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Osteoporosis

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Cassandra Diaz

on 7 November 2013

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Transcript of Osteoporosis

Osteoporosis
Risk Factors
Females> Males
Caucasian and Asian decent
Thin, small frame
Family History
Increased age
Post Menopause
Medications
Calcium Deficiency
Sedentary Lifestyle
Excessive consumption of caffeine or alcohol.
Cigarette smoking
Increased propensity for falling:
Dementia
Poor vision
Recent falls


Assessment
A complete health history including assessment of risk factors is pertinent in the prevention, early detection and treatment of osteoporosis.
There is an increased risk for fractures related to falls.
Remember to include a fall risk assessment in the heath history. This is especially important in elderly clients.
The Joint Commission’s National Patient Safety Goals (NPSG) specify the need to reduce risk for harm to patients resulting from falls

Medication
There are two categories of osteoporosis medication:
Antiresorptive medication
They slow the bone loss that occurs in the breakdown part of the remodeling cycle. When people first start taking these medicines, they stop losing bone as quickly as before, but still make new bone at the same pace. Therefore, bone density may increase. The goal of treatment with antiresorptive medicines is to prevent bone loss and lower the risk of breaking bones.
Anabolic medication
They increase the rate of bone formation. This is currently the only osteoporosis medicine approved by the FDA that rebuilds bone. The goal of treatment is to build bone and lower the risk of breaking bones.

Nursing Diagnosis
Acute/ Chronic Pain
Risk for Injury
Activity Intolerance
Imbalanced Nutrition: Less than body requirements
Disturbed Body Image
Impaired Physical Mobility
Knowledge Deficient
Anxiety
Readiness for Enhanced Nutrition

WHAT IS OSTEOPOROSIS?
Osteoporosis is a disease of the bones
It happens when you:
Lose too much bone
Make too little bone
Leads to fragile and thinner bones and subsequent risk of fractures


Atiya Latmore

Cassandra Diaz
Kathleen Fanelli
Pathophysiology
Osteoporosis means “porous bone.”
Under a microscope, bone usually looks like a honeycomb
With osteoporosis, the holes and spaces in the honeycomb are much bigger than they are in healthy bone.
lost density or mass causing structure of bone tissue to be abnormal
Less dense = weaker bones = they are more likely to break/fracture

ETIOLOGY
Primary Osteoporosis
Unknown origin but linked to aging and menopause
Most often occurs in post-menopausal women & men with low testosterone levels
Risk factors
Decrease calcium intake
Deficient estrogen
Sedentary lifestyle


By: Karina Bowen
EPIDEMIOLOGY
9 million Americans have Osteoporosis
48 million have low bone density
So, 60% of adults age 50 and older are at risk of breaking a bone and should be concerned about their bone health.
1 in 2 women and 1 in 4 men age 50 and older will break a bone due to osteoporosis.

Secondary Osteoporosis
Is directly caused by something else
Prolonged therapy of
Corticosteroids
Thyroid-reducing medications
Aluminum containing antacids
Anticonvulsants
Associated with:
Immobility
Alcoholism
Malnutrition/malabsorption

Osteoporosis affects women>men:

Signs & Symptoms
Asymptomatic
Back/pelvic/hip pain during weight bearing activities
Decrease in height
Fractures that occur more easily than expected
Restriction in movement
Kyphosis (stooped posture)

Physical Assessment
Inspect and palpate vertebral column
Assess for kyphosis or “dowager’s hump” of dorsal spine
Use gentle palpation for lower thoracic and lumbar vertebrae (T8-L3)
Assess level, quality and location of pain
Observe for signs & symptoms of fractures, swelling and malalignment
Assess common sites for fractures:
Distal end of radius (wrist), and hip
Assess height and weight. Compare to previous measurements if available
It is common for the client to report a loss of 2-3” within the previous 20 years

Laboratory Assessment
There is no definitive lab tests used to confirm the diagnosis of osteoporosis
Several tests can however, provide information about bone resorption. Increased levels can indicate a risk for osteoporosis
Bone-Specific Alkaline Phosphate (BSAP)
Osteocalcin
Pyridinium (PYD)
N-teleopeptide (NTX) and C-teleopeptide (CTX)
24-hour urine collection
Urinary calcium levels and serum protein

Imaging Assessment
Conventional x-rays can indicate fractures and decreased bone density of the spine and long bones (only after 25-40% bone loss has occurred)
The most commonly used screening and diagnostic tool to measure bone mineral density (BMD) is the dual x-ray absorptiometry (DXA). This is used for the spine and hip.
The peripheral DXA (pDXA) assesses the BMD of the heel, forearm and fingers. It’s typically used for community health screenings.
Quantitative computed tomography (QCT) is sensitive to changes in the vertebral column. It is more expensive, and exposes pt. to more radiation.
Peripheral quantitative ultrasound (pQUS) detects osteoporosis and predict risks for hip fractures commonly in the heel, tibia, and patella. No radiation, effective and low-cost.

Psychosocial Assessment
Osteoporosis can be associated with menopause, old age and decreased independence.
Assess for anxiety and fear related to increased risk for fractures from falls
Limitations of physical activities
Assess patients concept of body image disturbance.
Physical limitations and change in appearance may alter social interactions
Poor self-esteem may result from sexuality changes
Ask clients their thoughts about deformities and disabilities
Ask client about concerns regarding quality of life
What are your feelings about pain, insomnia, and depression?

Interventions
Nursing interventions for patients with osteoporosis include
Nutritional therapy:
Fruits and vegetables
Low-fat dairy products
Increased fiber and protein
Adequate amounts of vitamin D, C, iron, magnesium and calcium
Avoid caffeine and alcohol

Exercise and Lifestyle Changes:

Plays a role in pain management, cardiovascular function, and improved sense of well-being
Active and passive ROM exercises improve joint mobility and increase muscle tone
Avoid high impact recreational activities; may cause vertebral compression fractures
Avoid tobacco in all forms
Have a hazard-free environment (scatter rugs, wet floors, etc.)

Prevention
Complications
Severe chronic pain – especially in the neck and lower back
Depression R/T Impaired Mobility
Kyphosis (Dowager’s Hump)
Vertebrae can break or collapse and cause a hunched back
Lose some height

Staying active/ Building bone strength in younger years is the best defense against osteoporosis later in life.
Combine strength training with weight bearing activities (ex: regularly scheduled walks)
Adequate intake of Calcium and Vit D (especially before age 35)
Avoid excessive caffeine, alcohol consumption and cigarette smoking.

Fractured bones R/T a minor fall
Broken bones
This mostly occurs in the hip, spine and wrist
If surgery is needed, that warrents its own post-operative complications - especially in the older adult

Other agents
Parathyroid hormone: teriparatide (Forteo)
Thyroid hormone: Calcitonin

Estrogen Agonist/ Antagonists
A class of drugs designed to mimic estrogen in some parts of the body while blocking its effects elsewhere
Raloxifene (Evista)- only approved drug in this class for the treatment and prevention of osteoporosis in post menopausal women.
It increases bone mineral density (BMD), reduces bone resportion, and reduces the incidence of vertebral fractures.
Contraindicated for women with a history of thromboembolism
Drug Therapy
Calcium and Vitamin D supplements
Bisphosphonates (BP’s)- most common drug used for osteoporosis
It slows bone resorption.
Associated with esophagitis when tablets aren’t swallowed completely
Three FDA-approved BP’s for the prevention and treatment of osteoporosis are: alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel)

Bone Remodeling
Bone is living, growing tissue that constantly forms new bone while replacing older bone. Bone continuously renews and changes through a process called remodeling. The bone remodeling cycle consists of two distinct stages: bone resorption and bone formation. During resorption, special cells (osteoclasts) on the bone's surface dissolve bone tissue and create small cavities. During formation, other cells (osteoblasts) fill the cavities with new bone tissue.
Fosamax (Alendronate)
Fosamax is approved for the prevention and treatment of osteoporosis in postmenopausal women and for the treatment of osteoporosis in men. It also is approved for the treatment of glucocorticoid-induced osteoporosis in men and women as a result of long-term use of steroid medicines.
Fosamax reduces bone loss, increases bone density and reduces the risk of spine, hip and other broken bones by about 50 percent over two to four years.
Side Effects: Side effects of Fosamax may include bone, joint or muscle pain. Side effects of the oral tablets may include nausea, difficulty swallowing, heartburn, irritation of the esophagus and gastric ulcer.
Past experience with Fosamax suggests that upon discontinuation of any of these drugs, the benefits may continue for several years or longer. This is because the drugs remain in the bone for a long time. Eventually, however, the beneficial effect begins to lessen, bone remodeling rates increase and bone loss may occur.
When you take an osteoporosis medicine, you will not feel your bones getting stronger. This can make it hard to stay on a treatment plan. But it’s important that you take your medicine if you want it to work. You should take it just as your healthcare provider prescribed it, and you must remember to continue to take it. You also need to exercise regularly and get enough calcium and vitamin D.
Six weeks after starting the medication, Kat leaves a message for the nurse that she is experiencing increasingly, frequent and severe heartburn.
What action should the nurse take?
A) Advise Kat to go to the emergency department immediately
B) Ask Kat to describe her method of Fosamax administration
C) Instruct Kat to use an antacid PRN 2 hrs after her Flosamax dose
D) Reassure Kat that heartburn is a common side effect of Fosamax.
B. After taking a dose of Fosamax, the client must remain upright position for 30 minutes to prevent esophageal irritation and erosion
Kat tells the nurse that she played a lot of sports as a child and teenager. She states, "I guess I just put too much stress on my bones over the years.'
How should the nurse respond?
A) Excessive wear and tear during the growth years can weaken your bones as a adult
B) Being active in sports only increases the risk for osteoporosis if your bones break a lot
C) Brittle bones are primarily inherited and are not often affected by your level of activity
D) Participating in sports activities often helps the bones become stronger and denser
D. Building maximal bone mass as a child and adolescent is very important to reduce the risk of osteoporosis as an adult. Physical activity, along with adequate nutrient intake, is essential to strengthen bone density.
Which aspect of her medication history is most likely to impact Kat's risk for osteoporosis?
A) Discontinued use of estrogen therapy 4 yrs ago, 8 yrs after a hysterectomy.
B) Took an antidepressant for 6 months immediately following her husband's death
C) Began treatment for hyperlipidemia with lipitor 6 months ago
D) Has occasionally taken motrin for lower back pain for the last 2 yrs
A. Estrogen deficiency contributes to the onset of osteoporosis by causing an increase in osteoclastic activity, resulting in bone breakdown which occurs faster than bone formation (osteoblastic activity)
The nurse calls to schedule Kat's appointment for dual energy x-ray absorptiometry of the hip and spine. An appointment is available in 30 mins. The next available appointment is in 3 weeks.
Which action should the nurse implement?
A) Advise the client that an immediate appointment will not allow adequate time to maintain NPO status before the test
B) provide the client with the available choices of appointment times and allow the client to select the desired appointment
C) Schedule the client for the immediate appointment so that emergency treatment can be started, based on the test results
D) Instruct the client that it may be desired to have a family member available following the test to drive her home
B. The nurse should promote client autonomy by offering the client safe, reasonable choices. Since no special preparation is needed prior to the test, the client may choose to have the test completed immediately.
Kat states, "I guess I am not having any symptoms because I don't have osteoporosis yet"
How should the nurse respond?
A) Both terms mean the same thing, so you do have osteoporosis
B) Many persons with osteoporosis do not have symptoms
C) Weakness and fatigue often increases as the condition worsens
D) Your are fortunate that you are not having any symptoms yet
B. Osteoporosis is often first detected following a fracture, since there are frequently no symptoms associated with osteoporosis
In addition to evaluate for the presence of subjective symptoms, what assessment technique should the nurse include in the ongoing assessment of Kat's bone density?
A) Record her grip strength
B) Perform an Allen's test
C) Observe her feet and toes
D) Measure her height
D. Persons with osteoporosis often loose height over time as the vertebrae are compressed
Kat tells the nurse that she loves to hike and walks 2 miles every weekend to stay in shape.
How should the nurse respond?
A) It sounds as if your long walks provide plenty of weight-bearing exercise
B) It is important to increase the frequency of your walks to at least 5 times per week.
C) Walking more than a mile at one time is likely to increase your risk for another fracture
D) The best way to increase your bone strength is by lengthening your weekly walk by another mile
B. Regular exercise, 5 times per week for 30-60 min, provides the best protection against further loss of bone mass. In addition, regular exercise improved muscle strength and coordination, reducing the client's risk for falls
Which medication is most likely to have contributed to the decrease in Kat's bone density?
A) Lomotil, an antidirrheal, taken prior to the acute exacerbation for occasional episodes of diarrhea
B) Azulfidine, an antiinflammatory sulfonamide, administered during the acute exacerbation
C) Prednisone, a corticosteroid, taken during the acute exacerbation and for several months following
D) Pro-Banthine, an anticholinergic, adminstered during the acute exacerbation
C.

Glucocorticoids taken over a prolonged time period, are the most common class of medications associated with osteoporosis
The nurse instructs Kat to select a specific day of the week when she can take the medication first thing in the morning. Kat states, "Is that really necessary? I'm not much of a morning person."
How should the nurse respond?
A) The medication is much better absorbed when taken on an empty stomach
B) Increased nausea often occurs when the medication is taken late in the day
C) You may prefer to take the medication with a specific meal once a week
D) It is important to have a weekly routine so you won't forget to take the medication
A. Fosamax should be taken on an empty stomach with a full glass of water to promote the best absorption
The nurses also discusses the adverse effects of the medication. The nurse stresses the importance of reporting which problem?
A) Headache
B) Dyspepsia
C) Rhinitis
D) Bone pain
D. The client should be instructed to report bone pain and unexplained leg cramps, which may be indications of altered serum calcium levels
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