Fundamentals of Nursing Case Notes

Week 3 Case Study Part I Chief Complaint: 72-year-old woman who fell on her right hip. History: Margaret Donovan, a 72-year-old white female, is brought to the emergency room by her son-in-law after falling in her bathtub. She was previously in good health, despite leading a relatively sedentary lifestyle and having a 30-pack-year history of cigarette smoking. The only medication she currently takes is Inderal (propranolol) for mild hypertension. She fell upon entering the bathtub when her right leg slipped out from under her; she landed on her right hip. There was no trauma to her head, nor does she complain of right or left wrist pain. However, she reports severe pain in the right hip and upper thigh, and was unable to get up after her fall. An injection of oxymorphone hydrochloride (Numorphan) helped relieve her pain and she was taken to the radiology department for an X-ray of her right leg and hip. Physical Examination: The patient was alert, oriented to time, place, and date, and was responding appropriately to questions despite being in considerable pain. There were no signs of trauma to the head, neck, torso, arms, or left leg. The right thigh and hip were extremely tender and were immobilized by a leg splint. Heart and lung sounds were normal, and abdominal sounds were reduced. Radiology Report: The X-ray of the right hip revealed a complete, comminuted, intertrochanteric fracture of the right hip. No other fractures were noted in the right leg. There were also long-term osteoporotic changes in the femur, tibia, and fibula. 1. What is meant by a "complete, comminuted, intertrochanteric fracture of the right hip?" Be sure to tell specifically where this fracture is located. When reading the radiology report, the terminology is interpreted as follows: -Complete: refers to a fracture that extends completely though a bone. -Comminuted: means that the bone has shattered into many smaller pieces. -Intertrochanteric: identifies the location of the fracture, in this case, the fracture is located between the greater trochanter and the lesser trochanter of the patient’s right femur. 2. The radiologist reported signs of osteoporosis. a. Based upon the information in your text, why does osteoporosis affect spongy bone more than dense bone? According to the text on page 223, “spongey bone is more metabolically active than dense bone and has more surface area exposed to bone-dissolving osteoclasts.” This results in brittle bones and the greater incidence of pathological fractures following even the slightest trauma or stress. The text book references sitting down too quickly but it is also of note that even coughing or sneezing too hard can cause rib or even clavicular fractures in some cases. b. Osteoblasts, osteocytes and osteoclasts are three of types of bone cells. Which of the three is responsible for osteoporosis and why? Bone remodeling is ongoing throughout the life of an adult, made possible by the joint efforts of both osteoblasts and osteoclasts. Osteoblasts are responsible for new bone growth, while their counterparts, osteoclasts, take on the role of resorption. It is believed that the two types of cells are regulated by hormones. Osteoporosis is commonly related to a hormonal deficiency resulting in increased bone turn over where the resorption rate is higher than the rate of formation. c. Based upon the information in your textbook would you expect to find osteoporosis in both males and females? Which gender is the greatest risk of developing osteoporosis? While osteoporosis can effect both males and females of all ages, females, most specifically Caucasian and Asian females, are at far greater risk for the disease, especially when post-menopausal. It is noted that compared to male and African American females, the aforementioned at-risk group can begin losing bone density a the age of 35 and can continue to lose bone density rapidly, reducing their bone mass by 30 at the age of 70 on average. Once a female has entered menopause, the inevitable fluctuation in hormones and subsequent diminished estrogen levels can significantly impact a woman’s health for many years thereafter. d. What are the treatment options, and what is the objective of these treatments? Following a diet that incorporates foods that are rich in vitamin D and calcium is vital to the prevention of and treatment of osteoporosis. It is important to supplement but Vitamin D and calcium as they work in unison to maintain bone health. Exercise is strongly encouraged and although it does not increase bone health directly, it does strengthen muscles and improve balance, thereby reducing the risk of falls that could result in bone fractures. There are several prescription medications in varying classes available for the treatment of osteoporosis including vitamin D supplementation in the form of Cholecalciferol, Vertical which is FDA approved for treatment of calcium deficiencies as well as psoriasis, and drugs like Boniva and Fosamax which inhibit bone break-don on a cellular level, slowing the progression of bone loss. e. Estrogen-replacement therapy was once used as a treatment option? Why is this no longer recommended? Estrogen-replacement therapy was once the first line of treatment and for years, the only approved of treatment for osteoporosis, research indicates that its risks far outweigh the benefits. Estrogen-replacement therapies have been linked to increased risk/incidence of uterine, ovarian and breast cancers, s well as heart attack, stroke, blood clots and mental illness. 3. What risk factors does Margaret have for osteoporosis and why? Margaret is at greater risk for osteoporosis as she is a post-menopausal Caucasian female with a history of cigarette smoking, who leads a fairly sedentary lifestyle and is actively being treated for mild hypertension. Her race and sex automatically predispose her to the risk of osteoporosis based on research and statistical data. Margarets sedentary lifestyle lends to the likelihood that she may not possess the core muscle strength or balance to prevent falls that could result in fractures. Add to the aforementioned risk factors, the 30 year history of tobacco use, Margaret’s risk score continues to climb. The nicotine contained in the cigarettes, has been linked to the reduced production of osteoblasts, hindering the rate of bone production. Smoking decreased the body’s ability to absorb calcium which is vital for bone health, among other cellular functions. The chemicals within cigarettes have been found to have a great impact on hormone levels, namely estrogen, which is necessary for building and maintaining the skeletal system as a whole. Furthermore, smoking has been proven to compromise circulation, thereby reducing the amount and rate at which the blood supply reaches the bones. Noting that the patient also has a history of, and is being treated for mild hypertension with a beta-blocker, it is pertinent to mention the risk for osteoporosis has the potential further compounded. There are conflicting findings on the treatment of hypertension with relation to the effects of calcium levels within the body/blood stream. It has traditionally been theorized that the use of anti-hypertensives is closely associated with the loss of calcium as it is pulled from the bones and excreted through urine waste as a mechanism by the kidneys in efforts to decrease the workload of the heart. On the contrary, research over the last decade points toward some antihypertensive medications, namely beta-blockers, actually preventing fractures by way of increased bone formation and bone resorption. In a 2008 publication from the UK (Expert Opinion on Investigational Drugs), the patient’s prescribed medication, Propranolol, is mentioned specifically to have shown progress in female lab rats with their ovaries removed in relation to increased bone formation. 4. Based upon the information in your textbook, what parts of the skeleton (i.e. what bones) are most vulnerable and subjected to fractures as a result of osteoporosis? Although any bone can conceivably be effected by osteoporosis, the bones of the hips, spine (vertebral column) and wrists are at greatest risk for deterioration and pathological fracture. Part II 5. Describe the four steps that a broken bone undergoes as it is healing. Please give details in of each step. In the first stage of bone healing, a hematoma is formed at the break by the blood that escapes the blood vessels surrounding the break, forming a clot. This is often evidenced by visible bruising that can last days, sometimes weeks following the fracture. In the second stage, spongey bone begins to form nearest the developing blood vessels courtesy of the osteoblasts. Meanwhile, fibroblasts produce collagen fibers that are converted to fibrocartilaginous callus, consisting of hyaline and fibrocartilage that join the broken pieces, forms in the more distant areas of the area. This second stage takes approximately 3 weeks. During the third stage of bone healing, boney callus replaces the cartilage formed in the previous stage over the course of 2-4 months. This has closely mimics endochondral formation in that cartilage will become calcified; the presence of osteoblasts, osteoclasts, as well as bone matrix are also noted. Lastly, during remodeling, osteoclasts remove excess bony tissues (resorption), allowing compact bone to form around the outer reaches of the fracture as the structures to return to their near-original forms. During this remodeling stage, the healing is sometimes not yet be visible on x-rays, but will be evidenced by a thickened portion of the bones surface.