Postoperative Day One After Hip Fracture Repair in an Older Adult

New or worsened confusion in an older postoperative patient is a physiologic alarm, not an expected part of aging, so the nurse should look for reversible causes before labeling it delirium from anesthesia. First assess airway, breathing, and oxygenation: SpO2 of 94% on 2 L plus shallow breathing and no spirometer use raises concern for atelectasis or early pneumonia, and hypoxemia is a leading cause of postoperative delirium. Next assess hemodynamics and volume status: BP 104/58 with only 180 mL urine in 8 hours suggests hypoperfusion or dehydration, which worsens confusion and raises fall and pressure-injury risk. Then review medications: hydromorphone in an 84-year-old with cognitive impairment is a strong delirium contributor, and the nurse should quantify total opioid received, time of last dose, sedation level, and respiratory rate trend. Also screen for urinary retention, constipation, and pain itself, since unrelieved pain and a full bladder both drive agitation. Finally check glucose, temperature trend, and the surgical site. Only after these are addressed should the nurse consider whether the baseline cognitive impairment is simply more visible now.

The order is plausible but not automatically safe, and the nurse should not hang it without a quick risk-benefit check. In an 84-year-old with hypertension and possible heart failure risk, a 500 mL bolus can precipitate pulmonary edema, yet the oliguria and low-normal BP suggest she may indeed be volume depleted. The nurse should first clarify the indication with the provider, confirm there is no history of heart failure or renal disease on the chart, and verify current weight and recent creatinine. If proceeding, give it as ordered but reassess after each portion: lung sounds, work of breathing, SpO2, jugular venous fullness, and urine output. Reasonable monitoring: vital signs every 15 minutes during the bolus and for 30 minutes after, strict intake and output with hourly urine measurement, daily weights, and a prompt call to the provider if crackles develop, respiratory rate rises, or SpO2 falls. The nurse should also address the underlying cause of oliguria, including whether the patient is retaining urine, and document the reassessment. The key judgment is that fluid resuscitation in older adults is a monitored intervention, not a set-and-forget order.

The nurse should advocate for a multimodal, opioid-sparing plan rather than continuing as-needed hydromorphone alone. Because pain of 6/10 limits deep breathing and mobilization, undertreating pain is itself a delirium and pneumonia risk, but so is oversedation. A reasonable approach: scheduled acetaminophen if not contraindicated, small carefully titrated opioid doses with reassessment of sedation and respiratory rate before and after each dose, and nonpharmacologic measures such as repositioning, splinting the incision for coughing, and ice. For delirium prevention, the nurse should build a structured day: orient the patient frequently, keep glasses and hearing aids in reach, mobilize as soon as the surgical team allows, encourage incentive spirometry every hour while awake, maintain a normal sleep-wake pattern with lights off at night, avoid unnecessary catheters and tethers, and monitor bowel and bladder function. The nurse should also request that the glargine and correction insulin plan be reconciled with actual intake, since hypoglycemia can mimic or worsen delirium. Document the baseline cognitive status so the team can measure change objectively, and use a validated delirium screen each shift.