Case Study 9.1
Jessica Gragert
Lakeview College of Nursing
N309 Nursing of the Gerontological Client
July 13, 2012

Case Study 9.1
Osteoarthritis (OA) is described as a “degenerative joint disease” (Mauk, 2010, p.428) in which joint cartilage breaks down causing inflammation and possible joint deformity. Cartilage acts as a connection between the bone surfaces in a join and protects them from being damaged during movement. The deterioration of cartilage in OA can result in “bone-on-bone” joint movements, reduced or dysfunctional joint mobility, and pain (Mauk, 2010). While the exact cause of OA is unknown, individuals are at an increasing risk of developing this disease as they age. OA commonly affects joints that have sustained prolonged pressure or injury, and as one ages occurrences such as these can accumulate and result in lasting damage. Other contributors to an increased risk of occurrence of OA are muscle weakness and neural impairment, both of which commonly affect the elderly for various reasons. This combination of factors mean that individuals the risk of developing OA increases with age, and approximately one-third of adults aged 65 or older will suffer from this disorder (Mauk, 2010, p. 428).
There are multiple factors that place Ms. McConnell at risk for developing OA.  The given height and weight mean that Ms. McConnell is obese, which is a risk factor. Also her previous knee injury increases the risk of OA. Her lack of weight bearing exercise may leave her muscles in a weak state that increase the chances that she will develop OA. As mentioned previously, her advancing age places Ms. McConnell at an increased risk for OA, as does her female gender (Mauk, 2010).
The joints most commonly affected by OA are “the weight bearing joints such as the hips, knees, and lower spine” as well as joints in the fingers (Mauk, 2010, p. 190). Upon physical examination Ms. McConnell may show signs such as Herberden’s nodes which are “bony enlargements at the end joints of the fingers” and Bouchard’s nodes which are “bony enlargements at the middle joints of the fingers” (Mauk, 2010, p. 429). The RN may also note swelling or heat at the joint sites as well as decreased range of motion in the effected joints. The nurse may observe Ms. McConnell limping or note crepitus in the dysfunctional joints as well (Mauk, 2010). 
Using the Cockcroft Gault calculator, Ms. McConnell’s creatine clearance was determined to be sixty milliliters per minute, and this number can be used as an estimate of her glomerular filtration rate (GFR) (http://nephron.com/cgi-bin/CGSI.cgi). This rate corresponds with stage two kidney disease which is classified as GFRs between the levels of sixty and eighty-nine milliliters per minute ("Classification of Kidney Disease," 2002, table 10). Some factors that put Ms. McConnell at risk for non-steroidal anti-inflammatory drug (NSAID) related renal disease is her long term and around the clock use of ibuprofen to treat her arthritis pain, and her antihypertensive medication Prinizide which may increase NSAID induced renal impairment. Ms. McConnell’s use of ibuprofen also places her at increased risk of gastrointestinal bleeding, especially considering that she is over sixty-five years of age and has the comorbidity of hypertension (Risser, Donovan, Heintzman, & Page, 2009). 
Ms. McConnell’s concern that her arthritis pain will not be managed without ibuprofen is a valid one. Cynthia can help minimize that worry by educating Ms. McConnell to nondrug methods that may reduce her pain.  Exercise can allow her to lose some excess weight and increase muscle strength, both of which can decrease her symptoms of OA. Other options to reduce pain are the use of “heat or cold, splints, adaptive equipment, aquatic therapy, and nutrition” (Mauk, 2010, p. 430).  The American College of Rheumatology (2000), also discusses these treatment options and includes “patient education, self management programs, personalized support by phone, and physical and occupational therapies.”
The Center for Disease Control (CDC) describes the Arthritis Self-Management Program (ASMP) as “an effective self-management education intervention for people with arthritis” that teaches patients how to confidently care for themselves and OA symptoms. This course takes place for two hours every week for a period of six weeks (http://www.cdc.gov/arthritis/interventions/self_manage.htm). 
Ms. McConnell may require medications in addition to the nondrug therapies to manage her pain. As the ibuprofen is no longer a safe medication for her, her physician may recommend topical analgesics be applied to the affected joints as an alternative. Tramadol is another analgesic option and the injection of steroids in arthritic joints may decrease inflammation. Joint surgery or replacement may also be a possible option, albeit much more intrusive and places Ms. McConnell at the risk of complications (Mauk, 2010).  The recommendation to take glucosamine/chondroitin supplements for OA management is not without some merit. The combination of these two supplements is thought to decrease pain and loss of mobility brought on by OA and there are some studies that support this claim. Glucosamine and chondroitin have been shown to reduce joint pain better than celecoxib in some patients, but its effectiveness is not entirely proven.  Possible side effects of this supplement are mild gastrointestinal upset, drowsiness, headache, or rash. This supplement may be an option for Ms. McConnell in her treatment plan, but as an herbal supplement, will likely not be covered by her insurance which would require her to pay out of pocket for a treatment that is ultimately not yet proven effective (Collins Abrams, Barnett Lammon, & Smith Pennington, 2009).

References
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines
	 (2000). Recommendations for the medical management of osteoarthrits of the hip and 	knee. Retrieved July 13, 2012, from 	http://www.rheumatology.org/practice/clinical/guidelines/oa-mgmt.asp
Collins Abrams, A., Barnett Lammon, C., & Smith Pennington, S. (2009). . In Clinical Drug Therapy (9th ed., ). : Wolters Kluwer Health| Lippincott Williams & Wilkins.
KDOQI clinical guidelines for chronic kidney disease: Evaluation, classification, and stratification. (2002). Retrieved from http://www.kidney.org/professionals/KDOQI/guidelines_ckd/p4_class_g1.htm
Mauk, K. L. (2010). Gerontological nursing: competencies for care (2nd ed.). Sudbury, MA: Jones and Bartlett.
Risser, A., Donovan, D., Heintzman, J., & Page, T. (2009, December15). NSAID prescribing precautions. American Family Physician, 12, 1371-1378. Retrieved from http://www.aafp.org/afp/2009/1215/p1371.html