CASE Scenario – Geriatric Bones Q&A PDF

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CASE SCENARIO – GERIATRIC BONES Q&AChief Complaints: severe back pain and the inability to do simple chores such as lifting grocery bags and her grandchild without pain. Physical Examination: she is afebrile with unremarkable findings with exception to the musculoskeletal system. She weighs 132 ...

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CASE SCENARIO – GERIATRIC BONES Q&A

CASE SCENARIO: Case Scenario: Hot Spells, Porous Bones Mrs. Pringle is a 62-year-old female experiencing diffuse bone pain over the past several years after menopause. She has a history of fractures to her left hip and wrist. She states, “The pain is becoming worse and it is keeping me from doing my daily activities.” She currently complains that any weightbearing activity causes her severe discomfort. She is not taking hormone replacement or any other medication. She has been using a soy herbal supplement and vitamin E 400 IU daily. She knows the importance of preventive healthcare. She is up to date on all her gynecological exams, and past mammograms have been normal as have her health maintenance exams. She does not smoke or use alcohol. Her system reviews are unremarkable excluding today’s complaint.

Her family history reveals that her mother had a history of anxiety, osteoporosis, non-insulin dependent diabetes and hypertension. Her father has hypertension but is in otherwise good health. There is no history of breast disorders or arthritis, thyroid or any other metabolic disorder. She lives alone in a one-story house. She has three children and one grandchild. Her daughter lives in close proximity to her so she is able to enjoy visiting and caring for her 3-year-old grandson occasionally. She has no exercise routine and admits to a somewhat sedentary lifestyle. She admits to eating a vitamin-poor diet. Mrs. Pringle experienced menopause around the age of 47 when her menstrual periods stopped. Her previous physician recommended no hormone replacement because she was not suffering from any menopausal symptoms. However, she now reports having “hot spells” at different times throughout the day with some trouble sleeping for the past 3 months. She also complains of some vaginal dryness that she admits is bothersome.

Chief Complaints: -

severe back pain and the inability to do simple chores such as lifting grocery bags and her grandchild without pain.

Physical Examination: -

she is afebrile with unremarkable findings with exception to the musculoskeletal system. She weighs 132 pounds and is 5 feet 5 inches. At her last exam 8 months ago, she was 5 feet 6 inches. Upon palpation, guarding and tenderness are present in the cervical, thoracic and lumbar spine with limited range of motion. No spasticity, rigidity or flaccidity is present. She has active range of motion in all joints, with no edema, redness or heat present in joint areas. She exhibits notable guarding and rigidity performing range of motion of lower and upper back areas.

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There is also noticeable guarding with some limitation of movement at the cervical spine area. She is able to endure the exam with noticeable painful expressions on her face when asked to do range of motion with back, guarding and tenderness noted at cervical spine area. There is no presence of dowager’s hump. She has no evidence of herniation or disc displacement upon inspection. No scoliosis or lordosis is present. Her preliminary urinalysis and CBC are unremarkable. Her symptoms indicate post-menopausal osteoporosis. To confirm the diagnosis and rule out other medical conditions, lab tests were obtained to assess hormone, calcium, vitamin D, blood cholesterol levels and thyroid function. Also ordered were a sedimentation rate to check for arthritis, an X-ray of her back and a dual energy X-ray absorptiometry (DEXA) scan to rule out injury. DEXA scan is the gold standard in diagnosis of osteoporosis. Diagnostic tests revealed a lack of estrogen and calcium. The X-ray of her back showed degenerative changes but no disc dislocations or herniations. The DEXA scan showed a T score of -2.9. A T score greater than -2.5 confirms a diagnosis of osteoporosis and indicates hormonal treatment should be initiated.

Study Questions: 1. What treatment/s might you expect to help address the loss of bone mineral density of Mrs. Pringle and reduce the risk of hip fracture? 

In case scenario, diagnostic test revealed of Mrs. Pringle is lack of estrogen and calcium. The decline in the hormone estrogen during menopause causes a woman's bones to thin faster. She need an adequate intake of calcium. In older adults and menopausal women need to consume approximately 1200 mg calcium a day . Mrs. Pringle needs to consume calcium supplement as well as Bisphosphonates and Ibandronate which are responsible for bone resorption. Mrs. Pringles also need diet therapy (low fat diet, foods that rich in calcium and proteins). To reduce the risk of hip fracture, the nursing management by health teaching to prevent injury, isometric exercise to strengthen trunk muscles and avoid bending, strenuous lifting.

2. How will you set your treatment goals to comply with the Mrs. Pringle stated goal of ‘bothering vaginal dryness’? 

Vaginal dryness is a hallmark sign of the genitourinary syndrome of menopause, also known as atrophic vaginitis or vaginal atrophy. With this condition, vaginal tissues become thinner and more easily irritated resulting from the natural decline in your body's estrogen levels during menopause. o Estrogen levels can also drop because of:  Childbirth and breastfeeding  Radiation or chemotherapy treatment for cancer  Surgical removal of the ovaries  Anti-estrogen medications used to treat uterine fibroids or endometriosis The most common treatment for vaginal dryness due to low estrogen levels is topical estrogen therapy. These replace some of the hormone your body is no longer making. That helps relieve vaginal symptoms, but it doesn't put as much estrogen in your bloodstream as the hormone therapy you take in pills.  vaginal moisturizer like glycerin-min oil-polycarbophil (Replens)

3. Develop a nursing care plan according to your identified priority plan of care. ASSESSMENT Subjective: “The pain is becoming worse and it is keeping me from doing my daily activities.” Chief complaint severe back pain and the inability to do simple activity daily living. Objective:  Weight – 132 pounds  Height – 5’5  Guarding and tenderness are present in the cervical, thoracic and lumbar spine with limited range of motion.  Rigidity or flaccidity is present  Noticeable painful expressions on her face when asked to do range of motion with back, guarding and

DIAGNOSIS Impaired physical mobility related to alteration in bone structure integrity due to lack of estrogen and calcium.

PLANNING Short term After 2 hours of nursing Intervention the patient will: - Verbalize understanding of situation and individual treatment regimen and safety.

NURSING INTERVENTION  Assist with treatment of underlying condition causing pain or dysfunction  Encourage client’s significant others involvement in decision making as much as possible.

RATIONALE

EVALUATION

 To maximize the potential for mobility and function.

After 2 hours of nursing Intervention the patient - Verbalize understanding of situation and individual treatment regimen and safety.

 Enhances commitment to plan, optimizing outcome.

Long term After 5 days on nursing Intervention the patient will: - Participate in activities of daily living (ADLs) and desired activities.

 Identify energyconserving techniques for ADLs

 To limit fatigue, maximizing participation.

 Demonstrate us of standing aids amd mobility devices and have care provider demonstrate knowledge about, and safe of use of device.

 Promote independent and enhance safety of the patient to make a good outcome

 Promote and facilitate early ambulation when possible. Aid with

 These movements keep the patient as functionally

After 5 days on nursing Intervention the patient - Participate in activities of daily living (ADLs) and desired activities.

tenderness noted at cervical spine area.

each initial change: dangling legs, sitting in chair, ambulation.

 Encourage low fat diet and maintain an adequate calcium intake.

working as possible. Early mobility increases self-esteem about reacquiring independence and reduces the chance that debilitation will transpire.  To maintain strong bones and to carry out many important functions.

Collaborative:  Collaborate with Physical medicine specialist and occupational or physical therapist in providing range of motion exercise.

 To develop individual exercise and mobility program  To identify appropriate mobility devices  To limit or reduce effects and complications of immobility....