Evidence-Based Nursing Care for an 80-Year-Old Patient with Osteoarthritis - Essay Sample

Introduction

In the contemporary era, the emphasis on the vitality of delivering evidence-based care is firmly enshrined in the nursing practice. The nursing care integrates the best evidence possible with the existing institutional protocols with the primary objective of improving patient outcome. In the spirit of advancing best practice, this paper will assess an aspect of nursing care that an 80-year-old patient who had a total hip replacement on the right-side secondary to osteoarthritis complications. A brief history of the patient (herein referred to as Ms. PM - not her real name) reveals that she is a non-smoker, non-drinker, and known hypertensive patient with high cholesterol levels. The osteoarthritis condition has affected both her hip and knee although a decision was made to operate the hip (which was more affected) and later on operate the knee. This will be her incident surgery and has no history of food or drug allergies. Socially, she lived alone near a close watch of her family, but following the surgery, she will be living with her daughter.

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Context of Care

Evidenced from the history above, the patient (Ms. P) is elderly, having comorbidity, likely to be a polypharmacy case, and with compromise lower limb strength and stability. These are the major factors that increase the risks of falls incidences (Foley et al., 2006; Hill et al., 2012). A study conducted in Australia showed that the risk of falls is directly related to aging with a 25% chance of falls for those women in their 60s, 40% chance in their 70s, and 54% chance of those aged over 80 years (Waldron et al 2012). Ms. P belongs to the category of those aged 80 years, thus has a risk of 54% chance to falls. Having arthritis compromises lower extremity muscle joint strength causing gait and balance impairment (Hill et al., 2012). Arthritis increases the risk of falls by 20 – 35% when the lower limb joints are affected, with risk exacerbated with the severity of arthritis and involvement of the hip joint (Lavinger et al., 2012). Evidence presented in Arthritis Foundation data shows those elderly patients with two joints affected by arthritis, like Ms. P, have a74% chance of falls (Arthritis Foundation, 2020). Care Given at the Hospital

In respect to these risks, the nurses in the hospital took a deliberate effort to assess Ms. P's risk of falls using the Ontario Falls Assessment Tool. The tool is crucial in identifying mainly the extrinsic risks for falls enabling the care team to arrive at a feasible fall prevention strategy (Al-Aama, 2011). The intervention strategies that were put in place to reduce falls included offering support cradles or wheelchair to facilitate safe movement, use of bed rails to prevent toppling while in bed, vigilant monitoring, and reducing slippery floor. While these measures have proven significant in fall prevention (Dore et al, 2015), a perusal in the literature suggests that the administration of vitamin D supplements can have significant impacts on falls incidence reduction among elderly patients, especially those diagnosed with osteoarthritis.

Evidence on Administration of Vitamin D Supplements

Vitamin D is vital in the homeostasis of both calcium and phosphorous concentration in the blood by influencing parathyroid hormone functioning. The two elements are crucial in bone formation by maintaining strong bones. Furthermore, calcium is essential in muscle strength. A deficiency in vitamin D triggers secondary hyperparathyroidism which in turn leads to accelerated bone loss, osteoporosis, osteomalacia, and increased risk for fractures. In the elderly population, dietary changes or challenges may reduce the availability of vitamin D intake while intestinal changes reduce the rate at which the vitamin is absorbed. As a result, the availability of vitamin D is likely to be below the normal levels, which increase the risk or the incidence of osteoarthritis among the elderly population. The result is reduced muscle strength, impaired lower limb strength, and bones susceptible to fractures.

A meta-analysis of eight randomized controlled trials indicated that the use of daily vitamin D supplements in the levels of 700 – 1000IU reduced the risks of falls by 19% for people admitted in a health care facility (Bischoff-Ferrari et al., 2009). In the same review, a daily dosage of less than 700 IU showed no significant role in reducing fall risks. The same study showed that among community-dwelling elderly persons, 25(OH)D in the rates of less than 12ng/mL significantly compromised leg extension strength. The reports were related to those reported by Mowe et al. (1999) where the concentration of 25(OH)D was found to have statistical significance on influencing grip strength, ability to climb stairs, and involvement in physical strength.

Kalyani et al. (2010) in their systematic review found that the use of vitamin D supplements in the levels of 200 – 1000IU reduced the risk of falls by 14%. The preventive effect of vitamin D supplements was directly related to its dosage with low doses offering low prevention while high doses cholecalciferol up to 1000IU reducing the risk much better. In the review, Kalyani et al. (2010) further reported that the use of calcium adjuvant was statistically significant (p = 0.001) in reducing fall risk for these patients in the community. Annweiler et al. (2010) study, which assessed the role of vitamin D in fall prevention through non-bone effects further supports the relevance of administering supplements to the elderly population. The study showed a strong correlation between the levels of 25(OH)D and postural adaptations. Vitamin D enhances cognitive function, manly attention, and muscle strength thereby improving postural stability (Annweiler et al. 2010).

A meta-analysis by Murad et al. (2011) involving 26 randomized controlled trials comprising of 45782 elderly patients showed positive effects of vitamin D in reducing risks of falls (Odds Ratio 0.86; 95% CI, 0.77 – 0.96). The odd ratio reported by the meta-analysis was for having at least a single episode of fall. Elderly persons whose serum level of vitamin D was low below 50 nmol/L recorded a notable decline in the risk of falls as opposed to persons who had high baseline vitamin D serum levels (Murad et al., 2011). The review further showed that those in the healthcare facility recorded high levels of compliance with the daily dose of between 600 – 800IU of cholecalciferol as compared to community dwellers. The difference was statistically significant in influencing the results on risk reduction. Therefore, institutionalized patients should be sensitized on the importance of compliance with vitamin D supplements before being discharged home.

As an added advantage, vitamin D can also have some impact on managing osteoarthritis among elderly patients (such as Ms. P). In studies by Park (2019) and Heidari and Babaei (2019), there was a small yet impactful effect of cholecalciferol on reducing knee pain related to arthritis and improving knee function respectively. However, the role of vitamin D in managing arthritis is still unclear and inadequate to authoritatively recommend.

In conclusion, the evidence supports the administration of vitamin D in reducing the risk of falls among elderly persons such as Ms. P. The available evidence indicates that daily or weekly intake of vitamin D in doses of 600IU – 1000IU can help Ms. P in lowering the odds of having fall incidences. Vitamin D administration will help in easing her knee pain, increasing muscle strength, improving her attention, and stabilizing her postural equilibrium. However, the use of vitamin D in falls prevention should not be a solitary approach but should be taken in combination with other strategies. This evidence is critical in future practice by reinforcing my knowledge and confidence in fall prevention. With falls being a major contributor to morbidity and mortality among the elderly persons in Australia, evidence-based interventions can come in handy. Going forward, vitamin D administration should be incorporated with both primary and secondary fall prevention strategies.

Reference

Al-Aam, T. (2011). “Falls in the Elderly Spectrum and Prevention.” Canadian Family Physician, vol.57, no. 7, pp. 771 - 776

Annwiler, C. et al. (2010). “Fall Prevention and Vitamin D in the Elderly: an Overview of the Key Role of the Non-bone Effects.” Journal of NeuroEngineering and Rehabilitation, vol. 7, no. 50, pp. 1 -13

Arthritis Foundation (2020). “Osteoarthritis and Falls: How to Reduce Your Risk.” Arthritis Foundation. Accessed 28 May 2020 from < https://www.arthritis.org/health-wellness/healthy-living/managing-pain/joint-protection/osteoarthritis-and-falls>

Bischoff-Ferrari, H.A., Dawson-Hughes, B., Staehelin, H.B. et al. (2009). “Fall Prevention with Supplemental and Active forms of Vitamin D: A Meta-Analysis of Randomised Controlled Trials.” BMJ (Clinical Research Ed.) vol. 339, no. b3692

Doré AL et al. (2015). “Lower-Extremity Osteoarthritis and the Risk of Falls in a Community-based Longitudinal Study of Adults with and without Osteoarthritis.” Arthritis Care Res (Hoboken), vol. 67, no. 5, pp.633-639.

Heidari, B. & Babaei, M. (2019). “Therapeutic and Preventive Potential of Vitamin D Supplementation in Knee Osteoarthritis.” ACR Open Rheumatology, vol. 1, no. 5. Pp. 318 - 326

Levinger, P., Wallman, S. & Hill, K. (2012) “Balance Dysfunction and Falls in People with Lower Limb Arthritis: Factors Contributing to Risk and Effectiveness of Exercise Interventions.” European Review of Aging and Physical Activity, vol. 9, no. 1, pp. 17–25

Mowe M., Haug, E. & Bohmer, T. (1999). “Low Serum Calcidiol Concentration in Older Adults with Reduced Muscle Function. “Journal of American Geriatric Society, vol. 47, no. 1, pp. 220-226

Murad, M.H. et al. (2011). “The Effects of Vitamin D on Falls: A Systematic Review and Meta-analysis.” The Journal of Endocrinology & Metabolism, vol. 96, no. 10, pp. 2997 - 3006

Park, C.Y. (2019). “Vitamin D in the Prevention and Treatment of Osteoarthritis: From Clinical Interventions to Cellular Evidence.” Nutrients, vol. 11, no.2, pp. 243 - 256

Waldron, N., Hill, A.M. & Barker, A. (2012). “Falls Prevention in Older Adults: Assessment and Management.” Australian Family Physician, vol. 41, no. 12, pp. 930 – 935