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HSNS361 Wriiten Assignment

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HSNS361 Wriiten Assignment

  1. 1. Emily Bishop 220138178 HSNS361 – Written Assignment 1 HSNS361 Professional Practice: Application of Integrated Care Written Assignment Emily Bishop: 220138178 DUE DATE: 14/05/2016 SUBJECT COORDINATOR: Fiona Barrett WORD COUNT: 2500
  2. 2. Emily Bishop 220138178 HSNS361 – Written Assignment 2 This essay will discuss the how Mrs Gisbon’s risk factors for osteoporosis contribute to her bone density, the roles of hormones involved in bone remodelling and the effect of corticosteroid therapy on these cells, the immediate nursing priorities for Mrs Gibson and lastly the post operative and rehabilitation nursing care priorities. Osteoporosis is a skeletal disorder that is characterised by compromised bone strength which increases the risk of fractures and a decrease in bone mass (Bullock & Hales, 2012). The prevalence of the disease increases with age and mainly affects postmenopausal women, as females have a lower bone mass than males and the hormonal changes that occur at menopause (Marcus, 2013). Bone mass increases during childhood and adolescence before reaching a peak in the second decade of life, this is called the “peak bone mass” (Weaver et al., 2016). After peak bone mass is achieved, there is a period known as the consolidation period, where bone mass remains stable (Bonewald, 2011). From about the age of 30, bone mass begins to decline. In a male the loss of bone rate occurs at a steady rate, whereas in females the loss of bone is at a much higher rate and accelerates for around 5-10 years after menopause (Weaver et al., 2016). Osteoporosis occurs as a result of normal aging. In addition to age there are a number of risk factors that increase the chances of contracting osteoporosis. Female sex is a risk factor, as females have a lower bone mass density due the reduced size and cortical thickness characteristic of female bones and the decline in oestrogen at menopause (Janiszewska, Kulik, Dziedzic, & Żołnierczuk-Kieliszek, 2015). Women account for over 80% of osteoporosis diagnoses (Marcus, 2013). Oestrogen has a protective effect on bone, primarily by blocking osteoclast activity (Bullock & Hales, 2012). It achieves this through the inhibition of a number of cytokines, which otherwise activate mature osteoclasts (Bullock & Hales, 2012). The protective effect of oestrogen on females’ bones explains why women who suffer from early menopause can lead to low bone mass density and is the reason why hormone replacement therapy (HRT) is needed to avert osteoporosis (Sternberg et al., 2013). Postmenopausal oestrogen deficiency is the most significant non-genetic factor for being at risk of osteoporosis (Sternberg et al., 2013).
  3. 3. Emily Bishop 220138178 HSNS361 – Written Assignment 3 Ethnicity is another risk factor given people of Caucasian background are at a higher risk than other ethnic groups, given the difference in bone mass and density, compared with other ethnic groups (Svejme, Ahlborg, Nilsson, & Karlsson, 2012). A family history of osteoporosis is also another risk factor, especially a first degree relative. This family history could indicate that there may be a history of low bone mass, which is determined by genetic factors (Svejme, Ahlborg, Nilsson, & Karlsson, 2012). Bone quality is made up of the structural and properties of bone. Bone geometry and microarchitecture make up the structural properties of the bone, whereas, the material properties consist of the organisation and composition of the mineral and collagen components within the extracellular matrix (Kini & Nandeesh, 2012). The femoral head is supported by a relatively thin structure known as the femoral neck, which is more prone to fracture than the joint itself is to dislocation (Cummings- Vaughn & Gammack, 2011). The femoral neck is particularly vulnerable in patients suffering from bone disorders such as osteoporosis, osteomalacia, osteopetrosis and osteogenesis imperfect (Cummings-Vaughn & Gammack, 2011). The majority of patients, such as Mrs Gibson that present with femoral neck fractures are those suffering from osteoporosis. As osteoporosis is a disease in which the bones become fragile and are more likely to break, this can weaken the neck of the femur to the point that any increased stress may cause the neck of the femur to break suddenly (Bullock & Hales, 2012). As patients with osteoporosis are more likely to suffer from falls and have weakened bones are more predisposed to suffering fractures, a fall is not necessarily needed to suffer a fracture (Osteoporosis Australia, 2014). An uncertain step or a twist to the hip joint that places too much stress across the neck of the femur may result in a fracture, such as Mrs Gibson, without any trauma. The significance in observing limb length disparity and external rotation is used to assist in diagnosing hip fractures. Most hip fractures reveal that a patient is suffering from an abducted and externally rotated hip with a leg length discrepancy (Bullock & Hales, 2012).
  4. 4. Emily Bishop 220138178 HSNS361 – Written Assignment 4 Bone undergoes a continuous renewal process of bone resorption and formation, commonly known as bone remodelling, or bone turnover. Bone remodelling is the active and dynamic process of bone remodelling made up of the correct balance between osteoclast, which are multinucleated cells that destroy the bone matrix which used for bone resorption and bone deposition by osteoblasts (Kini & Nandeesh, 2012). The osteocytes, another important cell type arising from the osteoblasts, are also involved in the remodelling process (Kini & Nandeesh, 2012). The process of the osteoclasts and osteoblasts are very closely linked and work together in a harmonious state (Boyce, Rosenberg, de Papp, & Duong, 2012). If this state between the two is interrupted or disrupted, the correct bone mass could be compromised. The balance between bone resorption and bone formation, allows the bone to remove fatigue damage and replace it with new bone that reinforces the bone integrity (Boyce, Rosenberg, de Papp, & Duong, 2012). An imbalance between bone resorption and bone formation results in a loss or gain of bone tissue and affects bone mass density. Bone loss and osteoporosis are the direct result of an increase in the osteoclast function and/or a reduced osteoblast activity (Marcus, 2013). In contrast, other pathologies are related to osteoclast failure to reabsorb bone, such as osteoporosis, a rare genetic disorder characterized by an increased bone mass and also linked to an impairment of bone marrow functions. There are many molecular mechanisms regulating bone cell functions. Recent studies have shown there is a complex interplay between the immune and skeletal systems, which share several regulatory molecules including cytokines, receptors and transcription factors (Boyce, Rosenberg, de Papp, & Duong, 2012). Elderly patients for the treatment of rheumatic conditions commonly take medications such as corticosteroids (Mitra, 2011). Prolonged use of corticosteroids has been shown to reduce bone formation leading to bone fractures. The risk of fractures is dose dependant and bone mass loss occurs quickly within months of starting on a course of corticosteroids (Sternberg et al., 2013). Corticosteroids have been shown, when administered in doses greater than the physiological concentrations, the corticosteroids directly and indirectly with the bone cells that are involved in bone resorption and inhibit bone formation (Liu et al., 2013).
  5. 5. Emily Bishop 220138178 HSNS361 – Written Assignment 5 Corticosteroid exposure alters the balance between the osteoclast and osteoblast activity, which is involved in bone metabolism. The corticosteroid stimulates the osteoclast bone resorption and reduces the osteoblast bone formation. As a result of this effect the corticosteroids has, it results in increasing the bone resorption, while slowing the bone formation, which results bone is reabsorbed more quickly, than it is made (Liu et al., 2013). The two main effects of that corticosteroids have on bone metabolism, is they induce apoptosis in the osteoblasts and osteocytes involved in bone formation, which decrease the formation of bone as the cells die and prolong the lifespan of the osteoclasts, which increase bone resorption (Clarke, 2012). Due to these changes in the bone remodelling cycle, there is approximately 30% less bone tissue that is produced than in normal conditions. (Clarke, 2012) 3Based on the assessment of Mrs Gibson, there are a number of immediate nursing care priorities that are needed for her care. As Mrs Gibson is suffering from a Urinary tract infections (UTI), which are one of the most common infections suffered by the older population, occurring both in the community and in long-term care settings (Jarvis, Chan, & Gottlieb, 2014). With UTI’s there is a high mortality rate within the older population, with 5% of the older population reporting a 28-day mortality. In women such as Mrs Gibson, who are suffering from postmenopausal estrogen deficiency, it has been linked to recurrent UTI’s (Jarvis, Chan, & Gottlieb, 2014). The immediate nursing care priorities for Mrs Gibson in relation to her UTI after giving her a physical examination is to start Mrs Gibson on intravenous (IV) fluids in an effort to rehydrate her as she has poor skin turgor which is an indication of this and by increasing her fluid intake, will help flush the bacteria through the urinary tract (Berman, Snyder, & Frandsen, 2016). Also giving Mrs Gibson IV fluids, it allows for Mrs Gibson to start on a course of a combination of Trimethoprim and Sulphamethoxazole. They are both are antibiotics that are used to commonly treat different infections caused by bacteria such as UTI’s (Drugs for Urinary Tract Infections, 2014). Although there has been a progressive development of antimicrobial resistance to common antibiotics in UTI’s, Trimethoprim and Sulphamethoxazole should be used as first line treatment, as it is a broad spectrum
  6. 6. Emily Bishop 220138178 HSNS361 – Written Assignment 6 antibiotic Trimethoprim and Sulphamethoxazole work in conjunction by interfering with the synthesis of folate inside microbial organisms and inhibits the bacteria’s replication (Bullock & Manias, 2014). Other immediate nursing priorities for the treatment of Mrs Gibson’s UTI include monitoring the input and output characteristics of the urine, observe any changes in mental status, monitor the results from blood and urine tests and finally organize an incontinence pad for Mrs Gibson for short term management of her incontinence (Jarvis, Chan, & Gottlieb, 2014). Once the immediate nursing priorities have been arranged for Mrs Gibson and the treatment of her UTI, it is necessary to try and assess the pain that Mrs Gibson is in in regards to her hip fracture, as pain management is one of the most important aspects of care as it can lead to delirium, depression and poor sleep (Bastani et al., 2014). This may explain the confusion that Mrs Gibson is displaying and may not be related to the UTI. Uncontrolled pain may also interfere with treatment for other medical conditions. Pain should be assessed immediately on arrival and if Mrs Gibson is displaying signs of confusion, non-verbal cues signifying her pain levels should be assessed (Bastani et al., 2014). Mrs Gibson should be administered an analgesia such as morphine or even a nerve block to aid in her pain relief (Bastani et al., 2014). Mrs Gibson other immediate nursing priorities include being placed on a soft surface to protect heel and sacrum from pressure damage, making sure that there is adequate pain relief is administered allowing for the comfortable change of Mrs Gibson’s position and arrange for radiography to diagnose fracture and location of fracture (Berg & Bhatia, 2014). Hip fracture patients such as Mrs Gibson normally undergo surgery for the treatment of the fracture in an effort to preserve the function of the hip and the reduction of pain (Bastani et al., 2014). There are a very small minority of patients that are unsuitable for surgery due to the risk that surgery may exceed the benefits. Once surgery has been decided, the goal for the treatment of patients with hip fractures is to have a short short time to surgery, few or no complications, control of pain, and early mobilization for restoration of function. Hip fractures are common in older people
  7. 7. Emily Bishop 220138178 HSNS361 – Written Assignment 7 such as Mrs Gibson, especially those with osteoporosis. The mortality and morbidity rate associated with hip fractures are high, however can be related to the age of the of the patients and the comorbidities that are common in these patients (Marcus, 2013). As a result of undergoing surgery there are a number of postoperative complications could occur such as delirium induced by inadequate pain control, the risk of secondary fractures and poor mobilisation after surgery (McClung et al., 2013). By minimising the risk of post operative complications due to hip fractures, not only benefits the patient but places less and financial burden on the health care system. To assist in the reduction of postoperative complications, multidisciplinary teams have been shown to assist in the reduction of postoperative complications and provide better patients outcomes (Dy et al., 2011). When patients are cared for using a multidisciplinary approach is has been shown to hat patients have a shorter hospital stay than predicted, reduced admission rates, shorter time to surgery, low complication rates and low mortality rates (Dy et al., 2011). Within a multidisciplinary team, each medical professional is able to participate in discussions of the plans for rehabilitation and postoperative plans for the patient, as well as being aware of any changes in the patient. One of the main complications after hip surgery is inadequate pain control (Chin, Ho, & Cheung, 2013). More than half of patients, who undergo surgery, will experience an inappropriate level of postoperative pain, which can have detrimental affect on the outcome for the patient. Postoperative pain management aims to minimise patient discomfort, facilitate early mobilisation and recovery, stop acute pain from turning into chronic pain and reduce the incidence of delirium (Corke, 2013). A patient’s pain management should be managed in consultation with the orthopaedic surgeon, geriatric consultant and nursing staff. Nursing staff should conduct regular checks on the pain level of patients and notify the orthopaedic surgeon or geriatric consultant of any changes. Early mobilization is important for patient’s revering from surgery as it minimises minimizing complications like venous thromboembolism, pneumonia, and pressure sores (Cummings-Vaughn & Gammack, 2011). Early mobilisation is vital as it re-
  8. 8. Emily Bishop 220138178 HSNS361 – Written Assignment 8 establishes movement and function, following the fracture with the aim of returning the patient to pre injury function (Berman, Snyder, & Frandsen, 2016). Mobilisation can included movement between postures, having the ability to have an upright posture and being able to change direction and speed. Mobilisation is normally started twenty fours after surgery unless advised against by the orthopaedic surgeon for medical reasons. The sooner that the patient is able to regain their full mobilisation it has been shown that improves their quality of life, reduces the risk of falls and improved capacity for patient self-care (Menzies, Mendelson, Kates, & Friedman, 2010). A physiotherapist and/or occupation therapists, are able to provide patients with exercises, education and tools and aids that assist in the patient mobilizing early and regaining their pre injury mobilisation. Physiotherapists and occupational therapists can also provide ways for patients to reduce the risk of secondary fractures. Another important aspect of early mobilization is to ensure that adequate pain relief is being administrated to the patient (Foss, Kristensen, Palm, & Kehlet, 2008). As most hip fractures occur in elderly patients with comorbidities such as osteoporosis like Mrs. Gibson, a priority after surgery is to reduce the risk of secondary fractures. If patients such as Mrs. Gibson are not adequately treated for their osteoporosis, they are at increased risk for further osteoporotic fractures, which can include recurrent hip fractures (Janiszewska, Kulik, Dziedzic, & Żołnierczuk- Kieliszek, 2015). The multidisciplinary team should be aware of their patients comorbidities and have a plan of action, to ensure the patient is adequately treated in an effort for to maintain a high quality of life and reduce the risks of further fractures. To treat osteoporosis in patients, there a number of pharmacological options available to assist in preventing further fractures after surgery. With the assistance of the multidisciplinary team, such as the general practitioner, they are able to prescribe the best drug interventions suited to each individual patient. Most of the medications for the treatment of osteoporosis work by slowing down the osteoclasts, which break down the bone, while allowing the osteoblast to remain active and form new bone (McClung et al., 2013). Medications include bisphosphtes, denosumab, strontium ranelate, which is absorbed into the bone similar to calcium, and selective oestrogen receptor modulators, which act like the hormone oestrogen
  9. 9. Emily Bishop 220138178 HSNS361 – Written Assignment 9 (Zhang et al., 2013). Although the increases on bone density are minimal, they can have a positive effect and hip fractures can be reduced by 30-50% and positive effect can be seen as early as six to twelve months after treatment is started (Zhang et al., 2013). In conclusion, Mrs Gibson has a number of risk factors that contribute to her bone density and is the reason behind her hip fracture. Corticosteriod therapy has detrimental effects on the cells involved in the breaking down and formation of new bone and can contribute to patients suffering from low density and putting them at risk of bone fractures. There are also a number of immediate nursing care priorities that need to be attended to in relation to Mrs Gibson and also a number of postoperative and rehabilitation care priorities to assist Mrs Gibson in achieving positive outcomes for her care.
  10. 10. Emily Bishop 220138178 HSNS361 – Written Assignment 10 Bastani, A., Donaldson, D., Cloutier, D., Forbes, A., Ali, A., & Anderson, W. (2014). 287 Streamlining Patients With Isolated Hip Fractures from the Emergency Department to the Operating Room Utilizing a Novel Hip Fracture Pathway. Annals Of Emergency Medicine, 64(4), S101-S102. http://dx.doi.org/10.1016/j.annemergmed.2014.07.314 Berg, A. & Bhatia, C. (2014). Neck of femur fracture fixation in a bilateral amputee: an uncommon condition requiring an improvised fracture table positioning technique. Case Reports, 2014(feb21 1), bcr2013203504-bcr2013203504. http://dx.doi.org/10.1136/bcr-2013-203504 Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb's fundamentals of nursing (10th ed.). Bonewald, L. (2011). The holy grail of high bone mass. Nature Medicine, 17(6), 657- 658. http://dx.doi.org/10.1038/nm0611-657 Boyce, B., Rosenberg, E., de Papp, A., & Duong, L. (2012). The osteoclast, bone remodelling and treatment of metabolic bone disease. European Journal Of Clinical Investigation, 42(12), 1332-1341. http://dx.doi.org/10.1111/j.1365- 2362.2012.02717.x Bullock, S. & Hales, M. (2012). Principles of pathophysiology. Frenchs Forest, N.S.W.: Pearson Australia. Bullock, S. & Manias, E. (2014). Fundamentals of Pharmacology (7th ed.). Frenchs Forest, NSW: Pearson. Chin, R., Ho, C., & Cheung, L. (2013). Scheduled Analgesic Regimen Improves Rehabilitation After Hip Fracture Surgery. Clinical Orthopaedics And Related Research®, 471(7), 2349-2360. http://dx.doi.org/10.1007/s11999-013-2927-5 Clarke, B. (2012). Corticosteroid-Induced Osteoporosis. American Journal Of Clinical Dermatology, 13(3), 167-190. http://dx.doi.org/10.2165/11594250-000000000- 00000 Corke, P. (2013). Postoperative pain management. Aust Prescr, 36(6), 202-205. http://dx.doi.org/10.18773/austprescr.2013.079 Cummings-Vaughn, L. & Gammack, J. (2011). Falls, Osteoporosis, and Hip Fractures. Medical Clinics Of North America, 95(3), 495-506.
  11. 11. Emily Bishop 220138178 HSNS361 – Written Assignment 11 http://dx.doi.org/10.1016/j.mcna.2011.03.003 Drugs for Urinary Tract Infections. (2014). JAMA, 311(8), 855. http://dx.doi.org/10.1001/jama.2014.972 Dy, C., Dossous, P., Ton, Q., Hollenberg, J., Lorich, D., & Lane, J. (2011). Does a Multidisciplinary Team Decrease Complications in Male Patients With Hip Fractures?. Clinical Orthopaedics And Related Research®, 469(7), 1919-1924. http://dx.doi.org/10.1007/s11999-011-1825-y Foss, N., Kristensen, M., Palm, H., & Kehlet, H. (2008). Postoperative pain after hip fracture is procedure specific. British Journal Of Anaesthesia, 102(1), 111-116. http://dx.doi.org/10.1093/bja/aen345 Janiszewska, M., Kulik, T., Dziedzic, M., & Żołnierczuk-Kieliszek, D. (2015). Chosen risk factors for osteoporosis and the level of knowledge about the disease in peri- and postmenopausal women. Menopausal Review, 1, 27-34. http://dx.doi.org/10.5114/pm.2015.49999 Jarvis, T., Chan, L., & Gottlieb, T. (2014). Assessment and management of lower urinary tract infection in adults. Aust Prescr, 37(1), 7-9. http://dx.doi.org/10.18773/austprescr.2014.002 Kini, U. & Nandeesh, B. (2012). Physiology of Bone Formation, Remodeling, and Metabolism. Radionuclide And Hybrid Bone Imaging, 29-57. http://dx.doi.org/10.1007/978-3-642-02400-9_2 Liu, D., Ahmet, A., Ward, L., Krishnamoorthy, P., Mandelcorn, E., & Leigh, R. et al. (2013). A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy. Allergy, Asthma & Clinical Immunology, 9(1), 30. http://dx.doi.org/10.1186/1710-1492-9-30 Marcus, R. (2013). Osteoporosis. Oxford: Academic Press. McClung, M., Harris, S., Miller, P., Bauer, D., Davison, K., & Dian, L. et al. (2013). Bisphosphonate Therapy for Osteoporosis: Benefits, Risks, and Drug Holiday. The American Journal Of Medicine, 126(1), 13-20. http://dx.doi.org/10.1016/j.amjmed.2012.06.023 Menzies, I., Mendelson, D., Kates, S., & Friedman, S. (2010). Prevention and Clinical Management of Hip Fractures in Patients With Dementia. Geriatric Orthopaedic Surgery & Rehabilitation, 1(2), 63-72. http://dx.doi.org/10.1177/2151458510389465
  12. 12. Emily Bishop 220138178 HSNS361 – Written Assignment 12 Mitra, R. (2011). Adverse Effects of Corticosteroids on Bone Metabolism: A Review. PM&R, 3(5), 466-471. http://dx.doi.org/10.1016/j.pmrj.2011.02.017 Osteoporosis Australia. (2014). Osteoporosis.org.au. Retrieved 10 May 2016, from http://osteoporosis.org.au Sternberg, S., Levin, R., Dkaidek, S., Edelman, S., Resnick, T., & Menczel, J. (2013). Frailty and osteoporosis in older women—a prospective study. Osteoporosis International, 25(2), 763-768. http://dx.doi.org/10.1007/s00198- 013-2471-x Svejme, O., Ahlborg, H., Nilsson, J., & Karlsson, M. (2012). Early menopause and risk of osteoporosis, fracture and mortality: a 34-year prospective observational study in 390 women. BJOG: An International Journal Of Obstetrics & Gynaecology, 119(7), 810-816. http://dx.doi.org/10.1111/j.1471- 0528.2012.03324. Weaver, C., Gordon, C., Janz, K., Kalkwarf, H., Lappe, J., & Lewis, R. et al. (2016). The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporosis International, 27(4), 1281- 1386. http://dx.doi.org/10.1007/s00198-015-3440-3 Zhang, J., Delzell, E., Curtis, J., Hooven, F., Gehlbach, S., Anderson, F., & Saag, K. (2013). Use of pharmacologic agents for the primary prevention of osteoporosis among older women with low bone mass. Osteoporosis International, 25(1), 317-324. http://dx.doi.org/10.1007/s00198-013-2444-0

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