The main aim of this essay is to understand different aspects of medical conditions ranging from pathophysiology, symptoms, risk factors, and the management of two case studies. The first case study deals with osteoporosis and osteoarthritis. The second case deals with peptic ulcers and gastric esophageal reflux disease. To address both patients’ medical condition, knowing the condition’s pathophysiology is quintessential.
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Osteoarthritis is a disease of the joints, which affects the slippery tissue called cartilage which covers the joints (Kapoor, Martel-Pelletier, Lajeunesse, Pelletier & Fahmi, 2010). The cartilage in healthy individuals ensures smooth sliding of bones over each other and better shock absorbance. In osteoarthritic patients, wearing of the top layer of cartilage leads to rubbing of bones against one another (Swift, 2012). This causes inflammation of the joint evident from swelling, pain and limited joint activity as time progresses (Kapoor et al, 2010). Excessive rubbing leads to gradual decrease in bone mass with loss in shape, bone spurs growing at edges of joints and a more painful condition manifested by floating of broken bones at joints in joint spaces (Swift, 2012).
Osteoporosis on the other hand is marked by an imbalance between bone resorption and bone formation causing loss of skeletal mass (Huether & McCance, 2012). In the normal physiological condition, bone resorption and formation are always in balance, thus maintaining the bone strength and mass. Any disorder in these two processes such as increased resorption or decreased formation can lead to osteoporosis (Huether & McCance, 2012). In the above case Claire reported a fall and trauma which is a common symptom in an osteoporosis case.
The common modifiable risk factors associated with osteoporosis are vitamin D and calcium deficiency (Wickham, 2011). Similarly cola, alcohol intake and smoking are three modifiable factors which can increase the chances or severity of the disease. Excessive alcohol or cola drinks intake leads to secondary osteoporosis by affecting bone formation, absorption of calcium and vitamin D, and disorder in calcium regulating hormone (Metcalfe, 2008). Estrogen deficiency can lead to post menopause condition where bone resorption is faster than bone formation (Marini & Brandi, 2010). Lack of physical activity can make Claire prone to osteoporosis (Metcalfe, 2008).
Along with the above mentioned modifiable factors there are certain non-modifiable factors on which the control is less. Aging is the first factor which can lead to such disease (Barreiro, Acosta, Marquez, Rodriguez, & Arriaga, 2013). In ageing, the supply of osteoblasts decreases against the demand of the body. Similarly genetic predisposition and epigenetic are non-modifiable factors, the mother’s health status during pregnancy, child birth weight and weight at 1 year are predictive of bone mass till 70 years in female (Marini & Brandi, 2010). The bone diseases like rheumatoid arthritis can also leads to osteoporosis (Huether & McCance, 2012).
Experiencing pain may be the first factor Claire experiences with her osteoarthritis (Swift, 2012). The drying of synovial fluid leads to stiffness of joints which may have been felt by Claire in her hip and knee joints (Swift, 2012). The constant presence of stiffness may lead to muscle weakness in that area. The weakening of muscles, drying of fluid, and inflammation combined effect may restrict her movements such as bending, flexing and extending of joints (Goldring & Otero, 2011).
Osteoporosis often goes unnoticed until a fracture occurs (Brown, 2009). Claire was diagnosed with osteoporosis thus she may have experienced certain clinical manifestations which are common in osteoporosis. Since Claire has sustained fractures in her left colle’s and right tibia/fibula she may experience acute pain during movement of her hands and legs (Brown, 2009). The fractures she received due to osteoporosis may limit her movement and affect the weight bearing capacity of her legs (Brown, 2009). With constant loss of bone at area of fractures, Claire may find it hard to stand erect and may stand in a stoop posture. Loss of height may occur due to increased bone loss (Brown, 2009).
Post-operative nursing management of Claire involves a number of interventions to address the issues faced by Claire. In osteoarthritis and osteoporosis, the most common symptom experienced by patient is pain (Swift, 2012). Thus, the nurse’s interventions must be to reduce the pain, by doing a pain assessment through a recommended scale. The pain must be measured for areas affected, severity and Claire’s reporting of pain. The PRN medications must be administered to Claire as per prescription and timing must be noted for each medication and dose (Colon, 2012). The nurse should take care of any of Claire’s wounds through proper wound management interventions, in order to prevent inflammation and infection (Brown, 2009). Possibilities, of the fracture would mean Claire may stay in bed for a prolonged period, thus chances of having pressure ulcer increases. The same would apply for deep vein thrombosis which nurses can prevent by applying TED stockings (Brown, 2009). Nurses must change her position every 2 hours and a pillow can be provided at pressure areas to Claire. Nutrients, fluid and diet management should be prepared with consultation with a dietician or a nutritionist (Brown, 2009). Physiotherapist interventions are required to assist her with walking and simultaneously the neurovascular assessment must be assessed by nurses to prevent neurovascular degeneration (colon, 2012).
The immediate nursing interventions for Claire would be a primary assessment for immediate danger. The nurse should take a physical assessment on Claire, including assessing her airway patency and circulation. A pain assessment is essential as it provides the only way to ensure that management methods are appropriate and effective (Elliott & Coventry, 2012). The nurse should carry out a pain assessment on Claire using the “PQRST” model. This type of pain assessment gives a detailed account of pain helping nurses to administer pain reduction medications keeping in mind the allergic reactions and six rights (Elliott & Coventry, 2012). The nurse should document when analgesia was administered to Claire so other care team members will have a clear understanding of Claire’s pain (Brown, 2009). Claire must be assessed often for her presence of pain and she must be treated promptly and effectively (Elliott & Coventry, 2012).
A number of factors play an important role in eliciting complications (early and later) post fracture surgery. Complications which may be associated with Claire’s fracture surgery are; during surgery the skin and soft tissues are cut down to reach to the bones, thus chances of bacterial infections exist which can lead to fatal situations if not prevented properly (Brown, 2009). Another serious complication of fracture is compartment syndrome where it causes decreased capillary perfusion below the level necessary for tissue viability (Brown, 2009). Presence of other co morbidities can prolong the recovery stage. Venous thrombosis can also lead to a complication after fracture (Brown, 2009). Precipitating factor is venous stasis which can be caused by incorrectly applied casts to Claire (Brown, 2009). Another contributing factor for the fracture complication on Claire if not treated properly would be fat embolism syndrome where presence of systemic fat globules is distributed into tissues and organs after a traumatic skeletal injury (Brown, 2009).
Case study 2
Pathophysiology of gastro esophageal reflux disease is when the lower esophageal sphincter (LES) is attached to the stomach in the form of a plumbing circuit (Huether & McCance, 2012). Any structural changes occurring in between the stomach and esophageal barrier associated with abnormal relaxation of LES can lead to gastro esophageal reflux disease (Huether & McCance, 2012).
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Peptic ulcers occur with excess secretion of hydrochloric acid and pepsin, this impairs the balance between gastric luminal factors and the action of the gastric mucosal barrier, (Huether & McCance, 2012). The main functions of gastric mucosal barrier are; secretion of bicarbonate, defense of epithelial cells and mucosal blood flow. With increased secretion of acid, the mucosal barriers are affected and thus histamine is released. This activates the parietal cells to release more acids causing ulcers (Huether & McCance, 2012).
A clinical manifestation of peptic ulcers and gastro esophageal disease is heart burn, caused by acid reflux thus causing an inflamed esophagus (Huether & McCance, 2012). Regurgitation occurs due to the loss of the mechanical barrier between the stomach and esophagus and is aggravated by gastric acid reflux. Justin may experience upper abdominal pain within an hour of eating meals (Huether & McCance, 2012). Due to excessive diarrhea, skin may get irritated, red and swollen. The stool with blood in it may be black and have an offensive smell due to oxidation of hemoglobin (Huether & McCance, 2012). The dysphagia experienced by Justin could be due intake of alcohol or acid containing food which leads to esophageal spasms (Huether & McCance, 2012). Due to excessive fluid loss, nurses may have noted that Justin presented as dehydrated.
One common cause of Justin’s peptic ulcer could be his lifestyle of takeaway meals such as fried food, eating spicy and junk foods which has been hypothesized as a causal factor for ulceration (Huether & McCance, 2012). Another major cause could be infection of the gastric and duodenal mucosa with Helicobacter pylori and regular use of non-steroidal anti-inflammatory drugs (NSAIDs), especially those that are classified as COX-1 inhibitors (Huether & McCance, 2012). In Justin’s case, he has been buying over the counter medications for his chronic back pain which may increase the risk factor of gastric ulceration. The other associated factor would be alcohol consumption (Huether & McCance, 2012). The medications commonly used to treat peptic ulcers are acid suppressor’s antacids such as ranitidine and famotidine; they form a foam barrier between the stomach and esophagus thus preventing acid reflux (Brown, 2009). Similarly the H2 antagonists help in reducing the acid secretion in the stomach leading to healing of ulcers (Brown, 2009). Proton pump inhibitors such as omeprazole are effective in decreasing acid secretion from the stomach. PPIs are used in combination with antibiotics to treat ulcers caused by H. pylori (Brown, 2009).
Bowel preparation is the artificial method of removal of faeces from the colon in order to prepare Justin for any type of surgical procedure such as colonoscopy. The colons may have indigested food and fecal matters attached to them (Beck, 2010). The chances of infection increases if any surgical procedures are carried out nearby the colon area. Based upon Justin’s bowel movement patterns and stool characteristics he must be advised to go for a colon cleansing solution drink or laxative drink (Beck, 2010). This procedure can be done the day before scopes or some days before depending upon Justin’s condition. Enemas can also be administered based upon surgeons and specialists prescription. During the bowel preparation, nurses must keep in mind that Justin’s privacy must be maintained and hospital’s policies and procedures are followed. Documentation must be written in clear hand writing for other team members to read about Justin’s treatment (Blair & Smith, 2012).
Peptic ulcers are characterized by tarry and bloody stools due to ulcerations in gastrointestinal tract. Excessive blood loss can be fatal for Justin leading to unconsciousness and other complications, thus it is advised for nurses to check the amount of blood and blood type (clots) (Brown, 2009). This can help to determine the severity of the disease and further diagnosis. The nurse should help Justin to return to his bed as heavy loss of blood leads to fluid deficiency and lowering of blood pressure. Justin’s vital signs must be assessed and fluids must be provided to manage the deficiency (Brown, 2009). While checking Justin’s abdomen for firmness, tenderness and pain, curtains must be pulled to maintained Justin’s privacy. The findings must be documented and reported to the ward in charge doctor for further processing (Blair & Smith, 2012).
Post colonoscopy the nurse should manage Justin’s pain through an assessment of pain, using a severity scale on a specified area and administering PRN medications (Brown, 2009). In order to recover from injury caused by his condition and address other complications associated with the disease, Justin’s nutritional status and fluid balance should be maintained (Brown, 2009). Due to heavy blood loss and pain, the patient may feel frustrated and anxiety symptoms may develop. The nurse should calm Justin, establish effective communication and allow him to express his feelings (Brown, 2009).
In conclusion, the conditions such as osteoarthritis and osteoporosis can be disastrous to Claire as it can affect the quality of her life to a high degree. The case remains the same for peptic ulcer and gastro oesophageal disease and can affect the eating habits of Justin. Thus, it is important to address both patient’s pain level and other complications in order for them to be comfortable. The disease process can be controlled through nursing interventions along with other medical interventions such as surgery and pharmacological management. It is essential for nurses to know pathophysiology of conditions of both cases described above in order to best manage both patients’ issues.
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