Ambulation Decision After Hip Fracture in a Patient With Delirium
Mr. Bianchi is an 86-year-old man admitted with a displaced right femoral neck fracture, treated with hemiarthroplasty three days ago. He has mild baseline cognitive impairment, and post-operatively he has developed fluctuating confusion consistent with delirium (CAM-positive). He is on a urinary catheter and has a pressure injury on his sacrum. The surgeon orders "mobilize as tolerated." The therapist must decide whether to attempt standing and walking today, given the delirium and the risk of falls, while also considering the risks of immobility.
1. How should the therapist weigh the risks of early mobilization against the risks of immobility in a delirious post-operative patient?
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Risks of immobility: pressure injury progression, delirium worsening, deconditioning, pneumonia, venous thromboembolism, and loss of function.
Risks of mobilization: falls, dislocation (less likely with hemiarthroplasty but still possible), and injury to staff or patient.
Balancing: Early mobilization is generally beneficial and is recommended after hip fracture, but delirium requires a modified approach. The therapist should not abandon mobilization; instead, use a supervised, low-risk strategy: sit-to-stand at the edge of the bed with two staff, then standing with a walker if tolerated, with continuous supervision. Avoid walking if the patient is agitated or unable to follow commands. Coordinate with nursing and medical staff to address reversible delirium causes (pain, catheter, constipation, infection). Document the rationale and reassess daily. The decision is dynamic, not a one-time yes/no.
2. What specific precautions and adaptations would you use for today's session?
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Precautions and adaptations:
- Use a gait belt and two-person assistance.
- Ensure the environment is clear and the bed is at the correct height.
- Address pain before mobilization.
- Keep the session short (e.g., sit-to-stand, standing at the bedside).
- Monitor for orthostatic hypotension and confusion.
- Protect the sacral pressure injury; avoid prolonged supine positioning and check the area.
- Manage the catheter to avoid traction.
- Use simple, one-step commands and reorient the patient.
- Stop if the patient becomes agitated or unsafe.
Documentation: Record the session, tolerance, and any adverse events, and communicate with the team.
3. The patient becomes agitated and tries to stand without assistance. What is your immediate response and how do you prevent recurrence?
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Immediate response:
- Stay calm, use a reassuring voice, and guide the patient to sit or lie down safely.
- Call for assistance if needed; do not physically restrain unless necessary for safety.
- Check for causes of agitation (pain, full bladder, constipation, fear).
Prevention:
- Increase supervision and use a bed alarm if appropriate.
- Involve family or a sitter if available.
- Reorient the patient frequently.
- Coordinate with nursing and medical staff to manage delirium.
- Schedule mobilization when the patient is calm and rested.
- Document the event and update the care plan.