Nursing Care Plan Osteoporosis

1 Nursing Care Plan: Osteoporosis Name Institution Professor Course Date 2 Head to Toe Assessment Patient: The patient is a 49 years old woman who presents with back pain and swollen upper thigh/hip. CC: The patient complains of back pain, swollen hip, and significant weight loss in the last two and a half months. The Caucasian female visits the office with concerns over prolonged back pain, significant weight loss, and stopped posture. She reports that mild pain started three months ago but became more severe in the last two weeks. Her upper leg was hit by a chair one day ago, causing swelling. She expected the pain and swelling to go away, but it persisted, hence seeking medical care. The patient also reports that she has had fractures two times in the last year, and mild traumas caused all. She says that the pain is aggravated by minimal activities such as walking short distances, bending, and carrying out daily house chores with no relieving factors. She rates the pain as 8/10. She reports that she has also lost significant weight despite eating the same food she eats without engaging in physical activity. The patient reports she is currently unable to perform some ADLs due to pain and limited mobility. However, the patient denies loss of height, chills, headache, and tingling of feet. She is also not on medication but took Tylenol for pain before she decided to come for help. PMH: Pneumonia during childhood, bone fractures Surgical History: myomectomy six years ago Allergy: No known allergies Immunizations: The patient took a flu shot in 2019. Personal History: Married with two children and live together as a family in their apartment. The patient denies smoking or alcohol use. Family History: Father (deceased) had diabetes and hypertension. The mother has osteoporosis. Review of Systems: Subjective General: The patient denies headache, bruises, and chills but reports fever and is concerned about weight loss. 3 HEENT: Head- the patient denies headaches, hair loss, or notable masses. Ears- the patient reports no changes in hearing, ear discharge, or ringing in years. Eyes: The patient denies blurry vision but uses eyeglasses for reading. Nose-the patient denies congestion, nose bleeds, and dryness. Mouth: The patient denies bleeding gums, decayed or missing teeth, odors, and dryness. Neck: the patient denies swelling and enlarged lymph nodes, pain or difficulty swallowing, and stiffness. Throat: patient denies sore throat, erythema Cardiovascular: the patient denies chest pains or discomforts, fast/slow heart rates, and cold feet/hands. The patient reports swelling of the lower limb. Respiratory: The patient denies chest tightness, wheezing, pain, consistent coughs, and breathing difficulties. Skin: The patient denies discoloration, bruising, lumps, and open wounds Gastrointestinal: The patient denies constipation, abdominal pain/discomfort, heartburn, nausea, bowel movement changes, guarding and tenderness, and distension. Musculoskeletal: The patient denies back tenderness, stiffness, and joint swelling but reports back pain, limited ROM due to swelling at the hip area, and inability to bear weights. Neurological: The patient reports stooped posture and deny memory loss, tremors, severe headaches, and loss of consciousness. Endocrine: The patient denies swollen glands, excessive sweating, thyroid problems, and reports weight loss. ROS: Objective Data Vitals: T: 98.6F, BP: 125/82, Pulse: 85, W: 132, H: 5’4”, RR: 18 General: The patient appears distressed but alert and oriented to place and time. She shows limited movement. Her speech is soft with a clear tone. HEENT: Head: size and symmetry are normal on inspection, and hair is clean and fine. The scalp has no lesions and no tenderness noted on palpation. Eyes: has high eye acuity, pupils react to light, they are equal and round. The sclera is normal, white, and moist. No discharge was noted. The patient wears glasses. Ear: External year position and shape is normal on inspection. 4 No drainage was noted, and both years can hear. Nose: There is no drainage present, and patency is adequate. Mouth: lips are pink, the oral cavity is moist with no phlegm, the gums are pink and moist, and the patient has all teeth. The tongue is red with no cracks or sores. Neck: ROM is full, no masses on palpation. Cardiovascular: no murmurs, clicks hear on auscultation. S1, S2 are normal with regular heart rhythm and heart rate. Capillary refill is less than 2 seconds. Respiratory: normal breath sounds with no wheezing on auscultation. Respirations are effortless and regular. Musculoskeletal: The patient moves around the room with difficulty and reports pain in the back and hip area when moving. The patient reports pain on bending. Neurological: the patient has a stooped posture on observation with unstable balance. Speech is clear with a good tone. She answers questions appropriately. Gastrointestinal: no masses or tenderness of abdomen on palpation, the abdomen is not distended, and bowel sounds are positive and normal on all four quadrants. Assessment Outcomes Following the assessment of subjective and objective data, the primary diagnosis for the 49 years old woman is osteoporosis. This is supported by bone weakness which could be causing back pain due to a possible fracture of the vertebra. Also, the thigh bone's swelling at the hip area could be due to a hip fracture. The patient also has a stooped posture due to a possible back fracture and pain. The patient also has a history of bone fractures, including a family history of osteoporosis. A dual-energy ray absorptiometry (DXA) can be performed to confirm the diagnosis (Mayo Clinic, 2019). Plan of Care Nursing Diagnoses 1.Impaired physical mobility Care Plan Nursing Interventions Short-term. 1.Assess pain levels using a 1-10 rating 1. Relieve the scale and determine patient from Smart Goals Evaluative Findings Goals met The patient verbalized relief 5 pain. Specific: the goal is to relieve pain where the patient should verbalize pain relief in the next 1 hour. This goal is crucial since pain causes discomfort, distress, and distraction. Resources needed for pain include pain medication and emotional support. The nurse will be involved in the process. Measurable: the goal is measurable and will be tracked on a 1 to 10 pain scale. The goal will be achieved when the patient verbalizes pain lower than 3/10. Achievable: The goal can be achieved since the nurses have the required skills and resources. Also, following the right pain protocol will help achieve the goal. Relevant: The goal is appropriate for the condition since the patient reports pain at the hip and back. Timely: The goal will remain effective an the location, severity, and quality of pain 2. Provide appropriate pain management medication as instructed, such as morphine. from pain on a scale of 2/10 in 45 minutes. The patient responds to morphine The patient seems relaxed The patient participates in activities with minimal discomfort 6 hour after complaints of pain. 2. Provide knowledge about the condition Specific. The patient will verbalize the understanding of her condition and its management plan. This goal is crucial since it will help prevent falls, injuries, infection, and deterioration. Resources needed include learning tools such as brochures, videos, and nurses will lead. Measurable. The goal is measurable since the patient will be required to verbalize the required information about the condition. The goal will be achieved when the patient teach-back all the needed information. Achievable. The goal is achievable since the care center, and nurses have all resources and knowledge to address the knowledge gap. The patient will achieve this by following the 1. Assess the patient's disease knowledge level. This will provide the basis for developing appropriate teaching techniques. 2. Provide the patient with support for a lifestyle change to help cope with the condition's chronicity. The patient teaches back about osteoporosis The patient verbalizes the importance of lifestyle change needed for the management of the condition 7 instructions given. Relevant. The goal is appropriate since lack of knowledge could slow healing due to poor compliance. Also, the patient could fail to ask for assistance when turning, walking which makes the intervention vital. Timely. This goal will last in the first week of treatment. Intermediate goals 1. Prevent infections Specific. The goal is to reduce the risk of infection while at the hospital by achieving timely wood healing. This goal is crucial since the current state exposes her to infections that could lead to complications such as sepsis, shock, and death. Measurable. The goal will be measured by inspecting the patient for infection signs such as purulent drainage and erythema. Regular blood work will also help track outcomes. The goal will be achieved if the patient 1. Provide wound care as required in the protocol and use sterile equipment during care to prevent contamination 2. Assess the skin and pin sites for signs of infection such as fever, swelling, redness on the hip joint, foul odor, edema, and erythema. Also, the nurse should investigate pain since it could indicate infection. The patient verbalizes pain for inspection The patient's wood is healing appropriately The hip area is free of erythema and purulent drainage The swelling on the hip joint has reduced. Nurses are using sterile equipment in care 8 does not acquire any infection. Achievable. This goal is achievable if healthcare professionals follow appropriate infection prevention protocols such as frequent handwashing, sterile equipment, and PPEs. The care facility also has the needed resources to achieve the goal. Relevant. Preventing infections is an appropriate goal for the patient since infections could compromise skin integrity and increase complications. Timely. This goal is effective during the first weeks of healing when infection risk is high. 2.Maintaining skin integrity Specific. The goal is to maintain skin integrity by demonstrating techniques to prevent skin breakdown. The goal is important since it will ensure the skin remains intact to prevent complications 1. The nurse will give skincare and examine the skin for discoloration, open wounds, rashes, and bleeding to get information about skin circulation 2. The nurse will ensure the patient is repositioned and The patient verbalizes leg comfort The patient is achieving timely healing The pressure is being minimized on the legs and back. Skin integrity is intact 9 such as infection with necrosis and death (Murphree, 2017). The patient and nurses will be responsible for achieving this goal, and resources needed include hospital equipment, pillows, appropriate bed, and others Measurable. The goal will be measured by inspecting and documenting the skin condition in every shift. Capillary refill on toes/fingers, skin turgor, and sensitivity will be assessed. The goal will be achieved if the patient heals without cases of skin breakdown. Achievable. The goal is achievable since nurses have the knowledge, skills, and protocols needed to maintain skin integrity. The required resources are also available. Relevant. This goal is essential and appropriate since it will help in preventing infection at the hip area or the back. The outcome turned frequently to reduce pressure on the same area, which could cause skin breakdown 10 will also meet the current needs of the patient Time. This goal is appropriate for the first few weeks of treatment during the healing process. Long term Goals 1. Reduce the risk for trauma, falls, and injury Specific. The patient will be protected from falls and injuries during treatment. The goal is important since falls and injuries would cause complications leading to slow healing. The nurse, physical therapist, and the patient will be involved. Resources needed include ambulatory aids and environmental safety. Measurable. The goal will be measured by inspecting the patient for injuries, recording fall incidents, and outcomes will be achieved if no falls and injuries will be recorded during the treatment period. Achievable. The outcome can be 1.The nurse should provide limb rest and joint support to promote stability and comfort 2. Assess the need and instruct the patient to use ambulation aids such as a walker, crutches. Also, assist the patient in walking or turning to prevent falling. The patient is free from falls and injuries The patient utilizes walkers and crutches when walking around The patient is stable at the fracture site The patient asks for help/support when standing. 11 achieved if appropriate resources are utilized, and fall prevention protocols followed. Relevant. Preventing falls and injuries is a crucial way to maintain skin integrity and prevent infections and other complications. Also, the goal is relevant since falls are among the greatest causes of morbidity and mortality in hospitals (AHRQ, 2019). The patient's condition also exposes her to fall and injury risks Time. This goal will remain effective during the whole treatment period. 2.Prevent mobility complications Specific. The patient will be helped to achieve ROM to improve functional mobility and increase muscle strength. This goal is important since it will improve circulation and ensure the patient maintains ROM. The patient, family, and physical therapist will be 1. Assess the patient's degree of mobility and ROM to help establish a plan of care. 2. Provide isometric and ROM exercises during every shift to prevent joint contractures on the affected leg The patient maintains ROM The patient maintains tolerable functional mobility The patient uses adaptive changes for ambulation 12 involved in the process. Measurable. The goal will be measured by documenting successful movements and also the frequency and length of ambulation. The outcome will be achieved when the patient performs ROM, ambulates, and carry out ADL independently without limited ROM or discomfort. Achievable. The outcome can be achieved since the care facility has the resources and personnel such as therapists and nurses to help realize the goal. Relevant. The goal is relevant since improving ambulatory ability and ROM will improve circulation, muscle strength, prevent discomfort and injuries. The patient needs to be able to walk without falling. Timely. The timing for this goal is throughout the 13 treatment period while at the hospital and home. 2. Deficient knowledge Short-term 1. Understanding of the condition, prognosis, and complications Specific. The patient should verbalize understanding of osteoporosis, the prognosis, and potential complications associated with the condition. This is crucial since it will help the patient make informed treatment choices and know what to expect in the future. The nurse will be involved in providing this information. Measurable. The understanding will be traced by establishing whether the patient understands osteoporosis, her prognosis, and the complications she expects as taught. Achievable. The goal can be achieved since the nurse is knowledgeable about the condition. The 1. The nurse will teach the patient by reviewing the pathology, prognosis, complications, and future expectations of osteoporosis to keep the patient informed. 2. Assess the patient's knowledge of the disease as taught. The patient accurately describes the condition, prognosis, and what she expects in the future. The patient teaches-back accurately. 14 goal will be achieved when the patient teach-back what was taught correctly. Relevant. The goal is relevant since teaching the patient will help make the right treatment choice and understand how to participate in the management. Timely. The goal will remain open throughout the teaching period. 2.Teach the patient about medications Specific. The will be able to verbalize the medication and administration methods for prescribed drugs. This is crucial since it will help the patient understand the dosage appropriate to promote healing. The nurse and pharmacist will be involved in promoting this goal. Measurable. The goal will be measured by establishing whether the patient accurately verbalizes what is taught. The goal will be achieved when the patient 1. The nurse will instruct the patient about the drug regimen to help understand the dose, schedule, and appropriate administration 2. The nurse or pharmacist will inform the patient about the drug's side effects, potential adverse effects, expected results, and the need for follow-up The patient understands osteoporosis drugs, mode of administration, dosage, and side effects. The patient teachback about the drug accurately. 15 teach-back about medication, dosage, and administration as instructed. Achievable. The goal is achievable since the pharmacist can help in patient education. Relevance. Teaching the patient about the medication is crucial to ensure compliance and faster healing. This will also help avoid deterioration of the condition. Timely. The goal lasts during the teaching period. Intermediate 1. Improve patient's exercises Specific. The goal is to ensure the patient can perform daily exercises appropriate for the current limitations. This goal is important since it will help the patient avoid muscle wasting and prevent deterioration. The nurse, patient's family, and physical therapist will be involved Measurable. This goal will be tracked by assessing and recording the exercises that the 1. The nurse should instruct and encourage the patient to engage in regular exercising of joints, avoid lifting heavy objects or bending and allow the patient to engage in weight-bearing exercises. 2.Help the patient develop an exercise program appropriate for her current condition and capabilities to strengthen bones. The patient engages in regular walking The patient utilizes assistive devices to avoid falling. The patient can safely engage in low-impact aerobics. 16 patient performs frequency, tolerance level, and exercise length. The goal will be achieved when the patient regularly engages in exercises and maintains ambulation. Achievable. The goal is achievable since there are adequate resources and personnel to promote exercises. Also, the goal is realistic since the healthcare professionals have the skills needed to promote and monitor exercising. Relevant. The goal is sensible and appropriate since exercising will improve the patient's ROM, muscle strength, and circulation. Also, research shows that exercising improves bone density in osteoporotic patients (Benedetti et al., 2018). Timely. This goal will remain relevant during the treatment period. 17 2.Demonstrate the importance of calcium and vitamin D intake Specific. The goal is to ensure the patient verbalizes her dietary needs by increasing intake of calcium and vitamin D. This will help promote healing and improve wellbeing. The nurse and nutritionist/dietician will be involved. Measurable. The goal will be measured by determining the patient's ability to verbalize what she is instructed. The goal will be achieved when the patient demonstrates an understanding of the importance of calcium and Vitamin D intake. Achievable. The goal can be achieved since the nutritionist/dietician has the expertise to provide the appropriate knowledge. The nutritionist can also monitor progress effectively. Relevant. Diet plays 1. The nurse will 1. The patient discuss the patient's demonstrates that dietary needs to calcium and ensure the patient vitamin D understands the improves muscle importance of calcium strength and helps and Vitamin D-rich decrease bone foods in healing. loss. 2. The nurse will 2. The patient teach the patient about verbalizes the administering calcium right diet to take and vitamin D when managing supplements, among osteoporosis. other drug therapies, 3. The patient to decrease bone loss. teaches back about dietary needs accurately as instructed. 18 a crucial role in promoting healing for osteoporosis patients (Higgs et al., 2017). Understanding the role calcium and vitamin D plays in preventing bone loss is crucial to the patient. Timely. The goal will remain relevant before discharge Long term Goals 1. The patient will gain knowledge on compliance with the medical regimen to promote healing. Specific. The patient will show increased knowledge of the medical regimen to promote compliance with the treatment plan and minimize bones' demineralization. The nurse, pharmacist, nutritionist, and the patient will be involved in this goal. Measurable. This goal will be measured by asking the patient to verbalize her understanding of the medical regimen. The goal will be achieved when the patient accurately verbalizes 1. The nurse will encourage the patient to utilize ambulatory aids to prevent falls and injury-causing further damage 2. The nurse will discuss with the patient the importance of therapy and clinical follow-up. The nurse will instruct the patient about the osteoporosis medication and dietary needs The patient uses ambulatory aids (cane, walker, crutches)where appropriate. The patient verbalizes the importance of following up with physical and occupational therapy and clinical appointments. The patient verbalizes osteoporosis medication, benefits, and side effects. The patient teaches back information about her dietary needs. 19 the plan. Achievable. The goal is achievable since the healthcare professionals involved in the goal have the capacity to educate the patient on the medical regimen. Relevant. The goal is relevant in the sense that improving the patient's understanding of the medication regimen (diet, exercising, medication, and care plan) will help improve compliance since the patient understands the benefits. Timely. The goal will remain effective during the whole healing period. 2. Promote independence in carrying out ADLs. Specific. The goal or outcome is to ensure that the patient gains independence when performing ADLs with modifications. This goal is crucial since it will ensure the patient can move around with ease, take a bath, wear clothes 1. The nurse will instruct the patient about potential referrals for therapy to help improve exercising and improve the bone condition. 2. The nurse will instruct the patient on how to perform ADLs gradually to avoid bending and lifting, which could cause The patient understands the referrals for further help with exercises. The patient understands ways to engage in light ADLs to avoid fractures 20 and carry out other injuries activities without discomfort. Measurable. The goal's progress will be measured by assessing and recording the patient's ability to carry out various ADLs, exercises, and improved ROM. Achievable. The goal is achievable since the patient wants to walk, cook, and bend again without problems. Also, the nurse and other healthcare professionals have the capacity to improve ADLs. Relevant. The ability to perform ADLs is crucial in promoting the wellbeing of the patient. This makes the goal-relevant. Timely. The goal lasts during the whole treatment and healing period. Conclusion Considering that osteoporosis is associated with weak and brittle bones prone to fractures, nursing interventions aim to prevent risks and complications associated with the condition to ensure the patient receives proper management. Following the success of the various interventions in the care plan, the most appropriate intervention would be using an appropriate 21 drug regimen as instructed and a dietary intervention approach. For instance, intervention with bioposphates such as Alendronate, risedronate, zoledronic acid, and others, which are first-line treatments for the condition, can help modify bone loss risk factors. For instance, studies show that the drugs reduce osteoclast activity, which ensures slowed removal of old bone and improves bone density and strength (Upham, 2019). On the other hand, dietary intervention is critical since it complements drug therapy. Research shows that proteins play a crucial role in strengthening muscle tissues, calcium improves bone strength and density while vitamin C and D promote absorption of calcium in bones (Higgs et al., 2017). In this case, foods rich in these nutrients can help develop stronger and dense bones, reducing bone fracture risk, falls, and effective management of osteoporosis. A combination of medication and diet can go a long way to improve the patient's health and wellbeing.