OP Overview

What is OP?

• Bones become weak & brittle
• A fall or mild stress can cause fracture

Characteristics

• Most commonly occurs in the hip, wrist or spin
• Bone is being broken down
• Creation of new bone doesn’t keep up with loss of old bone

OP Disparity

• OP affect men and women of all races
• White and Asian women are at higher risk (especially post-menopause)

Causes of OP

• After the early 20s the process of making new bone slows
• Most people reach peak bone mass by age 30
• It depends on how much bone mass is attained in youth
• Peak bone mass is inherited and also varies by ethnic group

A visual look at Ossification

Primary Ossification

1. Mesenchymal cells group into clusters, and ossification centers form.
2. Secreted osteoid traps osteoblasts, which then become osteocytes.
3. Trabecular matrix and periosteum form.
4. Compact bone develops superficial to the trabecular bone, and crowded blood vessels condense into red marrow.

Secondary Ossification

1. Mesenchymal cells differentiate into chondrocytes.
2. The cartilage model of the future bony skeleton and the perichondrium form.
3. Capillaries penetrate cartilage. Perichondrium transforms into periosteum. Periosteal collar develops. Primary ossification center develops.
4. Cartilage and chondrocytes continue to grow at ends of the bone.
5. Secondary ossification centers develop.
6. Cartilage remains at epiphyseal (growth) plate and at joint surface as articular cartilage.

Risk Factors

Which of these risk factors does Mary possess?

Testing Mary for Osteoporosis

Laboratory tests in patients with osteoporosis are done to rule out or to detect common causes of osteoporosis in order to treat them

Bone Mineral Density (BMD)

Calcium

• PTH if serum calcium abnormal (done to help determine cause of abnormal calcium results)

Vitamin D

• Serum creatinine & estimated glomerular filtration rate (eGFR)
• To detect renal failure (which can affect bone health)

Serum C-telopeptide (CTX)

• Measures amount of degraded bone in circulation

Preventing Osteoporosis

Diet

• Good nutrition
• Body weight
• Calcium
• Vitamin D

Lifestyle

• Exercise
• Limit alcohol consumption
• Quit smoking

Surgical Repair

The type of repair depends on where & how severe the fracture is, displaced bone, age, & underlying health conditions.

Options include:

• Internal repair using screws
• Total hip replacement
• Partial hip replacement

Mary required a total hip replacement.

Rehabilitation

The nurses wanted Mary out of bed and moving on the 1st day post-op. Mary’s physical therapy will initially focus on range of motion and strengthening exercises

She was also recommended an at Home exercise program and follow-up PT appointments. Mary was instructed to use assistive devices to prevent another falls event: walker, cane, safety bars in bathtub, elevated toilet seat.

Mary’s Precautions to prevent a dislocation

Posterior Approach

• Do not bend at the waist past 90 degrees
• Do not cross legs
• Do not internally rotate surgical leg

Anterior Approach

• Do not step backwards with surgical leg
• Do not externally rotate surgical leg

Preventing Falls & Related Injuries

• Falls are a high-impact, high-cost health concern for older adults.
• They are the leading cause of fatal and nonfatal accidents for those ages 65 and older
• Important risk factors include a history of falls; visual impairment; polypharmacy; the use of psychotropic medications; postural hypotension; environmental risks; and impaired strength, balance, or gait. Most of these factors are modifiable.
• To prevent further falls in the future, members of the healthcare team such as social workers, nurses, doctors, respiratory therapists, physio and more all work together to ensure that not only the patient is stable enough to be discharged but also a plan that is developed to reduce the chances of them returning back to the hospital.

Critical Thinking & Application

What are some precautions that the Nurse and Physiotherapist could put in place upon Mary’s discharge to prevent falls at home and increase her mobility following her hip surgery?

Older Adults typically have decreased bone density and may develop disorders like Kyphosis (curvature of the spine) that makes them susceptible to fractures due to poor reabsorption of minerals and vitamins that impairs bone function and density. Therefore, protective factors to prevent falls in the Older Adult population include mobility aids like canes, walkers, and wheelchairs for safety.

Home Modifications

Nancy will have to modify her home for Mary that include:

• Remove throw rugs and mats from living spaces, including bathrooms. Alternatively, affix rugs and mats to floors, making sure the edges do not create a tripping hazard.
• Remove clutter from living spaces, entryways, and hallways.
• Improve lighting throughout the home.
• Although many modifications can be made by the older adult, caregiver, or other family members and friends, more complicated modifications, such as the installation of a ramp at an entryway, may require the assistance of a professional.
• Involve social workers in securing financial assistance for durable medical equipment and home modifications
• Arrange furniture to ensure there is space for the older adult to perform exercises.
• Mitigate environmental barriers by raising toilet seats, encouraging the older adult to use a walker or a walking frame with wheels, and installing grab bars.
• Arrange for contrast edging along steps and handrails.
• Acquire chairs and sofas that are high and stable enough to facilitate sitting and rising.
• Reverse hinges on doors to allow more space for walkers through narrow doorways, or install pocket doors.
• Remove or secure paving stones in walkways.
• Keep frequently used items on counters and low shelves for easy access and to prevent the older adult from reaching too far.

Mental Status Assessment

This is a structured assessment of a client’s behavioral and cognitive functioning – a vital component of nursing care that assists with evaluation of mental health conditions.

Mental state assessment consists of 4 components:

Appearance

• posture erect/relaxed
• Body movements deliberate, coordinated
• Dress is appropriate for setting, age , season, gender, put on properly
• Grooming & hygiene – use care here b/c sometimes reflect economic status not mental status

Behaviour

• Level of consciousness – alert, aware
• Facial expression – changes appropriately
• Speech: effortlessly & appropriate, Pace of conversation is moderate, able to articulate words, word choice is effortless & appropriate, completes sentences
• Mood & affect appropriate, cooperative

Cognitive Function

• Orientation – person , place time
• Attention span – ability to concentrate note any wandering, distractibility of difficulty following directions anxious, fatigued or drug intoxicated = distracted
• Memory: Recent memory – 24 diet recall or asking when person arrived at agency. Remote memory – ask about verifiable past events, i.e. health, job, anniversary dates
• New learning – the 4 unrelated words

Thought processes & perceptions

Does this person make sense? Person should think logically, goal directed, coherent & relevant, complete thoughts: Thought content, Perceptions, Screen for suicidal thoughts if expressed feelings of sadness, hopelessness, despair or grief

Critical Thinking & Application

What are the priority nursing assessments associated with an individual diagnosed with a major depressive disorder?

By asking a few simple questions about a person’s mood, symptoms, and behavior, a physician can determine whether further evaluation is needed. Questions such as “how would you rate your mood from 1-10”, “Have you had any thoughts of harming yourself or others”, “If yes, why do you think you are having these thoughts”. “Do you plan on carrying through this action”

How do you as a nurse determine the priority assessments?

By determining based on the answers that the patient has responded with wether they are at risk for harm (suicide or homicide common)

Mary begins to struggle after her surgery

In the weeks that followed her discharge and subsequent move to her daughter’s, Mary become more withdrawn.

Mary often spending the day in her pajamas, unwashed, and disengaged with those around her.

She is struggling with the many changes happening in her and Jack’s life, and begins to suffer from complications as a result of her surgery.

Complications

Complications can reduce independence. About half the people who have a hip fracture do not regain the ability to live independently.

Bone fractures:

• Particularly in the spine or hip
• Often caused by a fall & can result in disability
• Increase risk of death within the first year after injury
• Spinal fractures can occur without injury
• Vertebrae can weaken to the point of crumpling

Immobility may lead to:

• Blood clots
• Bedsores
• Urinary tract infections
• Pneumonia
• Furth loss of muscle mass
• Increase risk of falls & injury
• Death

Critical Thinking & Application

As Mary aged, she faced sudden deterioration in her health, mobility and independence, what mental health conditions may this predispose her to developing if she does not access her support systems?

The primary condition that Mary is demonstrating is clinical depression. Mary has recently experienced a plethora of sudden changes in her own health and independence at home prior to her fall. She was unable to participate in her full range of ADLs, had uncontrolled pain related to her osteoarthritis, and she isolated herself from her support system by limiting her interactions with her friends and family while suffering at home. This stress may accelerate Mary’s deterioration if uncontrolled, the priority is to support Mary and find outlets for her to express herself and promote independence. The priority intervention for the nurse would be to ask Mary if she feels helpless/ hopeless or has ever had thoughts of harming herself or another person recently.

What signs and symptoms of depression is Mary presenting with following her surgery, as a nurse how would you assess and collect evidence to update the plan of care?

Poor hygiene, social withdrawal, lack of self care, strained intramarital relations, stress of her husband’s health, difficulty accepting her own diagnosis.

Post-Operative Depression

Depression is a psychological illness that can lead to impaired decision-making, difficulty with day-to-day life, and may lead to physical illness. It can be challenging to differentiate between typical post-op recovery and depression symptoms.

Mary begins eating significantly less than is normal and is not getting enough. She is very fatigued and sometimes irritable. Her feelings of anxiety and stress makes her feel hopeless. She feels as though it is best that she stays in her home, away from her family. Mary suffers from post-operative depression.

Critical Thinking and Application

You are asked to speak at a local community center. The topic is the prevalence of depression and what individuals/families like Mary can do, if anything, to minimize the likelihood that they will experience depression. What will you include in your presentation and what do you think is the best format for your presentation?

The way I would format the presentation is to present the risk factors that lead to the development of depression. The best way to minimize it is to understand how a lot of things that are part of your lifestyle is a risk if you are doing that path. Afterwards, I would present the criteria and educate on how to recognize if you are going through depression with the following signs and symptoms that are presented on the criteria.

An individual attending your presentation asks, “if I am living a very healthy lifestyle, how likely is it that I may develop depression”?

Even if the individual may be living a very healthy lifestyle, depression can be carried on genetically. Also, the likelihood of the person who is living the healthy lifestyle comes to a crash and is not able to cope with it. The chances of having depression is very likely compared to everyone. So, depression is very likely with everyone, it’s how you tackle or manage or work around it.

By asking a few simple questions about a person’s mood, symptoms, and behavior, a physician can determine whether further evaluation is needed. Questions such as “how would you rate your mood from 1-10”, “Have you had any thoughts of harming yourself or others”, “If yes, why do you think you are having these thoughts”. “Do you plan on carrying through this action”.