A Case Study On

Lumbar Compression Fracture

In Partial Fulfillment ofNursing Care Management 203Related Learning Experience

Submitted by:

BSN 3 – GROUP 7Date of Defense: May 4, 2010

TABLE OF CONTENTS

I. Nursing Health History

II. Gordon’s Functional Pattern

III. Physical Assessment

IV. Laboratory Results

V. Anatomy and Physiology

VI. Pathophysiology

VII. Ideal Signs and Symptoms

VIII. Summary of Significant Findings

IX. Nursing Care Plans

X. Drug Study

XI. Discharge Plan

XII. References

Nursing Health History

DEMOGRAPHIC DATA :

Name : Patient Mrs. X

Address :

Age : 78 years old

Birthdate : September 13, 1931

Birthplace :

Sex : Female

Civil Status : Widow

Citizenship : Filipino

Religion : Roman Catholic

Occupation : Before Counselor for 5 years

Barangay Captain for 12 yearsFarm Inspector for 9 years

At Present Farmer, Midwife & Dressmaker

Informant : The patient

Ward : Medical ward-57A

Hospital :

Case no. :

Impression : Lumbar Compression Fracture2° to Osteoporosis

CHIEF COMPLAINT: LOW BACK PAIN

CURRENT HEALTH STATUSThe patient decided to seek medical help when she experienced

persistent severe lower back pain and muscle cramps in her legs. She went to ODH for consultation and was advised by the attending physician to be very careful in doing her daily activities to avoid further injury. She was given Arcoxia for medication and treatment.

After several days, the patient’s condition did not improve. She went back to ODH, and was advised by the physician for hospitalization, so she would be properly examined and diagnosed. She was confined in the hospital for five days (from April 22 to 26, 2010.) Her Roentgenologic Report manifested a compression fracture on her lumbar 2, Degenerative osteoarthrosis of Lumbar spine with straightening due to muscular spasm and osteoporosis. Her medications were Ketorolac 30mg, Tenoxicam 20mg and Calcium carbonate.

PAST MEDICAL HISTORYThe patient experienced common childhood diseases and minor

illnesses such as chickenpox, measles, mumps and common colds. She was never been hospitalized before due to these minor ailments nor undergone any kind of surgeries. Adult illnesses experienced were cough, colds, fever, asthma, malaria and rhinitis which she self-medicated with herbal medicines and/or over-the-counter drugs.

Last 2003, the patient fell off from a carabao and suffered severe lower back pain. She was brought to Cebu City for medications and treatment. She recovered from the indicent, she did not feel any pain in her lower back anymore until recently.

The patient learned that she had an asthma when she was hospitalized last June 2009 due to difficulty in breathing. The medications prescribed to her were multivitamins, Ponstan and Duevent.

She said that she had no allergies to food, drinks, drugs or any environmental substances. She could not identify the irritants that could trigger her asthma.

She also informed that she had immunizations given by their barangay, like BCG, Hepa B, Tetanus toxoid and Measles, because she knew that it was an important means of preventing illness

The patient was an alcohol drinker (tuba) and a tobacco smoker. According to her she consumed approximately 2-3 glasses of tuba per day and more or less 5 tobacco sticks per day.

FAMILY HISTORYThe patient’s father died because of a vehicular accident and her

mother died due to old age. She was the fourth child among the ten siblings of which eight were male and two were female. Five of her siblings, all male, were already dead. Two died due to an unknown cause, while the other three died due to severe headache, bone cancer and severe bleeding.

Mrs. X was a widow for seven years. Her husband died due to a heart disease. They had four children of which, two were boys and two were girls. All of their children have their own family now. Presently, the patient lived with her grandson.

The patient informed that her whole family got along with each other very well. They settled any misunderstandings and conflicts easily. Aside from herself, she considered all the members of her family healthy.

GENOGRAM:

Tibrosio – Conchita Rudy - Celestina (old age) (HPN) (DM) (Unknown)

Ruben Felomino Rodolfo Vivian Michael Ramon Georgina(unknown) (Vehicular Accident) (HPN) (HPN) (DM) (CVA) (Old age)

Francisco Andres Silverio Patient Conrada Victorio Augustine Dominador Pedring Arnulfo (Unknown) (Unknown) (Severe HA) 77 y.o. 73 y.o. (bone cancer) (arthritis) (bleeding) (asthma)

Legends:

- Patient

- Male

- Female

- Deceased Male Relative

Our patient, Mrs. X , 78 years old, female, widow, from Brgy. Domonar, Ormoc City.

Medical Diagnosis: Lumbar Compression Fracture

- Deceased Female Relative

Gordon’s Functional

Health Pattern

HEALTH PERCEPTION AND HEALTH MANAGEMENT The patient perceived herself as an unhealthy individual because

she couldn’t perform her daily normal activities, like working in the farm and doing household chores. She rated her health condition now as 1 in which 1 was the lowest and 10 was the highest

Her present illness was her primary reason for being not healthy, also her being an alcohol drinker and a smoker. She didn’t consult for medical advice whenever she had health problems, didn’t perform Breast Self-examination and have her blood pressure read. She only went to a doctor when her illness was getting worst and she couldn’t take the pain anymore.

Health for the patient was an important aspect of one’s life, because an individual had no freedom to do whatever she wanted if she was not healthy, especially if confined on bed like she was experiencing at present. Unhealthy for her means “dili na maayo ang panglawas”.

NUTRITION AND METABOLIC PATTERNBefore hospitalization ***24-HOUR DIETARY INTAKE REVIEW (Usual daily menu)

Breakfast : 2 pcs pandesal, 1 cup of coffee w/ milk, 1 glass of waterLunch : 1 cup of rice, 2 pcs of fish (Labtingaw) or pork,

8 oz softdrinks (sparkle), 1 glass of water Dinner : 1 cup of rice, 1 pc of fish (Labtingaw), soup, 1 glass of waterSnack : 1 glass of energen drink (1 sachet)

The patient usually took her meals at 7am-12nn-7:30pm. She was not fond of eating vegetables. But she sometimes took Vitamin C to boost her immune system. The patient bought her food in the public market and cooked it by herself.

The patient said that she had no problem in chewing food even she only had a few teeth left. Rarely, the patient find hard to swallow her food. She did not experience any nausea and vomiting when eating, and perceived to have no allergies in food and drugs.

The patient did not practice in visiting a dentist for regular check up because she perceived that she had no problem with her teeth. She seldom got sore throats and abdominal pains.

During hospitalization***24-HOUR DIETARY INTAKE REVIEW (Patient is under full diet)

Breakfast : none (she did not eat breakfast)Lunch : lugawSnack : 1 glass of milk and 1 piece of bread (pandesal)Dinner : 1 cup of rice, 1 cup pork (ginagmay), 1 cup mongos BLADDER ELIMINATION PATTERNBefore hospitalization

The patient’s fluid intake was approximately 8 glasses a day (1,920 ml). Her daily urine output averaged to 10 times a day (84 ml per voiding). Her urine was amber in color and clear. She had no problem in voiding her urine, like experiencing pain and having urinary incontinence or infection.

During hospitalizationNo changes in bladder elimination pattern during hospitalization.

BOWEL ELIMINATION PATTERNBefore hospitalization

Patient claimed that she usually experienced irregular bowel movement. She had it every 3-5 days despite her large amount of food and fluid intake. According to her, she had a hard time defecating, and needed to perform valsalva maneuver often. She never used any laxatives to ease her discomforts in defecation. Her stool was dark brown, hard formed and adequate in quantity.

During hospitalizationNo changes in bowel elimination pattern during hospitalization.

SLEEP-REST PATTERNBefore hospitalization

The patient had an average of 8 hours of sleep per night and a 30 minutes afternoon nap. Her sleep was sometimes interrupted when she frequently urinated at night and mostly this occurred during cold weather. She had no problem in falling asleep or in waking up. She had a comfortable foamed bed and laid either in supine or side-lying position. Watching television also made her fall asleep easily.

During hospitalizationShe had difficulty falling asleep in the hospital because of the

noisy and hot environment. She was not comfortable sleeping in the hospital bed too because the bed was a bit higher than she was used to.

ACTIVITY AND EXERCISE PATTERNBefore hospitalization

Her day started at 7am by preparing breakfast for herself and her grandson. After eating her breakfast and taking a bath, she would go to work, either tending her farm, sewing dresses or delivering babies. When she got home from work in the afternoon, she usually took a nap. Afterwards, she cooked dinner and ate with her grandson. She watched her favorite teleserye and news in the television before retiring to bed, which usually at 11 pm. Sometimes, she had a drinking session with her friends and neighbors in her house.

Mrs. X was happy and contented with her life. But now her illness hindered her drinking session with friends and doing her usual daily living activities.

During hospitalization Patient was confined on bed, but had toilet privileges with the helped of her significant other. She could only perform range of motion exercises while on bed.

EXERCISE ROUTINEMrs. X claimed that her means of daily exercise was doing her

work in the “hagna” and household chores. Her illness affected her daily activities.

OCCUPATIONAL ACTIVITIESShe used to be a farm inspector for 9 years, a counselor for 5

years and a Barangay Captain for 12 years in their place. At present, she worked as a farmer, a dressmaker and a midwife. Her ailment interfered her work and means of livelihood.

COGNITION AND PERCEPTION PATTERNBefore hospitalization

Patient was oriented to time, place and persons. She had a good short-term memory recall but could not remember other long-term events. She was able to answer questions asked and followed instructions logically and correctly.

o ABILITY TO UNDERSTAND AND COMMUNICATE

The patient understood what her doctor told her about her illness, particularly that it was impossible to cure, and to prevent progressions she had to take her medications religiously.

o ABILITY TO REMEMBERShe could recall some long term important events in her life like

their wedding, birthdates, anniversaries, graduations of her children and many more. She even remembered how she was courted by her husband and how they celebrated their first anniversary.

o ABILITY TO MAKE DECISIONSThe patient was having difficulty making a major decision

especially when it involved her family and work.During hospitalization

No changes in the patient’s cognition and perception pattern during hospitalization.

SELF PERCEPTION AND SELF CONCEPT PATTERNBefore hospitalization

The patient viewed herself as a simple individual. She was contented with her role as a wife to her husband before and a mother to her children. She had a happy marriage.

She looked satisfied with her body appearance. She spoke clearly in moderate tone with good eye contact while talking to others.

Patient claimed that her strength in life was her family. She got so affected every time they had a family problem but she remained strong for them.

During hospitalizationHer family was worried with her illness but she assured them

that she was handling it well. Mrs. X was really affected with her illness because she was incapable of doing things that she used to do.

Every time she saw disabled people, she couldn’t picture herself as being one of them and made her felt so sad.

ROLES AND RELATIONSHIP PATTERNBefore hospitalization

The patient used to be a farm inspector for 9 years, a counselor for 5 years and a Barangay Captain for 12 years. At present, she worked as a farmer, dressmaker and a midwife. She had no major problems with regards to her job. She could mingle well with her co-workers. For her, that was a very important aspect in her work.

She had a harmonious relationship with her husband when he was still alive. They helped each other in making major decisions particularly with regards to financial matter. She had a good relationship with her children also. Every time they had a family

problem they talked about it immediately. They maintained an open communication with each other. The patient was very close to her eldest child because she was matured enough to understand the situation. With regards to her illness now, the whole family was helping her to overcome it.

She also claimed that she got along with her neighbors very well and never had any quarrel with any of them. Her neighbors were very cooperative in their community activities. Because of this, Mrs. X was encouraged to join the barangay affairs like bingo games, etc.

During hospitalizationShe claimed that her hospital confinement altered her role as a

mother and grandmother. Because of this, she could no longer attend the needs of her family.

COPING AND STRESS TOLERANCE PATTERNThe main stressor the patient felt nowadays was the additional

expenses of her medication. Some of her happiness now was set aside because of this. Like instead of going for a vacation, she would rather stay home to save the money for her medications, and this was so painful to her. To cope with this, she just watched her favorite teleseries in the television. She also prayed to God and went to church every Sundays and firmly believed that God would help her in all her problems.

SEXUALITY AND REPRODUCTION PATTERN Age of menarche :16 years old Menstruation :3 days duration with moderate flow associated

with malaise and dysmenorrhea Age become sexually active :17 years old Age of marriage :21 years old No. of pregnancy :6 Deliveries :4 Attended :Hilot (all children) Number of living children :4 Abortion :2 Age of menopause :Patient cannot recall Associated physiologic change :irritability

Patient said that her menopause did not change her functions in life, particularly her sexual life. She preferred a single sexual partner. She talked to her husband when to have sex because they were not using any contraceptives. She had no history of any sexually transmitted disease.

VALUES AND BELIEF PATTERN The patient valued God and her family above all things.

She was a devoted Roman Catholic and attended mass regularly. She did not belong to any religious group but she helped whenever there were religious activities in their barangay. She had a strong faith in God and believed that God would grace her for being courageous and prayerful. No practice in her faith had any threat on her health.

She wanted to see her children grew older. She also liked to see her grandchildren finished their studies and had their own family someday.

Physical Assessment

MUSCULOSKELETAL SYSTEMThe patient had equal muscle sizes of both of his arms, thighs

and calves. No contractures and tremors were noted. Patient was able to perform shrugging of shoulders and turned her head against resistance. She could hold her arms up, flexed and extended against resistance that indicated equal strength of sternocleidomastoid, trapezius, deltoid, bicep, and tricep muscles. Patient could also abduct and adduct hips against resistance but experienced slight pain. Therefore, total grade for muscle strength in upper extremities was 5 which indicated full ROM against maximal resistance and 4 in lower extremities which indicated full ROM with minimal resistance.

Upon inspection of the spine, spinal disproportion was noted at the lumbar spine area.

GENERAL APPEARANCEPatient was a 78 years old, female, with an approximated height

of 4'11 ft. and weigh of 65 kilos with medium built body structure. She was conscious, coherent, well-groomed, with appropriate clothing, not so weak but unable to ambulate by herself due to lower back pain.

The patient had a pleasant facial expression and manner. She answered our questions without any apprehensions. Despite the patient’s advance age, she could still converse and listen well, had good comprehension and level of consciousness.

MENTAL STATUSDuring assessment, the patient was conscious and alert to all

questions being asked. She could answer promptly, but not able to expand her answers. She was oriented to time, place, person and present situation. She could recall recent events, but she could not remember other events that happened long time ago.

VITAL SIGNSTemperature : 36.8° C – per axillaryHeart Rate : 60 bpmRespiratory Rate : 20 cpmBlood Pressure : 110/80 mmHg at R armPain Scale : 8/10

HEAD AND SKULLHair was blackish-grey, equally distributed and with fine texture.Scalp was smooth and a little bit oily. Her scalp appeared clean

and no lumps or lesions noted.The patient’s head and skull was symmetrically round with

smooth skull contour, no nodules or masses noted. OBSERVE HEAD MOVEMENT

The patient’s head movements were still functioning well. She could move her chin to her chest, her chin could points upward, move her head towards her shoulders and turned her head left and right with less effort.

EYESThe patient’s eyes were positioned and aligned symmetrically. Eyebrows were black in color, thin, semi-symmetrical and evenly

distributed. Eyelashes were short and straight. No lesions, swelling and

secretions noted on both eyelids, inner and outer cantus. No edema on the lacrimal glands also noted.

Both eyes could move in coordination, with the outer cantus parallel with the pinna of the ears.

Six cardinal field of gaze was assessed to the patient, and she could perform it well and was able to close eyes symmetrically. Edema was not noted upon palpation of the eyes.

The pupil reaction to light test were made to the patient, and the result was both eyes constricted and reactive to light.

The patient’s pupils were color black. The size and shape were symmetrical. Unicteric sclerae with no lesions noted.

Grayish white ring around the corneal margin (arcus senils) noted.

The patient informed that she had a problem with her visual acuity. She was nearsighted and cannot clearly see far objects.

SKIN, HAIR AND NAILSThe patient’s skin was tan, dry, wrinkled with freckles and moles.

No signs of edema or lesion noted. Skin turgor test at the sternum was performed and no signs of dehydration noted.

Due to aging, hair was blackish-grey and equally distributed with fine texture.

No lesions or abnormalities noted with her fingernails and toenails.

Capillary refill test was performed and the result was <3 seconds which indicated good venous return.

EARS AND HEARINGThe patient’s ears were equal in size, same color with her facial

skin. No lesions, abnormalities, swelling or tenderness were found in the auricles and earlobes. The auricle aligned with outer canthus of the eye.

Dry cerumen were visible in the ear canals of both ears. Small papules were also noted at both tragus.

Auditory acuity to whispered or spoken voice was assessed to the patient, including watch tick test. The result was patient’s hearing ability was slightly diminished.

NOSE AND SINUSESThe patient’s nose was symmetrical and straight. Nasal septum

was intact and in midline with no signs of flaring, lesions and tenderness.

The nose had a similar color with the facial skin, no tenderness or lesions noted in the external nose. Air moves freely as the client breathes. The internal nasal cavity was normal, the mucosa was pink, and has clear, watery discharge. The sinuses were palpated and no evidence of swelling or lumps noted, and no pain felt by the patient either.

MOUTH AND OROPHARYNXThe patient’s lips were dry and slightly dark. Oral mucosa was

pinkish in color. She had 14 teeth, with few tartars and caries noted. Hard and soft palates were intact. The gums were slightly dark in color, moist and firm.

Tongue was in lateral margin, located at the center of the mouth, and movable. It was slightly pale in color, moist, slightly rough and had whitish coating. Tongue resistant test was performed by the patient and proven normal in functioning. The patient could still determine sweet, sour, bitter and salty taste.

Inspection of the oropharynx and tonsils were made and gag reflex was tested and assessed as functioning well.

NECKThe head was in the center of the neck. Patient could perform

head movements with no discomfort. The lymph nodes were not palpable.

The trachea was in normal placement in the midline of the neck and spaces were equal on both sides. The thyroid gland was not visible on inspection. The gland ascends normally during swallowing.

THORAX AND LUNGSThe patent’s chest was symmetric, skin was intact; no

tenderness and masses noted. Her chest expansion was 3 cm during deep respiration.

Upon auscultation, rhonchi was noted. The patient’s respiratory rate was 20 cpm.PERIPHERAL VASCULAR SYSTEM

The patient’s extremities were equal in length. Absence of any redness and edema noted. Her extremities skin color was tan and within normal temperature.

Her radial pulse were not equal in rate but it was in full pulsation (R= 65 bpm, L=60 bpm).

Apical pulse= 60 bpm Capillary refill = <3 sec

MOTOR FUNCTIONThe patient couldn’t sit nor stand by herself due to lower back

pain (lumbar area). But she could move her extremities, flexed her legs and arms with no discomfort felt.

The following Motor Function Tests were performed by the patient normally: Finger to finger Finger to nose test Alternating supination and pronation of hands Light touch sensation Palm sensation Tactile discrimination Patellar reflexes

Laboratories

LABORATORY FINDINGS

FINDINGS/ NORMALDATE LAB RESULT VALUE INTERPRETATION

04-22-10 Hematology:RBCWBC 14.2 5-10.0 X10.9g/L - due to presence of fracture

HGB 11.2 12-16gm% not significant HCT 0.38 38-48% normal

Differential Count:Neutrophils 78% 40-60%/L - due to presence of fracture Lymphocytes 22% 20-40%/L normal

ROENTGENOLOGIC REPORT

04-22-10 Lumbo sacral APL Findings: Diminished height noted of the vertebral body of L2.

There is absence of the normal lumbar lordosis.Presence of osteophytes noted along the anterolateralMargin of the lumbar spine.

Impression: --Compression fracture L2--Degenerative ostieoarthrosis of the lumbar spine with straightening due to muscular spasm.--Osteoporosis

Anatomy and Physiology

BonesBones are rigid organs that form part of the endoskeleton of vertebrates. They function to move, support, and protect the various organs of

the body, produce red and white blood cells and store minerals.

Cellular structure

There are several types of cells constituting the bone1. Osteoblasts (immature bone cells) are mononucleate bone-forming cells that descend

from osteoprogenitor cells. They are located on the surface of osteoid seams and make

a protein mixture known as osteoid, which mineralizes to become bone.

o The osteiod seam is a narrow region of newly formed organic matrix, not yet mineralized, located on the surface of a bone.

o Osteoid is primarily composed of Type I collagen.

2. Osteocytes (mature bone cells) originate from osteoblasts that have migrated into and become

trapped and surrounded by bone matrix that they themselves produce.

Their functions include to varying degrees:o formation of bone o matrix maintenanceo calcium homeostasiso act as mechano-sensory receptors — regulating the bone's

response to stress and mechanical load

3. Osteoclasts are the cells responsible for bone resorption (remodeling of bone

to reduce its volume).

These lacunae, or resorption pits, are left behind after the breakdown of the bone surface.

Because the osteoclasts are derived from a monocyte stem-cell lineage, they are equipped with phagocytic-like mechanisms similar to circulating macrophages.

Osteoclasts mature and/or migrate to discrete bone surfaces. Upon arrival, active enzymes, such as tartrate resistant acid

phosphatase, are secreted against the mineral substrate.

Osteoprogenitor cells

Osteoblasts

Osteocytes

Bone ossification and calcification

(Bone formation)

Osteoclasts

Bone resorption(Remodeling of bone to

reduce its volume)

Manufacture hormones, such as prostaglandins, to act on the bone itself.

Produce alkaline phosphatase, an enzyme that has a role in the mineralization of bone, as well as many matrix proteins.

Immature bone cells.

Osteiod seam

Their functions include to varying degrees:o formation of bone o matrix maintenanceo calcium homeostasi

so act as mechano-

sensory receptors — regulating the bone's response to stress and mechanical load

Remodeling Remodeling or bone turnover is the process of resorption

followed by replacement of bone with little change in shape and occurs throughout a person's life.

Osteoblasts and osteoclasts, coupled together via paracrine cell signalling, are referred to as bone remodeling units.

Purpose of Remodelingo regulate calcium homeostasiso repair micro-damaged bones (from everyday stress)o shape and sculpture the skeleton during growth.

Calcium balance The process of bone resorption by the osteoclasts releases stored

calcium into the systemic circulation and is an important process in regulating calcium balance.

As bone formation actively fixes circulating calcium in its mineral form, removing it from the bloodstream, resorption actively unfixes it thereby increasing circulating calcium levels.

These processes occur in tandem at site-specific locations.

Repair Repeated stress, such as weight-bearing exercise or bone healing,

results in the bone thickening at the points of maximum stress (Wolff's law).

It has been hypothesized that this is a result of bone's piezoelectric properties, which cause bone to generate small electrical potentials under stress.

Paracrine cell signalling The action of osteoblasts and osteoclasts are controlled by a

number of chemical factors which either promote or inhibit the activity of the bone remodeling cells, controlling the rate at which bone is made, destroyed or changed in shape.

The cells also use paracrine signalling to control the activity of each other.

Osteoblast stimulation Osteoblasts can be stimulated to increase bone mass through

increased secretion of osteoid and by inhibiting the ability of osteoclasts to break down osseous tissue.

Bone building through increased secretion of osteoid is stimulated by the secretion of growth hormone by the pituitary, thyroid hormone and the sex hormones (estrogens and androgens).

These hormones also promote increased secretion of osteoprotegerin.

 Osteoblasts can also be induced to secrete a number of cytokines that promote reabsorbtion of bone by stimulating osteoclast activity and differentiation from progenitor cells.

Vitamin D, parathyroid hormone and stimulation from osteocytes induce osteoblasts to increase secretion of RANK-ligand and interleukin 6, which cytokines then stimulate increased reabsorbtion of bone by osteoclasts.

These same compounds also increase secretion ofmacrophage colony-stimulating factor by osteoblasts, which promotes the differentiation of progenitor cells into osteoclasts, and decrease secretion of osteoprotegerin.

Osteoclast inhibition The rate at which osteoclasts resorb bone is inhibited

by calcitonin and osteoprotegerin. Calcitonin is produced by parafollicular cells in the thyroid gland,

and can bind to receptors on osteoclasts to directly inhibit osteoclast activity.

Osteoprotegerin is secreted by osteoblasts and is able to bind RANK-L, inhibiting osteoclast stimulation.

Osteoporosis

o Osteoporosis is a disease of bone, leading to an increased risk of fracture.

o In osteoporosis, the bone mineral density (BMD) is reduced, bone microarchitecture is disrupted, and the amount and variety of non-collagenous proteins in bone is altered.

o Osteoporosis is defined by the World Health Organization (WHO) in women as a bone mineral density 2.5 standard deviations below peak bone mass (20-year-old sex-matched healthy person average) as measured by DXA; the term "established osteoporosis" includes the presence of a fragility fracture.

o Osteoporosis is most common in women after the menopause, when it is called postmenopausal osteoporosis, but may develop in men and premenopausal women in the presence of particular hormonal disorders and other chronic diseases or as a result of smoking and medications, specifically glucocorticoids, when the disease is called steroid- or glucocorticoid-induced osteoporosis (SIOP or GIOP).

o Osteoporosis can be prevented with lifestyle advice and medication, and preventing falls in people with known or suspected osteoporosis is an established way to prevent fractures.

o Osteoporosis can be treated with bisphosphonates and various other medical treatments.

Pathophysiology

Genetics Age Nutrition Lifestyle Choices Medications Co-morbidty*Caucasian or Asian *Post menopause *Low calcium intake *Lack of weight-bearing *Corticosteroids *Anorexia nervosa*Female *Advanced age *Low vitamin D intake Exercise *Antiseizure meds *Hyperthyroidism*Family history *Low testosterone in men *High phosphate intake *Low weight and BMI *Heparin *Malabsorption *Small frame *Decreased calcitonin (carbonated drink) *Sedentary *Thyroid hormone syndrome

*Inadequate calories *Caffeine, alcohol, smoking *Renal failure

*Lack of exposure to sunlight

Predisposes to Hormones (estrogen, Reduces nutrients * Reduces Affects Calcium

Low bone mass calcitonin, and testos- needed for bone osteogenesis in absorption &

terone) inhibit bone loss remodeling bone remodeling metabolism

* Bones need stress for bone mainte-

nance

Reduction of bone density &change in bone structure

Rate of bone resorption isgreater than the rate of

bone formation

The bones becomesprogressively porous

brittle and fragile

Compression fracture

Skeletal deformity(kyphosis)

S/sx: *Cramps in the legs at night. *Constipation *Broken bones or Pathologic Fracture *Compression Fracture (Lumbar 2) *Brittle nails *Curved upper back (Deformity in Lumbar Spine) *Lower back pain *loss of height

Ideal Signs and Symptoms

Ideal sign/symptoms Patient's manifestation Rationale

1. Cramps in the legs at night.

2. Constipation

3. Broken bones (Pathologic Fracture)

> Patient experienced persistent severe lower back pain and muscle cramps in her legs 3-4 days before hospitalization.

>Unable to defecate for 3 to 5 days before and during hospitalization.

>Manifested per X-ray result. Impression: Compression fracture Lumbar 2

A problem with muscle cramps can sometimes be a problem with the muscle not being able to function properly due to a lack of proper electrolyte balance. Potassium (K), Calcium (Ca), and Magnesium (Mg) are absolutely essential for a muscle to be able to properly fire....and to properly relax. If there is a lack of these minerals in the body, the muscle can temporarily lose the ability to relax and, therefore, cramps.

Curvature in the vertebral column protrudes the abdomen and compresses the gastrointestinal tract thus decreases gastrointestinal motility and eventually results to constipation.

-Vitamin D (calcitriol) acts with calcium and phosphorus in promoting bone formation. Low level of vitamin D leads to bone softening.

4. Compression fractures

5. Brittle nails

6. Curved upper back(Deformity in the Lumbar Spine)

7.Lower back pain

8.Loss of Height

> Manifested per X-ray result. Impression: Compression fracture Lumbar 2

>not manifested by patient

>Spinal disproportion at the Lumbar spine area.

>Patient experienced persistent Severe lower back pain.

> From : not assessed

-Due to rate of bone resorption greater than the rate formation and causes bone to become progressively porous brittle and fragile.

-A compression fracture occurs when an injury to a spinal bone (vertebra) causes it to fracture and collapse (compress). A weakened vertebra may collapse because of a minor injury or without an obvious injury, often as the result of osteoporosis, which is most common in women after menopause.-When several vertebrae have been fractured, a person may lose height. Compression fractures may lead to a hump in the upper back and may cause back pain.

Calcium is required for healthy and strong nails,. Low intake of calcium or vitamin D will lead to brittle and dry nails.

An abnormally curved upper back, or dowager's hump, develops when the bones of the upper spine (vertebrae) become thin and brittle and collapse on each other. Having collapsed vertebrae in any part of the spine results in a loss of height.

When the upper spine curves, the lower back makes adjustments to keep the body in balance, which may cause muscle pain. This pain often stops in 1 or 2 years as the body adjusts to its new shape.

Loss of height can also be associated with multiple

To : 4’11 ft. vertebral compression fractures. Individuals suffering from multiple vertebra compression fractures that result in a kyphotic posture will often suffer a loss of height. Individuals with a loss of more than one or two inches of height are usually the result of compression fractures.

Summary of Significant Findings

Significant Normal Findings Value Nursing Diagnosis Clinical Significance

Gordon’s Health Pattern: Acute Pain r/t G7, P1, P2, P4, P5, P6,1. Perceived herself as Fracture & muscle spasm P7, P8, L5 Unhealthy (scale: 1/10)2. Altered mobility Impaired physical mobility G2, G7, P1, P2, P4, P5,3. Loss of appetite r/t pain and discomfort of P6, P7, P8, L54. Urinary frequency lumbar area5. Constipation6. Difficulty in sleeping Self-care deficit: Bathing, G2, G7, P1, P2, P5, P6,7. Altered ADL Toileting r/t pain & discom- L5

fort when moving

Disturbed self-esteem r/t G1, G2, G7, P2, P5, P6,

Physical Assessment: loss of health status & inde- L51. Pain in the hipbone pendent functioning

(Pain scale: 8/10)2. Can’t stand and sit Risk for injury: fracture r/t G2, G7, P1, P2, P8, L53. Altered LT memory decrease in bone mass4. Facial grimace density 2° to osteoporosis5. Pain upon moving6. Guarding behavior Risk for altered nutrition: less G37. Moaning than body requirement r/t8. Spinal disproportion loss of appetite

at the lumbar spineConstipation r/t decrease phy- G2, G5, G7sical mobility 2° to osteoporosis

Laboratory: Sleep pattern disturbance r/t G4, G6, P1, P41. WBC 14.20 5-10.0 X10.9/L pain and environmental factors2. HGB 11.12 12-16gm%3. Neutrophils 0.78 40-60%/L Altered urinary pattern r/t G44. Lymphocytes 0.22 20-40%/L urinary frequency

Roentgenologic Report:5. Lumbo sacral APL

Nursing Care Plan

Drug Study

Generic Name: TenoxicamPatient’s dose: 20mg 1 tab ODClassification: NSAIDS (Nonsteroidal anti-inflammatory drugs)

Indications: Used to relieve inflammation, swelling, stiffness, & pain associated with rheumatoid arthritis, osteoarthritis, ankylosing spondylitis ( a type of arthritis involving the spine), tendonitis (inflammation of a tendon), bursitis (inflammation of a bursa, a fluid filled sac located around joints & near the bones), & periarthritis of the shoulders or hips (inflammation of tissue surrounding these joints).

Contraindication: Contraindicated to patient allergic to tenoxicam or to any of the

ingredients of the medication Senior who has been given anesthesia/surgery At risk of increased bleeding Risk of kidney failure Has an active inflammation disease involving the stomach or

intestine (ulcerative colitis) Has an active stomach/intestinal ulcer Has had an acute asthmatic attack, hives, rhinitis (inflammation

of the inner lining of the nasal passage) or other allergic reactions caused by ASA (acetylsalicylic acid) or other Nonsteroidal Anti-inflammatory Drugs (NSAIDs; diclofenac, ibuprofen, indomethacin, naproxen)

Side Effects: Abdominal pain or discomfort (mild/moderate) Diarrhea or constipation Dizziness or lightheadedness Flatulence or gas Headache (mild/moderate) Heartburn Nausea or vomiting

Nursing consideration: Should be taken at the same time each day & immediately after

a meal or after food to avoid stomach upset.

It is important to use the medication exactly as prescribed by the doctor. If you miss a dose, take it as soon as possible & continue on with your regular schedule. If it is almost time for your next dose, skip the missed dose & continue with your regular dosing schedule. Do not take a double dose to make up for a missed one.

Advise the patient to avoid activities that requires reflexes due to dizziness.

Generic Name: Calcium carbonatePatient’s dose: 1 tab ODClassification: Antacid, Electrolyte

Therapeutic actions: essential elements of the body; helps maintain the functional integrity of the nervous & muscular systems; helps maintain cardiac function, blood coagulation; is an enzyme cofactor & affects the secretory activity of endocrine & exocrine glands; neutralizes or reduces gastric acidity.

Indications: Used to treat and prevent osteoporosis in postmenopausal women. It can also be used to prevent steroid-induced osteoporosis (osteoporosis caused by taking corticosteroids such as prednisone forlong periods of time).

Contraindications & Cautions: Contraindicated with allergy to calcium, renal calculi,

hypercalcemia, ventricular fibrillation during cardiac resuscitation & patients with the risk of existing digitalis toxicity.

Use catiously with renal impairment, pregnancy, lactation.

Side Effects: diarrhea dizziness flatulence headache heartburn nausea

Nursing intervention: Do not administer oral drugs within 1-2 hr of antacid

administration. Have patient chew antacid tablets thoroughly before swallowing;

follow with a glass of water or milk. Give calcium carbonate antacid 1- 3 hr after meals & at bedtime. Take drug between meals & at bedtime. Do not take with other oral drugs. Absorption of those

medications can be blocked; take other oral medications at least 1-2 hrs after calcium carbonate.

Report loss of appetite, nausea, vomiting, abdominal pain, constipation, dry mouth, thirst, increased voiding.

Advise the patient to increase fluid intake.

Generic Name: KetorolacPatient’s dose: 30mg IVTTClassification: NSAIDs, Antipyretic, Nonopioid analgesic

Mode of transmission: the primary mechanism of action responsible for ketorolac’s anti-inflammatory, antipyretic & analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme cyclooxygenase (COX). Like most NSAIDs, ketorolac is a non-selective COX inhibitor.

Indications: it is used for the short-term treatment (5-7days) of moderate to moderately severe acute pain associated with muscle sprains & strains, dental pain & pain after surgery or giving birth. It works by reducing pain, swelling & inflammation.

Contraindications: Contraindicated to Patient’s with previously demonstrated

hypersensitivity to ketorolac. Patient’s with complete/partial syndrome of nasal polyps,

angioedema, bronchospastic reactivity or other allergic manifestations to aspirin/other NSAIDs (due to possibility of severe anaphylaxis).

As with all NSAIDs, ketorolac should be avoided in patients with renal dysfunction.( Prostaglandins are needed to dilate the afferent arteriole; NSAIDs effectively reverse this).

The patients at highest risk, especially in the elderly, are those with fluid imbalances or with compromised renal function(heart failure,diuretic use,cirrhosis,dehydration & renal insufficiency).

Side Effects: More common

abdominal or stomach pain (mild or moderate) bruising at place of injection diarrhea dizziness drowsiness headache indigestion nausea

Less common or rare bloating or gas burning or pain at place of injection constipation feeling of fullness in abdominal or stomach area increased sweating

vomiting

Nursing interventions: be aware that patient may be at increased risk for CV events, GI

bleeding, renal toxicity; monitor accordingly. Do not use during labor, delivery or while nursing. Every effort be made to administer the drug on time to control

pain; dizziness, drowsiness can occur (avoid driving or using dangerous machinery)

Report sore throat, fever, rash, itching, weight gain, swelling in ankles or fingers; changes in vision; black,tarry stools, easy bruising.

Discharge Plan

MEDICATION: Advise patient and significant others regarding her home

medications:o Tenoxicam 20 mg 1 tablet once a dayo Calcium 05mg 1 tablet once a day

Stress the importance and advantages of compliance with medication regimen and dietary restrictions.

ENVIRONMENT: Encourage client and SO to provide a peaceful and well-

ventilated environment conducive for recovery and healthy living.

Advise client and SO to keep the surroundings clean and free from stress.

Encourage the patient to install safety devices, such as grab bars and railings, at home.

Advice patient to use support canes/walking cane when walking or standing.

Encourage client to have a regular rest periods during the day.

TREATMENT/VISIT: Review medication that will be taken home and stress

importance of following prescribed regimen. Stress the importance of having follow-up examinations and

treatment to the patient and presence of changing physical status.

HEALTH TEACHING/EDUCATION: Discuss with patient her understanding of her condition and how

it affects her body. Encourage patient to have an adequate sunlight exposure every

early morning, before 10am. Encourage patient to have a good personal hygiene. Advise the SO to give the client the whole support needed.

Advise patient to follow the discharge instructions given by the doctor.

Remind patient and family of the importance of participating in health promotion activities and recommend health screening.

Encourage patient to apply lumbosacral binder to support lumbosacral area when moving.

Advise patient to have an ROM exercise daily with the help of SO to prevent muscle contractures due to limited mobility.

Teach patient proper body mechanics to prevent further injury. Advise patient to exclude alcohol, smoking, caffeine and other

sedentary lifestyle that may worsen her condition.

OBSERVABLE SIGNS AND SYMPTOMS: Encourage patient to have immediate consultation if the

following signs and symptoms occur, such as:o Severe pain (lumbar area, legs & joints)o Severe leg cramps and spasmo Swelling (lumbar area, legs and joints)o Loss of sensation below the affected lumbar areao Urinary and fecal incontinence

DIET: Stress to patient the importance of adequate intake of caloric

and nutrient food rich in calcium and vitamin D to increase bone density.

SPIRITUAL: Encourage the client to pray every day. Encourage the client to strengthen her faith and trust in God. Encourage client to participate in religious activities that are

not strenuous and have contact with spiritual advisers.

Reference

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th EditionBy: Suzanne C. Smeltzer Vol. 2 pgs. 2404-2407

Essentials of Human Anatomy & Physiology 8th EditionBy: Elaine N. Marieb pgs. 145-152

http://en.wikipedia.org/wiki/Bones

http://emedicine.medscape.com/article/309615-overview#IntroductionPathophysiology