consideration which supports the above argument is that research studies have also shown that average length of hospital stay after hip surgery in elderly was considerably higher in the group having dementia than those without dementia.
• Patient had considerable blood loss and has received packed cells and was on bed. She needs to be assessed for orthostatic hypotension too. And appropriate scheduling of ambulation and safety measures is required. Sudden rising from bed is to be avoided.
• Patient should also be assessed for ‘Homan's Sign’ and other signs of venous thrombo embolism.
• Another point to note is patient was febrile post transfusion, so infection has to be ruled out. Assess for urinary tract infections, quite common due to urinary catheterization in hip surgery clients.

After that gradual resumption of activities can be planned.