Patient X is an 87-year-old male with a history of osteoporosis, anemia, pulmonary edema, A-fib, BPH, CAD, bradycardia with pacemaker, CKD, HTN, HF, and venous insufficiency. He is currently
nursing case study
Help answer the points at the end.
Evaluate Outcomes
Care Plan
Discussion
Recommendation
Requirements:
Patient Introduction
Patient X is an 87-year-old male with a history of osteoporosis, anemia, pulmonary edema, A-fib, BPH, CAD, bradycardia with pacemaker, CKD, HTN, HF, and venous insufficiency. He is currently on furosemide, metoprolol, aspirin, iron supplements, vitamin C, calcium paired with vitamin D, tamsulosin, and Eliquis is hospital stay to prevent blood clots.
Case Presentation
Patient X is an 87-year-old male recently admitted to the surgical orthopedics floor of Saint Vincent Hospital on February 1st, 2023. He was diagnosed with an open right ankle fracture after an unwitnessed non mechanical fall at home. Patient states he felt his knee give out? and fell. He then explained he had to crawl across the kitchen floor to retrieve his phone to call 911 for help and was brought into the hospital by ambulance. Patient X is a widower who values his independence and lives by himself in his home. He has a strong support system that includes his four children and grandchildren who frequent him during his hospital stay. Patient X is in moderate pain, rating 5/10 pain of the right ankle. Vital signs include? He is expected to receive two surgeries to fix his fracture. First surgery is an I/D of the ankle with external fixation, and second surgery on the 15th to remove hardware.
Pathophysiology
Patient X has an extensive renal complications history. The possible explanation for the patient feeling as though his knee gave out on him? as he was walking could be a complication of the patients osteoporosis. The patient has known risk factors associated with this disease due to him being over 65 years old (older age causes increased degeneration of bone tissue) and his medical diagnosis of chronic kidney disease (the kidneys play a huge role in regulating calcium and phosphorus homeostasis that involves bone mineralization and development) (Wei).
Osteoporosis could have also made him more susceptible to sustain his open right ankle fracture.
Renal osteodystrophy may occur as a result of chronic kidney disease. Problems in bone metabolism and structure caused by low calcium levels and high phosphorus levels leads to renal osteodystrophy. The poor absorption of calcium and continuous bone mineral loss causes bone pain, spinal sclerosis, fractures, bone density loss, osteomalacia, and tooth calcium loss resulting in thin, fragile bones that carry a great risk for fracture even with the slightest trauma.
The patients CKD may also be responsible for their pulmonary edema, anemia, atrial fibrillation, heart failure, and hypertension.
Osteoporosis is a chronic disease of cellular regulation in which bone loss causes significant decreased bone density and possible fracture. This occurs when osteoclastic (bone resorption) activity is greater than osteoblastic (bone-building) activity. As the body ages osteoclastic activity outpaces osteoblastic. A lack of testosterone or calcium is a likely source of osteoporosis in patient X. Diet lacking calcium and vitamin D stimulates the parathyroid gland to produce parathyroid hormone which triggers the release of calcium from the bony matrix, further reducing bone density.
Recognized Cues
Monitor vital signs
Low Blood Pressure, Tachycardia, Increased respiratory rate.
Pain Assessment
Monitor labs.
Calcium, phosphorus, vitamin D, RBC, HgB, HCT, INR, PTT
Neurovascular assessment
Analyzed Cues
Bones are very vascular; with any fracture you want to assess for bleeding which can lead to hypovolemic shock. To assess, monitor for low blood pressure, tachycardia, increased respiratory rate.
Fractures can cause a great deal of pain, and open fractures involves breaking of the skin as well which can lead to increased pain. Pain should be managed by analgesics such as opioids in controlled quantities at the discretion of the provider. It is important that the patient feels comfortable and actively participating in treatment care plan.
Monitoring for decreased calcium, vitamin D, and phosphorus can be an indicator of improper bone tissue function.
Monitoring a decrease in HgB, Hct, & RBC and PTT/ INR prolonged times can signify blood loss from fracture.
Check perfusion to affected ankle.
Check cap refill of toes (no more than 5 seconds), pulse (thready & weak), motility (ability to move toes), color of skin (signs of cyanosis), temperature (cool to the touch)
Laboratory and Diagnostic Assessment
Dual x-ray absorptiometry (DXA) to measure bone mineral density and show renal osteodystrophy.
Provides the T-score to determine degree of lost bone density.
Complete metabolic panel
Serum calcium and phosphorus levels to be monitored r/t CKD and inverse mineral relationship.
Monitor creatinine, BUN, and GFR r/t CKD.
Complete blood count
Monitor patients RBCs, HCT, and HgB for signs of hemorrhage r/t anemia and post-surgery.
Monitor patients WBCs for monitoring inflammatory response and signs of infection.
Prioritize Hypothesis
Infection due to recent surgery, impaired tissue integrity, and CKD disrupting WBC production and function.
Osteomyelitis due to broken bone and internal fixation of right leg
Avascular necrosis due to disruption in blood supply to the affected bone as a result of trauma
Physical immobility due to injury to right leg
Blood clots due to atrial fibrillation, CAD, HTN, venous insufficiency, reduced mobility, and post-op status
Compartment syndrome due to pressure buildup from swelling of compartments in the affected extremity
Fat embolism due to breaking of long bone
Bleeding due to CKD reducing erythropoietin level, RBC production, and RBC survival time
Generate Solutions & Appropriate Interventions
Manage pain.
Patient education
Protein restriction to decrease BUN and uremia levels and reduce calcium elimination.
Reduce caffeine intake to reduce calcium loss through urine.
Reduce carbonated beverage intake as they increase phosphorus levels, leading to calcium loss.
Promote incentive spirometer use to reduce chance of atelectasis or pneumonia.
Monitor for symptoms of fluid overload q4 hours:
Evidenced by decreased urine output, rapid bounding pulse, shallow respirations, dependent edema, crackles or wheezes, distended neck veins, decreased oxygen saturation, elevated BP, narrowed pulse pressure.
Weigh patient X daily and document I/Os to monitor for fluid overload r/t CKD
Blood clot prophylaxis
Apply sequential compression devices, administer aspirin, and encourage leg exercises.
Evaluate Outcomes
Care Plan
Discussion
Recommendation
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