The Osteoporosis Disease - Report Example

Mrs. K was admitted to a rehabilitation ward with a fractured left tibia plateau. The 70 years old sustained the fracture when she fell in her home while under the influence of alcohol. Mrs. K suffers from osteoporosis hyperlipidemia and is a heavy smoker. She admitted to have smoked an average of 40 sticks of cigarette per day for the last 50 years besides consuming 3-4 glasses of wine daily. Mrs. K has a history of THR post MVA, which she suffered 30 years ago. The condition was complicated by osteomyletis and was so severe that she had to undergo a girdlestone procedure, which resulted into the shortening of her left leg. Osteoporosis is a disease that affects the bones causing them to become weak, brittle and fragile (Australian Institute of Health and Welfare [AIHW], 2008). The condition develops when the rate of bone resorption is higher than the rate at which the bones are formed. It results in significant decreases in bone density and alteration in the structure of bones (Farrell & Dempsey, 2011). Mrs. K has several risk factors for the development and exacerbation of osteoporosis. First of all, Mrs. K is a female and the condition is known to be common among women past the menopause stage. Her small body and Caucasian origin predispose her to low bone mass (Farrell & Dempsey, 2011). At 70, Mrs. K has low estrogen levels which exacerbate the rate of bone loss (Simmons, 2011). Because one of her legs is shortened due to a previous girdlestone procedure, Mrs. K has lost movement of that leg and has suffered from impaired mobility for the last 30 years. In addition, the capacity of her weight bearing exercises has been limited significantly and bone maintenance has been hindered because bones require stress for them to be restored (Farrell & Dempsey, 2011). Her heavy smoking and drinking habits seem to have impacted on the ability of her bones to regenerate. It has been observed that osteogenesis in bone remodeling is reduced in patients who smoke heavily or drink excessively (Sampson, 2012). Mrs. K. admitted to have sustained the fracture when she fell on her way to the toilet at night. Bessette et al have noted that fragility bone fractures can occur either spontaneously or after a minor trauma such as falling from standing height or an area less than 1 meter to the floor. There is a wide range of factors that may lead aged persons to obtain bone fractures. These include immobility, chronic pain, restrictions in social activities, decreased ability to perform activities of daily life and loss of independence (Roth, Kammerlander, Gosch, Luger & Bauth, 2010). If an aged person suffering from osteoporosis sustains an initial fracture, there are chances that the person will obtain the fracture again (Cooper et al, 2008). The poor condition of Mrs. K’s bones as a result of osteoporosis has made surgical intervention on the fracture impossible. To reduce stress, her doctor ordered a complete non-weight on the affected leg for a period of 12 weeks. To immobilize the knee joint, the doctor ordered that a knee brace remain in situ for a month until further assessment. This will help reduce any swellings and inflammations and also provide stability to the limb after a tibia plateau fracture (Farrell & Dempsey, 2011). For a quick recovery after the tibia plateau fracture, it was recommended that Mrs. K takes a physiotherapy exercise. The exercise would help strengthen the other limb that was not affected so as to aid for transfers. In addition, physiotherapy exercises would prepare both limbs for the prolonged duration during which the patient would remain non-weight bearing (Farrell & Dempsey, 2011). Special attention was required to ensure that the patient’s quadriceps and hamstring muscles in the affected limb are properly developed so as to ensure strength in stabilizing and assisting the knee (Gaston, Will & Keating, 2005). Mrs. K had to attend two, one-hour long physiotherapy visits each day. The physiotherapy team provided a schedule for the times she was required to attend the sessions. This schedule had to be strictly followed by Mrs. K. and the physiotherapy team which included the nursing staff coordinator. The nurses had to regularly remind Mrs. K of the schedules so that she could be able to perform activities of daily living before attending the sessions. This allowed her to reap optimum benefit of each session if she arrived in a timely manner. To manage the pain, Mrs. K had to take a regular dosage of Panadol. She, however, said that the pain exacerbated during activity. This necessitated a pain assessment, which required her to be given PRN pain relief prior to attending the physiotherapy sessions. Mrs. K had PRN order for Endone 5-10mg QID. It takes about 20-25 minutes for Endone to take effect (Tizianni, 2007). As such, she had to take the medicine about 30 minutes before the schedule physiotherapy session. This allowed efficient time management procedure and allowed Mrs. K to attend the physiotherapy sessions in a timely manner. The main focus for rehabilitation of patients with fractures is to restore them to the highest level of functioning possible. This is achieved by teaching them adaptive ways of managing activities of daily life by using special equipment and devices (Crisp & Tailor, 2009). A physiotherapist helped teach Mrs. K how to ambulate and transfer safely using a pick up frame. This was enforced and monitored closely by the nurses during the entire duration of her stay in the ward. Skin care Assessment: The Braden risk assessment tool was used to evaluate the chances of Mrs. K developing a pressure area as a consequence of limited mobilization. The Braden risk assessment scale is made of 6 categories, which are: sensory perception; activity; moisture; nutrition; mobility and friction and shear. Each of these six elements can contribute to the development of pressure ulcers. A low score on the Braden assessment indicates that the risks of developing a pressure area are high. Mrs. K scored 17 points on the scale. This placed her in the low risk category, but the nurses considered that her skin was at risk of breaking because of poor skin integrity (Joanna Briggs, 2009). This risk was related to a preexisting severe urticaria on her back, buttocks and sacrum. According to Mrs. K, this had become worse following her admission into the ward. Mrs. K was also observed to have poor nutrition and was underweight. In fact, her body mass index (BMI) was 18. Research studies have indicated that pressure ulcers are more prevalent in elderly patients with low body mass index (BMI of less than 18.5) (Compher, Kinosian, Ratcliffe, & Baumgarten, 2007). Actions/preventative measures: Mrs. K was advised to change positions every 2 hours and asked to refrain from scratching the affected area as this could make the condition worse. She was also administered ceterizine 10mg daily for treating urticaria. Any affected areas of her skin were assessed three times and calamine lotion was applied to sooth and give protection to the skin. The nurses encouraged Mrs. K to consume 1 Ensure plus nutrition daily to help improve nutritional status. Actual Outcomes: Mrs. K affirmed that the regular use of calamine and cetirizine reduced the discomfort arising from the urticarial. This was physically noticeable through reduction in both size and redness of the affected area. Mrs. K was found to comply with the instructions to change her position but her poor nutritional intake did not improve because of her failure to use the required nutritional supplement. Analysis of Evidence: O'Connell, Lockwood & Thomas (2008), have explained that the Braden scale is a good tool for predicting risks than a nurse’s judgment. Use of this assessment tool offers the best sensitivity and specificity balance and highest prediction capacity. The Joanna Briggs Institute’s systematic reviews on prevention and management of pressure ulcers indicate no evidence that nutritional supplements promote healing of pressure ulcers (2009). However, the recommended practice guidelines for pressure area care from the same institution indicate that altered nutritional care is a major risk factor for damages related to pressure. Falls Assessment: The Fall Risk Assessment Scoring System (FRASS) was used to assess the level of fall in Mrs. K’s case. FRASS takes into consideration the patient’s age, mental status, toileting needs, emotional status, sensory impairment, transfer needs, falls history within the past six months and medication history of the patient. A higher FRASS score indicates that the risks for fall are high. Following the Bayside health guidelines (2007), the FRASS tool was completed within a day of Mrs. K’s admission into the hospital. After all, Mrs. K’s condition and environment changed and hence the FRASS assessment had to be repeated. K scored 9 on the FRASS and this placed her in the high risk category. Actions/Preventative Measures: Different care practices were implemented and these included preventive measures against falls. To facilitate response and constant observation of Mrs. K’s progress, the nurse call bell and the pick up frame were ensured to be within an easy reach. Any obstacles and clutters from Mrs. K’s room were removed and a clear pathway to the toilet and bathroom maintained. It was necessary to ensure that the floor was dry all the time and this involved monitoring the shared bathrooms especially during mornings when they were actively used by other patients. The bed used by Mrs. K was maintained at an appropriate height and a non-slip foot wear was placed within her reach. In addition, Mrs. K was also provided with adequate education about the effects of hypertension as relates to her use of Endone. It was necessary to regularly monitor her blood pressure. Relevant documentations such as the FRASS tool as well as the handover sheet were completed and helped alert staff members of Mrs. K’s mobility status and level of risk. Mrs. K was advised to attend physiotherapy sessions twice a day and this helped her learn to use her pick up frame correctly, transfer safely and build muscle strength. Actual Outcomes: On several occasions, Mrs. K was found to be non-compliant with remedial measures to maintain her safety. For instance, she could not ambulate with socks on at times. The nursing staff observed strict adherence to environmental safety measures. While I was working at the hospital facility, Mrs. K did not sustain any falls or near misses. Upon admission to the hospital, it was required that Mrs. K be supervised for all transfers. After attending physiotherapy sessions for two sessions, Mrs. K was upgraded to being able to ambulate short distances in the ward without being supervised. Analysis of Evidence: Toba (2008) has noted that history of falls has been determined as one of the most important risk factors in assessing the risks of falls among the elderly. This view has also been supported by Brown (2004). Toba (2008) has also found that the risks of falling increase with age. The two factors (age and history of falls) were taken into account when making an assessment for FRASS tool. The use of falls risk assessment tool has been supported by best practice recommendations in falls prevention and intervention from the Joanna Briggs Institute (2010). The institute has also recommended individualized programs consisting of muscle strengthening exercises, balance restraining and environmental hazard screening and modification. Use of multimedia technologies and supporting devices has also been suggested by the Joanna Briggs Institute (2010) as being effective in the education of elderly patients about falls prevention. This has been supported by Hills and Haines (2009) who have noted that using a multimedia approach to educate elderly people in hospitals about falls is more effective than the written approach. Unfortunately, the hospital where Mrs. K was admitted lacks the capacity to offer this innovative approach. It was, therefore, necessary to use verbal communication to advice her since neither written nor multimedia information was available. Independence in ADL's: Prevention in functional decline Assessment: Mrs. K was assessed by an occupational therapist upon admission to determine the level of assistance required with her activities of daily life. Since she was admitted into a rehabilitation facility as opposed to an aged care institution, certain tools such as the Katz were not utilized. Instead, individual assessments by other disciplines were entered into Mrs. K’s progress notes and these were discussed during team meetings. Actions/Preventative measures: Mrs. K gained independence with her ADL except the preparation of meals which was provided by the facility. This being a rehabilitation facility, particular emphasis was focused on promoting maximum levels of independence for the patients. It was necessary to ensure that personal items were easily accessible and such aids as shower chair and pick up frame were provided so that Mrs. K could be able to carry on her ADSL with minimum assistance from the staff. Actual outcomes: Mrs. K was able to maintain her independence. This was extremely important to her as she had been very active and independent prior to her admission. Analysis of Evidence: The clinical Epidemiology & Health Services Evaluation Unit (2004) has found that "The rate of loss of strength might be as high as 5% a day with bed rest, and is greater in the lower limbs than in the upper limbs". It advises that it is important to develop a care plan that encourages activity throughout the day. Although Mrs. K attended physiotherapy sessions twice a day, there were no other regular programs to encourage extra activity. In fact, Mrs. K spent most of her time in bed apart from taking herself outside on a wheel chair to smoke. While planning Mrs. K’s discharge, it was imperative to seek input from the nursing staff and three other disciplines. Mrs. K provided a description of her home living environment which helped the care team to determine that Mrs. K had to climb three stairs to access her home. The information was important and was used by the physiotherapy team to plan an appropriate program, including being able to manage stairs. A home visit was scheduled by her occupational therapist. This would help identify potential risks and difficulties that could be encountered upon returning home. The visit could also help in determining appropriate aids to be installed and if referrals could have to be made to the community support services by a social worker. Currently, Mrs. K has a significantly altered level of mobility and this puts her in a greater risk of experiencing falls again (Cooper et al, 2008). In order for Mrs. K to attain maximum independence and quality of life, it is important that she is prepared adequately prior to returning home. She has to be educated on measures that she can take to prevent further falls, manage her ADL with ease and improve nutritional status and maintain good skin integrity. Read More