Table 4.

NP Role in Managing Fractures in LTC.

Using a Holistic Approach

“I think the NP approach is more of a nursing focus, we tend to try and look at the whole picture and not just at the disease and what are we going to do about it. We try to look at the whole picture for the person. And because in this role or field, I’ve developed a rapport with all these different care personnel that we have no trouble working together.” (NP 4)

“It’s the whole um, story again, but knowing that, we can’t fix that fracture. And it’s going to take quite a while if it heals at all, it’s going to take a while and the healing will probably be a tenuous type of healing so we really have to focus on the pain and not having the pain management mess up their bowels or their nutritional intake, that’s a really fine line to find.” (NP 6)

Managing Medications

“I’ve worked hard at convincing staff that vitamin D is very important. What’s so funny that I find with the staff that you know, there’s always this issue of the number of meds that people in long-term care get and of course they want the doctor to help them and treat them. So they’d stop calcium or vitamin D, they’d stop that over stopping some of the psychotropics and I’m always saying no, let’s change this, we don’t need that, we can cut the psychotropics … It’s you know, not just meds, its multi-factorial, you have to address all of them.” (NP 1)

“I would say that at certain times, just the volume of medication and the competing comorbidities make it very difficult in terms of what medications to keep and what medications are going to go. So if you have somebody who has problem eating or struggling a bit then I think that’s something as well. And I also, I also think there is also a component that isn’t recognized with the idea that it may be a symptom of a decline in general overall health. Sometimes you see that with our dementia population there are lots of balance things that kind of signal things are changing within in them, and so they do have an increased risk with fracture [right] not necessarily just because of poor bone qualities but also because of ah, the comorbidities that they face.” (NP 8)

Utilizing a Multidisciplinary Approach to Prevent Falls

“Well it’s multidisciplinary that shows the strongest evidence right, so I think physio it’s really hard, but I think the big one physio, Tai-chi, lots of strengthening. I will give you more though, footwear, they have poor feet, you know, they are stumbling adequate footwear because of foot pain. A lot of people ignore this, underestimate, they are the things that we walk on and if you don’t have the proper footwear you have deformities and you’ve got ulcers and our feet enlarge as we age and so want to use their other shoes, so that attributes to it as well. Making sure they are on Vitamin D so that you improve the muscle strength and they’ve shown that as well. Pain control if they are in pain you know, they are more likely to fall, you know, so wide use of opioids then you don’t have the Tylenol. Increase lighting so they don’t fall there are so many things, that’s why it’s multidisciplinary, there’s so many factors, muscle control. Keeping the physio in LTC is very important.” (NP 10)

Caring for Residents Immediately After a Fall

“We typically get called into that in regards to frequent fallers. So we will get called and somebody has had a laceration and needs sutures to the head and then we also discover that they have had frequent falls and have had a fracture in the past so we get involved with individuals like that.” (NP 3)

Caring for Residents Upon Readmission After Hospital Stay

“… and just their whole quality of life, their ability to be socially active etc, all of that is very important, so how do you do manage pain and still allow them to have a life to live with.” (NP 11)

“We really look at what happened to cause that fracture [okay] and so we try to think of interventions around what happened that we can put in place to prevent it from happening again. And we usually do that in a multidisciplinary way in our falls, we call it our falls meeting [oh okay] so we have input from everyone on the team, and that’s a very important aspect.” (NP 7)

Managing Osteoporosis and Vertebral Fractures

“And then once we have an indication that they might be osteopenic or osteoporotic, we look at their medications and what they are on. Are they on a bisphonsonate and should they be, because there are reasons to not be on those also. Are they on calcium, although now there is a lot of controversy about how effectively calcium is absorbed and maybe at the maximum 500 milligrams a day should be given? We look at their dietary intake and of course Vitamin D, right now our standard is about 1000 international units. I know that there is controversy out there too, with some saying 2000 should be a standard dose. Right now our doctor, our main doctor is, looks for the 1000 international dosage. sometimes there is that sort of interaction or could be an order of some kind, blood pressure is a big thing, we watch blood pressures. I am finding more and more I’m taking people off blood pressure pills because you know what, you get on when you are 55, 65, even 75, you may not need when you are in this situation here when you are not worried about driving anywhere or have those normal stresses in your life. So blood pressure is a big thing that we look at … ” (NP 2)

“Well that’s a big area that is often overlooked hip fractures are the obvious ones, but vertebral fractures because they lose their balance. So one you’ve got problems eating, you’ve got problems with their respiratory so they are prone to pneumonia because of the acute posture. You’ve got them off balance because the center of gravity has moved over so there’s a higher risk for more falls and you’ve got the pain. Vertebral fractures are a big area but there is so much that can be done to prevent further and to reduce the pain.” (NP 9)

Note. NPs = nurse practitioners. LTC = long-term care.