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Case Study 9.6 and 11.5
Brittany M. Hicks
Lakeview College of Nursing
N-309
February 29, 2012

Case Study 9.6
1.	Translate Violet’s activities as to what is recommended for osteoporosis prevention currently.
	Violet feels that just consuming vitamin D, tended a vegetable garden, never smoked or drank booze. All of the activities that Violet partook in did help prevent osteoporosis, eating vegetables, vitamin D intake, and not smoking. Some other preventative measures that can be taken against osteoporosis today include: beans, whole grains, high protein meats, vegetables, dairy (low-fat yogurt, cheese, and milk), and regularly exercising (Prevention and Healthy Living, 2011).
2.	What risk factors for osteoporosis are suggested with this statement?
	I interpreted Lillian’s comment about race, frame, and gender as her mother’s race, frame, and being a woman is putting her at more risk for the development of osteoporosis. What about her race frame and gender?
3.	Find a video on the internet using Google or another source which shows the DEXA (or DXA) test available for assessing bone density and explain how it functions.
	The DEXA scan is used to detect bone loss and the detention of osteoporosis. There are three different types of DEXA scanners: small, regular, and peripheral (Eck, 2009). It takes about 10-15 minutes for this test to be done and it painless for the patient (Bone Densitometry, 2012). The DEXA scan works by evaluating the amount of radiation that is absorbed by the bones (Bone Densitometry, 2012).. The DEXA bone scan consists of two beams of x-ray, one detects soft tissue and the second beam is to identify bone (Bone Densitometry, 2012). It is imperative for the test not to consume vitamins or supplements the day of the test (Bone Densitometry, 2012).
4.	What outcome from a hysterectomy would result in middle-age screening for osteoporosis?
	It is vital to do a Bone Mineral Density (BMD), this will establish a baseline for how strong there bones are prior to the hysterectomy and they can refer back to it for later testing (Osteoporosis and the Menopause, N.D.). When a hysterectomy is performs they remove the ovaries and because of this estrogen levels will be low (Osteoporosis and the Menopause, N.D.). The cause of Osteoporosis is the loss of calcium in the bones. There are two types of osteoporosis type one and type two. Type one is characterized by loss of inner layering of the bone and the absence of sex hormones (Osteoporosis and the Menopause, N.D.). Type one osteoporosis occurs when woman endure early menopause or have a hysterectomy (Osteoporosis and the Menopause, N.D.). Type two occurs in the outer portion of the bone, this result from lack of vitamin D or calcium (Osteoporosis and the Menopause, N.D.).
5.	Discuss each of these medications in relation to: drug category, route/frequency, and action.
Medications	Drug Category	Route/Frequency	Mechanism of Action	
Os-Cal	Antacid, Calcium supplement
(Skidmore-Roth, 2011)	Oral; 1000-1500mg/day in adults over 51 years old-take during the am (Skidmore-Roth, 2011).	Reduces gastric acidity
(Skidmore-Roth, 2011)	
Reclast (Zoledronic acid)	Bone reabsorption inhibitor
(Skidmore-Roth, 2011)	IV INF 5mg (infused in 15 minutes) every other year (Skidmore-Roth, 2011).	Stops osteoclastic bone reabsorption, stops osteoclastic activity and skeletal calcium release caused by stimulating factors released by tumors (Skidmore-Roth, 2011).	
Evista (Raloxifene)	Bone reabsorption inhibitor 
(Skidmore-Roth, 2011)	Taken orally max dose per day is 60mg (Skidmore-Roth, 2011).	Tissue-selective estrogen agonist/antagonist. The agonist stimulates action in the bone and lipid breakdown. The antagonist is active on the breast and uterus. Treats and prevents Osteoporosis in post- menopausal. women (Skidmore-Roth, 2011).	

6.	The nurse has provided teaching for a patient prescribed an oral bisphosphonate alendronate (Fosamax), for the prevention of osteoporosis. Which statement indicates further teaching is necessary?
b. Taking this medication right before bedtime is recommended.
According to Mosby’s Nursing Drug Reference, teach patient to remain upright for at least 30 minutes, to reduce esophageal irritation, never double dose (Skidmore-Roth, 2011). This medication is to be administered before the first morning meal with 6-8oz. of regular water only (no minerals) (Skidmore-Roth, 2011).
7.	Discuss safety measures which can eliminate potential home hazards resulting in fall or injury.
There are many measures that can be taken to ensure safety precautions to stop falls from occurring. They are: 
•	Reduce number of rugs in the home
•	Secure all stair wells
•	Reduce clutter
•	Secure wires or cords
•	Handicapped toilet (bars to hold for support)
•	Rubber soled shoes
8.	Osteoporosis has been identified as a national public health issue priority; provide a rationale for this.
	I believe that Osteoporosis is identified as a national public health issue because it contributes to falls and injuries in people all the time. The number one injury in elderly is attributed to falls, making sure that patients have the necessary supplements can help this problem.Also the Baby Boomers are aging

Case Study 11.5
1.	What history, lab results, or physical examination findings should be the great concern to the admission nurse? What might these finding represent?
	The greatest concern is his blood sugar level being 180 and his elevated hemoglobin A1C (8.3%). His hemoglobin A1C (8.3%) indicates that this has been out of control for some time. He has been diagnosed with type II diabetes, which is uncontrolled with the glipizide medication he was prescribed. Insulin may need to be considered for Mr. Nightwolf. I believe that this is priority because it is putting stress on the kidneys causing the BUN (24) to be increase; this indicates that there may be kidney damage (Porth, 2011). He coronary artery disease is not exactly low priority either, he has elevated triglycerides and cholesterols.  
2.	What changes seen in Mr. Nightwolf’s physical exam might be due to common age-related changes? Use the Hartford Institute for Geriatric Nursing evidence-based practice guidelines (Smith & Cotter, 2008) and identify age-associated cardiovascular changes shown by Mr. Nightwolf at: http://consultgerirn.org/topics/normal_aging_changes/want_to_know_more#item_4
	There are many age related factors that could be contributing to Mr. Nightwolf’s condition. The first is his hypertension, this occurs because the artery walls stiffen, atrial hypertrophy, sclerosis of both atrial and mitral valves (Smith & Cotter, 2008). The cardiac sclerosis of the valves is not helping his condition, acute coronary syndrome. Respiratory changes that occur with age are: decreased response to hypoxia and hypercapnia decrease respiratory muscle strength, and cough reflex diminishes (Smith et. al, 2008).  His elevated BMI may be due to the bodies in ability to absorb carbohydrates like it did when he was younger and as we age our gastrointestinal motility is slower (Smith et. al, 2008). 
 Age-Associated Cardiovascular Changes
Isolated systolic hypertension: systolic BP 140 mmHg and diastolic BP 90 mmHg.
1. Arterial wall thickening and stiffening, decreased compliance.
2. Left ventricular and atrial hypertrophy.
3. Sclerosis of atrial and mitral valves.
Implications
1. Decreased cardiac reserve.
a. At rest: No change in heart rate, cardiac output.
b. Under physiological stress and exercise: Decreased maximal heart rate and cardiac output, resulting in fatigue, SOB, slow recovery from tachycardia.
2. Risk of isolated systolic hypertension; inflamed varicosities. Risk of arrhythmias, postural, and diuretic-induced hypotension. May cause syncope. Strong arterial pulses, diminished peripheral pulses, cool extremities

3.	What other tests should the nurse expect to be carried out for Mr. Nightwolf?  What assessments should the nurse perform?
	The nurse would expect for the labs to be ran again to see if his status has changed these include: cholesterol, triglycerides, HDL, LDL, serum glucose level, hemoglobin A1C, BUN, and creatinine. The doctor may also want to do an EKG to analyze his heart function and possible a cardiac stress test. The nurse should provide Mr. Nightwolf with a thorough heart assessment as well as taking his vitals as recommended by the physician. 
Cardiac assessment: ECG; heart rate, rhythm, murmurs, heart sounds. Assess BP (lying, sitting, and standing) and pulse pressure. Palpate carotid artery and all peripheral pulses for symmetry 

4.	Why is Mr. Nightwolf at greater risk for a cardiovascular event, such as a cerebrovascular accident (stroke) or myocardial infarction (heart attack)?
Mr. Nightwolf’s ethnicity places him at high risk for both stroke and myocardial infarction. Statistic show that American Indians males are at 5.8% higher risk for stroke, 1,777 American Indians died of coronary heart disease in 2008, and Myocardial Infarction cause over 600 deaths (American Indian/Alaska Natives & Cardiovascular Diseases, 2011). 
 The following statistics are taken directly from the American Indians/Alaska Natives and Cardiovascular Diseases—Statistics (2010 update):
Among American Indian men ages 45–74, the incidence of CVD ranges from 15 to 28 per 1,000 population. Among women, it ranges from 9 to 15 per 1,000.
• Use of any tobacco product in 2006 was 42.3% for non-Hispanic American Indians and Alaska Natives age 12 and older.
• American Indians (67.5%) and Blacks (66.2%) were more likely to report not engaging in vigorous activity than white respondents (57.2%).
• Among American Indians/Alaska Natives age 18 and older, 69.6% are overweight or obese (42.1% are obese).
• The CDC analyzed data from 1994 to 2004 collected by the Indian Health Service
(IHS), which indicated that the age-adjusted prevalence per 1,000 population
of diabetes mellitus increased 101.2% among American Indian/Alaska Native adults of age 35 and older (from 8.5%–17.1%).

5.	What can Steve suggest to Mr. Nightwolf to reduce his fat and salt in his diet? Identify at least five dietary changes that Mr. Nightwolf could make that would reduce his risk of stroke and heart attack?
Mr. Nightwolf could start by making healthier food choices; he needs to look at the food labels at the sodium content as well as the fat it contains. He needs to modify the amount of saturated fat and not eat foods that contain trans-fat. Foods that would be specifically better for Mr. Nightwolf are: fresh fruit and vegetables, whole grains (breads), chicken breast with skin removed, fish, and tofu. He should avoid eating fast food (high fat and sodium), prepackaged, and canned goods as they usually contain more sodium.
6.	What information could Steve give to Mr. Nightwolf to safely allow him to exercise?
It is important for Mr. Nightwolf to work out about an hour after he has eaten his meal. Another essential component about working out that Steve may want to talk with him about his the amount of time that he exercises. He needs to start out slow (walking) and gradually increase as tolerated. He will also show him how to check his pulse rate and what is an acceptable rate. I would walk in normal daylight, not to hot weather conditions, and on a smooth surface.

7.	What improvements can Steve identify in Mr. Nightwolf’s lab tests? What do they represent? 
	All of his levels have improved, except his total cholesterol. I believe that the total cholesterol raising is due to his smoking habit. The improved lab results mean that his kidneys are functioning better, his diabetes is more controlled, and his triglycerides are lower. I would conclude from these findings that he has better control on his diabetes and that he is making adjustments in his life. I also think that his working out each day is helping his health status, encourage him to continue his work -out regimen. I would advise him to spread his meals out, eating one meal a day is not recommended. I would also try and help find something to help him quit smoking this will improve his overall health.
8.	Find an online source for “Life Simple 7” and discuss each element; cite the source used.
The simple 7 consists of: get active, control blood pressure, control cholesterol, eat better, lose weight, reduce blood sugar, and stop smoking (The Simple 7, 2012). Get active: walking 30 minutes a day direct you to a healthier lifestyle (The Simple 7, 2012). Exercising regularly can also reduce your risk for heart disease, stroke, and diabetes (The Simple 7, 2012). It is also important to start children out right; they need a minimum 60 minutes of exercise daily (The Simple 7, 2012). Some ways that you can help improve your exercise is by parking farther from the doors when you go to a store, riding a bike to work, and organizing group exercise activities (The Simple 7, 2012).
	Controlling the blood pressure is essential to a healthy lifestyle. Regulating blood pressure will reduce injury to the blood vessel walls and blockages, and make sure that oxygenated blood will adequately reach all of the tissues (The Simple 7, 2012). Factors that can help control blood pressure are: eating heart healthy diet low in sodium, exercising, and not smoking (The Simple 7, 2012). Monitoring Cholesterol is another vital part of a healthy lifestyle. High Cholesterol can block arteries and cause heart attacks if not detected (The Simple 7, 2012). The plaques can affect kidneys with blockages causing imbalance in fluid and hormones (The Simple 7, 2012). Tools that can help decrease your cholesterol are: maintaining a healthy weight, regular exercise, and screening your cholesterol levels often (The Simple 7, 2012). 
	Eating a healthy diet is essential to a healthy lifestyle. It is important to eat foods from each category of the food pyramid. Implementing healthier eating can be done by stocking the kitchen with these items; you can also keep a food journal to help you monitor (The Simple 7, 2012). Healthy food choices include: fish, whole grain foods, fresh fruits and vegetables, and cutting back on fat intake (The Simple 7, 2012). Eating healthy can help you maintain or lose weight if it is needed. Using the Body Mass Index to accurately measure your body fat composition may be done to help gauge where you are at, BMI of more than 30 increases your risk of heart disease (The Simple 7, 2012). Losing weight will help decrease the workload on your heart, skeletal system, lungs and blood vessels The Simple 7, 2012). Over 2/3 of the American population is overweight, this increases our risks for many diseases (especially heart disease) (The Simple 7, 2012).
	Monitoring your blood glucose can aid in healthier organs as well as overall health. Your blood sugar should be under 100 to be within a healthy range (The Simple 7, 2012). When the body stops secreting insulin from the pancreas, blood sugars rise, and this could ultimately cause diabetes (The Simple 7, 2012). Diabetes increases your risks of stroke and heart attack increase. If you suspect that you are at risk for diabetes, you want to check your glucose often, exercise regularly, and reduce sugary foods from your diet (The Simple 7, 2012). The last and probably the hardest for most people is to quit smoking. Smoking is the number one cause of early death in America (The Simple 7, 2012). Some people may not realize of once you quit smoking, the lungs begin to restore from the damage that has occurred (The Simple 7, 2012). Smoking not only damages your lungs, but also puts you at risk for: heart disease, blood clots, hardening arteries, and circulatory system (The Simple 7, 2012). Cigarette ultimately reduces your life, therefore do whatever it takes to quit smoking (The Simple 7, 2012).

References for 9.5
Bone Densitometry. (2012). Retrieved from http://www.radiology.ca/bone-densitometry.html
Eck, J. C. (2009). Bone density scan. MedicineNet.com. Retrieved from http://www.medicinenet.com/bone_density_scan/page4.htm
The Hysterectomy Association. (n.d.) Osteoporosis and the menopause. Retrieved from http://www.hysterectomy-association.org.uk/index.php/information/the-menopause/osteoporosis-and-the-menopause/
National Osteoporosis Foundation. (2011) Prevention, why halthy living is important. Retrieved from http://www.nof.org/aboutosteoporosis/prevention/healthyliving
Skidmore-Roth , L. (Ed.). (2011). Mosby’s 2012 nursing drug reference25th ed.). St. Louis: Mosby.
Vann, M. (2012). Fall prevention strategies that reduce osteoporosis fracture risk. Retrieved from http://www.everydayhealth.com/womens-health/osteoporosis/living/index.aspx
References for 11.5
 American Indian/Alaska Natives & Cardiovascular Diseases. (2011). Retrieved from http://www.heart.org/idc/groups/heart-public/@wcm/@sop/@smd/documents/downloadable/ucm_319569.pdf
  Life’s Simple 7. (2010). American Heart Association. Retrieved from http://mylifecheck.heart.org/Multitab.aspx?NavID=14&CultureCode=en-US
  Porth, C. M. (2011). In H. Surrena (Ed.), Essentials of Pathophysiology (3rd ed.).                         
  Smith, C.M., & Cotter, V.T. (2008). Nursing standard of practice protocol: Age-Related changes   in health. Hartford Institute for Geriatric Nursing. Retrieved from http://consultgerirn.org/topics/normal_aging_changes/want_to_know_more#item	_4