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FRACTURED NECK OF FEMUR PROFORMA SW 03/10 Consultant Hosp Number Forename(s Surname Date / Time Date of Birth SHO/ NOF coordinator Next of Kin Bleep Ward Tel *36 hour breach date/ time:__________________ (MUST be completed for all patients) History (Please obtain collateral from Relative if present or contact care home where appropriate) Past Medical History: Does it include? (Tick relevant box and indicate when in the adjoining box) Myocardial infarction yes no Dementia yes no Angina yes no CVA yes no CCF yes no Epilepsy yes no Hypertension yes no Parkinson’s Disease yes no Diabetes Mellitus yes no Rheumatoid Arthritis* yes no COPD* yes no Hiatus Hernia yes no Asthma* yes no Peptic Ulcer yes no Previous # yes no Carcinoma yes no (please indicate site) If carcinoma, which type? * Is there a history of previous falls? Yes/ No Is there a history of osteoporosis? Yes/ No (if yes, ensure relevant medication is completed in the drug history section) Any Visual impairment? Yes/ No Other Past Medical History Proforma filled in by: SIGNATURE………………… Designation………………… PRINT NAME……………………… Bleep……… 1 FRACTURED NECK OF FEMUR PROFORMA SW 03/10 NAME……………………………………………………. DOB………………………… Not suitable for theatre without Ortho Geriatric Senior or Medical team review if: 1. 2. 3. 4. MI or CVA in last 1 month (If new MI or CVA refer to Medical SpR Immediately) Poorly controlled angina or CCF Uncontrolled Arrhythmias eg AF Rate > 100 Severe respiratory problems (Peak Flow less than 150L/min or hypoxic) * If COPD/Asthma, PEFR essential & consider arterial blood gases ON AIR * If Pacemaker it should have been checked in the last 1 year * If Carcinoma SEND Surgical Samples For Histology and X-Ray ALL of the Femur Social History Own house Sheltered Residential Meals on Wheels x wk Home help x wk Nursing home Other Carer? District Nurse x wk Day Centre x wk Barthel score in week prior to admission Bowels Grooming Toilet Incontinent 0 Incontinent 0 Unable 0 Unable 0 Occ. accident 1 Occ. accident 1 Help 1 Some help 1 Continent 2 Continent 2 Independent 2 Independent 2 Needs Help 0 Dependent 0 Immobile 0 Unable 0 Independent 1 Independent 1 Wheelchair 1 Major help 1 Dependent Some help Independent 0 1 2 Dependent Some help Independent 0 1 2 Walks with 1 Independent 2 3 Bladder Bathing Dressing Feeding Mobility Stairs Transfer 2 Minor help 3 Independent Total Score /20 Walking Aid & Type? Smoker (Number/day) Alcohol (unit/day) Medication (Dose & Times) All medications MUST BE LISTED in this section and not just on the drug chart * IF YES: Give Reason for Anticoagulation & check INR. See Trust guidelines for Warfarin and hip #. Anticoagulant * Allergies 2 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… Leg Shortened and Rotated? YES □ NO General Appearance (Anaemia; Breasts; lymphadenopathy) TEMPERATURE On Examination: Mild Pain = 1 No Pain = 0 PAIN Score Moderate Pain = 2 □ Severe Pain = 3 Cardiovascular System BP Pulse Rate Heart Sounds Other Pacemaker MmHg /minute Yes Acceptable Theatre Range Systolic 150-100 / Diastolic 50-100 Rhythm No Murmur to neck? Yes No If uncontrolled arrhythmias, aortic/mitral stenosis or evidence of ischaemia, not for theatre until reviewed by medical team (see ECHO guidelines). If Pacemaker has not been checked in last 1yr not for theatre until checked. Respiratory System Creps, Wheeze, Breath Sounds RESPS 02 sats. % % PEFR On air If 02 saturation less than 90% on air, not for theatre; refer for medical review & consider ABG on litres/02 litres/min If PEFR less than 150 l/min, not for theatre until reviewed by medical team Abdomen o 3 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… Central Nervous System Evidence of CVA? Yes No If evidence of new CVA, Refer to Stroke Nurse/ Medical Team Immediately & not for theatre till reviewed. Yes No If swallow reflex not OK, keep NBM & refer to Speech & Language Therapist (x6090) If yes, describe: If new CVA, is swallow reflex OK? MTS (MANDATORY) GCS Age D.O.B. Year Place Time (To Hour) Queen WWI Recognise 2 people 20 -1 backwards Recall Address Total /10 Eye Opening Verbal Response Motor Response Spontaneous To Command To Pain None Orientated Confused Random Grunts None Obeys Localises pain Withdraws Flexes to Pain Extends to pain None =4 =3 =2 =1 =5 =4 =3 =2 =1 =6 =5 =4 =3 =2 =1 Total / 15 MUSCULOSKELETAL SYSTEM Please document site and nature of any additional injuries identified Pressure Areas : please indicate if the following areas have any signs of pressure damage: SACRUM: Y/N RIGHT HEEL: Y/N LEFT HEEL: Y/N 4 Other site(specify: SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… Pre-operation Check List. - Not for Theatre Until Completed Results of investigations (MUST BE COMPLETED BY ADMITTING DOCTOR): Hip X ray comments (if any) Type of fracture - please circle on diagram LEFT □ RIGHT □ OR EXTRA CAPSULAR INTRA CAPSULAR Femur proximal, # trochanteric region Femur proximal, # of the neck Does it look pathological? Yes IF YES: Consent for and request biopsy for histology at operation & X-Ray entire Femur. No Bloods: Must be checked in ALL patients and results recorded below by 8am on day of surgery. Acceptable Pre-OP values Result Result Acceptable Pre-Op values Hb More than 10 g/dl Na 130 - 145 mmol/l WBC Less than 12 x 109 /l K 3.4 - 5.5 mmol/l 9 Plts 100 - 400 x 10 /l Urea Less than 15 mmol/l MCV Normal range 82-98 Creat Less than 200 umol/l INR <1.5 CCa 2.15-2.60 mmol/l Glucose/BM Less than 15 CRP 0-10 Sickle If Applicable Urine DStick + If [K ] < 4 Add K+ to IV fluids Group and Save? YES □ NO □ Chest X-Ray Performed? YES □ NO □ (MUST Have Pre-Op.) Results of Chest X ray LVF Yes No Infection Yes No Other Findings ECG Performed? ECG findings: YES □ NO □ 5 If evidence of LVF or infection, not for theatre until reviewed by medical team SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… Treatment Plan PLEASE REFER to A to Z for ELDERLY TRAUMA PATIENTS FOR PRE-OPERATIVE MANAGEMENT GUIDELINES MUST BE COMPLETED BY ADMITTING DOCTOR Blood results reviewed and acted on If on Anti-coagulation and INR>1.5, ensure appropriate action to reverse anticoagulation has been followed (SEE A to Z GUIDANCE NOTES) Group & Save sent Thromboprophylaxis risk assessment form completed online *THIS MUST BE COMPLETED FOR ALL PATIENTS* Give Clexane 40mg s/c od and TEDS (unless Clexane & TEDS contraindicated). Review dose in renal failure (eGFR<30) prescribed IFB requested (SEE PAGE 7) Analgesia prescribed All patients must be referred to anaesthetist for consideration of IFB (AVOID NSAIDS AND TRAMADOL in the elderly) Give Paracetamol 1g IV/ po QDS Codeine Phosphate and Morphine PRN ONLY N/ Saline(1L over 8 hr) - consider alternative fluid with IV fluids hyper/ hyponatraemia or seek advice if patient has signs of prescribed cardiac failure Prescribe Cyclizine 50mg TDS PRN unless Parkinsons Anti-emetic patient ( in PD use Domperidone 10mg TDS PRN) prescribed Laxido i sachet BD +/- Senna i-ii tablets nocte prescribed Prescribe CHO loading drinks and regular Fresubin i BD CHO loading regimen: 1 drink evening before surgery (all patients) then 1 drink 6am (morning list pts) OR 1 drink 11am (afternoon list pts) MRSA screen sent and Protocol Prescribed Test urine (if catheterised send urine for MRSA) Only Catheterise if clinically indicated e.g acute retention Dementia screening online assessment and AMTS (MANDATORY) NO ROUTINE ECHO If valvular stenosis suspected, use invasive monitoring, meticulous haemo-dynamic control & vasoactive agents ESM ?Aortic Stenosis GET OLD NOTES/ ECHO RESULTS Known Aortic Stenosis Last ECHO within 1 yr Documented results OK No new symptoms New ESM Any of: New symptoms SOBOE/ orthopnoea Angina Drop attacks Abnormal ECG (LVH, arrhythmia) High BP, narrow pulse pressure? YES No ECHO required ECHO required 6 NO No ECHO required SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… 7 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA Fascia-iliaca blocks (Bleep 504 or 930 to request block) This section to be completed by clerking doctor IFB requested: Yes □ □ No Date/ Time requested……………………………… Anaesthetist contacted: 504 □ 930 □ 730 □ (if 504 or 930 are unable to attend, contact obstetric anaesthetist on Bleep 730) Expected time of attendance………………………… Yes □ Any delay expected? No □ Reason for delay………………………………………………………………………… Alternative analgesia prescribed: Yes □ No □ This section to be completed by anaesthetist Anaesthetist (name/ designation/ bleep): Time attended: (*Name and bleep number of person completing IFB must be documented*) Consent Obtained: Yes □ Sterile: Yes □ Contraindications…………………………………………………. Time inserted: ) Single Shot IFB: Yes □ No □ Needle Tuohy …………..G Pump started: Yes / No Pain score- initial Catheter: Yes □ No □ Catheter……cm Levobupivicaine 0.25%............ml Pump prescribed: Yes/ No /10 Post IFB /10 Any Complications (please document) Pre-operative anaesthetic assessment and anaesthetic chart completed: Yes □ No □ Aim for IFB catheter where possible. IFB catheters should be reviewed for removal at 48 hours post-op. 8 FRACTURED NECK OF FEMUR PROFORMA SW 03/10 If For theatre – please tick when completed If For medical review Obtain consent If urgent or immediate need, bleep duty medical registrar Mark limb Surgery within 36 hours of Admission. Ensure Anaesthetist Aware of patient. *If unfit for surgery for Orthogeriatric Review next day or On call Medical Team Put on trauma list Yes / No Time Fit For surgery Nil by mouth from May eat & drink Please circle appropriate order -Indicate Nil by mouth only if patient is admitted between 12 midnight & 6 am and due to go to theatre. Cardiopulmonary Resuscitation Status FOR CPR or Not FOR CPR COMPLETE YELLOW DNAR FORM. See Hospital Guidelines. *Details of the person completing this proforma MUST be completed* SIGNATURE………………… Designation………………… PRINT NAME……………………… Bleep……… Date……… Time…………… 9 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… ASA score Class I II III Completely healthy Mild systemic disease Severe systemic disease – not incapacitating Incapacitating disease threatening life Moribund – unlikely to survive +/- surgery IV V Score= NHFS Age Sex Admission HB Living in a home No. of comorbidities Admission MTS Malignancy Variable 66-85 >=86 Male <10g/L Yes >=2 Score 3 4 1 1 1 1 <6/10 Yes 1 1 Score= Charlson Score 1. Acute MI; CVA; CCF I50; Connective Tissue Disorder; Dementia; Pulmonary Disease; PVD 2. Diabetes; Diabetes complications; Renal Disease; Paraplegia; Liver Disease; >3. Metastatic Ca; Severe Liver Disease; Cancer; HIV Score= 10 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… Orthogeriatric Review Orthogeriatrician…………………. Date……………. Time…………….. Pre- op □ Post op □ Day(s) post op: 1/ 2/ 3/ 4 (please circle) Operation performed: Hemi-arthroplasty □ DHS □ Cannulated Screws □ IM nail □ THR □ 11 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… 12 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA Name............................................................................... DOB............................................... Orthogeriatric falls and bone health assessment checklist: Bone Protection used (all patients>75yrs) Bisphosphonate/ Yes No If no, why not Strontium Calcium & Vitamin D Yes No Reason Strontium used If no, Why not **NOT FOR STRONTIUM IF HISTORY OF VTE OR IMMOBILE (d/w ortho-geriatric team directly) Osteoporosis risk factors (all males >50 and females 50-74yrs should be risk assessed) TICK ALL THAT APPLY BMI<19 Steroids EtoH Previous fragility fracture Smoking Premature menopause Sedentary Rheumatoid arthritis Parental History Coeliac disease DEXA Yes/ NO Inpt/ Outpt If no, why not Date: Osteoporosis screening bloods (Men over 50yrs and females under 75yrs) Vitamin D PSA (men) PTH Testosterone (men) Serum electrophoresis LH/FSH/Prolactin (if applicable) Urine electrophoresis Coeliac screen Medical Falls Assessment Medication review Postural BP Likely cause of fall Accidental/mechanical Unwitnessed Falls investigations requested 24hr tape 24hr BP monitor Visual Assessment Syncope Other (specify) ECHO Other AMTS (must be completed 72 hours post op) Score: Will this patient require OPD follow-up/ investigation: Orthopaedics Multi-factorial TILT test /10 Date completed: Medical 13 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA NAME……………………………………………………. DOB………………………… POST OPERATIVE ORTHOPAEDIC REVIEW ORTHOPAEDIC CONSULTANT………………………………….. Date of Operation………………… Procedure………………………………………………………………….. DAY 1 post-op review Date/ time……………………… Findings: Wound review: Check X-Ray result: Weight-bearing status (please circle): NWB/ PWB/ FWB * If NWB/ PWB, review in …….weeks Reviewed by (sign & print name)………………………. Designation……….. Bleep……... DAY 4 post-op review Date/ time……………………… Findings: Wound review: Check X-Ray result: Weight-bearing status (please circle): NWB/ PWB/ FWB * If NWB/ PWB, review in …….weeks Reviewed by (sign & print name)………………………… Designation………… Bleep……... Ortho happy for ongoing care under orthogeriatricians (please circle): YES/ NO (Patients will be reviewed at the request of the ortho-geriatric team if concerns arise) On-going daily orthopaedic input required (please circle): YES / NO (e.g. NOF patients with wound infection, peri-prosthetic or re-fracture, revision surgery, other site fractures requiring ongoing orthopaedic management) 14 SW 03/10 FRACTURED NECK OF FEMUR PROFORMA 15