NURSING PROCESS: THE PATIENT WITH A SPONTANEOUS VERTEBRAL FRACTURE RELATED TO OSTEOPOROSIS
Health promotion, identification of people at risk for osteoporo-sis, and recognition of problems associated with osteoporosis form the basis for nursing assessment.
The health history includes questions concerning the occurrence of osteopenia and osteoporosis and focuses on family history, previous fractures, dietary con-sumption of calcium, exercise patterns, onset of menopause, and use of corticosteroids as well as alcohol, smoking, and caffeine in-take. Any symptoms the patient is experiencing, such as back pain, constipation, or altered body image, are explored.
Physical examination may disclose a fracture, kyphosis of the thoracic spine, or shortened stature. Problems in mobility and breathing may exist as a result of changes in posture and weak-ened muscles.
Based on the assessment data, the major nursing diagnoses for the patient who experiences a spontaneous vertebral fracture related to osteoporosis may include the following:
· Deficient knowledge about the osteoporotic process and treatment regimen
· Acute pain related to fracture and muscle spasm
· Risk for constipation related to immobility or development of ileus (intestinal obstruction)
· Risk for injury: additional fractures related to osteoporosis
The major goals for the patient may include knowledge about os-teoporosis and the treatment regimen, relief of pain, improved bowel elimination, and absence of additional fractures.
Patient teaching focuses on factors influencing the development of osteoporosis, interventions to arrest or slow the process, and measures to relieve symptoms. Adequate dietary or supplemental calcium and vitamin D, regular weight-bearing exercise, and modification of lifestyle, if necessary (eg, cessation of smoking, reduced use of caffeine and alcohol), help to maintain bone mass. Diet, exercise, and physical activity are the primary keys to de-veloping high-density bones that are resistant to osteoporosis. It is emphasized that all people continue to need sufficient calcium, vitamin D, sunshine, and weight-bearing exercise to slow the pro-gression of osteoporosis.
Patient teaching related to medication therapy is important. Because gastrointestinal symptoms and abdominal distention are frequent side effects of calcium supplements, the nurse instructs the patient to take the calcium supplements with meals. Also, it is important to teach the patient to drink adequate fluids to re-duce the risk of renal calculi. If HRT is prescribed, the nurse teaches the patient about the importance of compliance and pe-riodic screening for breast and endometrial cancer. Alendronate requires compliance: it must be taken on an empty stomach with water, and then the patient must not consume foods or liquids or assume a reclining position for 30 to 60 minutes. Nasal calcitonin is administered daily, alternating the nares. An adequate daily in-take of dietary calcium and vitamin D is needed along with these prescribed medications.
Relief of back pain resulting from compression fracture may be accomplished by resting in bed in a supine or side-lying position several times a day. The mattress should be firm and nonsagging. Knee flexion increases comfort by relaxing back muscles. Inter-mittent local heat and back rubs promote muscle relaxation. The nurse instructs the patient to move the trunk as a unit and to avoid twisting. The nurse encourages good posture and teaches body mechanics. When the patient is assisted out of bed, a lum-bosacral corset may be worn for temporary support and immobi-lization, although such a device is frequently uncomfortable and is poorly tolerated by many elderly patients. The patient gradu-ally resumes activities as pain diminishes. Vertebroplasty may be considered for some patients.
Constipation is a problem related to immobility and medications. Early institution of a high-fiber diet, increased fluids, and the use of prescribed stool softeners help to prevent or minimize consti-pation. If the vertebral collapse involves the T10–L2 vertebrae, the patient may develop an ileus. The nurse therefore monitors the patient’s intake, bowel sounds, and bowel activity.
Physical activity is essential to strengthen muscles, improve bal-ance, prevent disuse atrophy, and retard progressive bone de-mineralization. Isometric exercises can strengthen trunk muscles. The nurse encourages walking, good body mechanics, and good posture. Daily weight-bearing activity, preferably outdoors in the sunshine to enhance the body’s ability to produce vitamin D, is encouraged. Sudden bending, jarring, and strenuous lifting are avoided.
Elderly people fall frequently as a result of environmental haz-ards, neuromuscular disorders, diminished senses and cardio-vascular responses, and responses to medications. The patient and family need to be included in planning for care and preven-tive management regimens. For example, the home environment should be assessed for safety and elimination of potential hazards (eg, scatter rugs, cluttered rooms and stairwells, toys on the floor, pets underfoot). A safe environment can then be created (eg, well-lighted staircases with secure hand rails, grab bars in the bathroom, properly fitting footwear). Other safety devices, such as hip protectors (Fig. 68-10), have been used to diminish the impact of a fall and have reduced the hip fracture rate (Kannus et al., 2000).
Expected patient outcomes may include:
1) Acquires knowledge about osteoporosis and the treatment regimen
a) States relationship of calcium and vitamin D intake and exercise to bone mass
b) Consumes adequate dietary calcium and vitamin D
c) Increases level of exercise
d) Takes prescribed hormonal or nonhormonal therapy
e) Complies with prescribed screening and monitoring procedures
2) Achieves pain relief
a) Experiences pain relief at rest
b) Experiences minimal discomfort during ADLs
c) Demonstrates diminished tenderness at fracture site
3) Demonstrates normal bowel elimination
a) Has active bowel sounds
b) Reports regular bowel movements
4) Experiences no new fractures
a) Maintains good posture
b) Uses good body mechanics
c) Consumes a diet high in calcium and vitamin D
d) Engages in weight-bearing exercises (walks daily)
e) Rests by lying down several times a day
f) Participates in outdoor activities
g) Creates a safe home environment
h) Accepts assistance and supervision as needed
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