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Case Study 9.6 & 11.5
Simone Walker
Lakeview College of Nursing
Nursing of the Gerontological Client
March 4, 2012

Case Study 9.6 & 11.5
Case Study 9.6
1. Translate Violet’s activities as to what is recommended for osteoporosis prevention currently.
	Violet’s activities that have helped prevent the development of osteoporosis the lifestyle changes that she made in her early twenties. This is where Violet worked on a dairy farm and consumed their products, and tended to and ate from a vegetable garden, and she never smoked or drank alcohol. There are several steps that one can take to prevent osteoporosis by having habits that help build strong bones before the age of 20 (when a person’s bones are fully developed), eating a well-balanced diet with plenty of calcium and vitamin D, no smoking or excessive alcohol intake, plenty of weight-bearing exercises, and discussing any needed treatments with the physician to minimize the risk of the disease (Mauk, 2010).  
2. What risk factors for osteoporosis are suggested with this statement?
	The risk factors that are suggested in this statement are being a female, being of white, Asian, African American or Hispanic American ethnic background/origin and having a small frame and/or being thin (Mauk, 2010). Actually the most at risk are the white or Asian elderly that have a small frame and female.
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 (cite the source)
	Bone density scanning, also known as a dual-energy x-ray absorptiometry (DXA) or bone densitometry, is an enhanced form of x-ray technology that is used to measure bone loss. The DXA machine sends a thin, invisible beam of low-dose x-rays with two distinct energy peaks through the bones that are being examined. One peak is absorbed mainly by the soft tissue and the other by bone. The soft tissue amount is subtracted from the total and what remains is a patient's bone mineral density. DXA uses machines that have special software that compute and display the bone density measurements on a computer monitor. The doctor then compares the patient’s results against that of a young adult of the same gender with peak bone mass (Kaye, 2011). 
4. What outcomes from a hysterectomy would result in middle-age screening for osteoporosis?
	The outcomes from having a hysterectomy that can result in middle-age screening for osteoporosis is because when women have a total hysterectomy, they put themselves in menopause because they do not have their ovaries which produces estrogen. Estrogen is needed to help prevent bone loss. This is why doctors encourage women, who are menopausal, to be on estrogen replacement therapy. Estrogen replacement therapy (ERT) is known to be very beneficial in preventing osteoporosis. Especially immediately after menopause because this is a time where accelerated bone loss occurs. Mechanisms in ERT protects against bone loss and fractures are thought to include decreased bone breakdown, increased calcium absorption from the intestines and increased calcitriol (active form of vitamin D that promotes absorption and use of calcium in bone building) concentration (Abrams, Pennington, & Lammon, 2009).  
5. Discuss each of these medications in relation to: drug category, route/frequency, and action.
	Os-Cal: drug category: calcium carbonate (calcium supplement), route/frequency: Adults older than 51 years old: by mouth 1000-1500 mg/day elemental calcium; Adult 19-50 years old: by mouth 1000 mg/day elemental calcium; action: Neutralizes gastric acidity and calcium supplement for people with osteoporosis (Skidmore-Roth, 2012).
	Vitamin D: drug category: calcitriol vitamin D3 (vitamin D hormone); route/frequency: Adult by mouth 0.5-1mcg/day, adjust to serum calcium levels; action: increases intestinal absorption of calcium, provides calcium for bones, increases renal tubular resorption of phosphate (Skidmore-Roth, 2012).  
Reclast: drug category: bone resorption inhibitor; route/frequency: Adult IV infusion 5 mg over 15 minutes or more every 12 months; action: Potent inhibitor of osteoclastic bone resorption; inhibits osteoclastic activity, inhibits skeletal calcium release caused stimulating factors released by tumors; reduction of abnormal bone resorption is responsible for therapeutic effect in hypercalcemia; may directly block dissolution of hydroxyapatite bone crystals (Skidmore-Roth, 2012).
Evista: drug category: bone resorption inhibitor; route/frequency: Adult by mouth 60 mg/day; action: Tissue-selective estrogen agonist/antagonist; agonist activity in bone and lipid metabolism; antagonist activity on breast and uterus; reduces resorption of bone and decreases bone turnover (Skidmore-Roth, 2012).	
6. The nurse has provided teaching for a patient prescribed an oral bisphosphonate, alendronate 
    (Fosamax), for prevention of osteoporosis. Which statement indicates further teaching is  
    necessary? 
a.	“Drink milk while on the drug is a good idea”
b.	“Taking this med right before bedtime is recommended”
c.	“I only have to take this once a week”
d.	“This medicine should be taken on an empty stomach”
The answer is B.
7. Discuss safety measures which can eliminate potential home hazards resulting in a fall or 
    injury.
	The safety measures that should be implemented to prevent falls or injury at home are: keep stairways clear and uncluttered, maintain walkways, stairs and railings in good repair, keep stairs, hallways, outside walkways and working areas well lit, apply nonslip adhesive strips to the bottom surface of the tub or shower, eliminate scatter rugs, or secure them with adhesive strips on the underside, have toilet seat raised with support arms, and have grab bars next to the toilet and in the tub or shower area (Taylor, Lillis, LeMone, & Lynn, 2011).
8. Osteoporosis has been identified as a national public health issue priority; provide a rationale 
    for this.
	Osteoporosis is a major health problem because of its large impact on disability and the need for supportive and rehabilitative services. It is estimated that 10 million Americans suffer from osteoporosis and another 34 million people are at risk for the disease due to low bone mass. The majority of osteoporosis cases occur in women (8 million) more than men (2 million). Osteoporosis causes progressive bone loss with age, which leads to an increased risk for fractures. It has been estimated that the cost of fractures related to osteoporosis will be 25.3 billion dollars by 2025 (Mauk, 2010). Since people in the America are living longer, it is important to educate all age group populations about the importance of preventing and treating osteoporosis and what steps one can take to minimize fractures/injuries if they already have osteoporosis. If we do not educate people about osteoporosis there will be a higher population of people who will develop fractures from having osteoporosis at a younger age, who will be forced to retire early or go on disability. Even if the individual recovers from the fracture, they may never be back to their normal self, like walking without any assistive devices or putting on their clothes without any help. Depending on what type of fracture the individual experiences can affect their activities of daily living because they can no longer do these activities by themselves anymore.   

Case Study 11.5
1. What history, laboratory results, or physical examination findings should be of the greatest 
    concern to the admissions nurse? What might these findings represent?
	The nurse should be concerned with the patient’s history of coronary artery disease, type II diabetes, angina, and smoking of four cigarettes a day, blood pressure 142/88mmHg, BMI 28.6, dorsalis pedis pulses 1+, triglycerides 330mg/dl, HDL-cholesterol 38mg/dl, LDL-cholesterol 130mg/dl, serum glucose level 180mg/dl, and hemoglobin A1c 8.3%. All of these findings can contribute to the patient being at risk for having a stroke or heart attack. What about the BUN & creatinine?
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
Patient could have arterial wall thickening and stiffening; sclerosis of atrial and mitral valves due to patient having high triglyceride and LDL levels. Left ventricular and atrial hypertrophy may result from patient’s history of coronary artery disease and angina. Make sure patient is compliant with their medication regimen. Isolated systolic hypertension (systolic BP >140 mmHg or diastolic BP <90 mmHg), strong arterial pulses, diminished peripheral pulses, and decreased cardiac reserve due to when the patient is under physiological stress and exercise; they experience decreased maximal heart rate and cardiac output, which results in fatigue, SOB, slower recovery time from tachycardia (Smith & Cotter, 2008).
3. What other tests should the nurse expect to be carried out for Mr. Nightwolf? What 
     assessments should the nurse perform?
	The other tests that may be ordered is complete blood count (CBC), fasting blood glucose test, electrocardiogram (ECG), cardiac biomarkers (CPK, CK-MB & troponin), C-reactive protein, echocardiogram, chest x-ray, stress tests, intravascular ultrasound, electrolyte imbalances, arterial blood gas and urinalysis for the presence of microalbuminuria, ketones, protein, and sediment (Swearingen, 2008). The assessments the nurse should perform: physical findings of anxiety, hypertension, tachycardia, pulmonary congestion, diaphoresis, stable or progressively worsening angina, and symptoms of hyperglycemia or hyperosmolar hyperglycemic nonketotic (HHNK) syndrome (Swearingen, 2008). 
4. Why is Mr. Nightwolf at greater risk for a cardiovascular event, such as a cerebrovascular 
     accident (stroke) or myocardial infarction (heart attack)? Go to the following Web site and
     identify at least four statistics that explain Mr. Nightwolf’s risks.   
     http://www.americanheart.org/downloadable/heart/1260726706304FS02AM10.pdf
	Mr. Nightwolf is at a greater risk for a stroke or heart attack because he has a history of type II diabetes (that is not well controlled), coronary artery disease, high triglyceride and LDL levels, being overweight, and smoking. According to the American Heart Association on American Indians/Alaska Natives and Cardiovascular Diseases- Statistics (2010), the four statistics that can explain Mr. Nightwolf’s risk factors is being overweight, physical inactivity, high blood pressure, smoking, and diabetes mellitus.  
5. What can Steve suggest to Mr. Nightwolf to reduce the 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. 
	Increase/encourage intake of fresh fruits and vegetables, grains, legumes. 
Reduce/limit their intake of refined sugar. 
Reduce/limit their intake of sodium. 
Reduce/limit their intake of cholesterol.
Reduce/limit their intake of saturated fats.
Monitor/count the amount of carbohydrates they a eating.
Increase fiber intake.
Cooking their own meals and reducing canned foods and frozen foods because these items have high levels of sodium in them.
6. What information could Steve give to Mr. Nightwolf to safely allow him to exercise?
	Steve can give Mr. Nightwolf information on how walking for 30 minutes a day is a safe way for him to exercise. 
 First, Mr. Nightwolf should discuss an exercise plan with his primary care provider.
If permitted, Mr. Nightwolf could
• work in the garden or mow the grass
• rake leaves, prune, dig, and pick up trash
• go out for a short walk before breakfast, after dinner or both. Start with 5–10 minutes and work up to 30 minutes
• when walking, pick up the pace from leisurely to brisk. Choose a hilly route. When watching TV, sit up instead of lying on the sofa. Throw away the video remote control
• stand up while talking on the telephone
• walk the dog
• park farther away while shopping and walk the extra distance; wear walking shoes and walk lap or two around the store
• stretch to reach items in high places and squat or bend to look at items at floor level 

7. What improvements can Steve identify in Mr. Nightwolf’s lab tests? What do they represent?
	Slight increase in the total cholesterol from 172 mg/dl to 182 mg/dl, since this is still below the 200 mg/dl, continue to monitor (no action is required). Triglycerides level has decreased from 330 mg/dl to 250 mg/dl. HDL-cholesterol has increased from 38 mg/dl to 39 mg/dl. LDL-cholesterol has decreased from 130 mg/dl to 110 mg/dl. Serum glucose level has decreased from 180 mg/dl to 148 mg/dl. Hemoglobin A1c has decreased from 8.3% to 7.2%. All of the findings indicate that some of the life style changes that Mr. Nightwolf has made are helping to decrease his chances of having a heart attack and stroke.
8. Find an outline source for “Life’s Simple 7” and discuss each; cite the source used.
	According to Life’s Simple 7 (2010), there are 7 things that an individual can do to minimize their chances of having a heart attack or strokes are:
1.	Manage blood pressure- blood pressure is one of the main causes of heart disease 
2.	Get active- walking for 30 minutes a day can help reduce the risks of heart disease, stroke and diabetes
3.	Control cholesterol- doing this will allow the arteries to be free from blockage, which deceases the risk for heart attack and stroke
4.	Eat better- eating foods low in saturated fat and trans fat, cholesterol, sodium and added sugars and consuming foods that are high in whole grain fiber, lean protein, and a variety of colorful fruits and vegetables can reduce risk factors of developing a heart attack, stroke, diabetes and obesity.
5.	Lose weight- A BMI of 18.5-25 is normal to have. Having a BMI of 25 and up puts a person at risk for heart disease, high blood pressure, high cholesterol and diabetes. This can also put a strain on a person’s heart because the heart is working harder to pump blood throughout the body.
6.	Reduce blood sugar- having blood sugar levels below 100 is vital in protecting one’s vital organs. Diabetes along with other factors like obesity, high blood pressure, and high cholesterol and triglyceride levels can increase the risk of having a heart attack and stroke.
7.	Stop Smoking- smoking can damage your entire circulatory system, which can increase the risk for coronary heart disease, hardened arteries, aneurysm and blood clots and can also reduce your good cholesterol (HDL) and your lung capacity, making it harder to get the physical activity you need for better health.

References
Abrams, A. C., Pennington, S. S., & Lammon, C. B. (2009). Clinical drug therapy: Rationales
	for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.
American Indians/Alaska natives and cardiovascular diseases-Statistics. (2010). American Heart 
	Association. Retrieved from 
	http://www.americanheart.org/presenter.jhtml?identifier=3000929
Kaye, J. J. (Producer). (2011). Your radiologist explains bone density scans [Video file].
	Retrieved from: http://www.radiologyinfo.org/en/info.cfm?pg=dexa
Life’s Simple 7. (2010). American Heart Association. Retrieved from 
	http://mylifecheck.heart.org/Multitab.aspx?NavID=3&CultureCode=en-US
Mauk, K. L. (2010). Gerontological nursing: Competencies for care (2nd ed.). Sudbury, MA:
	Jones & Bartlett.
Skidmore-Roth, L. S. (Ed.).  (2012). Mosby’s 2012 nursing drug reference (25th ed.). St. Louis, 	MO: 	Elsevier.
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
Swearingen, P. L. (2008). All-in-One care planning resource (2nd ed.). St. Louis, MO: Mosby
	Elsevier. 
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing: The art and 
	science of nursing care (7th ed.). Philadelphia, PA: Lippincott Williams and Wilkins.