Emily Bishop 220138178 HSNS361 – Written Assignment

HSNS361

Professional Practice: Application of Integrated

Care

Written Assignment

Emily Bishop: 220138178

DUE DATE: 14/05/2016

SUBJECT COORDINATOR: Fiona Barrett

WORD COUNT: 2500

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Emily Bishop 220138178 HSNS361 – Written Assignment

This essay will discuss the how Mrs Gisbon’s risk factors for osteoporosis contribute

to her bone density, the roles of hormones involved in bone remodelling and the

effect of corticosteroid therapy on these cells, the immediate nursing priorities for

Mrs Gibson and lastly the post operative and rehabilitation nursing care priorities.

Osteoporosis is a skeletal disorder that is characterised by compromised bone

strength which increases the risk of fractures and a decrease in bone mass (Bullock

& Hales, 2012). The prevalence of the disease increases with age and mainly affects

postmenopausal women, as females have a lower bone mass than males and the

hormonal changes that occur at menopause (Marcus, 2013).

Bone mass increases during childhood and adolescence before reaching a peak in

the second decade of life, this is called the “peak bone mass” (Weaver et al., 2016).

After peak bone mass is achieved, there is a period known as the consolidation

period, where bone mass remains stable (Bonewald, 2011). From about the age of

30, bone mass begins to decline. In a male the loss of bone rate occurs at a steady

rate, whereas in females the loss of bone is at a much higher rate and accelerates

for around 5-10 years after menopause (Weaver et al., 2016).

Osteoporosis occurs as a result of normal aging. In addition to age there are a

number of risk factors that increase the chances of contracting osteoporosis. Female

sex is a risk factor, as females have a lower bone mass density due the reduced size

and cortical thickness characteristic of female bones and the decline in oestrogen at

menopause (Janiszewska, Kulik, Dziedzic, & Żołnierczuk-Kieliszek, 2015). Women

account for over 80% of osteoporosis diagnoses (Marcus, 2013). Oestrogen has a

protective effect on bone, primarily by blocking osteoclast activity (Bullock & Hales,

2012). It achieves this through the inhibition of a number of cytokines, which

otherwise activate mature osteoclasts (Bullock & Hales, 2012). The protective effect

of oestrogen on females’ bones explains why women who suffer from early

menopause can lead to low bone mass density and is the reason why hormone

replacement therapy (HRT) is needed to avert osteoporosis (Sternberg et al., 2013).

Postmenopausal oestrogen deficiency is the most significant non-genetic factor for

being at risk of osteoporosis (Sternberg et al., 2013).

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Emily Bishop 220138178 HSNS361 – Written Assignment

Ethnicity is another risk factor given people of Caucasian background are at a higher

risk than other ethnic groups, given the difference in bone mass and density,

compared with other ethnic groups (Svejme, Ahlborg, Nilsson, & Karlsson, 2012).

A family history of osteoporosis is also another risk factor, especially a first degree

relative. This family history could indicate that there may be a history of low bone

mass, which is determined by genetic factors (Svejme, Ahlborg, Nilsson, & Karlsson,

2012).

Bone quality is made up of the structural and properties of bone. Bone geometry and

microarchitecture make up the structural properties of the bone, whereas, the

material properties consist of the organisation and composition of the mineral and

collagen components within the extracellular matrix (Kini & Nandeesh, 2012).

The femoral head is supported by a relatively thin structure known as the femoral

neck, which is more prone to fracture than the joint itself is to dislocation (Cummings-

Vaughn & Gammack, 2011). The femoral neck is particularly vulnerable in patients

suffering from bone disorders such as osteoporosis, osteomalacia, osteopetrosis and

osteogenesis imperfect (Cummings-Vaughn & Gammack, 2011). The majority of

patients, such as Mrs Gibson that present with femoral neck fractures are those

suffering from osteoporosis.

As osteoporosis is a disease in which the bones become fragile and are more likely

to break, this can weaken the neck of the femur to the point that any increased

stress may cause the neck of the femur to break suddenly (Bullock & Hales, 2012).

As patients with osteoporosis are more likely to suffer from falls and have weakened

bones are more predisposed to suffering fractures, a fall is not necessarily needed to

suffer a fracture (Osteoporosis Australia, 2014). An uncertain step or a twist to the

hip joint that places too much stress across the neck of the femur may result in a

fracture, such as Mrs Gibson, without any trauma.

The significance in observing limb length disparity and external rotation is used to

assist in diagnosing hip fractures. Most hip fractures reveal that a patient is suffering

from an abducted and externally rotated hip with a leg length discrepancy (Bullock &

Hales, 2012).

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Emily Bishop 220138178 HSNS361 – Written Assignment

Bone undergoes a continuous renewal process of bone resorption and formation,

commonly known as bone remodelling, or bone turnover. Bone remodelling is the

active and dynamic process of bone remodelling made up of the correct balance

between osteoclast, which are multinucleated cells that destroy the bone matrix

which used for bone resorption and bone deposition by osteoblasts (Kini &

Nandeesh, 2012). The osteocytes, another important cell type arising from the

osteoblasts, are also involved in the remodelling process (Kini & Nandeesh, 2012).

The process of the osteoclasts and osteoblasts are very closely linked and work

together in a harmonious state (Boyce, Rosenberg, de Papp, & Duong, 2012). If this

state between the two is interrupted or disrupted, the correct bone mass could be

compromised. The balance between bone resorption and bone formation, allows the

bone to remove fatigue damage and replace it with new bone that reinforces the

bone integrity (Boyce, Rosenberg, de Papp, & Duong, 2012). An imbalance between

bone resorption and bone formation results in a loss or gain of bone tissue and

affects bone mass density.

Bone loss and osteoporosis are the direct result of an increase in the osteoclast

function and/or a reduced osteoblast activity (Marcus, 2013). In contrast, other

pathologies are related to osteoclast failure to reabsorb bone, such as osteoporosis,

a rare genetic disorder characterized by an increased bone mass and also linked to

an impairment of bone marrow functions. There are many molecular mechanisms

regulating bone cell functions. Recent studies have shown there is a complex

interplay between the immune and skeletal systems, which share several regulatory

molecules including cytokines, receptors and transcription factors (Boyce,

Rosenberg, de Papp, & Duong, 2012).

Elderly patients for the treatment of rheumatic conditions commonly take

medications such as corticosteroids (Mitra, 2011). Prolonged use of corticosteroids

has been shown to reduce bone formation leading to bone fractures. The risk of

fractures is dose dependant and bone mass loss occurs quickly within months of

starting on a course of corticosteroids (Sternberg et al., 2013). Corticosteroids have

been shown, when administered in doses greater than the physiological

concentrations, the corticosteroids directly and indirectly with the bone cells that are

involved in bone resorption and inhibit bone formation (Liu et al., 2013).

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Emily Bishop 220138178 HSNS361 – Written Assignment

Corticosteroid exposure alters the balance between the osteoclast and osteoblast

activity, which is involved in bone metabolism. The corticosteroid stimulates the

osteoclast bone resorption and reduces the osteoblast bone formation. As a result of

this effect the corticosteroids has, it results in increasing the bone resorption, while

slowing the bone formation, which results bone is reabsorbed more quickly, than it is

made (Liu et al., 2013).

The two main effects of that corticosteroids have on bone metabolism, is they induce

apoptosis in the osteoblasts and osteocytes involved in bone formation, which

decrease the formation of bone as the cells die and prolong the lifespan of the

osteoclasts, which increase bone resorption (Clarke, 2012). Due to these changes in

the bone remodelling cycle, there is approximately 30% less bone tissue that is

produced than in normal conditions. (Clarke, 2012)

3Based on the assessment of Mrs Gibson, there are a number of immediate nursing

care priorities that are needed for her care. As Mrs Gibson is suffering from a Urinary

tract infections (UTI), which are one of the most common infections suffered by the

older population, occurring both in the community and in long-term care settings

(Jarvis, Chan, & Gottlieb, 2014). With UTI’s there is a high mortality rate within the

older population, with 5% of the older population reporting a 28-day mortality. In

women such as Mrs Gibson, who are suffering from postmenopausal estrogen

deficiency, it has been linked to recurrent UTI’s (Jarvis, Chan, & Gottlieb, 2014).

The immediate nursing care priorities for Mrs Gibson in relation to her UTI after

giving her a physical examination is to start Mrs Gibson on intravenous (IV) fluids in

an effort to rehydrate her as she has poor skin turgor which is an indication of this

and by increasing her fluid intake, will help flush the bacteria through the urinary tract

(Berman, Snyder, & Frandsen, 2016). Also giving Mrs Gibson IV fluids, it allows for

Mrs Gibson to start on a course of a combination of Trimethoprim and

Sulphamethoxazole. They are both are antibiotics that are used to commonly treat

different infections caused by bacteria such as UTI’s (Drugs for Urinary Tract

Infections, 2014). Although there has been a progressive development of

antimicrobial resistance to common antibiotics in UTI’s, Trimethoprim and

Sulphamethoxazole should be used as first line treatment, as it is a broad spectrum

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Emily Bishop 220138178 HSNS361 – Written Assignment

antibiotic Trimethoprim and Sulphamethoxazole work in conjunction by interfering

with the synthesis of folate inside microbial organisms and inhibits the bacteria’s

replication (Bullock & Manias, 2014).

Other immediate nursing priorities for the treatment of Mrs Gibson’s UTI include

monitoring the input and output characteristics of the urine, observe any changes in

mental status, monitor the results from blood and urine tests and finally organize an

incontinence pad for Mrs Gibson for short term management of her incontinence

(Jarvis, Chan, & Gottlieb, 2014).

Once the immediate nursing priorities have been arranged for Mrs Gibson and the

treatment of her UTI, it is necessary to try and assess the pain that Mrs Gibson is in

in regards to her hip fracture, as pain management is one of the most important

aspects of care as it can lead to delirium, depression and poor sleep (Bastani et al.,

2014). This may explain the confusion that Mrs Gibson is displaying and may not be

related to the UTI. Uncontrolled pain may also interfere with treatment for other

medical conditions. Pain should be assessed immediately on arrival and if Mrs

Gibson is displaying signs of confusion, non-verbal cues signifying her pain levels

should be assessed (Bastani et al., 2014). Mrs Gibson should be administered an

analgesia such as morphine or even a nerve block to aid in her pain relief (Bastani et

al., 2014).

Mrs Gibson other immediate nursing priorities include being placed on a soft surface

to protect heel and sacrum from pressure damage, making sure that there is

adequate pain relief is administered allowing for the comfortable change of Mrs

Gibson’s position and arrange for radiography to diagnose fracture and location of

fracture (Berg & Bhatia, 2014).

Hip fracture patients such as Mrs Gibson normally undergo surgery for the treatment

of the fracture in an effort to preserve the function of the hip and the reduction of pain

(Bastani et al., 2014). There are a very small minority of patients that are unsuitable

for surgery due to the risk that surgery may exceed the benefits. Once surgery has

been decided, the goal for the treatment of patients with hip fractures is to have a

short short time to surgery, few or no complications, control of pain, and early

mobilization for restoration of function. Hip fractures are common in older people

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Emily Bishop 220138178 HSNS361 – Written Assignment

such as Mrs Gibson, especially those with osteoporosis. The mortality and morbidity

rate associated with hip fractures are high, however can be related to the age of the

of the patients and the comorbidities that are common in these patients (Marcus,

2013).

As a result of undergoing surgery there are a number of postoperative complications

could occur such as delirium induced by inadequate pain control, the risk of

secondary fractures and poor mobilisation after surgery (McClung et al., 2013). By

minimising the risk of post operative complications due to hip fractures, not only

benefits the patient but places less and financial burden on the health care system.

To assist in the reduction of postoperative complications, multidisciplinary teams

have been shown to assist in the reduction of postoperative complications and

provide better patients outcomes (Dy et al., 2011). When patients are cared for using

a multidisciplinary approach is has been shown to hat patients have a shorter

hospital stay than predicted, reduced admission rates, shorter time to surgery, low

complication rates and low mortality rates (Dy et al., 2011). Within a multidisciplinary

team, each medical professional is able to participate in discussions of the plans for

rehabilitation and postoperative plans for the patient, as well as being aware of any

changes in the patient.

One of the main complications after hip surgery is inadequate pain control (Chin,

Ho, & Cheung, 2013). More than half of patients, who undergo surgery, will

experience an inappropriate level of postoperative pain, which can have detrimental

affect on the outcome for the patient. Postoperative pain management aims to

minimise patient discomfort, facilitate early mobilisation and recovery, stop acute

pain from turning into chronic pain and reduce the incidence of delirium (Corke,

2013). A patient’s pain management should be managed in consultation with the

orthopaedic surgeon, geriatric consultant and nursing staff. Nursing staff should

conduct regular checks on the pain level of patients and notify the orthopaedic

surgeon or geriatric consultant of any changes.

Early mobilization is important for patient’s revering from surgery as it minimises

minimizing complications like venous thromboembolism, pneumonia, and pressure

sores (Cummings-Vaughn & Gammack, 2011). Early mobilisation is vital as it re-

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Emily Bishop 220138178 HSNS361 – Written Assignment

establishes movement and function, following the fracture with the aim of returning

the patient to pre injury function (Berman, Snyder, & Frandsen, 2016). Mobilisation

can included movement between postures, having the ability to have an upright

posture and being able to change direction and speed. Mobilisation is normally

started twenty fours after surgery unless advised against by the orthopaedic surgeon

for medical reasons. The sooner that the patient is able to regain their full

mobilisation it has been shown that improves their quality of life, reduces the risk of

falls and improved capacity for patient self-care (Menzies, Mendelson, Kates, &

Friedman, 2010). A physiotherapist and/or occupation therapists, are able to provide

patients with exercises, education and tools and aids that assist in the patient

mobilizing early and regaining their pre injury mobilisation. Physiotherapists and

occupational therapists can also provide ways for patients to reduce the risk of

secondary fractures. Another important aspect of early mobilization is to ensure that

adequate pain relief is being administrated to the patient (Foss, Kristensen, Palm, &

Kehlet, 2008).

As most hip fractures occur in elderly patients with comorbidities such as

osteoporosis like Mrs. Gibson, a priority after surgery is to reduce the risk of

secondary fractures. If patients such as Mrs. Gibson are not adequately treated for

their osteoporosis, they are at increased risk for further osteoporotic fractures, which

can include recurrent hip fractures (Janiszewska, Kulik, Dziedzic, & Żołnierczuk-

Kieliszek, 2015). The multidisciplinary team should be aware of their patients

comorbidities and have a plan of action, to ensure the patient is adequately treated

in an effort for to maintain a high quality of life and reduce the risks of further

fractures. To treat osteoporosis in patients, there a number of pharmacological

options available to assist in preventing further fractures after surgery. With the

assistance of the multidisciplinary team, such as the general practitioner, they are

able to prescribe the best drug interventions suited to each individual patient. Most of

the medications for the treatment of osteoporosis work by slowing down the

osteoclasts, which break down the bone, while allowing the osteoblast to remain

active and form new bone (McClung et al., 2013). Medications include bisphosphtes,

denosumab, strontium ranelate, which is absorbed into the bone similar to calcium,

and selective oestrogen receptor modulators, which act like the hormone oestrogen

(Zhang et al., 2013). Although the increases on bone density are minimal, they can

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Emily Bishop 220138178 HSNS361 – Written Assignment

have a positive effect and hip fractures can be reduced by 30-50% and positive

effect can be seen as early as six to twelve months after treatment is started (Zhang

et al., 2013).

In conclusion, Mrs Gibson has a number of risk factors that contribute to her bone

density and is the reason behind her hip fracture. Corticosteriod therapy has

detrimental effects on the cells involved in the breaking down and formation of new

bone and can contribute to patients suffering from low density and putting them at

risk of bone fractures. There are also a number of immediate nursing care priorities

that need to be attended to in relation to Mrs Gibson and also a number of

postoperative and rehabilitation care priorities to assist Mrs Gibson in achieving

positive outcomes for her care.

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Emily Bishop 220138178 HSNS361 – Written Assignment

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