A fall at home, a short trip to the toilet at night, and suddenly an older person cannot stand. Hip fracture is one of the most common and serious injuries in later life. Around a quarter of older people die within a year, and many never regain their previous level of independence. Good nursing care, from the moment the patient arrives to the day they go home, makes a measurable difference to these outcomes.
Who gets hip fractures?
Most hip fractures happen in people over 65 after a simple fall from standing height. Risk factors include:
- Osteoporosis, especially in women after menopause
- Previous falls or fractures
- Dementia, delirium and poor eyesight
- Medicines that cause drowsiness or low blood pressure (sedatives, antihypertensives)
- Low body weight and poor nutrition
- Long-term steroid use
As populations age across Africa, Asia and Latin America, hip fractures are becoming more common in places where services for older people are still developing.
Recognising a hip fracture
Classic signs are:
- Pain in the hip or groin, sometimes felt in the knee
- Inability to stand or bear weight
- A shortened and externally rotated leg on the injured side
- Bruising and swelling around the hip
Some patients, especially those with dementia, may still walk with an impacted fracture, or may be unable to describe pain. Any older person who falls and has new hip pain or a new inability to walk needs an X-ray.
The first hours: emergency nursing priorities
- Assess for other injuries, such as head injury (especially if on anticoagulants), wrist fractures and pressure damage from a “long lie” on the floor.
- Find out why they fell. A fall may be caused by infection, stroke, a heart rhythm problem, dehydration or a medicine. Do a full set of observations, an ECG and blood glucose.
- Treat pain early. Good analgesia lets the patient be examined and moved more comfortably, and reduces delirium. Paracetamol and carefully titrated opioids are commonly used. Many guidelines, including NICE CG124, recommend a fascia iliaca or femoral nerve block in the emergency department for suitable patients.
- Protect the skin. Patients who have lain on the floor are at very high risk of pressure ulcers. Use a pressure-relieving mattress from the start and check heels and sacrum.
- Start IV fluids if the patient is dehydrated, as prescribed, and monitor urine output.
- Screen for delirium with a validated tool such as the 4AT.
- Bloods and preparation for surgery: full blood count, urea and electrolytes, group and save, clotting if on anticoagulants.
- Speed matters. Most patients do best with surgery on the day of or the day after admission. Delays increase complications and death.
Before surgery
- Keep fasting as short as possible. Many units allow clear fluids up to two hours before anaesthesia. Long “nil by mouth” periods in frail older people cause dehydration, hypoglycaemia and delirium.
- Review medicines with the team, especially anticoagulants, antiplatelets, diabetic medicines and Parkinson’s medicines (which must be given on time).
- Prevent blood clots as prescribed.
- Check consent and capacity. Many patients have dementia or delirium; involve families and follow local law on decision-making.
- Keep glasses, hearing aids and dentures with the patient. Disorientation worsens without them.
After surgery: preventing the big complications
1. Delirium
Delirium affects a large share of older people after hip fracture and is linked to longer stays, care home admission and death. Nurses can reduce it by:
- Regular orientation: clocks, calendars, explaining where they are
- Good pain control
- Encouraging fluids and food
- Avoiding constipation and urinary retention
- Promoting sleep at night with low noise and lights off
- Early mobilisation
- Involving family members who know the patient
2. Pressure ulcers
Reposition regularly, use pressure-relieving equipment, offload heels and keep skin clean and dry. Document skin checks at least every shift.
3. Infection
Watch for chest infections (encourage deep breathing, sit the patient up), urinary infections (remove catheters as early as possible) and wound infection.
4. Blood loss and anaemia
Monitor haemoglobin, observations and wound drainage. Anaemia contributes to fatigue, falls and delirium.
5. Venous thromboembolism
Give prescribed prophylaxis, encourage movement and watch for calf swelling or breathlessness.
6. Malnutrition
Many patients are already undernourished. Screen with a tool such as MUST, offer supplements and help with eating. Watch for refeeding risk in very malnourished patients.
7. Constipation
Opioids and immobility cause constipation, which worsens pain and confusion. Give laxatives as prescribed and record bowel movements.
Early mobilisation
Getting the patient out of bed, ideally the day after surgery, is one of the most important interventions. Unless the surgeon has advised otherwise, most patients can bear weight as tolerated. Work with physiotherapists to sit the patient out, stand and walk with a frame. Every day in bed costs an older person muscle strength they may never regain.
Bone health and falls prevention
A hip fracture is a warning sign. Before discharge, the team should:
- Assess bone health and start treatment for osteoporosis where appropriate (for example calcium, vitamin D and bisphosphonates).
- Do a multifactorial falls assessment: medicines review, eyesight, continence, footwear, home hazards and balance.
- Arrange strength and balance exercises.
Discharge planning starts on day one
- Find out how the patient lived before: alone or with family, stairs, mobility aids.
- Involve occupational therapy for home assessment and equipment such as raised toilet seats and walking frames.
- Teach patients and families about wound care, pain relief, signs of infection or clots, and how to get up safely after a fall.
- Plan follow-up and rehabilitation.
- Be honest and compassionate with families about recovery. Some patients will need more help than before.
When surgery isn’t possible or appropriate
For a few very frail patients near the end of life, surgery may still be the best way to control pain, but sometimes a palliative approach is chosen. In these cases, nursing care focuses on comfort, pain relief, pressure care and supporting the family.
Summary
- Suspect a hip fracture in any older person who falls and can’t walk.
- Give good pain relief early, including nerve blocks where available.
- Protect skin, prevent delirium and minimise fasting.
- Aim for surgery within 36 hours and mobilise the next day.
- Treat bone health and prevent future falls before discharge.
Hip fracture care is a team effort, but nurses are with the patient 24 hours a day. Small actions such as a glass of water, a pair of glasses, a turn in bed and a calm explanation add up to big differences in survival and independence.