Osteoporosis

I. Definition
- A disorder in which bones lose density and become porous and fragile.
- It occurs when the body fails to form enough new bone, when too much old bone is reabsorbed by the body, or
both.
II. Synonym
- Brittle bone disease
III. Types of Osteoporosis
1. Primary Osteoporosis - is associated with the process of normal aging.
2. Secondary Osteoporosis - caused by certain lifestyle factors, diseases, or medications.
IV. Causes
Risk factors:
a. Personal Characteristics:
Gender (Female)
Advance Age
White (Fair, thin skin)
b. Lifestyle:
Diet low in calcium and vitamin D
Cigarette smoking
Use of alcohol and/or caffeine
c. Drug and Disease related:
Aluminum containing antacids
Anticonvulsants
Heparin
Corticosteroids or Cushing s disease
Gastrectomy
Diabetes Mellitus

Estrogen deficiency or menopause

Low weight and body mass index
Family history
Lack of weight-bearing exercise
Lack of exposure to sunshine

Chronic Obstructive lung disease

Malignancy
Hyperthyroidism
Hyperparathyroidism
Rheumatoid Arthritis

 V. Anatomy and Physiology

Spine
The spine or backbone is made of 33 individual bony vertebrae. This spinal column provides the main
support for the body, allowing you to stand upright, bend, and twist, while protecting the spinal cord
from injury.

Functions of the Spine

Protect the spinal cord, nerve roots and several of the bodys internal organs.
Provide structural support and balance to maintain an upright posture.
Enable flexible motion.

Regions of the Spine

Typically, the spine is divided into four main regions: cervical, thoracic, lumbar and sacral. Each
region has specific characteristics and functions.

Cervical Spine
The neck region of the spine is known as the Cervical Spine. This region consists of seven vertebrae,
which are abbreviated C1 through C7 (top to bottom). These vertebrae protect the brain stem and the
spinal cord, support the skull, and allow for a wide range of head movement.
The first cervical vertebra (C1) is called the Atlas. The Atlas is ring-shaped and it supports the skull.
C2 is called the Axis. It is circular in shape with a blunt peg-like structure (called the Odontoid
Process or dens) that projects upward into the ring of the Atlas. Together, the Atlas and Axis enable
the head to rotate and turn. The other cervical vertebrae (C3 through C7) are shaped like boxes with
small spinous processes (finger-like projections) that extend from the back of the vertebrae.

Thoracic Spine
Beneath the last cervical vertebra are the 12 vertebrae of the Thoracic Spine. These are abbreviated T1
through T12 (top to bottom). T1 is the smallest and T12 is the largest thoracic vertebra. The thoracic
vertebrae are larger than the cervical bones and have longer spinous processes.
In addition to longer spinous processes, rib attachments add to the thoracic spines strength. These
structures make the thoracic spine more stable than the cervical or lumbar regions. In addition, the rib
cage and ligament systems limit the thoracic spines range of motion and protect many vital organs.

Lumbar Spine
The Lumbar Spine has 5 vertebrae abbreviated L1 through L5 (largest). The size and shape of each
lumbar vertebra is designed to carry most of the bodys weight. Each structural element of a lumbar
vertebra is bigger, wider and broader than similar components in the cervical and thoracic regions.
The lumbar spine has more range of motion than the thoracic spine, but less than the cervical spine.
The lumbar facet joints allow for significant flexion and extension movement but limit rotation.

Sacral Spine
The Sacrum is located behind the pelvis. Five bones (abbreviated S1 through S5) fused into a
triangular shape, form the sacrum. The sacrum fits between the two hipbones connecting the spine to
the pelvis. The last lumbar vertebra (L5) articulates (moves) with the sacrum.
Immediately below the sacrum are five additional bones, fused together to form the Coccyx (tailbone).

 The Pelvis and the Skull

Although not typically viewed as part of the spine, the pelvis and the skull are anatomic structures that
closely inter-relate with the spine, and have a significant impact on the patients balance.

Spinal Curves
When viewed from the front (Coronal Plane) the healthy spine is straight. (A sideways curve in the
spine is known as scoliosis.) When viewed from the side (Sagittal Plane) the mature spine has four
distinct curves. These curves are described as being either kyphotic or lordotic.
A kyphotic curve is a convex curve in the spine (i.e. convexity towards the back of the spine). The
curves in the thoracic and sacral spine are kyphotic.
A lordotic curve is concave (i.e. concavity towards the back of the spine), and is found in the cervical
and lumbar levels of the spine.

Vertebral Structures
All vertebrae consist of the same basic elements, with the exception of the first two cervical vertebrae.
The outer shell of a vertebra is made of cortical bone. This type of bone is dense, solid and strong.
Inside each vertebra is cancellous bone, which is weaker than cortical bone and consists of loosely knit
structures that look somewhat like a honeycomb. Bone marrow, which forms red blood cells and some
types of white blood cells, is found within the cavities of cancellous bone.
Vertebrae consist of the following common elements:

Veterbral Body
The largest part of a vertebra. If looked at from above it generally has a somewhat oval shape. When
looked at from the side, the vertebral body is shaped like an hourglass, being thicker at the ends and
thinner in the middle. The body is covered with strong cortical bone, with cancellous bone within.

Pedicles
These are two short processes, made of strong cortical bone, that protrude from the back of the
vertebral body.

Laminae
Two relatively flat plates of bone that extend from the pedicles on either side and join in the midline.

Processes
There are three types of processes: articular, transverse and spinous. The processes serve as connection
points for ligaments and tendons.

The 4 articular processes link with the articular processes of adjacent vertebrae to form the facet joints.
The facet joints, combined with the intervertebral discs, allows for motion in the spine.
The spinous process extends posteriorly from the point where the two laminae join, and acts as a lever
to effect motion of the vertebra.

Endplates
The top (superior) and bottom (inferior) of each vertebral body is coated with an endplate. Endplates
are complex structures that blend into the intervertebral disc and help support the disc.

Intervertebral Foramen
The pedicles have a small notch on their upper surface and a deep notch on their bottom surface. When
the vertebrae are stacked on top of each other the pedicle notches form an area called the intervertebral

foramen. This area is of critical importance as the nerve roots exit from the spinal cord through this
area to the rest of the body.

Facet Joints
The joints in the spinal column are located posterior to the vertebral body (on the backside). These
joints help the spine to bend, twist, and extend in different directions. Although these joints enable
movement, they also restrict excessive movement such as hyperextension and hyper-flexion (i.e.
whiplash).
Each vertebra has two facet joints. The superior articular facet faces upward and works like a hinge
with the inferior articular facet (below).
Like other joints in the body, each facet joint is surrounded by a capsule of connective tissue and
produces synovial fluid to nourish and lubricate the joint. The surfaces of the joint are coated with
cartilage that helps each joint to move (articulate) smoothly.

Intervertebral Discs
Between each vertebral body is a "cushion" called an intervertebral disc. Each disc absorbs the stress
and shock the body incurs during movement and prevents the vertebrae from grinding against one
another. The intervertebral discs are the largest structures in the body without a vascular supply.
Through osmosis, each disc absorbs needed nutrients.
Each disc is made up of two parts: the annulus fibrosis and the nucleus pulposus.

Annulus Fibrosus
The annulus is a sturdy tire-like structure that encases a gel-like center, the nucleus pulposus. The
annulus enhances the spines rotational stability and helps to resist compressive stress.
The annulus consists of water and layers of sturdy elastic collagen fibers. The fibers are oriented at
different angles horizontally similar to the construction of a radial tire. Collagen gains its strength from
strong fibrous bundles of protein that are linked together.

Nucleus Pulposus
The center portion of each intervertebral disc is a filled with a gel-like elastic substance. Together with
the annulus fibrosus, the nucleus pulposus transmits stress and weight from vertebra to vertebra.
Like the annulus fibrosus, the nucleus pulposus consists of water, collagen and proteoglycans.
However, the proportion of these substances in the nucleus pulposus is different. The nucleus contains
more water than the annulus.
VI. Pathophysiology

VII. Signs/Symptoms/Complaints

Bone pain or tenderness

Fractures with little or no trauma
Loss of height (as much as 6 inches) over time
Low back pain due to fractures of the spinal bones
Neck pain due to fractures of the spinal bones
Stooped posture or kyphosis, also called a "dowager's hump"

VIII. Laboratory and Diagnostic Test

X-ray

 - These tests will help detect whether any of the bones in the patients spine (vertebrae) have broken or
collapsed due to compression fractures.
Result: Presence of fractures

Bone Mineral Density (BMD) test

Measures how much calcium and other types of minerals are in an area of the bone.
This test helps to detect osteoporosis and predict the risk of bone fractures.
Result:
- T score below -2.5 indicates osteoporosis.
- Normal range: +1 and -1

IX. Medical management

a. Diet
Adequate intake of calcium, Vitamin D and Vitamin K

Calcium and vitamin D decrease the risk of non-vertebral fractures in those with postmenopausal
osteoporosis by approximately 18%. High intake of vitamin D reduces fractures in the elderly. Vitamin
K prevents bone loss and/or fractures in those with postmenopausal osteoporosis.

b. Medication:
Bisphosphonates
- Primary drugs used to both prevent and treat osteoporosis in postmenopausal women.
Calcitonin
- It is a medicine that slows the rate of bone loss and relieves bone pain. It comes as a nasal spray or
injection. The main side effects are nasal irritation from the spray form and nausea from the
injectable form.
Teriparatide (Forteo)
- It is approved for the treatment of postmenopausal women who have severe osteoporosis and are
considered at high risk for fractures.
Raloxifene (Evista)
- It is used for the prevention and treatment of osteoporosis. Raloxifene can reduce the risk of spinal
fractures by almost 50%.

X. Surgical Management

a. Vertebroplasty
- It is a minimally invasive procedure used to reinforce vertebrae with compression fractures, which
are common in patients with osteoporosis. Vertebroplasty involves injecting an acrylic compound
into the collapsed vertebra to stabilize the weakened bone.
b. Kyphoplasty
- It is a minimally invasive procedure that is used to restore the height of the vertebrae and stabilize
weakened bone. Kyphoplasty cannot correct established spine deformities and is used in patients
who have experienced recent fractures (within 24 months).

XI. Identify nursing problems/ Diagnosis

a. Pain related to bone/fracture discomfort

b. Impaired physical mobility related to reduced musculoskeletal stamina.

c. Deficient knowledge about the osteoporotic process and treatment regimen

XII. Nursing Care/ Intervention:

Pain related to bone/fracture discomfort

Elevate and support injured extremity.
Rationale: Promotes venous return, decreases edema, and may reduce pain.
Elevate bed covers and keep linens off toes.
Rationale: Maintains body warmth without discomfort due to pressure of bedclothes on affected
parts.
Encourage client to discuss problems related to injury.
Rationale: Helps alleviate anxiety. Client may feel need to relive the accident experience.
Perform and supervise passive or active ROM exercises.
Rationale: Maintains strength and mobility of unaffected muscles and facilitates resolution of
inflammation in injured tissues.
Provide emotional support and encourage use of stress managements techniquesprogressive
relaxation, deep breathing exercises, and visualization or guided imagery; provide therapeutic touch.
Rationale: Refocuses attention, promotes sense of control, and may enhance coping abilities in the
management of the stress of traumatic injury and pain, which is likely to persist for an extended
period.

Impaired physical mobility related to reduced musculoskeletal stamina.

Assess degree of immobility produced by injury and/or treatment and note clients perception of
immobility.
Rationale: Client may be restricted by self-view or self-perception out of proportion with actual physical
limitations, requiring information and interventions to promote progress toward wellness.
Encourage participation in diversional or recreational activities. Maintain stimulating environment
radio, TV, newspapers, personal possessions, pictures, clock, calendar, and visits from family and
friends.
Rationale: Provides opportunity for release of energy, refocuses attention, enhances clients sense of
self-control and self-worth, and aids in reducing social isolation.
Instruct client in active, or assist with passive, ROM exercises of affected and unaffected extremities.
Rationale: Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility;
and prevent contractures, atrophy, and calcium resorption from disuse.
Assist with and encourage self-care activities such as bathing, shaving, and oral hygiene.
Rationale: Improves muscle strength and circulation, enhances client control in situation, and promotes
self-directed wellness.
Assist with mobility by means of wheelchair, walker, crutches, and/or canes as soon as possible. Instruct
in safe use of mobility aids.
Rationale: Early mobility reduces complications of bedrest, such as phlebitis, and promotes healing and
normalization of organ function. Learning the correct way to use aids is important to maintain optimal
mobility and client safety.
Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after
first bowel movement.
Rationale: In the presence of musculoskeletal injuries, early good feeding is needed as nutrients
required for healing are rapidly depleted. This can have a profound effect on muscle mass, tone, and
strength. Note: Protein foods increase contents in small bowel, resulting in gas formation and
constipation. Therefore, gastrointestinal (GI) function should be fully restored before protein foods are
increased.


Deficient knowledge about the osteoporotic process and treatment regimen
Assess vital signs every 2 hours.

Rationale: To determined if theres any alteration with the normal vital signs.
Determine clients ability to learn.

Rationale: To know the clients level of learning ability.

Assess the level of the clients capabilities and the possibilities of situation.

Rationale: To know clients coping ability towards the situation.

Motivate client by providing information relevant to the situation.
Rationale: To help client acquire relevant information.
Provide active role for client in learning process.
Rationale: May assist with further learning/promote learning at own pace.
Explain purpose of activity restrictions and need for balance between activity/rest.

Rationale: Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of
fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of
cellular perfusion.
Instruct client/ family in disease process, progression, what to expect, and answer all questions honestly.

Rationale: Promotes optimal learning environment when client show willingness to learn. Family
members may assist with helping the client to make informed choices regarding the treatment. Anxiety
or large volumes of instruction may impede comprehension and limit learning.
XIII. Rehabilitation
a. Individualized treatment program
- Its includes exercise, diet modifications and medication, as well as professional support for pain and
depression and peer support.

b. Bracing
- If the patient gets a spinal fracture, the doctor may recommend a back brace for a short period of
time. As the vertebra or vertebrae heal, a brace will support the spine. With the bones weakened
by osteoporosis and by the fracture the back muscles will need extra help to support your body
weight during the healing period.