A Case Study

On

Lumbar Compression
Fracture
In Partial Fulfillment of
Nursing Care Management 203
Related Learning Experience

Submitted by:

BSN 3 – GROUP 7
Date of Defense: May 4, 2010
 TABLE OF CONTENTS

I. Nursing Health History

II. Gordon’s Functional Pattern

III. Physical Assessment

IV. Laboratory Results

V. Anatomy and Physiology

VI. Pathophysiology

VII. Ideal Signs and Symptoms

VIII. Summary of Significant Findings

IX. Nursing Care Plans

X. Drug Study

XI. Discharge Plan

XII. References
Nursing Health
History
DEMOGRAPHIC DATA :

Name : Patient Mrs. X

Address :

Age : 78 years old

Birthdate : September 13, 1931

Birthplace :

Sex : Female

Civil Status : Widow

Citizenship : Filipino

Religion : Roman Catholic

Occupation :
Before Counselor for 5 years
Barangay Captain for 12 years
Farm Inspector for 9 years

At Present Farmer, Midwife & Dressmaker

Informant : The patient

Ward : Medical ward-57A

Hospital :

Case no. :

Impression : Lumbar Compression Fracture

2° to Osteoporosis
CHIEF COMPLAINT: LOW BACK PAIN

CURRENT HEALTH STATUS

The patient decided to seek medical help when she experienced
persistent severe lower back pain and muscle cramps in her legs. She
went to ODH for consultation and was advised by the attending
physician to be very careful in doing her daily activities to avoid
further injury. She was given Arcoxia for medication and treatment.
After several days, the patient’s condition did not improve. She
went back to ODH, and was advised by the physician for
hospitalization, so she would be properly examined and diagnosed.
She was confined in the hospital for five days (from April 22 to 26,
2010.) Her Roentgenologic Report manifested a compression fracture
on her lumbar 2, Degenerative osteoarthrosis of Lumbar spine with
straightening due to muscular spasm and osteoporosis. Her
medications were Ketorolac 30mg, Tenoxicam 20mg and Calcium
carbonate.

PAST MEDICAL HISTORY

The patient experienced common childhood diseases and minor
illnesses such as chickenpox, measles, mumps and common colds. She
was never been hospitalized before due to these minor ailments nor
undergone any kind of surgeries. Adult illnesses experienced were
cough, colds, fever, asthma, malaria and rhinitis which she self-
medicated with herbal medicines and/or over-the-counter drugs.
Last 2003, the patient fell off from a carabao and suffered
severe lower back pain. She was brought to Cebu City for medications
and treatment. She recovered from the indicent, she did not feel any
pain in her lower back anymore until recently.
The patient learned that she had an asthma when she was
hospitalized last June 2009 due to difficulty in breathing. The
medications prescribed to her were multivitamins, Ponstan and
Duevent.
She said that she had no allergies to food, drinks, drugs or any
environmental substances. She could not identify the irritants that
could trigger her asthma.
She also informed that she had immunizations given by their
barangay, like BCG, Hepa B, Tetanus toxoid and Measles, because she
knew that it was an important means of preventing illness
 The patient was an alcohol drinker (tuba) and a tobacco smoker.
According to her she consumed approximately 2-3 glasses of tuba per
day and more or less 5 tobacco sticks per day.

FAMILY HISTORY
The patient’s father died because of a vehicular accident and her
mother died due to old age. She was the fourth child among the ten
siblings of which eight were male and two were female. Five of her
siblings, all male, were already dead. Two died due to an unknown
cause, while the other three died due to severe headache, bone cancer
and severe bleeding.
Mrs. X was a widow for seven years. Her husband died due to a
heart disease. They had four children of which, two were boys and two
were girls. All of their children have their own family now. Presently,
the patient lived with her grandson.
The patient informed that her whole family got along with each
other very well. They settled any misunderstandings and conflicts
easily. Aside from herself, she considered all the members of her
family healthy.
GENOGRAM:

Tibrosio – Conchita Rudy - Celestina

(old age) (HPN) (DM) (Unknown)

Ruben Felomino Rodolfo Vivian Michael Ramon

Georgina
(unknown) (Vehicular Accident) (HPN) (HPN) (DM) (CVA)
(Old age)

Francisco Andres Silverio Patient Conrada Victorio Augustine

Dominador Pedring Arnulfo
(Unknown) (Unknown) (Severe HA) 77 y.o. 73 y.o. (bone
cancer) (arthritis) (bleeding) (asthma)

Legends:
Our patient, Mrs. X , 78
years old, female, widow,
- Patient from Brgy. Domonar,
Ormoc City.

Medical Diagnosis:
- Male Lumbar Compression
Fracture

- Female
 - Deceased Male Relative

- Deceased Female Relative

Gordon’s
Functional
Health Pattern
HEALTH PERCEPTION AND HEALTH MANAGEMENT
The patient perceived herself as an unhealthy individual because
she couldn’t perform her daily normal activities, like working in the
farm and doing household chores. She rated her health condition now
as 1 in which 1 was the lowest and 10 was the highest
Her present illness was her primary reason for being not healthy,
also her being an alcohol drinker and a smoker. She didn’t consult for
medical advice whenever she had health problems, didn’t perform
Breast Self-examination and have her blood pressure read. She only
went to a doctor when her illness was getting worst and she couldn’t
take the pain anymore.
Health for the patient was an important aspect of one’s life,
because an individual had no freedom to do whatever she wanted if
she was not healthy, especially if confined on bed like she was
experiencing at present. Unhealthy for her means “dili na maayo ang
panglawas”.

NUTRITION AND METABOLIC PATTERN

Before hospitalization
***24-HOUR DIETARY INTAKE REVIEW (Usual daily menu)

Breakfast : 2 pcs pandesal, 1 cup of coffee w/ milk, 1 glass of water

Lunch : 1 cup of rice, 2 pcs of fish (Labtingaw) or pork,
8 oz softdrinks (sparkle), 1 glass of water
Dinner : 1 cup of rice, 1 pc of fish (Labtingaw), soup, 1 glass of water
Snack : 1 glass of energen drink (1 sachet)

The patient usually took her meals at 7am-12nn-7:30pm. She

was not fond of eating vegetables. But she sometimes took Vitamin C
to boost her immune system. The patient bought her food in the public
market and cooked it by herself.
The patient said that she had no problem in chewing food even
she only had a few teeth left. Rarely, the patient find hard to swallow
her food. She did not experience any nausea and vomiting when
eating, and perceived to have no allergies in food and drugs.
The patient did not practice in visiting a dentist for regular check
up because she perceived that she had no problem with her teeth. She
seldom got sore throats and abdominal pains.

During hospitalization
***24-HOUR DIETARY INTAKE REVIEW (Patient is under full diet)

Breakfast : none (she did not eat breakfast)

Lunch : lugaw
Snack : 1 glass of milk and 1 piece of bread (pandesal)
Dinner : 1 cup of rice, 1 cup pork (ginagmay), 1 cup mongos
BLADDER ELIMINATION PATTERN
Before hospitalization
The patient’s fluid intake was approximately 8 glasses a day
(1,920 ml). Her daily urine output averaged to 10 times a day (84 ml
per voiding). Her urine was amber in color and clear. She had no
problem in voiding her urine, like experiencing pain and having urinary
incontinence or infection.

During hospitalization
No changes in bladder elimination pattern during hospitalization.

BOWEL ELIMINATION PATTERN

Before hospitalization
Patient claimed that she usually experienced irregular bowel
movement. She had it every 3-5 days despite her large amount of
food and fluid intake. According to her, she had a hard time
defecating, and needed to perform valsalva maneuver often. She
never used any laxatives to ease her discomforts in defecation. Her
stool was dark brown, hard formed and adequate in quantity.

During hospitalization
No changes in bowel elimination pattern during hospitalization.

SLEEP-REST PATTERN
Before hospitalization
The patient had an average of 8 hours of sleep per night and a
30 minutes afternoon nap. Her sleep was sometimes interrupted when
she frequently urinated at night and mostly this occurred during cold
weather. She had no problem in falling asleep or in waking up. She
had a comfortable foamed bed and laid either in supine or side-lying
position. Watching television also made her fall asleep easily.
During hospitalization
She had difficulty falling asleep in the hospital because of the
noisy and hot environment. She was not comfortable sleeping in the
hospital bed too because the bed was a bit higher than she was used
to.

ACTIVITY AND EXERCISE PATTERN

Before hospitalization
Her day started at 7am by preparing breakfast for herself and
her grandson. After eating her breakfast and taking a bath, she would
go to work, either tending her farm, sewing dresses or delivering
babies. When she got home from work in the afternoon, she usually
took a nap. Afterwards, she cooked dinner and ate with her grandson.
She watched her favorite teleserye and news in the television before
retiring to bed, which usually at 11 pm. Sometimes, she had a drinking
session with her friends and neighbors in her house.
Mrs. X was happy and contented with her life. But now her
illness hindered her drinking session with friends and doing her usual
daily living activities.

During hospitalization
Patient was confined on bed, but had toilet privileges with the
helped of her significant other. She could only perform range of motion
exercises while on bed.

EXERCISE ROUTINE
Mrs. X claimed that her means of daily exercise was doing her
work in the “hagna” and household chores. Her illness affected her
daily activities.

OCCUPATIONAL ACTIVITIES
She used to be a farm inspector for 9 years, a counselor for 5
years and a Barangay Captain for 12 years in their place. At present,
she worked as a farmer, a dressmaker and a midwife. Her ailment
interfered her work and means of livelihood.

COGNITION AND PERCEPTION PATTERN

Before hospitalization
Patient was oriented to time, place and persons. She had a good
short-term memory recall but could not remember other long-term
events. She was able to answer questions asked and followed
instructions logically and correctly.

o ABILITY TO UNDERSTAND AND COMMUNICATE

 The patient understood what her doctor told her about her
illness, particularly that it was impossible to cure, and to prevent
progressions she had to take her medications religiously.

o ABILITY TO REMEMBER
She could recall some long term important events in her life like
their wedding, birthdates, anniversaries, graduations of her children
and many more. She even remembered how she was courted by her
husband and how they celebrated their first anniversary.

o ABILITY TO MAKE DECISIONS

The patient was having difficulty making a major decision
especially when it involved her family and work.
During hospitalization
No changes in the patient’s cognition and perception pattern
during hospitalization.

SELF PERCEPTION AND SELF CONCEPT PATTERN

Before hospitalization
The patient viewed herself as a simple individual. She was
contented with her role as a wife to her husband before and a mother
to her children. She had a happy marriage.
She looked satisfied with her body appearance. She spoke
clearly in moderate tone with good eye contact while talking to others.
Patient claimed that her strength in life was her family. She got
so affected every time they had a family problem but she remained
strong for them.

During hospitalization
Her family was worried with her illness but she assured them
that she was handling it well. Mrs. X was really affected with her
illness because she was incapable of doing things that she used to do.
Every time she saw disabled people, she couldn’t picture herself
as being one of them and made her felt so sad.

ROLES AND RELATIONSHIP PATTERN

Before hospitalization
The patient used to be a farm inspector for 9 years, a counselor
for 5 years and a Barangay Captain for 12 years. At present, she
worked as a farmer, dressmaker and a midwife. She had no major
problems with regards to her job. She could mingle well with her co-
workers. For her, that was a very important aspect in her work.
She had a harmonious relationship with her husband when he
was still alive. They helped each other in making major decisions
particularly with regards to financial matter. She had a good
relationship with her children also. Every time they had a family
problem they talked about it immediately. They maintained an open
communication with each other. The patient was very close to her
eldest child because she was matured enough to understand the
situation. With regards to her illness now, the whole family was
helping her to overcome it.
She also claimed that she got along with her neighbors very
well and never had any quarrel with any of them. Her neighbors were
very cooperative in their community activities. Because of this, Mrs. X
was encouraged to join the barangay affairs like bingo games, etc.

During hospitalization
She claimed that her hospital confinement altered her role as a
mother and grandmother. Because of this, she could no longer attend
the needs of her family.

COPING AND STRESS TOLERANCE PATTERN

The main stressor the patient felt nowadays was the additional
expenses of her medication. Some of her happiness now was set aside
because of this. Like instead of going for a vacation, she would rather
stay home to save the money for her medications, and this was so
painful to her. To cope with this, she just watched her favorite
teleseries in the television. She also prayed to God and went to church
every Sundays and firmly believed that God would help her in all her
problems.

SEXUALITY AND REPRODUCTION PATTERN

• Age of menarche :16 years old
• Menstruation :3 days duration with moderate flow associated
with malaise and dysmenorrhea
• Age become sexually active :17 years old
• Age of marriage :21 years old
• No. of pregnancy :6
• Deliveries :4
• Attended :Hilot (all children)
• Number of living children :4
• Abortion :2
• Age of menopause :Patient cannot recall
• Associated physiologic change :irritability

Patient said that her menopause did not change her functions in
life, particularly her sexual life. She preferred a single sexual partner.
She talked to her husband when to have sex because they were not
using any contraceptives. She had no history of any sexually
transmitted disease.

VALUES AND BELIEF PATTERN

The patient valued God and her family above all things.
She was a devoted Roman Catholic and attended mass regularly.
She did not belong to any religious group but she helped whenever
there were religious activities in their barangay. She had a strong faith
in God and believed that God would grace her for being courageous
and prayerful. No practice in her faith had any threat on her health.
She wanted to see her children grew older. She also liked to see
her grandchildren finished their studies and had their own family
someday.

Physical
Assessment
MUSCULOSKELETAL SYSTEM
The patient had equal muscle sizes of both of his arms, thighs
and calves. No contractures and tremors were noted. Patient was able
to perform shrugging of shoulders and turned her head against
resistance. She could hold her arms up, flexed and extended against
resistance that indicated equal strength of sternocleidomastoid,
trapezius, deltoid, bicep, and tricep muscles. Patient could also abduct
and adduct hips against resistance but experienced slight pain.
Therefore, total grade for muscle strength in upper extremities was 5
which indicated full ROM against maximal resistance and 4 in lower
extremities which indicated full ROM with minimal resistance.
Upon inspection of the spine, spinal disproportion was noted at
the lumbar spine area.

GENERAL APPEARANCE
Patient was a 78 years old, female, with an approximated height
of 4'11 ft. and weigh of 65 kilos with medium built body structure. She
was conscious, coherent, well-groomed, with appropriate clothing, not
so weak but unable to ambulate by herself due to lower back pain.
The patient had a pleasant facial expression and manner. She
answered our questions without any apprehensions. Despite the
patient’s advance age, she could still converse and listen well, had
good comprehension and level of consciousness.

MENTAL STATUS
 During assessment, the patient was conscious and alert to all
questions being asked. She could answer promptly, but not able to
expand her answers. She was oriented to time, place, person and
present situation. She could recall recent events, but she could not
remember other events that happened long time ago.

VITAL SIGNS
Temperature : 36.8° C – per axillary
Heart Rate : 60 bpm
Respiratory Rate : 20 cpm
Blood Pressure : 110/80 mmHg at R arm
Pain Scale : 8/10

HEAD AND SKULL

Hair was blackish-grey, equally distributed and with fine texture.
Scalp was smooth and a little bit oily. Her scalp appeared clean
and no lumps or lesions noted.
The patient’s head and skull was symmetrically round with
smooth skull contour, no nodules or masses noted.
OBSERVE HEAD MOVEMENT
The patient’s head movements were still functioning well. She
could move her chin to her chest, her chin could points upward, move
her head towards her shoulders and turned her head left and right
with less effort.

EYES
The patient’s eyes were positioned and aligned symmetrically.
Eyebrows were black in color, thin, semi-symmetrical and evenly
distributed.
Eyelashes were short and straight. No lesions, swelling and
secretions noted on both eyelids, inner and outer cantus. No edema on
the lacrimal glands also noted.
Both eyes could move in coordination, with the outer cantus
parallel with the pinna of the ears.
Six cardinal field of gaze was assessed to the patient, and she
could perform it well and was able to close eyes symmetrically. Edema
was not noted upon palpation of the eyes.
The pupil reaction to light test were made to the patient, and the
result was both eyes constricted and reactive to light.
The patient’s pupils were color black. The size and shape were
symmetrical. Unicteric sclerae with no lesions noted.
Grayish white ring around the corneal margin (arcus senils)
noted.
 The patient informed that she had a problem with her visual
acuity. She was nearsighted and cannot clearly see far objects.

SKIN, HAIR AND NAILS

The patient’s skin was tan, dry, wrinkled with freckles and
moles. No signs of edema or lesion noted. Skin turgor test at the
sternum was performed and no signs of dehydration noted.
Due to aging, hair was blackish-grey and equally distributed
with fine texture.
No lesions or abnormalities noted with her fingernails and
toenails.
Capillary refill test was performed and the result was <3 seconds
which indicated good venous return.

EARS AND HEARING

The patient’s ears were equal in size, same color with her facial
skin. No lesions, abnormalities, swelling or tenderness were found in
the auricles and earlobes. The auricle aligned with outer canthus of the
eye.
Dry cerumen were visible in the ear canals of both ears. Small
papules were also noted at both tragus.
Auditory acuity to whispered or spoken voice was assessed to
the patient, including watch tick test. The result was patient’s hearing
ability was slightly diminished.

NOSE AND SINUSES

The patient’s nose was symmetrical and straight. Nasal septum
was intact and in midline with no signs of flaring, lesions and
tenderness.
The nose had a similar color with the facial skin, no tenderness
or lesions noted in the external nose. Air moves freely as the client
breathes. The internal nasal cavity was normal, the mucosa was pink,
and has clear, watery discharge. The sinuses were palpated and no
evidence of swelling or lumps noted, and no pain felt by the patient
either.

MOUTH AND OROPHARYNX

The patient’s lips were dry and slightly dark. Oral mucosa was
pinkish in color. She had 14 teeth, with few tartars and caries noted.
Hard and soft palates were intact. The gums were slightly dark in
color, moist and firm.
Tongue was in lateral margin, located at the center of the
mouth, and movable. It was slightly pale in color, moist, slightly rough
and had whitish coating. Tongue resistant test was performed by the
patient and proven normal in functioning. The patient could still
determine sweet, sour, bitter and salty taste.
Inspection of the oropharynx and tonsils were made and gag
reflex was tested and assessed as functioning well.

NECK
The head was in the center of the neck. Patient could perform
head movements with no discomfort. The lymph nodes were not
palpable.
The trachea was in normal placement in the midline of the neck
and spaces were equal on both sides. The thyroid gland was not visible
on inspection. The gland ascends normally during swallowing.

THORAX AND LUNGS

The patent’s chest was symmetric, skin was intact; no
tenderness and masses noted. Her chest expansion was 3 cm during
deep respiration.
Upon auscultation, rhonchi was noted. The patient’s respiratory
rate was 20 cpm.
PERIPHERAL VASCULAR SYSTEM
The patient’s extremities were equal in length. Absence of any
redness and edema noted. Her extremities skin color was tan and
within normal temperature.
Her radial pulse were not equal in rate but it was in full pulsation
(R= 65 bpm, L=60 bpm).
• Apical pulse= 60 bpm
• Capillary refill = <3 sec

MOTOR FUNCTION
The patient couldn’t sit nor stand by herself due to lower back
pain (lumbar area). But she could move her extremities, flexed her
legs and arms with no discomfort felt.
The following Motor Function Tests were performed by the
patient normally:
• Finger to finger
• Finger to nose test
• Alternating supination and pronation of hands
• Light touch sensation
• Palm sensation
• Tactile discrimination
• Patellar reflexes
Laboratories
 LABORATORY FINDINGS

FINDINGS/ NORMAL
DATE LAB RESULT VALUE
INTERPRETATION

04-22-10 Hematology:
RBC
WBC 14.2 5-10.0 X10.9g/L - due to
presence of fracture
HGB 11.2 12-16gm% not significant
HCT 0.38 38-48% normal

Differential
Count:
Neutrophils 78% 40-60%/L - due to presence of
fracture
Lymphocytes 22% 20-40%/L normal

ROENTGENOLOGIC REPORT

04-22-10 Lumbo sacral APL

 Findings: Diminished height noted of the vertebral body
of L2.
There is absence of the normal lumbar lordosis.
Presence of osteophytes noted along the
anterolateral
Margin of the lumbar spine.

Impression: --Compression fracture L2

--Degenerative ostieoarthrosis of the lumbar
spine with
straightening due to muscular spasm.
--Osteoporosis
 Anatomy and
Physiology

Bones
Bones
• are rigid organs that form part of the endoskeleton of vertebrates.
• They function to move, support, and protect the various organs of
the body, produce red and white blood cells and store minerals.

Cellular structure
There are several types of cells constituting the bone
1. Osteoblasts (immature bone cells)
• are mononucleate bone-forming cells that descend
from osteoprogenitor cells.
• They are located on the surface of osteoid seams and make
a protein mixture known as osteoid, which mineralizes to become
bone.
 o The osteiod seam is a narrow region of newly formed
organic matrix, not yet mineralized, located on the surface of
a bone.
o Osteoid is primarily composed of Type I collagen.

2. Osteocytes (mature bone cells)

• originate from osteoblasts that have migrated into and become
trapped and surrounded by bone matrix that they themselves
produce.
• Their functions include to varying degrees:
o formation of bone
o matrix maintenance
o calcium homeostasis
o act as mechano-sensory receptors — regulating the bone's
response to stress and mechanical load

3. Osteoclasts
• are the cells responsible for bone resorption (remodeling of bone
to reduce its volume).
• These lacunae, or resorption pits, are left behind after the
breakdown of the bone surface.
• Because the osteoclasts are derived from a monocyte stem-
cell lineage, they are equipped with phagocytic-like mechanisms
similar to circulating macrophages.
• Osteoclasts mature and/or migrate to discrete bone surfaces.
• Upon arrival, active enzymes, such as tartrate resistant acid
phosphatase, are secreted against the mineral substrate.

Osteoprogenitor
 Manufacture hormones,
cells such as prostaglandins,
to act on the bone
itself.
Osteiod seam
 Produce alkaline
phosphatase,
an enzyme that has a
role in the
Osteoblasts mineralization of bone,
as well as many matrix
proteins.

Osteocytes
 Their functions include to
varying degrees:
o formation of bone
o matrix
maintenance
o calcium homeosta
sis
Bone ossification and o act as mechano-
calcification sensory receptors —
(Bone formation) regulating the
bone's response to

Osteoclasts

Bone resorption
(Remodeling of bone to
reduce its volume)

Remodeling
• Remodeling or bone turnover is the process of resorption
followed by replacement of bone with little change in shape and
occurs throughout a person's life.
• Osteoblasts and osteoclasts, coupled together via paracrine cell
signalling, are referred to as bone remodeling units.
• Purpose of Remodeling
o regulate calcium homeostasis
o repair micro-damaged bones (from everyday stress)
o shape and sculpture the skeleton during growth.

Calcium balance
• The process of bone resorption by the osteoclasts releases stored
calcium into the systemic circulation and is an important process in
regulating calcium balance.
• As bone formation actively fixes circulating calcium in its mineral
form, removing it from the bloodstream, resorption
actively unfixes it thereby increasing circulating calcium levels.
• These processes occur in tandem at site-specific locations.

Repair
• Repeated stress, such as weight-bearing exercise or bone healing,
results in the bone thickening at the points of maximum stress
(Wolff's law).
• It has been hypothesized that this is a result of
bone's piezoelectric properties, which cause bone to generate small
electrical potentials under stress.

Paracrine cell signalling

• The action of osteoblasts and osteoclasts are controlled by a
number of chemical factors which either promote or inhibit the
activity of the bone remodeling cells, controlling the rate at which
bone is made, destroyed or changed in shape.
• The cells also use paracrine signalling to control the activity of each
other.
 Osteoblast stimulation
• Osteoblasts can be stimulated to increase bone mass through
increased secretion of osteoid and by inhibiting the ability of
osteoclasts to break down osseous tissue.
• Bone building through increased secretion of osteoid is stimulated
by the secretion of growth hormone by the pituitary, thyroid
hormone and the sex hormones (estrogens and androgens).
• These hormones also promote increased secretion
of osteoprotegerin.
• Osteoblasts can also be induced to secrete a number
of cytokines that promote reabsorbtion of bone by stimulating
osteoclast activity and differentiation from progenitor cells.
• Vitamin D, parathyroid hormone and stimulation from osteocytes
induce osteoblasts to increase secretion of RANK-
ligand and interleukin 6, which cytokines then stimulate increased
reabsorbtion of bone by osteoclasts.
• These same compounds also increase secretion ofmacrophage
colony-stimulating factor by osteoblasts, which promotes the
differentiation of progenitor cells into osteoclasts, and decrease
secretion of osteoprotegerin.

 Osteoclast inhibition
• The rate at which osteoclasts resorb bone is inhibited
by calcitonin and osteoprotegerin.
• Calcitonin is produced by parafollicular cells in the thyroid gland,
and can bind to receptors on osteoclasts to directly inhibit
osteoclast activity.
• Osteoprotegerin is secreted by osteoblasts and is able to bind
RANK-L, inhibiting osteoclast stimulation.

Osteoporosis
o Osteoporosis is a disease of bone, leading to an increased risk
of fracture.
o In osteoporosis, the bone mineral density (BMD) is reduced,
bone microarchitecture is disrupted, and the amount and
variety of non-collagenous proteins in bone is altered.
o Osteoporosis is defined by the World Health
Organization (WHO) in women as a bone mineral density
2.5 standard deviations below peak bone mass (20-year-old
sex-matched healthy person average) as measured by DXA;
the term "established osteoporosis" includes the presence of
a fragility fracture.
o Osteoporosis is most common in women after
the menopause, when it is called postmenopausal
osteoporosis, but may develop in men and premenopausal
women in the presence of particular hormonal disorders and
other chronic diseases or as a result
of smoking and medications, specifically glucocorticoids, when
 the disease is called steroid- or glucocorticoid-induced
osteoporosis (SIOP or GIOP).
o Osteoporosis can be prevented with lifestyle advice and
medication, and preventing falls in people with known or
suspected osteoporosis is an established way to prevent
fractures.
o Osteoporosis can be treated with bisphosphonates and
various other medical treatments.
 Pathophysiolog
y

Genetics Age Nutrition Lifestyle Choices

Medications Co-morbidty
*Caucasian or Asian *Post menopause *Low calcium intake *Lack of weight-bearing
*Corticosteroids *Anorexia nervosa
*Female *Advanced age *Low vitamin D intake Exercise *Antiseizure
meds *Hyperthyroidism
*Family history *Low testosterone in men *High phosphate intake *Low weight and BMI
*Heparin *Malabsorption
*Small frame *Decreased calcitonin (carbonated drink) *Sedentary
*Thyroid hormone syndrome
*Inadequate calories *Caffeine, alcohol, smoking
*Renal failure
*Lack of exposure to sunlight

Predisposes to Hormones (estrogen, Reduces nutrients * Reduces

Affects Calcium
Low bone mass calcitonin, and testos- needed for bone osteogenesis
in absorption &
terone) inhibit bone loss remodeling bone remodeling
metabolism
* Bones need stress
for bone mainte-
nance

Reduction of bone density &

change in bone structure

Rate of bone resorption is

greater than the rate of
bone formation

The bones becomes

progressively porous
brittle and fragile

Compression fracture

Skeletal deformity
(kyphosis)

S/sx:
*Cramps in the legs at night.
*Constipation
*Broken bones or Pathologic Fracture
*Compression Fracture (Lumbar 2)
*Brittle nails
*Curved upper back (Deformity in Lumbar Spine)
*Lower back pain
*loss of height
Ideal Signs and
Symptoms
 Ideal Patient's Rationale
sign/symptoms manifestation
1. Cramps in the legs > Patient experienced A problem with muscle
at night. persistent severe cramps can sometimes
lower back pain and be a problem with the
muscle cramps in her muscle not being able
legs 3-4 days before to function properly
hospitalization. due to a lack of proper
electrolyte balance.
Potassium (K), Calcium
(Ca), and Magnesium
(Mg) are absolutely
essential for a muscle
to be able to properly
fire....and to properly
relax. If there is a lack
of these minerals in the
body, the muscle can
temporarily lose the
2. Constipation >Unable to defecate ability to relax and,
for 3 to 5 days before therefore, cramps.
and during
hospitalization. Curvature in the
vertebral column
protrudes the abdomen
and compresses the
gastrointestinal tract
3. Broken bones thus decreases
(Pathologic >Manifested per X-ray gastrointestinal motility
Fracture) result. Impression: and eventually results
Compression fracture to constipation.
Lumbar 2
-Vitamin D (calcitriol)
acts with calcium and
phosphorus in
promoting bone
formation. Low level of
vitamin D leads to
bone softening.
4. Compression -Due to rate of bone
fractures > Manifested per X-ray resorption greater than
result. Impression: the rate formation and
Compression fracture causes bone to become
Lumbar 2 progressively porous
 brittle and fragile.

-A compression
fracture occurs when
an injury to a spinal
bone (vertebra) causes
it to fracture and
collapse (compress). A
weakened vertebra
may collapse because
of a minor injury or
without an obvious
injury, often as the
result of osteoporosis,
5. Brittle nails which is most common
>not manifested by in women after
patient menopause.
-When several
vertebrae have been
6. Curved upper back fractured, a person
(Deformity in the may lose height.
Lumbar Spine) >Spinal disproportion Compression fractures
at the may lead to a hump in
Lumbar spine area. the upper back and
may cause back pain.

Calcium is required for

healthy and strong
nails,. Low intake of
7.Lower back pain calcium or vitamin D
will lead to brittle and
dry nails.
>Patient experienced
persistent An abnormally curved
Severe lower back upper back, or
pain. dowager's hump,
develops when the
8.Loss of Height bones of the upper
spine (vertebrae)
become thin and brittle
and collapse on each
other. Having collapsed
> From : not vertebrae in any part of
assessed the spine results in a
To : 4’11 ft. loss of height.
When the upper spine
curves, the lower back
makes adjustments to
keep the body in
balance, which may
cause muscle pain.
This pain often stops in
1 or 2 years as the
body adjusts to its new
shape.

Loss of height can also

be associated with
multiple vertebral
compression fractures.
Individuals suffering
from multiple vertebra
compression fractures
that result in a kyphotic
posture will often suffer
a loss of height.
Individuals with a loss
of more than one or
two inches of height
are usually the result of
compression fractures.
 Summary of
Significant
Findings

Significant Normal
Findings Value Nursing Diagnosis
Clinical Significance

Gordon’s Health Pattern: Acute Pain r/t G7,

P1, P2, P4, P5, P6,
1. Perceived herself as Fracture & muscle spasm P7,
P8, L5
Unhealthy (scale: 1/10)
2. Altered mobility Impaired physical mobility G2,
G7, P1, P2, P4, P5,
3. Loss of appetite r/t pain and discomfort of P6,
P7, P8, L5
4. Urinary frequency lumbar area
5. Constipation
6. Difficulty in sleeping Self-care deficit: Bathing, G2,
G7, P1, P2, P5, P6,
7. Altered ADL Toileting r/t pain & discom- L5
fort when moving

Disturbed self-esteem r/t G1,

G2, G7, P2, P5, P6,
Physical Assessment: loss of health status & inde-
L5
1. Pain in the hipbone pendent functioning
(Pain scale: 8/10)
2. Can’t stand and sit Risk for injury: fracture r/t G2,
G7, P1, P2, P8, L5
3. Altered LT memory decrease in bone mass
4. Facial grimace density 2° to osteoporosis
5. Pain upon moving
6. Guarding behavior Risk for altered nutrition: less G3
7. Moaning than body requirement r/t
8. Spinal disproportion loss of appetite
at the lumbar spine
Constipation r/t decrease phy- G2,
G5, G7
sical mobility 2° to osteoporosis

Laboratory: Sleep pattern disturbance r/t G4,

G6, P1, P4
1. WBC 14.20 5-10.0 X10.9/L pain and environmental factors
2. HGB 11.12 12-16gm%
3. Neutrophils 0.78 40-60%/L Altered urinary pattern r/t
G4
4. Lymphocytes 0.22 20-40%/L urinary frequency

Roentgenologic Report:
5. Lumbo sacral APL
Nursing Care
Plan
Drug Study
Generic Name: Tenoxicam
Patient’s dose: 20mg 1 tab OD
Classification: NSAIDS (Nonsteroidal anti-inflammatory drugs)

Indications: Used to relieve inflammation, swelling, stiffness, & pain

associated with rheumatoid arthritis, osteoarthritis, ankylosing
spondylitis ( a type of arthritis involving the spine), tendonitis
(inflammation of a tendon), bursitis (inflammation of a bursa, a fluid
filled sac located around joints & near the bones), & periarthritis of the
shoulders or hips (inflammation of tissue surrounding these joints).

Contraindication:
• Contraindicated to patient allergic to tenoxicam or to any of the
ingredients of the medication

• Senior who has been given anesthesia/surgery

• At risk of increased bleeding

• Risk of kidney failure

• Has an active inflammation disease involving the stomach or

intestine (ulcerative colitis)

• Has an active stomach/intestinal ulcer

• Has had an acute asthmatic attack, hives, rhinitis (inflammation

of the inner lining of the nasal passage) or other allergic
reactions caused by ASA (acetylsalicylic acid) or other
Nonsteroidal Anti-inflammatory Drugs (NSAIDs; diclofenac,
ibuprofen, indomethacin, naproxen)

Side Effects:
• Abdominal pain or discomfort (mild/moderate)

• Diarrhea or constipation

• Dizziness or lightheadedness

• Flatulence or gas
 • Headache (mild/moderate)

• Heartburn

• Nausea or vomiting

Nursing consideration:
• Should be taken at the same time each day & immediately after
a meal or after food to avoid stomach upset.

• It is important to use the medication exactly as prescribed by

the doctor. If you miss a dose, take it as soon as possible &
continue on with your regular schedule. If it is almost time for
your next dose, skip the missed dose & continue with your
regular dosing schedule. Do not take a double dose to make up
for a missed one.

• Advise the patient to avoid activities that requires reflexes due to

dizziness.
Generic Name: Calcium carbonate
Patient’s dose: 1 tab OD
Classification: Antacid, Electrolyte

Therapeutic actions: essential elements of the body; helps maintain

the functional integrity of the nervous & muscular systems; helps
maintain cardiac function, blood coagulation; is an enzyme cofactor &
affects the secretory activity of endocrine & exocrine glands;
neutralizes or reduces gastric acidity.

Indications: Used to treat and prevent osteoporosis in

postmenopausal women. It can also be used to prevent steroid-
induced osteoporosis (osteoporosis caused by taking corticosteroids
such as prednisone forlong periods of time).

Contraindications & Cautions:

• Contraindicated with allergy to calcium, renal calculi,
hypercalcemia, ventricular fibrillation during cardiac resuscitation
& patients with the risk of existing digitalis toxicity.

• Use catiously with renal impairment, pregnancy, lactation.

Side Effects:
• diarrhea
• dizziness
• flatulence
• headache
• heartburn
• nausea

Nursing intervention:
 • Do not administer oral drugs within 1-2 hr of antacid
administration.

• Have patient chew antacid tablets thoroughly before swallowing;

follow with a glass of water or milk.

• Give calcium carbonate antacid 1- 3 hr after meals & at bedtime.

• Take drug between meals & at bedtime.

• Do not take with other oral drugs. Absorption of those

medications can be blocked; take other oral medications at least
1-2 hrs after calcium carbonate.

• Report loss of appetite, nausea, vomiting, abdominal pain,

constipation, dry mouth, thirst, increased voiding.

• Advise the patient to increase fluid intake.

Generic Name: Ketorolac

Patient’s dose: 30mg IVTT
Classification: NSAIDs, Antipyretic, Nonopioid analgesic

Mode of transmission: the primary mechanism of action responsible

for ketorolac’s anti-inflammatory, antipyretic & analgesic effects is the
inhibition of prostaglandin synthesis by competitive blocking of the
enzyme cyclooxygenase (COX). Like most NSAIDs, ketorolac is a non-
selective COX inhibitor.

Indications: it is used for the short-term treatment (5-7days) of

moderate to moderately severe acute pain associated with muscle
sprains & strains, dental pain & pain after surgery or giving birth. It
works by reducing pain, swelling & inflammation.

Contraindications:
• Contraindicated to Patient’s with previously demonstrated
hypersensitivity to ketorolac.
• Patient’s with complete/partial syndrome of nasal polyps,
angioedema, bronchospastic reactivity or other allergic
manifestations to aspirin/other NSAIDs (due to possibility of
severe anaphylaxis).
• As with all NSAIDs, ketorolac should be avoided in patients with
renal dysfunction.( Prostaglandins are needed to dilate the
afferent arteriole; NSAIDs effectively reverse this).
 • The patients at highest risk, especially in the elderly, are those
with fluid imbalances or with compromised renal function(heart
failure,diuretic use,cirrhosis,dehydration & renal insufficiency).

Side Effects:
More common
• abdominal or stomach pain (mild or moderate)
• bruising at place of injection
• diarrhea
• dizziness
• drowsiness
• headache
• indigestion
• nausea

Less common or rare

• bloating or gas
• burning or pain at place of injection
• constipation
• feeling of fullness in abdominal or stomach area
• increased sweating
• vomiting

Nursing interventions:
• be aware that patient may be at increased risk for CV events, GI
bleeding, renal toxicity; monitor accordingly.

• Do not use during labor, delivery or while nursing.

• Every effort be made to administer the drug on time to control

pain; dizziness, drowsiness can occur (avoid driving or using
dangerous machinery)

• Report sore throat, fever, rash, itching, weight gain, swelling in

ankles or fingers; changes in vision; black,tarry stools, easy
bruising.
Discharge Plan
MEDICATION:
• Advise patient and significant others regarding her home
medications:
o Tenoxicam 20 mg 1 tablet once a day
o Calcium 05mg 1 tablet once a day
• Stress the importance and advantages of compliance with
medication regimen and dietary restrictions.

ENVIRONMENT:
• Encourage client and SO to provide a peaceful and well-
ventilated environment conducive for recovery and healthy
living.

• Advise client and SO to keep the surroundings clean and free

from stress.
• Encourage the patient to install safety devices, such as grab bars
and railings, at home.
• Advice patient to use support canes/walking cane when walking
or standing.
• Encourage client to have a regular rest periods during the day.

TREATMENT/VISIT:
• Review medication that will be taken home and stress
importance of following prescribed regimen.

• Stress the importance of having follow-up examinations and

treatment to the patient and presence of changing physical
status.
HEALTH TEACHING/EDUCATION:
• Discuss with patient her understanding of her condition and how
it affects her body.

• Encourage patient to have an adequate sunlight exposure every

early morning, before 10am.

• Encourage patient to have a good personal hygiene.

• Advise the SO to give the client the whole support needed.

• Advise patient to follow the discharge instructions given by the

doctor.

• Remind patient and family of the importance of participating in

health promotion activities and recommend health screening.

• Encourage patient to apply lumbosacral binder to support

lumbosacral area when moving.

• Advise patient to have an ROM exercise daily with the help of SO

to prevent muscle contractures due to limited mobility.

• Teach patient proper body mechanics to prevent further injury.

• Advise patient to exclude alcohol, smoking, caffeine and other

sedentary lifestyle that may worsen her condition.

OBSERVABLE SIGNS AND SYMPTOMS:

• Encourage patient to have immediate consultation if the
following signs and symptoms occur, such as:
o Severe pain (lumbar area, legs & joints)
o Severe leg cramps and spasm
o Swelling (lumbar area, legs and joints)
o Loss of sensation below the affected lumbar area
o Urinary and fecal incontinence

DIET:
• Stress to patient the importance of adequate intake of caloric
and nutrient food rich in calcium and vitamin D to increase
bone density.
SPIRITUAL:
• Encourage the client to pray every day.

• Encourage the client to strengthen her faith and trust in God.

• Encourage client to participate in religious activities that are

not strenuous and have contact with spiritual advisers.

Reference

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing 11th

Edition
By: Suzanne C. Smeltzer Vol. 2 pgs. 2404-2407

Essentials of Human Anatomy & Physiology 8th Edition

By: Elaine N. Marieb pgs. 145-152

http://en.wikipedia.org/wiki/Bones

http://emedicine.medscape.com/article/309615-overview#IntroductionPathophysiology