Nursing Diagnosis: (2)
#1: Acute pain related to vertebral compression,
AEB pain of the lower spine 6/10 Pain Scale.
#2: Deficient knowledge, related to new
diagnosis AEB pt states she is unaware how to
prevent falls from occurring.
Resources:
Burton, M., & May, L. L. J (2011). Study
guide to accompany fundamentals of
nursing care: Concepts, connections &
skills. F.A. Davis Co.
Goals: (4) ( 1 STG and 1 LTG for EACH NANDA)
STG:pt will have pain level reduced to a 5 on the
pain scale by the end of the shift. Goal met via pt
verbalizing ease of pain.
LTG: pt will have a pain level off 0-3 on the Pain
scale by discharge date. Pt level of pain 0/10. Day
of d/c.
STG: be able to utilize call bell to ask For
assistance, goal not met by end of shift d/t CNA
observed pt getting oob w/o assistance.
LTG: verbalized and practices safety precautions to
prevent fractures due to falls before discharge to
ensure prevention of fall re-occurrence.
.
Nursing Interventions: (8)
① administer pain meds Pan ② teach deep breathing and
relaxation technique ③ educate pt. About non
pharmacological methods For acute pain such as; imagery
distraction techniques ④ provide feedback about loss of
weight & bone integrity and potential outcomes of
treatments. ⑤ assess current knowledge regarding
treatment of osteoporosis ⑥ instruct dietary and calcium
supplements that help prevent effects of osteoporosis ⑦
discuss physical exercises that help prevent complications
⑧ review safety and fall precautions, and provide
literature regarding now to create a safe home
environment
Assessment:
Upon assessment, hr slightly tachycardic at
110bpm, rr 24. Verbalized 6/10 pain. Able to do
active ROM in all extremities. There is a great
discomfort in upright position as per the pt.
statement.
Noted a slight "hump" on upper back and is 1”
shorter in height than in her last admission.
Diagnostics:
Dexa Scan (bone density scanner)
Ultrasound scan of the heel bone
Risk Factors:
Disorder:
Osteoporosis
Pathophysiology:
Osteoporosis is a metabolic diseases that on
a cellular level results From osteoclastic
bone resorption not compensated by
osteoblastic bone formation. This causes
bones to become weak and fragile, this
increasing risk of fractures.
① female gender ② Caucasian or Asian race
③ family history of osteoporosis ④ smoking
⑤ Alcohol use
Complications & Actions to Prevent:
Fractures occurring more frequently
Increased pain
Eat calcium-rich food
Have a healthy and varied diet with plenty
of fresh fruits and veggies
Avoid smoking
Do regular weight-bearing and strengthtraining activities
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