Web Case Study - NEETA MONTEIRO, RN, BSN, CNRN, MS, …



Web Case StudyNeeta Monteiro, RN, BSNWright State University-Miami Valley College of Nursing and HealthNUR 7103January 30, 2013History and PhysicalIdentifying dataThe patient is a 65 year old Caucasian woman. The information is obtained from the patient, and is reliable. The patient’s primary language is English. Chief complaint“Discuss results of the bone density scan”.History of Present IllnessThe patient presents to the office for a post hospitalization visit and to review the results of the dual-energy X-ray absorptiometry (DXA) scan. The patient’s problems started two weeks ago when she tripped and fell in the shower at her home. Following the fall the patient developed severe lower back pain and was diagnosed with a compression fracture at the lumbar L4 vertebrae. A dual-energy X-ray absorptiometry (DXA) scan was ordered to assess the patient’s bone mineral density. Presently the patient is taking Tylenol which is helping with pain management. The patient denies any other previous fractures, falls or injury. The patient denies pain in any other location, swelling, fever, changes in mental status, headache, palpitation, syncope, weakness or injury to any other part of the body since the fall. Medications: Metoprolol 25 mg PO BID, Tylenol 625 mg PO Q6H as needed. Patient denies use of any complimentary or alternative medications. Allergies: No known drug, food, or other allergies.Smoking/Alcohol/drugs: Denies use of alcohol, any illicit drugs, or smoking.Past Medical HistoryMajor childhood illnesses: Chickenpox and measles. No scarlet fever or rheumatic fever. Adult illnesses: The patient has a history of hypertension and seasonal allergies. Fracture of the L4 vertebrae two weeks ago, treated symptomatically. She denies any recent illnesses or exposures.Surgeries: Appendectomy, tonsillectomy, and hysterectomy. OB/Gynecology: Initiation of menarche at age 15 years. Patient is nulliparous. She underwent total abdominal hysterectomy (TAH) at the age of 40 years due to endometriosis. Immunizations: Tetanus vaccination in 2005; flu and pneumonia vaccinations in November 2012. Personal and Social HistoryThe patient was born and raised in Dayton, Ohio; completed high school; single and has never been married; no children. She retired 6 months ago and worked as a sales clerk for 20 years at her last job. The patient lives independently in an apartment and feels safe at home. She does not have any pets. She does not have to use any steps or stair way at her apartment. Prior to the fall the patient was able to carry out her activities of daily living independently. Recently has been stressed and anxious but denies depression. The patient has one brother and one sister who are younger than her. Her sister and two of her close friends are her source of support and comfort and are helping her out during her recovery phase. She is involved in church activities and attends church regularly. Exercise and diet: Does not follow any exercise regimen. The patient’s only source of physical activity is carrying out regular household chores. She drinks two cups of tea per day. She has always been physically lean and eats small meal portions; she has never had a big appetite. Usually eats at home alone and prepares own meals. Leisure and hobbies: Enjoys reading, knitting, and quilting. Family HistoryParents and grandparents are deceased. Mother died at age 80 years and had history of hypertension and osteoporosis. Father died at age 70 years and had history of hypertension and hyperlipidemia. Brother, age 62 years, has history of hypertension, otherwise healthy; sister age 58 years has no significant health history. Patient does not have information regarding her grandparents’ health history. Review of symptoms General: Reports being is good health generally. No recent night sweats, weight alteration, respiratory illnesses, or high temperature. Skin: No rash or alterations in skin integrity. Neurological: Denies any confusion, memory loss, visual changes, vertigo, headache, weakness or mood swings. Has no history of seizures, strokes, multiple sclerosis, or dizziness. HEENT: Head- denies any head injury, headaches, migraines, or syncope. Eyes- she denies eye injury, pain, dryness, history of glaucoma or cataracts; uses glasses, last checked 3 months ago. Ears- has no hearing loss, infection, pain, or ringing in the ears. Nose- no nose bleeds, or nasal drainage; has seasonal allergies. No sinus pain or inflammation. Throat- no soreness, difficulty in swallowing or speaking; has undergone tonsillectomy. Mouth- no mouth sores, pain, or bleeding gums; wears partial dentures; brushes twice a day. Last dental visit was five months ago.Neck: No lumps, swollen lymph nodes, pain, or issue with neck range of motion. Breast: No swelling, pain, nipple discharge, lumps or swollen glands; performs monthly breast self-examination. No family history of breast disease. Respiratory: Has at least one episode of upper respiratory infection per year; presently no issues. No chest pain, breathing difficulty, shortness of breath or wheezing; has never smoked. Cardiovascular: Has hypertension. She is taking Metoprolol 25 mg bid for the last two years and “blood pressure is under control”. She denies palpitation, chest pain, syncope, shortness of breath, or edema. No history of murmur, atherosclerosis, cardiac arrhythmias or atrial fibrillation; occasional fatigue. Gastrointestinal: Moderate appetite, no heartburn, dysphagia, dyspepsia, vomiting, nausea, bloating, or abdominal distension; has regular bowel movements. No rectal bleeding or hemorrhoids. She had appendectomy in 1970. No history of liver disease or ulcers.Urinary: No burning micturition, frequency, urgency or hematuria. She denies any pain or swelling in groin, supra-pubic area, and flanks. Sometimes has stress incontinence. Genitalia/sexual health: Has undergone total abdominal hysterectomy at age 40 years. Has occasional vaginal itching and dryness. No discharge or lesions; not sexually active.Musculoskeletal: Has pain in her lower back since the fall; non-radiating. She uses over the counter Tylenol with adequate pain relief. Pain is improving. Uses back brace for support. Patient used a walker for the first ten days, has been able to ambulate without walker or any support since the last four days. Has no pain, swelling, redness, tenderness, or stiffness in any other joints. No history of gout or arthritis. Patient has not had any other falls or fractures prior to the last fall.Psychosocial: Patient is anxious to know the results of her DXA scan since her mother had a history of osteoporosis. Patient denies any history of depression, anxiety, mood swings, irritability or thoughts of harming self. No problems with insomnia or restlessness. Hematologic: No bleeding problems, sickle cell anemia or any blood disorders. Endocrine: No history of diabetes or thyroid problems. No increase in frequency of urination, thirst, or increase appetite. Denies heat or cold intolerance, weight loss or weight gain. Physical ExaminationGeneral appearance: Patient is pleasant, tall, lean, well dressed and appears tensed. She answers appropriately and is sitting comfortably in the chair. Measurements: The patient is 5’ 7” tall and weighs 122 pounds. Her vital signs include temperature of 98.2 o F, heart rate of 88 beats/minute, respirations 20 breaths/minute, blood pressure 118/76 mmHg, and oxygen saturation of 96% on room air.Neurological: Patient is alert and oriented. Speech is clear and appropriate. Memory is intact. Pupils are equal, round and reactive. Extraocular movements are intact. Patient denies any vision loss or diplopia. Face is symmetric. Strength in all four extremities is 5/5. Denies numbness and tingling in face or extremities. No limb ataxia noted. Gait is steady and walks without support. Patient is wearing a back brace. Assessment of cranial nerves II through XII is normal. Reflexes are 2 + and symmetric.HEENT: Head is normocephalic and non-tender on palpation. Scalp without lesions, average hair. Pupils are equal and round, 3+; Conjunctiva and sclera are clear. Ear, no discharge or inflammation noted. Tympanic membranes are pearly gray. Whispered sounds heard equal bilaterally. No drainage noted through the nasal passage. Lips are pink, mouth is moist and without any mouth lesions or ulcers; patient has partial upper dentures.Neck: Trachea midline; Jugular veins not distended. Neck is supple with full range of motion. Lymph nodes are non-palpable and non-tender. Thyroid non-enlarged. Carotid pulses are 2+ without bruits. Lymph nodes: No cervical, axillary, epitrochlear or inguinal adenopathy noted. Respiratory: Thorax is symmetric with good expansion and excursion. Lung fields are resonant. Breath sounds are vesicular with no added sounds such as rales, wheezing and rhonchi. Cardiovascular: Carotid upstroke brisk, without bruits. Crisp S1, S2; no S3 or S4; without murmurs or extra sounds. Breast: symmetric, pendulous, no masses; nipples void of any discharge.Abdomen: Abdomen is flat, non-distended, no visible pulsations noted. Tympany noted on percussion. Bowel sounds are normal in all four quadrants. No hepatomegaly or splenomegaly noted. No tenderness noted at the costovertebral angle. Extremities: Warm, without edema. Pulses are 2 + in bilateral upper and lower extremities. Musculoskeletal: Strength in all four extremities 5/5. Mild tenderness noted at the L4 level, without swelling or redness. Gait is steady. No redness, swelling and tenderness noted in any other joint. Range of motion is intact in all four extremities. Skin: Dry, intact, and warm to touch; without rashes, lesions or bruises. Old scar on abdomen from TAH.Laboratory findingsTable 1 Comprehensive Metabolic Panel (CMP)CMPResultsNormal ValuesCMPResultsNormal ValuesSodium137 mEq/L136-144mEq/LAlbumin4.2 g/dL3.9-5.0 g/dLPotassium4.2 mEq/L3.7-5.2 mEq/LAlk phos88 IU/L44 -147 IU/LChloride102mmol/L96-106mEq/LALT20 IU/L8-37 IU/LCalcium8.6 mg/dL8.5-10.9mg/dLAST23 IU/L10-34 IU/LGlucose92 mg/dL60-100 mg/dLBicarbonate24 mmol/L23-29 mEq/LBUN15 mg/dL7-20 mg/dlTotal bilirubin1.3 mg/dL0.2-1.9 mg/dlCreatinine1.0 mg/dL0.8-1.4 mg/dlTotal protein7.0 g/dL6.3 -7.9 g/dLCreatinine Cl99 ml/min88-128ml/minBUN/Creat rt1510:1-20:1Anion Gap9.2 mEq/L8-16 mEq/LMagnesium2.0 mg/dL1.6-2.4 mEq/L25 (OH) D55ng/mL30-74 ng/mLPhosphorus3.4 mg/dL2.5-5.2 mEq/LTable 2 Thyroid Test and Lipid PanelThyroid TestResultsNormal RangeLipid panelResultsNormalTSH1.2mlU/L0.4 - 4.0mlU/LTotal Cholesterol130mg/dL<200 mg/dLT3130ng/dL100-200ng/dLHDL65 mg/dL>40-60mg/dLT47.1mcg/dL4.5-11.2mcg/dLDL85 mg/dL< 130 mg/dLPTH40 pg/mL10 - 55 pg/mLTriglycerides85 mg/dL10-150 mg/dLTable 3 Complete Blood Count (CBC)CBCResultsReferenceCBCResultsReferenceWBC6,000 c/mcL4,500-10,000MCH2827-31 pg/cellRBC4.5 mc/mcL4.2-5.4MCHC3332-36 gm/dLHemoglobin14 g/dL12-15 g/dLMCV9580-95 femtoliterHematocrit40 %36-44 %Platelet350,000/mcl100,000 - 450,000Dual-energy X-ray absorptiometry (DXA) scan resultsThe patient’s central DXA scan of the spine revealed T scores of 2.9 standard deviations below normal healthy young women. According to the World Health Organization [WHO] (2007), bone mineral density of 2.5 standard deviations or more below the mean for healthy young individual of similar sex (T- score of -2.5 or below) as measured by central DXA scan is the gold standard for diagnosing osteoporosis (Normal BMD = T-score -1.0 and above; osteopenia between -1.0 and -2.5).DiagnosisTaking into consideration the patients age (65 years), surgically induced menopause at age 40 years, low weight-for height ratio (ht. 5’7”; wt.122 lbs.), family history of osteoporosis, compression fracture at L4, laboratory results, the results of the DXA scan and physical examination, all lead the clinician to the diagnosis of postmenopausal osteoporosis. Serum alkaline phosphate, calcium, and phosphorus are usually normal in patients with postmenopausal osteoporosis. Laboratory tests are helpful in obtaining baseline information of the patient’s health status, and to rule of secondary causes of osteoporosis, which is imperative prior to starting pharmacological treatment (Sweet, Sweet, Jeremiah, & Galazka, 2009).Differential DiagnosisSome of the differential diagnoses and secondary causes of osteoporosis are osteomalacia, tumor necrosis, rheumatoid arthritis, systemic lupus erythematosus, metastatic bone disease, primary hyperparathyroidism, hyperthyroidism, multiple myeloma, malabsorption syndrome and Paget disease. Osteomalacia and primary hyperparathyroidism are the two metabolic bone disorders that closely imitate osteoporosis (Sweet, Sweet, Jeremiah, & Galazka, 2009).The laboratory values that are helpful in differentiating the different diagnoses are, alkaline phosphate levels are usually high in Paget disease; hypocalcemia is commonly seen in malabsorption disorders and vitamin D deficiency. If bone marrow malignancy is suspected complete blood count will be abnormal. In hyperthyroidism the thyroid-stimulating hormone levels are low and in vitamin D deficiency the 25-hydorxyvitamin D [25 (OH) D] levels are low (Sweet, Sweet, Jeremiah, & Galazka, 2009). Osteomalacia is caused due to insufficient and hindered mineralization of the bone matrix resulting in soft bones susceptible to fractures (McCance & Huether, 2009). The most significant causative factor of osteomalacia is vitamin D deficiency secondary to intestinal malabsorption, insufficient dietary intake, and lack of exposure to sunlight (Cantorna, Zhu, Froicu & Wittke, 2004). The clinical manifestations include bone pain and tenderness especially in the hips, decreased muscular strength, and fragility fractures. Significant laboratory values diagnostic for osteomalacia are hypocalcemia, high alkaline phosphate, hypophosphatemia, and low 25(OH) D. Radiologic studies show changes in bone structure (Khan, Sultan, Khan, & Younis, 2007). Primary hyperparathyroidism is caused due to the hyperactivity of the parathyroid gland resulting in high PTH levels. High levels of PTH cause greater osteoclastic activity than osteoblastic activity leading to weak bones. The clinical manifestations of primary hyperparathyroidism include pathologic fractures, kyphosis of the dorsal vertebrae, and compression fractures of the spine. Hypercalcemia and hyperphosphatemia are the classic characteristics of primary hyperparathyroidism (McCance & Huether, 2009).PlanAccording to the National Osteoporosis Foundation [NOF] (2010), patients who have sustained a hip or spine fracture and whose T scores are below 2.5 standard deviations than normal, should be started on pharmacological therapy. The treatment plan for the patient comprises of fall prevention, weight bearing exercises, calcium intake of at least 1,200 mg/day, vitamin D supplementation a minimum of 800 to 1,000 IU/day, and treatment with a US Food and Drug Administration (FDA) approved pharmacological options such as bisphosphonates, calcitonin, estrogens, estrogen agonist/antagonist and parathyroid hormone (NOF, 2010). American Association of Clinical Endocrinologists [AACE] (2010) recommends alendronate, risedronate, zoledronic acid, and denosumab as the first line pharmacological therapy for the treatment of postmenopausal osteoporosis. The plan for the patient embraces fall prevention strategies such as assessing vision, mental competence, and gait imbalance, and also assessing fracture risk using the fracture risk assessment tool (FRAX) developed by the WHO. The patient’s home should be evaluated for safety and if necessary grab handles should be placed in bathrooms and walkways. Movable mats/rugs should be removed and lighting should be enhanced. Any medications that can cause dizziness and affect consciousness should be stopped or not prescribed (Sweet, Sweet, Jeremiah, & Galazka, 2009). The patient is taking Metoprolol for hypertension; dizziness, vertigo and confusion are some of the side effects of the medication (Lexi-comp, 2013). Per patient she has not experienced any of these side effects since starting Metoprolol two years ago and therefore is considered safe to continue. Patient should be encouraged to incorporate exercise such as weight bearing, muscle and bone building, and balance training. Appropriate exercise decreases the risk of falling (NOF, 2010). If patients condition warrants physical therapy may be consulted. Drug of Choice: The choice of drug therapy was carefully selected taking into consideration the patient’s diagnosis, existing health history, financial status, insurance plan, psychological status, ability to follow instructions and existing research. Alendronate sodium (generic) 70 mg once a week orally will be prescribed. The recommended dosage of alendronate sodium for the treatment of osteoporosis in postmenopausal women is 10 mg once a day or 70 mg once a week (LexiComp, 2013). Alendronate 70 mg once a week was opted due to the ease of administration. Rationale: According to the NOF (2010) Alendronate declined bone breakdown, improved bone mineral density and decreased the frequency of spine and hip fractures by about 50 percent. Availability: Alendronate is available in the following dosages 5 mg, 10 mg, 40 mg, and 70 mg tablets. Brand names of alendronate available in the US are Fosamax 70 mg; and Binosto oral [effervescent] 70 mg (LexiComp, 2013). Action: Bisphosphonates act on osteoclasts or osteoclast precursors and thereby prevent bone resorption causing an improvement in bone mineral density (LexiComp, 2013)Uses: Alendronate is indicated in the prevention and treatment of osteoporosis in post-menopausal women. The other uses of alendronate are treatment of osteoporosis in males, Paget’s disease, and glucocorticoid-induced osteoporosis (LexiComp, 2013). Contraindications: Contraindications include allergic reaction to alendronate, low blood calcium level, and severe kidney problems. The medication is used carefully in patients with mild to moderate kidney disease, high serum phosphate levels, hepatic insufficiency, systemic infection and diseases of the esophagus. Prior to starting the medication the patient should be assessed for any difficulty in swallowing, dental issues, clotting abnormalities, low hemoglobin, decreased vitamin D and gastrointestinal (GI) ulcers (LexiComp, 2013).Administration: Prior to initiating treatment with alendronate, low serum calcium levels should be corrected. In the patient serum calcium are within normal range and therefore alendronate can be started without suspension. Alendronate should be taken in the morning, on an empty stomach, and the patient should be instructed to sit upright, walk or stand for at least 30 minutes after administration to prevent esophageal irritation. Consumption of food, fluids, or any other medication is not allowed for at least 30 minutes after taking alendronate, since food decreases the bioavailability of the drug. The tablet should be consumed whole with at least 180 ml of plain water and no other beverage, mineral water or liquid. Alendronate should not be taken within two hours of consumption of calcium comprising diet, drink or drug. Any dental procedures should be completed prior to commencement of treatment (LexiComp, 2013). Storage: The medication should be stored at room temperature in a secure container.Adverse effects: Alendronate can cause low serum calcium levels, low serum phosphate levels, damage to the gastrointestinal mucosa, inflammation, ulceration, and other GI symptoms such as unsettled stomach, queasiness, intestinal ache, indigestion, irregular bowel movements, excessive gas formation, body ache, headache, osteonecrosis of the jaw, and skin irritation. The patient should be instructed to inform the clinician of any fever accompanied with joint and/or muscle pain, convulsions, respiratory distress, bloody feces, mouth ulcers and dental/jaw problems (LexiComp, 2013).Drug-drug interaction: Alendronate increases the effect/concentration of Deferasirox and phosphate supplements. The medications that can cause an increase in the effect of alendronate are Aminoglycosides, aspirin and NSAIDS. The medications that can cause a decrease in the effect of alendronate are proton pump inhibitors, antacids, calcium, magnesium, and iron salts (LexiComp, 2013).Pharmacokinetics: The amount of medication that is absorbed from the GI tract is approximately 0.6% when fasted. Food and drinks hinder the absorption of alendronate and reduces the bioavailability by up to 60%; 78% of the drug is bound to protein. The onset of action is within three to six weeks. The medication is rapidly taken up by the skeletal system and is not metabolized. Unabsorbed medication is excreted in the urine and feces. The half-life of the medication is beyond ten years (LexiComp, 2013).Monitoring Parameters: After initiation of therapy serum calcium, serum 25(OH) D, blood phosphate, serum alkaline phosphate, 24 hour urinary calcium, creatinine clearance, serum electrolytes, and hepatic and renal function panel will be closely monitored. A central DXA scan will be done at least every two years, height and weight will be assessed annually and serum bone turnover markers will be assessed at base line and during treatment. The medication will be stopped if the patient’s creatinine clearance goes below 35 ml/min (LexiComp, 2013) In addition to alendronate the patient will be supplemented with calcium 1,200 mg/day and vitamin D 800 IU/day. Prince, Devine, Dhaliwal, & Dick (2006), in a meta-analysis demonstrated reduced fracture rates in elderly women when supplement with calcium. According to the NOF (2010), a daily dose of 800 IU of vitamin D is effective in preventing fractures. The patient should be reminded that calcium alters the absorption of several medications including alendronate sodium and therefore should be taken two hours before or after calcium supplements. To prevent vitamin D toxicity measurement of serum levels is crucial (Sweet, Sweet, Jeremiah, & Galazka, 2009). APN authority to prescribe In the state of Ohio an advance practice nurse (APN), with an up-to-date certificate to prescribe (CTP), may prescribe alendronate within their scope of practice and the practice specialty of the collaborating physician for the treatment of osteoporosis (Ohio Board of Nursing, 2012). Clinical StudyReid et al. (2008) conducted a direct head-to-toe study to compare the efficacy of the bisphosphonates- alendronate and risedronate (the recommended first line oral pharmacological interventions) with regards to change in BMD, biochemical markers and upper GI adverse effects on postmenopausal women with osteoporosis over a period of 24 months. Participants in the study were females age 40 years and older, living in the community, at least 6 months postmenopausal, able to ambulate, with a BMD more than 2.0 SD below normal young women, at the hip, trochanter, femoral neck, or lumbar vertebrae, and required to be in reasonably good health and able to endure the DXA scan. The baseline characteristics of participants of both the groups were similar. Participants unable to sit or stand for 30 minutes post medication administration, anomalies of the esophagus such as stricture, and secondary causes of osteoporosis were excluded from the study. The study design conducted was a randomized double-blind, active controlled, multicenter international study which included 75 international sites in the first 12 months, out of which 72 sites continued to participated in the 24 month study. The study was approved by the institution review board and written informed consent was taken from participants before the study. A total of 936 postmenopausal females with a diagnosis of osteoporosis were randomly assigned to either receive alendronate 70 mg once a week (OW) or risedronate 35 mg OW. All study contestants were explained to take the medications on the same day each week and consume 1000 mg of calcium and 400 IU of vitamin D daily (either dietary or supplemental). Effectiveness of the treatment was measured in term of BMD by DXA scan at the hip trochanter, lumbar vertebrae, total hip, and femoral neck, and levels of four bone turnover markers (NTX, CTX, BSAP and P1NP) at 6, 12 and 24 months. The 24 month study was completed by 798 participants. Any nonlife-threatening adverse drug reactions were reported by phone. Analysis of variance (ANOVA) was used to assess the percentage change from baseline, and 95% CIs were calculated to estimate treatment differences. The percentage of women with BMD escalation and the percentage of BMD decrease at each BMD site were evaluated by a mantel-Haenszel test arranged by study center. A significantly larger improvement from baseline was noted with alendronate in BMD at all the four sites (trochanter, hip, lumbar and femoral neck), compared to risedronate at 24 months, with an adjusted mean treatment difference of 1.5 % (95 % CI: 0.74%, 2.26%; p < 0.001). Similarly significantly larger geometric mean percent decreases (p < 0.001) from baseline were seen for all four bone turnover markers with alendronate compared to risedronate with adjusted mean treatment differences ranging from 8.9% to 25.3%. The incidences of side effects including upper GI sensitivity were alike in both groups. Due to the size of the study, measuring considerable differences in fracture rates between the two groups was prohibited, although 5.7 % of the patients of the alendronate group and 6.3% of the patients in the risedronate group reported fractures. The researchers concluded that alendronate was superior in its efficacy as demonstrated by a higher BMD and greater decreases in bone turnover marker levels than risedronate over 24 months, with similar upper GI adverse effects.IssuesWhen determining drug of choice it is vital that the patient’s problem is clear, in this case it is postmenopausal osteoporosis. Any secondary causes of osteoporosis should be ruled out, which will otherwise change the treatment plan. The objective of treatment of postmenopausal osteoporosis is to increase BMD, and thereby prevent fractures, thus decreasing mortality and morbidity. The FDA has approved bisphosphonates as a recommended choice of medication for the treatment of osteoporosis, which helps increase BMD. The choice of drug therapy is then made depending on results of reliable and accurate research such as randomized control trials and meta-analysis. Making sure the choice of medication is suitable for the patient in terms of administration, cost, tolerability, and existing co-morbidities is vital. When choosing bisphosphonates it is important that the patient be able to swallow the medication whole, take it first thing in the morning, and be able to sit or stand for at least 30 minutes after administration. The patient does not have any issues with her esophagus and does not have any swallowing problems. She is able to walk and reports no issues with sitting or standing for 30 minutes. The patient’s laboratory reports do not indicate any secondary causes of osteoporosis. She is able to understand all the instruction provided and is able to read. The patient has been taking Metoprolol for the last two years and is adherent with treatment. Therefore chances of adherence to the new medication appear promising. Instructions regarding exercising, fall prevention, supplementing calcium and vitamin D are important part of the treatment plan for this patient. Educating the patient regarding the new medication, the side effects and reporting adverse effects is imperative; written information must be clear and according to the patient’s level of understanding. Evaluating therapy is the key to determine if the treatment is effective. If not, treatment options should be altered to obtain the necessary outcomes. In the patient regular calcium levels, 25(OH) D levels, creatinine clearance, assessment of back pain, measuring height and weight annually, assessing bone turnover markers and getting a DXA scan at least every two years is essential. The treatment prescribed should be cost-effective. In regards to cost, alendronate sodium (generic) 70 mg 4 tablets (one month treatment) cost $13.99; and research indicates that the medication is effective in improving BMD. If the patient is able to tolerate the mediation the therapy will be continued for at least three to five years with periodic evaluation. Further continuation of the medication will depend on the patient’s health status and success of treatment. If bisphosphonate therapy is not successful because of GI intolerance, noncompliance, occurrence of fractures or no change in BMD other options as outlined by NOF and AACE may be considered. Finally clinicians should be knowledgeable and update themselves with the current regimens. Looking up information when unsure and having easy access to drug references will help prevent errors and improve patient outcomes (Pollock, Bazaldua, & Dobbie, 2007). Legal and Ethical considerationsLegal and ethical considerations are a priority before prescribing any medications. The APN must have a current certificate to prescribe (CTP) issued by the Ohio board of Nursing (OBN) and prescribe within the scope of practice and standard care agreements. All APNs should familiarize themselves with the formulary developed by the committee on prescriptive governance (OBN, 2012). Prior to prescribing any medication respecting the patient’s autonomy and obtaining informed consent is a must. Providing the patient with information regarding alendronate including indication, adverse effects and answering questions will help the patient in consenting to treatment. The principle of non-maleficence, which is doing no harm, should be taken into consideration before starting the patient on alendronate. The patient’s liver function, kidney function, calcium and vitamin D levels are within normal range. The patient does not have any underlying dental problems and patient’s general health is satisfactory. Therefore, starting the patient on alendronate does not foresee any life threatening harm. The principle of beneficence, the act of doing good, holds true when considering alendronate. Research has revealed significant improvement in BMD when treated with alendronate, with the hope of preventing and reducing fractures, and thereby improving patient’s quality of life. The principle of justice, treating all individuals fairly without discriminating in terms of age, race, color, sex, economic, educational status and level of understanding is important. As practitioners being truthful to the patients regarding medication, diagnosis, adverse effects, treatment period and outcomes is vital. Honoring commitments, maintaining privacy and confidentiality is essential for practice (Scordo, 2013). Providers are responsible to inform the patient if there are any recalls on the medication, withdrawing the medication or introducing new treatments (OBN, 2012). All these factors should be taken into consideration when planning treatment for a patient with postmenopausal osteoporosis and starting on alendronate sodium. Discussion Questions1. Discuss the efficacy, safety, and suitability of Zoledronic acid and Denosumab in the treatment of postmenopausal osteoporosis. Also indicate if APN has authority to prescribe these medications. 2. If the recommended treatment plan is not successful what will be the next step in the management of the patient? Discuss treatment options. ReferenceAmerican Association of Clinical Endocrinologists (2010). Medical guidelines for clinical practice for the diagnosis and treatment of postmenopausal osteoporosis. Retrieved from , M. T., Zhu, Y., Froicu, M., & Wittke, A. (2004). Vitamin D status, 1, 25-dihydroxyvitamin D3, and the immune system. The American Journal of Clinical Nutrition, 80, 1717-1720. Retrieved from http;//ajcn.content/80/6/1717S.full.pdf Khan, M., Sultan, S., Khan. A., & Younis, M. (2007). Bilateral protrusion of femoral head into the pelvis in neglected osteomalacia. Journal of Ayub Medical College, Abbottabad: JAMC, 19, 54-55. Retrieved from Lexi-Comp, Inc. (2013). Lexi-Drugs TM. Lexi-Comp. Inc. Accessed January 29, 2013. McCance, K., & Huether, S. (2009). Pathophysiology: The biologic basis for disease in adults and children (6th ed.). St. Louis: Mosby. National Osteoporosis Foundation (2010). Clinician’s guide to prevention and treatment of osteoporosis. Retrieved from Board of Nursing (2012). The formulary developed by the committee on prescriptive governance. Retrieved from , M., Bazaldua, O., & Dobbie, A. (2007). Appropriate prescribing of medications: An eight-step approach. American Family Physicians, 75(2), 231-236. Retrieved from Prince, R. L., Devine, A., Dhaliwal, S. S., & Dick, I. M. (2006). Effects of calcium supplementation on clinical fracture and bone structure: results of 5-year, double-blind, placebo-controlled trial in elderly women. Archives of Internal Medicine, 166, 869-875. Retrieved from D. M. Hosking, D., Kendler, D., Brandi, M. L., Wark, J. D., Marques-Neto, J. F.,…Melton, M. E. (2008). A comparison of the effect of alendronate and risedronate on bone mineral density in postmenopausal women with osteoporosis: 24-month results from FACTS-International. International Journal of Clinical Practice, 64(4), 575-584. doi:10.1111/j.1742-1241.2008.01704.x Scordo, K. A. (2013). Applied pharmacology and therapeutics for advanced practice [class handout]. College of Nursing and Health, Wright State University, Dayton, OH. Sweet, M. G., Sweet, J. M., Jeremiah, M. P., & Galazka, S. S. (2009). Diagnosis and treatment of osteoporosis. American Family Practice, 79(3), 193-200. Retrieved from World Health Organization (2007). WHO scientific group on the assessment of osteoporosis at primary health care level. Retrieved from ................
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