Chest Pain at Day Two After Hip Fracture Surgery
Mrs. Nakamura is an 81-year-old woman on day two after a cemented hemiarthroplasty for a displaced femoral neck fracture sustained in a fall at home. She had spinal anaesthesia, has an indwelling urinary catheter, and is receiving dalteparin 5000 units nightly. Her haemoglobin is 92 g/L and her eGFR is 38 mL/min. The ward nurse asks you to get her up for the first time because she has been in bed for two days and the family is worried about pressure injuries. At 08:40, before you begin, she tells you she has new central chest discomfort, which she rates 5/10, and feels mildly breathless. She looks pale and slightly anxious. Observations: respiratory rate 24, SpO2 93% on room air (her admission baseline was 97%), heart rate 104 and irregular, blood pressure 138/74 mmHg, temperature 37.4 degrees Celsius, capillary glucose 7.8 mmol/L. The right calf measures 2 cm larger than the left, as it did yesterday. She has no chest-wall tenderness and no new leg pain.
1. Do you proceed with mobilisation? Justify your decision and state your actions for the next 30 minutes.
Read the worked answer
Do not mobilise. This is an escalation, not a treatment session.
Reasoning from the findings:
- New central chest discomfort plus breathlessness, tachycardia (104, irregular), a fall in SpO2 from a known baseline of 97% to 93%, pallor and anxiety on post-operative day two after major lower-limb orthopaedic surgery is a cardiorespiratory emergency until excluded.
- The differential, in priority order, is pulmonary embolism (immobility, pelvic/hip surgery, active but asymmetric calf swelling), acute coronary syndrome, atelectasis or pneumonia, fluid overload given eGFR 38, symptomatic anaemia (Hb 92 g/L), wound-site haematoma/bleeding, and anxiety as a diagnosis of exclusion.
- Dalteparin prophylaxis reduces but does not eliminate PE risk, and calf asymmetry that was already present still counts as a supporting feature.
- Exertion raises oxygen demand and right ventricular workload; mobilising a patient with a possible PE can precipitate collapse. The pressure-injury concern is real but does not outweigh this.
Actions: stay with her, call for help, sit her upright, give oxygen only under your local protocol/medical order (usual target SpO2 94-98%), apply continuous monitoring, repeat full observations with a 15-minute trend, obtain a 12-lead ECG, do not send her to the toilet or walk her, and request immediate medical review. If she deteriorates (falling SpO2, hypotension, reduced consciousness), activate the rapid response or medical emergency team. Document that therapy was withheld and why.
2. What must you record and how do you structure the escalation?
Read the worked answer
Documentation principles Record facts with times, not conclusions. Write her own words ('new central chest discomfort, 5/10'), the full observation set with the admission baseline for comparison (97% to 93%), heart rate and rhythm, calf measurement with the site used, and the time each observation was taken. State what you did (positioned upright, stayed with her, withheld mobilisation), who you notified, by what route, at what time, and what they said they would do, plus the time the medical review occurred. Write 'findings concerning for pulmonary embolism - escalated' rather than asserting a diagnosis; recognising and escalating sits inside physiotherapy scope, diagnosing does not.
Escalation structure (SBAR)
- Situation: 'Mrs. Nakamura, 81, day 2 hemiarthroplasty, new central chest pain and desaturation.'
- Background: hip fracture, spinal anaesthesia, dalteparin, Hb 92, eGFR 38, immobile two days, right calf 2 cm larger since admission.
- Assessment: chest pain 5/10, RR 24, SpO2 93% on room air against baseline 97%, HR 104 irregular, BP 138/74, afebrile to 37.4, anxious and pale.
- Recommendation: 'Please review now; I have not mobilised her. Do you want oxygen, an ECG, and a CTPA pathway started?'
Complete an incident report if your organisation requires one, and hand over directly to the nurse in charge rather than leaving a message.
3. Two days later she is medically cleared and the first mobilisation is rescheduled. What do you check before you stand her up, and how does each item change what you do?
Read the worked answer
Before the session
- Clearance and results: what was diagnosed and what the treatment plan is (anticoagulation intensity, any inferior vena cava filter, duration of bed rest ordered). If she has had a PE, early mobilisation is usually still indicated once therapeutic anticoagulation is established and she is stable, but timing is a medical decision.
- Haemoglobin and transfusion status: Hb 92 g/L explains some tachycardia and predisposes to exertional dizziness; recheck the current value and whether she has been transfused.
- Platelet count if she has had several days of heparin - a falling platelet count raises heparin-induced thrombocytopenia and would change anticoagulation.
- Timing of dalteparin: peak effect is roughly 4 hours after a subcutaneous dose. This does not contraindicate mobilisation, but it raises the consequence of a fall, so mobilise with a gait belt and two assistants if she is unsteady rather than deferring the session.
- Orthostatic risk: two days supine plus residual spinal anaesthesia and possible hypovolaemia. Measure lying and standing blood pressure; if systolic falls 20 mmHg or more with symptoms, sit on the edge of the bed first and re-dose the progression.
- Post-operative orders: weight-bearing status, hip precautions, catheter and fluid balance, pain score at rest and on movement, and screen for delirium (acute confusion is common and changes supervision and consent).
- Have a plan for the first stand: sit to the edge, pause, reassess symptoms and observations, then stand with assistance; stop for chest pain, disproportionate breathlessness, dizziness or SpO2 below the agreed threshold, and document the outcome.