Renfrow

Brunner: 2057-2062, 1627-1628, 1990-1996

Handbook: 567, 576

OSTEOPOROSIS

 Metabolic bone disorder in which there is a reduction of bone density

(demineralization of bone)
 Bones become progressively porous, brittle, and fragile.
 They fracture easily under stress that would normally not break them.
 Rate of bone resorption is greater than the rate of bone formation.

Who’s at Risk?
 Postmenopausal women
 Women over age 35
 Small-framed, non-obese Caucasian women
 Asian women of slight build

End Results
 Compression fractures of thoracic and lumbar spine
 Fractures of neck
 Fractures of intertrochanteric region of femur
 Colles’ fractures of wrist
 Multiple fractures can cause skeletal deformity.

Causative Factors
 Female
 White or Asian
 Hereditary
 Aging – withdrawal of estrogen at menopause
 Low body weight
 Diet with insufficient calories, Ca+, vitamin D
 Lifestyle choices  smoking, alcohol, caffeine, soft drinks (high in phosphorus)
 Immobility
 Lack of weight-bearing exercise
 Meds  corticosteroids (asthma patients), heparin, antiseizure meds, thyroid hormone
 GI surgery
 Endocrine disorders
 Stress

Hormone Action Age-Related Changes

Calcitonin Inhibits bone resorption & promotes bone formation Decreases

Estrogen Inhibits bone breakdown Decreases
Parathyroid hormone Increases bone turnover & resorption Increases

Coexisting Medical Conditions

 Malabsorption syndromes  lactose intolerance
 Alcohol abuse
 Liver failure
 Renal failure
 Cushing’s syndrome
 Hyperthyroidism
 Hyperparathyroidism
 Anorexia nervosa
Clinical Manifestations
 May be asymptomatic
 Observed as progressive dorsal kyphosis  Dowager’s hump 1st sign  gradual collapse of
vertebrae
 Cervical lordosis
 Loss of height
 Pulmonary insufficiency  SOB, dyspnea
 Fatigue

Diagnostics
 Shown on X-rays if 25%-40% demineralization
 Quantitative ultrasound (QUS) studies of the heel are used for Dx and to predict risk of hip and
nonvertebral fracture.
 Serum Ca+, serum PO4, serum alkaline phosphatase
 Urine Ca+ excretion, urinary hydroxyproline excretion, Hct, erythrocyte sedimentation rate
 Dual-energy x-ray absorptiometry (DEXA)
- Provides info about BMD at spine and hip
- Analyzed and reported as T-scores

WHO Criteria for Osteoporosis in Women

Normal BMD < 1 SD below the young adult mean value

Low Bone Mass

BMD 1.0 to 2.5 SD below the young adult mean value
(Osteopenia)
Osteoporosis BMD at least 2.5 SD below the young adult mean value

Severe Osteoporosis BMD > 2.5 SD below the young adult mean value with Hx of 1 or more fractures

Goals
 Decrease bone resorption
 Maintain bone
 Prevent fractures

Management
 Increase Ca+ & vitamin D intake 
- Ca+ 1200-1500 mg if > 51 y.o.
- Vitamin D 400-600 IU/day
- 1 cup milk  300 mg Ca+
- 1 cup yogurt  400 mg Ca+
- Cheese
- Broccoli
- Salmon
- Green, leafy veggies  turnip greens, collard greens, spinach
- TUMS, calcium carbonate, calcium citrate
 Weight-bearing exercise at least 20-30 minutes 3 days a week
 Meds
Drug Actions Nursing Implications
Hormone
Replacement Therapy Decreases bone resorption and
Teach risks involved in estrogen use.
(Estrogen & increases bone mass
Progesterone)
Assess for allergy to salmon or fish products.
Give skin test to any patient with history of
Calcitonin, Calcimar Inhibits osteoclast function allergies.
Give SC, IM, or intranasally.
Watch for nosebleeds.
Preserves bone mineral density Administer daily without regard to food.
Selective Receptor
without estrogenic effects on the Monitor for possible long-term effects
Modulators (SERMs)
uterus. Used for prevention and including cancer, thrombosis.
 Raloxifene (Evista)
treatment. Arrange for periodic blood counts.
Give in a.m. with full glass of water, at least
Biphosphonates  30 minutes before any beverage, food, or
alendronate medications.
(Fosamax), Inhibits osteoclast function Do not take Ca+/vitamin D supplements at
Risedronate (Actonel), same time of day as biphosphonates.
calcitonin Stay upright for 30 minutes.
Can cause esophagitis.

Ibandronate (Boniva)

Pain Relief
 Compression fracture  Lie in supine or side-lying position several times a day.
 Firm, nonsagging mattress
 Knee flexion  relaxes back muscles
 Intermittent local heat
 Back rubs
 Move trunk as a unit.
 Avoid twisting.
 Proper body mechanics
 Good posture

Preventing Injuries
 Avoid sudden bending, jarring, and strenuous lifting
 Isometric exercises to strengthen trunk muscles
 Physical activity
 Walking
 Daily weight-bearing activity

Nursing Dx
 Chronic pain r/t decreased bone mass and/or fractures
 Acute pain r/t fracture and muscle spasm
 Risk for constipation r/t immobility or development of ileus (intestinal obstruction)
 Risk for injury r/t lack of awareness of environmental hazards
 Knowledge deficit r/t disease process and treatment regimen
 Activity intolerance r/t fracture and altered mobility
 Altered nutrition r/t inadequate Ca+ & vitamin D intake
 Altered mobility r/t decreased bone mass and possible fractures
 Disturbed body image r/t body changes

** For every ounce of protein you take in over 4 jounces, you need an extra 100 mg of Ca+ to stay even.

OSTEOARTHRITIS

 AKA degenerative joint (rheumatic) disease (DJD)

 A common disabling joint disorder
 Commonly called arthritis – inflammation of joint

Risk Factors
 Increased age
 Obesity
 Previous joint damage
 Repetitive use
 Anatomic deformity
 Genetic susceptibility
 Congenital diseases  Legg-Calve-Perthes…
 Gout

Clinical Manifestations
 Pain
 Stiffness
 Functional impairment
 Change in alignment of joints
 Heberden’s nodes  bony proliferations over distal interphalangeal joints
 Bouchard’s nodes  bony knobs over proximal interphalangeal joints (PIP)

Diagnostics
 Physical assessment
 Location and pattern of pain
 X-rays  looking for narrowing of joint spaces/osteophytes (spurs)
 Labs  ESR, RH…

Goals of Therapeutic Management

 Decrease joint pain and stiffness
 Improve joint mobility and stability
 Increase ability to perform ADLs
 Optimize functional ability

Medical Management
 Weight loss
 Injury prevention
 Ergonomic modifications
 Heat/cold application
 Rest joint when inflamed
 Supportive devices for joints
 Exercise  isometric, postural, aerobic
 OT/PT
  Drug therapy
- Acetaminophen (Tylenol)
- Salicylates (Aspirin)
- NSAIDs  Take with food.
- Celebrex (Cox-2 inhibitor)  GI bleeding  Know if patient has cardiac or BP problems.
- Opiates
- Corticosteroids
- Glucosamine/Chondroitin
- Hyaluronic acid (Synvisc)
- Topical analgesics (Capsaicin, methylsalicylate)

Surgical Management

Osteotomy
 To alter the force distribution in the joint

Arthroplasty
 Diseased joint components are replaced with artificial products

Viscosupplementation
 The reconstitution of synovial fluid viscosity
 Hyaluronic acid (Synvisc) acts as a lubricant and shock-absorbing fluid in the joint
 Series of 3-5 weekly intra-articular injections
 Provides pain relief for up to 6 months

Tidal Irrigation
 Large volume of saline is flushed through cannulas in the knee
 Provides pain relief for up to 6 months

Joint Protection
 Correct body mechanics
 Avoid grasping actions that strain finger joints.
 Spread weight of an object over several joints.
 Maintain good posture.
 Use strongest muscles to pick up things.

Nursing Dx
 Chronic pain r/t joint degeneration
 Impaired physical mobility r/t restricted joint mobility
 Body image disturbance r/t visible body changes
 Self-care deficit r/t immobility
 Knowledge deficit
 Ineffective individual/family coping or compromise
 DEGENERATIVE DISK DISEASE

 Most back problems are related to disk disease.

 The intervertebral disk is a cartilaginous plate that forms a cushion between the vertebral
bodies.
 This tough fibrous material is incorporated in a capsule.
 Nucleus pulposus  ball-like cushion in the center of the disk
 Each disk has a soft center surrounded by tough, fibrous outer rings.
 Healthy disks are elastic and springy, absorbing pressure, which allows the vertebrae to move.
 In herniation of the disk, the nucleus of the disk protrudes into the annulus (fibrous ring around
the disk), resulting in subsequent NERVE COMPRESSION.
 Healthy spine protects spinal cord and supports the body while allowing it to bend, sit, twist,
turn, and lift freely and comfortably.
 Herniated disk may occur in any portion of vertebrae:
- Cervical  pain in shoulder, arm, outer side of little finger
- Thoracic  pain in trunk  rare
- Lumbar  pain in lower back, leg, buttocks
 7 cervical, 12 thoracic, 5 lumbar

Causes
 Injury
 Natural aging process
 Premature aging due to misuse (not protecting back the way you should)
 Certain spinal problems

Clinical Manifestations
 Pain
 Stiffness
 Tingling/numbness
 Muscle spasms

 Manifestations are dependent upon:

- Location
- Rate of development
- Effect on surrounding tissue structures

Diagnostics
 Neurological examination
 X-ray
 MRI  most accurate  shows soft tissue damage
 EMG  shock you to determine if nerve root is involved
 CT
 Myelography

Management
 Bedrest
 Medication
- Analgesics
- Muscle relaxants
- NSAIDs
 PT
 Immobilization devices
- Cervical collar for support
- Traction
 - Lumbar braces

Surgical Procedures
 Goal is to reduce the pressure on the nerve root to relieve pain and reverse neurologic deficits.
 Surgical excision of a herniated disk is performed when there is evidence of a progressing
neurologic deficit (muscle weakness and atrophy, loss of sensory and motor function, loss of
sphincter control), and continuing pain and sciatica (leg pain resulting from sciatic nerve
involvement) that are unresponsive to conservative management.

Discectomy
 Removal of herniated or extruded fragments of intervertebral disk

Laminectomy
 Removal of entire laminae
 Helps release pressure when disk is bulging

Laminotomy
 Division of the laminae of the vertebrae
 Removes a portion of the laminae

Discectomy with Fusion

 Bone graft used to fuse vertebral spinous process
 Bridges over defective disk to stabilize spine and decrease rate of
recurrence

Post-Op Teaching/Plan of Care

Cervical
 May be kept flat in bed for 12-24 hours
 Monitor for hematoma/swelling that could affect airway.
 Assess site & mouth for bleeding.
 Positioning
 LOC
 VS
 Neuro checks
 Make sure can move arms and feel touch
 Pain relief
 TCDB
 Cervical collar (6 weeks)
 JP drain
 Gag reflex
 Throat lozenges for sore throat/hoarseness, due to temporary edema
 Listen to voice and watch for changes.
 Pureed diet if experiencing dysphagia
 Check dressing for serosanguineous drainage  If present, meningitis is a threat.
 Log roll with 2-3 people.
 Avoid sitting or standing > 30 minutes.
 Keep head in neutral position.  No pillows or prone position
 Wear low-heeled shoes.
 Wash neck twice a day with mild soap.
 Report to MD:
- Serosanguineous drainage
- Severe localized pain not relieved by analgesics
- Change in neurological status (motor or sensory function)  suggests
hematoma formation
 Lumbar
 LOC
 VS
 Assess for hemorrhage
 Strength/sensation/pulses/movement in extremities
 Output/ability to void/urinary retention
 Bed rest for 1-2 days on a firm mattress
 Pillow between legs when lying on side
 Pillow under head and knee rest elevated to relax back muscles
 Avoid extreme knee flexion when lying on one side.
 Logroll with pillow between the legs
 Ambulation to bathroom same day as surgery
 Avoid sitting except for defecation.
 Avoid heavy work 2-3 months.

Nursing Dx
 Pain r/t surgery
 Knowledge deficit r/t surgical repair
 Recurrent pain
 Return of pain post-op
 Impaired mobility
 Infection
 CP: Hemorrhage