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Nursing Diagnosis for Herniatednucleus pulposus : Acute pain related to nerve compression, muscle spasm Nursing Interventions for HNP: Assess complaints of pain, location, duration of attacks, precipitating factors / which aggravate. Set scale of 0-10 Maintain bed rest, semi-Fowler position with spinal, hip and knee in flexion, supine position Use logroll (board) during a change of position Assist patients in the installation of brace / corset Limit your activity during the acute phase according to the needs Teach relaxation techniques Collaboration: analgesics, traction, physiotherapy

2. Nursing Diagnosis: Impaired physical mobility related to pain, muscle spasm, restrictive therapy, and neuromuscular damage Nursing Interventions: Give / aids patients to perform passive range of motion exercises and active Assist patients in ambulation activities progressive Provide good skin care, massage point pressure after rehap change in position. Check the state of the skin under the brace with the periods of time. Note the emotional responses / behaviors in immobilizing Demonstrate the use of auxiliary equipment such as a cane. Collaboration: analgesic

3. Nursing Diagnosis for HNP: Anxiety related to the ineffectiveness of individual coping Nursing Interventions: Assess the patient's anxiety level Provide accurate information Give the patient the opportunity to reveal problems such as the possibility of paralysis, the effect on sexual function, changes in roles and responsibilities. Review of the secondary problems that may hinder the desire to heal and may impede the healing process. Involve the family.

4. Nursing Diagnosis for Herniated nucleus pulposus: Deficient knowledge related to the lack of information about the condition, prognosis Nursing Interventions: Explain the process of disease and prognosis, and restrictions on activities Provide information about your own body mechanics to stand, lift and use ancillary shoes Discuss the treatment and its side effects. Recommend to use the board / mat is strong, a small pillow under the neck a bit flat, sloping bed with knees flexed, avoiding the tummy. Avoid the use of heaters in a long time Provide information about signs that need attention such as stab of pain, loss of sensation / ability to walk.

A hip fracture is a femoral fracture that occurs in the proximal end of the femur (the long bone running through the thigh), near the hip. The term "hip fracture" is commonly used to refer to four different fracture patterns and is often due to osteoporosis; in the vast majority of cases, a hip fracture is a fragility fracture due to a fall or minor trauma in someone with weakened osteoporotic bone. Most hip fractures in people with normal bone are the result of highenergy trauma such as car accidents. In the UK, the mortality following a fractured neck of femur is between 20% and 35% within one year in patients aged 82, 7 years, of which 80% were women.
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Femoral head fracture denotes a fracture involving the femoral head. This is usually the result of high energy trauma and a dislocation of the hip joint often accompanies this fracture. It may be classified into four Pipkin's degrees.

Femoral neck fracture (sometimes Neck of Femur (NOF), subcapital, or intracapsular fracture) Subtrochanteric fracture actually involves the shaft of the femur immediately below the lesser trochanter and may extend down the shaft of the femur.

Signs and symptoms The classic clinical presentation of a hip fracture is an elderly patient who sustained a low-energy fall and now has pain and is unable to bear weight. On examination, the affected extremity is often shortened and unnaturally, externally rotated compared to the unaffected leg. Risk factors Hip fracture following a fall is likely to be a pathological fracture. The most common causes of weakness in bone are: Osteoporosis. Homocysteine, a toxic 'natural' amino acid linked to the cause of heart disease, Other metabolic bone diseases such as Paget's disease, osteomalacia, osteopetrosis and osteogenesis imperfecta. Stress fractures may occur in the hip region with metabolic bone disease. Benign or malignant primary bone tumours are rare causes of hip fractures. Metastatic cancer deposits in the proximal femur may weaken the bone and cause a pathological hip fracture. Infection in the bone is a rare cause of hip fracture.

Diagnosis X-rays of the affected hip usually make the diagnosis obvious; AP and lateral views should be obtained. In situations where a hip fracture is suspected but not obvious on x-ray, an MRI is the next test of choice. If an MRI is not available or the patient can not be placed into the scanner a CT may be used as a substitute. MRI sensitivity for radiographically occult fracture is greater than CT. Bone scan is another useful alternative however substantial drawbacks include decreased sensitivity, early false negative results, and decreased conspicuity of findings due to age related metabolic changes in the elderly.

As the patients most often require an operation, full pre-operative general investigation is required. This would normally include blood tests, ECG and chest x-ray. Femoral neck Femoral neck fracture three months after surgery. Femoral neck fractures involve the narrow neck between the round head of the femur and the shaft. This fracture often disrupts the blood supply to the head of the femur. British orthopaedic surgeon Robert Symon Garden described a classification system for this type of fracture, [3][4] referred to as the Garden classification and consisting of four grades: Type 1 is a stable fracture with impaction in valgus. Type 2 is complete but non-displaced. Type 3 is partially displaced (often externally rotated and angulated) with varus displacement but still has some contact between the two fragments. Type 4 is completely displaced and there is no contact between the fracture fragments.

The blood supply of the femoral head is much more likely to be disrupted in Garden types 3 or 4 fractures. Surgeons may treat these types of fracture by replacing the fractured bone with a prosthesis arthroplasty. Alternatively the treatment is to reduce the fracture (manipulate the fragments back into a good position) and fix them in place with metal screws. Common practice is to use repair Garden 1 and 2 fractures with screws, and to replace Garden 3 and 4 fractures with arthroplasty, except in young patients in whom screw repair is attempted [5] first, followed by arthroplasty if necessary. This is done in an effort to conserve the natural joint since prosthetic joints ultimately wear out and have to be replaced. A serious but common complication of a fractured femoral neck is avascular necrosis. The vasculature to the femoral head is easily disturbed during fractures or from swelling inside the joint capsule. This can lead to strangulation of the blood supply to the femoral head and death of the bone and cartilage.

Management Most hip fractures are treated by orthopedic surgery, which involves implanting an orthosis. The surgery is a major stress on the patient, particularly in the elderly. Pain is significant, forcing the patient to remain immobilized. Since prolonged immobilization can be more of a health risk than the surgery itself, post-op patients are encouraged to become mobile as soon as possible, often with the assistance of rehabilitation professionals such as occupational therapy and physical therapy (physiotherapy). Skeletal traction pending surgery is not supported by the [6] evidence. If operative treatment is refused or the risks of surgery are considered to be too high the main emphasis of treatment is on pain relief. Skeletal traction may be considered for long term treatment. Aggressive chest physiotherapy is needed to reduce the risk of pneumonia and skilled rehabilitation and nursing to avoid pressure sores and DVT/pulmonary embolism Most people will be bedbound for several months. Non[citation needed] operative treatment is no longer an alternative in developed countries with modern health care.

Fractured neck of femur Fracture treated with cannulated screws For low-grade fractures (Garden types 1 and 2), standard treatment is fixation of the fracture in situ with screws or a sliding screw/plate device. This treatment can also be offered for displaced fractures after the fracture has been reduced. In elderly patients with displaced or intracapsular fractures many surgeons prefer to undertake a hemiarthroplasty, replacing the broken part of the bone with a metal implant. The advantage is that the patient can mobilize without having to wait for healing. Traction is contraindicated in femoral neck fractures due to it affecting blood flow to the head of the femur. Complications of Fracture Neck of Femur The important complications are: a) Non-union b) Avascular necrosis of head of femur. Non-union Failure of union of this fracture still occurs due to improper reduction of imperfect internal fixation. When this occurs, the patient complains of pain and develops instability on walking. The condition is treated by intertrochanteric osteotomy (McMurray) in the younger age group and replacement arthroplasty in the elderly. In the very old patient with poor general condition, the only treatment possibly may be to keep the leg between sand bags and attend to the general care of the patient. As soon as the general condition is restored and the local pain relieved, physiotherapy is started. Movements of the hip are encouraged and the patient is got up on crutches about three weeks after the injury. Gradual weight bearing will lead to painless nonunion. This end result is practicable and is still useful in our country, in places where good surgical and hospital facilities are not available. Avascular Necrosis Avascular necrosis of the head of the femur is an unpredictable complication met with after any type of internal fixation. The patient presents with pain in the hip and limping. There is limitation of all movements of the hip with muscle spasm. Radiography shows patchy areas of increased density in the head of the femur. Treatment in the early stages is by rest, traction and weight relieving caliper. When indicated, osteotomy or replacement arthroplasty is done.

ANATOMY AND PHYSIOLOGY Anatomical factors The structure of the head and neck of femur is developed for the transmission of body weight efficiently, with minimum bone mass, by appropriate distribution of the bony trabeculae in the neck. The tension trabeculae and compression trabeculae along with the strong calcar femorale on the medial cortex of the neck of the femur form an efficient system to withstand load bearing and torsion under normal stresses of locomotion and weight bearing. In old age, osteoporosis of the region occurs. The incidence of fracture neck of femur is higher in old age. Blood supply to the head and neck of femur The profunda femoris artery arising from the femoral artery gives off medical circumflex femoral artery. This gives off the lateral epiphyseal and superior and inferior metaphyseal arteries. The lateral epiphyseal arteries are

important and supply the laterial 2/3 of the femoral head. The superior metaphyseal artery supplies the superior aspect of the femoral neck. The inferior metaphyseal artery supplies the inferior part of the neck and the adjacent part of the head derived from the metaphysis. The medial epiphyseal artery supplies a circumfoveal sector of the head. It is a continuation of the artery of the ligamentum teres which arises from the acetabular branch of the obturator artery. Femoral neck fractures that are intracapsular and may threaten any or all of the three sources of blood to the femoral head: the cervical vessels in the retinaculum of the joint capsule - usually damaged if the fracture is displaced intramedullary vessels - always torn from the ligamentum teres - usually contributes minimally in the elderly and not uncommonly, may be non-existent

In addition to the damage to the blood supply, the intracapsular nature of the fracture hinders recovery from the injury: intra-articular bone has only a thin periosteum and has no contact with soft tissues - the response to injury - callus formation - is weak blood remains inside the joint capsule, increasing intracapsular pressure and further damaging the femoral head; synovial fluid hinders clotting