416417654-Ncp-Osteoporosis PDF

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Summary

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Description

Assessment

Nursing Diagnosis

Planning

Implementation Assess patient’s knowledge of disease, diet, medication, and exercise program to arrest progression of bone deterioration.

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Assess the patient’s understanding of osteoporosis.

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Assist to plan exercise program according to capabilities. Teach patient about nutrition and calcium intake. Instruct patient in methods to perform activities of daily living and to avoid lifting, bending, or carrying heavy objects.

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Verbalization of the problem and request for information Fear of further bone loss and fractures Presence of preventable complication

Deficient Knowledge and Osteoporotic process and treatment regimen

After 8 hours of nursing intervention, the patient will be able to: 

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Achieve increased knowledge and compliance with medical regimen to minimize bone demineralizat ion and injury. Compliant with medication and dietary instructions. Perform daily exercises within identified limitations and to prevent further bone loss or deterioration.

Scientific Rationale

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Provides basis for teaching and techniques to promote compliance. Disease is not usually detected until 24-40% of calcium in bone is lost. Most individuals with osteoporosis are not diagnosed until an acute fracture occurs. Exercise will strengthen bone.

Adequate calcium helps to prevent osteoporosis. Prevents injury that can occur with osteoporosis with minimal trauma.

Evaluation

After 8 hours of nursing intervention, the patient was able to accurately verbalize understanding of medications and methods of administration and patient exhibits no injury, fall, or trauma that may predispose to a fracture.

Assessment

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Reports of pain Distraction; selffocusing/narro wed focus; facial mask of pain Guarding, protective behavior; alteration in muscle tone; autonomic responses

Nursing Diagnosis Acute Pain related to Fracture and muscle spasm

Planning

After 8 hours of nursing intervention, the patient will be able to:  

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Verbalize relief of pain. Display relaxed manner; able to participate in activities, sleep/rest appropriately . Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Implementation

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Maintain immobilization of affected part by means of bed rest, cast, splint, traction. Elevate bed covers; keep linens off toes. Evaluate and document reports of pain or discomfort, noting location and characteristics, including intensity (0–10 scale), relieving and aggravating factors. Provide alternative comfort measures (massage, backrub, position changes). Administer medications as prescribed by the physician. Provide emotional support and encourage use of stress management techniques.

Scientific Rationale

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Relieves pain and prevents bone displacement and extension of tissue injury. Maintains body warmth without discomfort. Absence of pain expression does not necessarily mean lack of pain.

Improves general circulation; reduces areas of local pressure and muscle fatigue. Given to reduce pain or muscle spasms. Refocuses attention, promotes sense of control, and may enhance coping abilities.

Evaluation

After 8 hours of nursing intervention, the patient was able to verbalize decrease pain intensity and demonstrate use of relaxation techniques and understanding of the importance of non-pharmacologic nursing pain management.

Assessment

Nursing Diagnosis

Planning

Risk Factors:  Malnutrition  Physical (e.g., broken skin, altered mobility)  Biochemical, regulatory function (e.g., sensory dysfunction, integrative dysfunction, effector dysfunction, tissue hypoxia)  Decreased hem oglobin  Developmental age (physiological, psychosocial)

Risk for Injury: Fracture related to osteoporotic bone

After 8 hours of nursing intervention, the patient will be able to:

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Assess general status of the patient.

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Be free from injuries. Explain methods to prevent injury. Identify factors that increase risk for injury. Relate intent to practice selected prevention measures. Increase daily activity, if feasible.

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Avoid use of restraints. Obtain a physician’s order if restraints are needed. Provide medical identification bracelet for patients at risk for injury. Ask family or significant others to be with the patient to prevent him or her from accidentally falling or pulling out tubes. Aid patients sit in a stable chair with armrests.

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Implementation

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Use culturally relevant injury prevention programs whenever

Scientific Rationale This is to determine the patient’s condition that may cause injury. If patients are restrained, they can sustain injuries.

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Signs are vital for patients at risk for injury.

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This is to prevent the patient from accidentally falling or pulling out tubes.

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Patients are likely to fall when left in a wheelchair. To prevent occurrence of injury.

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Evaluation

After 8 hours of nursing intervention, the patient was able to verbalize different measures on how to prevent injury and the patient was free from any injuries.

possible.

Assessment

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Inability to move purposefully within physical environment, including bed mobility, transfers, and ambulation Inability to perform action as instructed Limited ROM Reluctance to attempt movement

Nursing Diagnosis

Planning

Impaired Physical Mobility related to bone loss as evidenced by spontaneous fracture

After 8 hours of nursing intervention, the patient will be able to: 

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Maintain functional mobility as long as possible within limitations of disease process. Have a few, if any, complications related to immobility as disease condition progresses.

Implementation

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Assess patient’s functional ability for mobility and note changes. Provide range of motion exercises every shift. Reposition patient every 2 hours and prn.

Scientific Rationale

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Apply trochanter rolls and/or pillows to maintain joint alignment. Avoid restraints as possible.

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Encourage participation in diversional or recreational activities. Instruct family regarding ROM exercises, methods of transferring patients from bed to

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Identifies problems and helps to establish a plan of care. Helps to prevent joint contractures and muscle atrophy. Turning at regular intervals prevents skin breakdown from pressure injury. Prevents musculoskeletal deformities. Inactivity created by the use of restraints may increase muscle weakness and poor balance. Provides opportunity for release of energy, refocuses attention. Prevents complications of immobility and knowledge assists family members to be better prepared

Evaluation

After 8 hours of nursing intervention, the patient was able to receive assistance from the family and the nurse in performing ADLs and patient was able to perform activities to maintain functional mobility.

Assessment

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Deformity Kyphosis Loss of height Fractures Low Calcium level

Nursing Diagnosis

Planning

Imbalanced Nutrition related to inadequate Calcium and Vitamin D

After 8 hours of nursing intervention, the patient will be able to:  Present understanding of significance of nutrition to healing process and general health.  Verbalize and demonstrates selection of foods or meals that will accomplish a termination of weight loss.  Demonstrate behaviors, lifestyle changes to recover and/or keep appropriate weight.

wheelchair, and turning at routine intervals. Implementation

for home care.

Scientific Rationale

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Instruct recommended daily intake for calcium.

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Instruct on the importance of adequate exposure to sunlight to prevent vitamin D deficiency. Instruct patient to perform gentle exercises. Provide a balanced diet.

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Limit alcohol intake.

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Take a nutritional history with the participation of significant others.

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Vitamin D aids in absorption of calcium and improves muscle strength. The patient should be outside 15 minutes daily.

Exercise can help build strong bones and slow bone loss. A diet high in nutrients that support skeletal metabolism: vitamin D, calcium, and protein. Alcohol may decrease bone formation and reduce the body’s ability to absorb calcium. It may provide more accurate details on the patient’s eating habits.

Evaluation

After 8 hours of nursing intervention, the patient was able to verbalize different ways on how to have proper selection of foods that is needed for her condition....