NURS 504 Week 7 Osteoarthritis Case Study Analysis Example

Osteoarthritis Case Study Analysis: Taking a Retired Letter Carrier With Kidney Disease Off Daily Naproxen Without Taking Away Pain Relief

Case Summary

The patient is a 68-year-old who carried mail on a walking route for thirty years and now has pain in both knees, worse on the right, that limits walking to about ten minutes and makes stairs difficult. Morning stiffness lasts about fifteen minutes. Radiographs show joint space narrowing and osteophytes in both knees. For the past year the patient has taken over-the-counter naproxen 220 mg, two tablets twice a day, every day. The patient also has hypertension, treated with lisinopril 20 mg each morning, and stage 3a kidney disease, with filtration estimated at 55 and urine albumin of 40 mg for each gram of creatinine. Body mass index is 33. Office blood pressure today is 146/88 mm Hg, higher than at the last visit, and potassium is 5.0 mmol/L.

Assessment

This is symptomatic osteoarthritis of both knees with functional limitation. The more urgent finding is medication-related: daily high-dose naproxen in a patient with chronic kidney disease who also takes an ACE inhibitor. Nonsteroidal anti-inflammatory drugs block prostaglandin synthesis, and in the kidney prostaglandins help maintain blood flow; combined with an ACE inhibitor, which lowers pressure within the glomerulus, the NSAID can reduce filtration and cause acute kidney injury, especially if a diuretic is ever added (Burchum & Rosenthal, 2019). NSAIDs also raise blood pressure and potassium, which may explain the rising readings and the high-normal potassium. The KDIGO 2024 guideline advises avoiding prolonged NSAID use in people with chronic kidney disease (Stevens et al., 2024). The patient's pain plan is quietly working against the patient's kidneys and blood pressure, and the first step is to change it.

Treatment Plan

Exercise, Weight and Function First

The 2019 guideline strongly recommends exercise for knee osteoarthritis and weight loss for people who are overweight, and it places these ahead of drugs (Kolasinski et al., 2020). Physical therapy aimed at strengthening the thigh muscles, paired with a walking program that adds a few minutes each week, fits this patient, who values walking. A cane used in the hand opposite the more painful knee reduces load, and a 5% to 10% weight loss can meaningfully reduce knee pain.

Stop Daily Oral Naproxen

The patient should stop taking naproxen every day. Because abrupt loss of pain relief can lead patients to resume the drug on their own, the change should be made together with the substitutions below, and the reason should be explained in terms of the kidneys and blood pressure.

Topical Diclofenac

Diclofenac sodium 1% gel applied to each painful knee four times a day is the main pharmacologic substitute. Topical NSAIDs carry a strong recommendation for the knee in the 2019 guideline, and gels like this one produce far lower blood levels than oral NSAIDs, making them a safer choice for older adults with kidney or cardiovascular risk (Kolasinski et al., 2020). The patient should use the dosing card to measure each dose, avoid applying it to broken skin and wash hands afterward.

Acetaminophen as an Adjunct

Acetaminophen can be added for additional relief, up to 3 grams a day in an older adult, though the guideline recommends it only conditionally because its benefit in osteoarthritis is small (Kolasinski et al., 2020). The patient must count acetaminophen in combination cold and sleep products toward the daily limit.

Intra-Articular Corticosteroid

For a painful flare that limits exercise, an intra-articular corticosteroid injection, which the guideline strongly recommends for the knee, can provide several weeks of relief and help the patient participate in physical therapy (Kolasinski et al., 2020).

Duloxetine if Needed

If pain remains limiting after these measures, duloxetine, a serotonin and norepinephrine reuptake inhibitor that reduces central pain processing, is a conditionally recommended option (Kolasinski et al., 2020). It should start at 30 mg daily, with attention to nausea, dizziness and low sodium in older adults, and its dose should be reviewed if kidney function declines further.

Treatments Not Recommended

The guideline recommends against glucosamine and chondroitin for knee osteoarthritis, against hyaluronic acid injections in most cases, and against opioids other than tramadol, which itself is only conditionally recommended because of dependence, falls and other harms (Kolasinski et al., 2020). For a 68-year-old with kidney disease, avoiding opioids also reduces risks of sedation and falls. Explaining these choices helps the patient resist advertising for supplements and requests for stronger painkillers. It also prepares the patient for conversations with friends and family, who often recommend whatever helped them.

Measuring Pain and Function

Progress should be measured, not guessed. A simple numeric pain scale at rest and with walking, the patient's own walking time and the number of stairs managed without stopping give practical baselines. A validated tool such as the Western Ontario and McMaster Universities Osteoarthritis Index can track pain, stiffness and function over time if the clinic uses it. Writing down the baseline today allows the six-week visit to show whether the new plan works as well as naproxen did, which is the comparison the patient will be making.

Cost and Access

Diclofenac 1% gel is available without a prescription at a modest cost, though large daily use can add up, and some insurance plans cover the prescription form. Physical therapy may require a copay per visit; if cost is a barrier, a few visits to learn a home program, followed by community options such as senior center exercise classes or a walking group, can sustain the benefit.

Looking Ahead

If symptoms remain severe despite a full trial of these measures and imaging shows advanced disease, referral to an orthopedic surgeon to discuss knee replacement is appropriate. The decision belongs to the patient, and good preparation, including weight loss and strength, improves surgical outcomes.

Monitoring

Kidney function, potassium and blood pressure should be rechecked two to four weeks after stopping naproxen; blood pressure may fall enough to reconsider whether more antihypertensive treatment is needed. Pain and function should be reviewed at six to eight weeks, using the patient's walking time and stair use as practical measures. Topical diclofenac can cause local skin irritation; acetaminophen requires attention to alcohol use and liver disease; duloxetine, if started, requires review for nausea, dizziness and drug interactions (Wells et al., 2018).

Patient Education

The patient should understand why naproxen was harmful in this situation and that other over-the-counter NSAIDs, such as ibuprofen, carry the same risk. The patient should learn how to use the gel, the daily acetaminophen limit, the home exercise program and the signs of kidney problems, such as reduced urination or swelling, that require a call. Because pain often improves slowly with exercise, the patient should also hear that the first two or three weeks may feel harder before walking gets easier, and that a day of more soreness after exercise is expected and not a reason to stop.

Teaching Points for Nursing Students

This case teaches students to ask about over-the-counter drugs at every visit, because many patients do not consider them medications. It shows how a common analgesic can interact with a common blood pressure drug to harm the kidneys. And it reminds students that in osteoarthritis the most effective treatments are often exercise and weight management, which nurses can encourage at every encounter, even a brief one.

References

Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care (10th ed.). Elsevier.

Kolasinski, S. L., Neogi, T., Hochberg, M. C., Oatis, C., Guyatt, G., Block, J., Callahan, L., Copenhaver, C., Dodge, C., Felson, D., Gellar, K., Harvey, W. F., Hawker, G., Herzig, E., Kwoh, C. K., Nelson, A. E., Samuels, J., Scanzello, C., White, D., . . . Reston, J. (2020). 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care & Research, 72(2), 149-162. https://doi.org/10.1002/acr.24131

Stevens, P. E., Ahmed, S. B., Carrero, J. J., Foster, B., Francis, A., Hall, R. K., Herrington, W. G., Hill, G., Inker, L. A., Kazancıoğlu, R., Lamb, E., Lin, P., Madero, M., McIntyre, N., Morrow, K., Roberts, G., Sabanayagam, D., Schaeffner, E., Shlipak, M., . . . Levin, A. (2024). KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney International, 105(4S), S117-S314. https://doi.org/10.1016/j.kint.2023.10.018

Wells, B. G., DiPiro, J. T., Schwinghammer, T. L., & DiPiro, C. V. (2018). Pharmacotherapy handbook (10th ed.). McGraw-Hill Education.