Week 11 RLE Course Task (Individual Task)

Magbanua, Jaira L.

BSN- 3YA-2

Case Scenario: Hot Spells, Porous Bones

Mrs. Pringle is a 62-year-old female experiencing diffuse bone pain over the past several years after
menopause. She has a history of fractures to her left hip and wrist. She states, “The pain is becoming
worse and it is keeping me from doing my daily activities.” She currently complains that any weight-
bearing activity causes her severe discomfort. She is not taking hormone replacement or any other
medication. She has been using a soy herbal supplement and vitamin E 400 IU daily. She knows the
importance of preventive healthcare. She is up to date on all her gynecological exams, and past
mammograms have been normal as have her health maintenance exams. She does not smoke or use
alcohol. Her system reviews are unremarkable excluding today’s complaint.

Her family history reveals that her mother had a history of anxiety, osteoporosis, non-insulin dependent
diabetes and hypertension. Her father has hypertension but is in otherwise good health. There is no
history of breast disorders or arthritis, thyroid or any other metabolic disorder.

She lives alone in a one-story house. She has three children and one grandchild. Her daughter lives in
close proximity to her so she is able to enjoy visiting and caring for her 3-year-old grandson occasionally.
She has no exercise routine and admits to a somewhat sedentary lifestyle. She admits to eating a
vitamin-poor diet.

Mrs. Pringle experienced menopause around the age of 47 when her menstrual periods stopped. Her
previous physician recommended no hormone replacement because she was not suffering from any
menopausal symptoms. However, she now reports having “hot spells” at different times throughout the
day with some trouble sleeping for the past 3 months. She also complains of some vaginal dryness that
she admits is bothersome.

Her chief complaint is severe back pain and the inability to do simple chores such as lifting grocery bags
and her grandchild without pain. Upon physical exam, she is afebrile with unremarkable findings with
exception to the musculoskeletal system. She weighs 132 pounds and is 5 feet 5 inches. At her last exam
8 months ago, she was 5 feet 6 inches. Upon palpation, guarding and tenderness are present in the
cervical, thoracic and lumbar spine with limited range of motion. No spasticity, rigidity or flaccidity is
present. She has active range of motion in all joints, with no edema, redness or heat present in joint
areas. She exhibits notable guarding and rigidity performing range of motion of lower and upper back
areas.

There is also noticeable guarding with some limitation of movement at the cervical spine area. She is
able to endure the exam with noticeable painful expressions on her face when asked to do range of
motion with back, guarding and tenderness noted at cervical spine area. There is no presence of
dowager’s hump. She has no evidence of herniation or disc displacement upon inspection. No scoliosis
or lordosis is present. Her preliminary urinalysis and CBC are unremarkable. Her symptoms indicate
post-menopausal osteoporosis. To confirm the diagnosis and rule out other medical conditions, lab tests
were obtained to assess hormone, calcium, vitamin D, blood cholesterol levels and thyroid function. Also
ordered were a sedimentation rate to check for arthritis, an X-ray of her back and a dual energy X-ray
absorptiometry (DEXA) scan to rule out injury. DEXA scan is the gold standard in diagnosis of
osteoporosis.

Diagnostic tests revealed a lack of estrogen and calcium. The X-ray of her back showed degenerative
changes but no disc dislocations or herniations. The DEXA scan showed a T score of -2.9. A T score
greater than -2.5 confirms a diagnosis of osteoporosis and indicates hormonal treatment should be
initiated.

Study Questions:

1. What treatment/s might you expect to help address the loss of bone mineral density of Mrs.
Pringle and reduce the risk of hip fracture?
- To address the patient’s bone mineral density loss, her treatment should include a calcium
supplement 1200 mg paired with vitamin D daily, alendronate sodium 10 mg daily,
teriparatide and conjugated estrogens 0.625 mg daily. This routine treatment should
provide adequate relief and help prevent future bone loss. Hormone replacement needs to
be used to increase the absorption of the calcium, vitamin D and estrogen concurrently to
prevent further bone loss and increase her quality of life.
2. How will you set your treatment goals to comply with the Mrs. Pringle stated goal of ‘bothering
vaginal dryness’?
- What Mrs. Pringles is experiencing is postmenopausal vaginal atrophy wherein there is
vaginal dryness associated with loss of naturally produced estrogen due to her menopause.
In this situation, the decreasing levels of estrogen causes the vaginal tissue and the vulvar
skin of the genitals to become atrophic- meaning the skin begins to lose its normal, thick
structure. To manage her vaginal dryness, Mrs. Pringles’ treatment goals must focus on the
application of a variety of non-hormonal over the counter vaginal preparations and
prescribed estrogen replacement must be made.
- Non hormonal over-the-counter vaginal preparations include vaginal moisturizers (Replens,
RepHresh,Emerita, K-Y Liquibeads) that is inserted into the vagina with a applicator once
every few days to relieve itching and general discomfort. Water-based vaginal moisturizers
adhere to the surface of the vagina, releasing water and producing a moist film over vaginal
tissue. They also help restore vaginal pH. Vaginal moisturizers can be messy (the vagina
absorbs what it needs and sheds the rest), so it may be helpful to wear a sanitary pad or
panty liner while using one. Another is vaginal lubricants (Astroglide, eros, ID Millennium, K-
Y Personal Lubricant, K-Y Sensual Silk) which can relieve vaginal discomfort.
- Low dose vaginal estrogen can also be prescribed which is applied directly to the vagina to
restore vaginal health and relieve vaginal dryness. Improvements usually occur within a few
 weeks, although complete relief may take several months. The planning for low dose vaginal
estrogen cream can be comfortably inserted at bedtime.
3. Develop a nursing care plan according to your identified priority plan of care.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Chronic Short term: Independent: Independent: Short term:
pain 1. Assess 1. To
“The pain is related to After 2 hours of the iden After 2
becoming worse loss of implementing the client’s tify hours of
and it is keeping bone nursing functiona probl implementin
me from doing y density intervention, the l ability em g the
daily activities,” as secondary client will be able for and nursing
verbalized by the to to mobility. help intervention
patient osteoporo  Verbalize Note for to , the client
sis as understan muscle estab will be able
Objective: evidenced ding of strength lish a to
 History of by her and tone, plan •Verbalize
fractures guarding situation joint of understandi
to her left behavior and mobility, care ng of her
hip and and treatment balance situation
wrist verbalizati regimen and and
 Severe on of the  Demonstr enduranc treatment
back pain patient ate e regimen
and the technique 2. Assess •Demonstra
inability s that will degree of te
to do enable pain and techniques
simple her to discomfo that will
chores continue rt felt by enable her
such as her the client 2. To to continue
lifting activities deter her activities
grocery of daily mine of daily
bags and living pain living
her mana
grandchil Long term: geme Long term:
d without nt
pain Through the 3. Determin appr Through the
 Weight- course of her e client’s opria course of
bearing treatment, the perceptio te for her
activity client will be able n about the treatment,
causes to: her impr the client
her  Prevent situation ovem will be able
severe further ent to:
discomfor progressio of •
t n of her client
 Guarding osteoporo ’s Prevent
and sis mobi further
tendernes  Maintain lity progression
 s are or 3. This of her
present in increase 4. Assist could osteoporosis
the the with help •
cervical, strength treatmen in
thoracic of the t of deter Maintain or
and affected underlyin mini increase the
lumbar part g ng strength of
spine with  Prevent condition client the affected
limited complicati causing ’ part
range of ons pain expe •
motion related to 5. Advise ctati
 Notable immobilit client to ons Prevent
guarding y as aplly and complication
and disease trochant belief s related to
rigidity condition er rolls s immobility
performin progresse and/or regar as disease
g range of s pillows ding condition
motion of to her progresses
lower and maintain condi
upper joint tions
back alignmen 4. To
areas t maxi
 DEXA 6. Avoid mize
scan restraint the
showed a as pote
T score of possible ntial
-2.9 for
mobi
lity
and
func
tion

5. To
prev
7. Instruct ent
significan musc
t others ulosk
eletal
defor
mati
es
 6. Inacti
vity
creat
ed by
the
8. Encourag use
e client of
to restr
participat ains
e in may
diversion incre
al or ase
recreatio musc
nal le
activities. weak
Maintain ness
a and
stimulati poor
ng balan
environm ce
ent 7. Famil
(Radio, y
TV, mem
Newspap ber
er, shoul
personal d be
possessio invol
ns, ved
pictures, in
clock, the
calendar, care
visits of
from the
family, client
and by
friends) havin
9. Instruct g
client or enou
assist gh
with know
active ledge
and to
passive bette
ROM r
exercises prep
of are
affected for
and hom
 unaffecte e
d care
extremiti 8. Provi
es des
an
oppo
rtuni
ty for
relea
10. Encourag se of
e use of ener
isometric gy ,
exercises refoc
starting usses
with the atten
unaffecte tion,
d limb. enha
nce
patie
nt’s
sens
e of
self-
contr
ol
and
self-
11. Provide wort
footboar h and
d, wrist aids
splints, inred
hand ucing
rolls as social
appropri isola
ate tion

12. Stress
the 9. Incre
importan ases
ce of bloo
adhering d
 in the flow
proper to
dietary musc
regimen. les
Provide a and
diet high bone
proteins, to
carbohyd impr
rates, ove
vitamins musc
(vitamin le
d) and tone,
minerals main
(Calcium) tain
joint
Dependent: mobi
1. Administ lity;
er prev
medicati ent
ons as contr
ordered actur
es or
atrop
hy
and
calci
um
resor
ption
from
disus
e
10. Isom
etric
exerc
ise
enabl
e
contr
actio
n of
musc
les
with
out
bend
ing
joints
 or
movi
ng
limbs
and
help
main
tain
musc
le
stren
gth
and
mass
11. Usef
ul in
main
taini
ng a
func
tiona
l
positi
on of
extre
mitie
s,
hand
s,
and
feet,
and
prev
entin
g
comp
licati
ons
12. This
can
help
stren
gthe
n
them
uscul
oskel
etal
 syste
m of
the
client
by
impr
oving
her
bone
and
musc
le
mass

Dependent:
1. It is
esse
ntial
for
main
taini
ng
the
bone
mass
nece
ssary
to
supp
ort
the
skele
ton.
This
is
also
helps
in
main
taini
ng
musc
le
and
nerv
e
func
tion.