Osteoporosis 2

Osteoporosis Notes

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1. OSTEOPOROSIS a. Osteoporosis is a disorder in which there is a reduction of bone density. b. Bones become progressively porous, brittle, and fragile, and they fracture easily, under stress that would normally not break bones c. The rate of bone resorption is >the rate of bone formation d. Who’s at Risk? 1. Postmenopausal women 2. Small-framed, non-obese Caucasian women are at greatest risk (“little white women”) 3. Asian women of slight build are at risk for low peak BMD (bone mineral density) 4. African American women are less susceptible 5. Osteoporosis occurs in men at an older age and a lower rate. e. Frequently results in: 1. compression fractures of thoracic and lumbar spine 2. fractures of neck 3. fractures of intertrochanteric region of femur 4. Colles’ fractures of wrist f. multiple fractures = skeletal deformity!! 2. PATHO a. Normal bone remodeling increases bone mass until the early 30’s. b. The onset of osteoporosis begins when bone mass peaks and then begins to decline. c. Osteoporosis is not a disease of the elderly, although consequences of the disease occur with aging (fractures). d. The following factors influence peak bone mass and the development of osteoporosis: 1. Gender - female 2. Race – white or Asian 3. Genetics – runs in your family 4. Aging 5. Low body weight 6. Nutrition – need a balanced diet w/adequate calories, Ca, Vit D 7. Lifestyle choices – smoking, alcohol, caffeine 8. Physical activity – immobility contributes to osteo - bone formation is enhanced by the stress of weight and muscle activity – resistance and impact activity most beneficial – when immobilized by casts, general inactivity, paralysis, or other disability = bone is reabsorbed faster than it is formed = osteo e. Bone loss is a universal phenomenon associated with aging. Hormone Calcitonin

Action inhibits bone resorption and promotes bone formation

Age Related Changes Decreases

Estrogen

inhibits bone breakdown

Decreases

Parathyroid hormone

increases bone turnover and resorption

Increases

f. Consequence is net loss of bone mass over time. 3. S&S a. may be asymptomatic b. observed as progressive kyphosis – “dowager’s hump” c. loss of height d. can produce pulmonary insufficiency e. fatigue 4. RISK-LOWERING STRATEGIES a. Increase dietary calcium and vitamin D intake 1. fortified milk is the best source of dietary calcium - A cup of milk or calcium fortified orange juice contains about 300 mg calcium. 2. increase Ca intake during adolescence, young adulthood, and middle age to prevent against skeletal demineralization 3. Other Ca – cheese, broccoli, salmon, yogurt, turnip greens, collard greens

Osteoporosis Notes

b. c. d. e. f.

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4. Can take Ca supplements (TUMS, Ca carbonate) 5. Adequate calcium intake: 9 – 19 years of age – 1300 mg/day 19 – 51 years of age – 1000 mg/day >51 years of age – 1200 mg/day 6. Adequate Vitamin D intake 400 – 600 IU/day Stop smoking - Tobacco Quitline Mississippi: 800-244-9100 Moderate consumption of alcohol and caffeine. Regular weight-bearing exercise to promote bone formation (20 – 30 minutes, 3 days/wk or more) Walk out of doors – to get the Vit D from sunlight If taking corticosteroids or anti-seizure meds – need to institute therapies to reverse the development of osteoporosis

5. DX a. b. c. d.

X-rays may identify osteoporosis when there has been a 25% to 40% demineralization. Laboratory studies, including serum calcium and serum phosphate, and radiographs are used to exclude other diagnoses. Quantitative ultrasound (QUS) studies of the heel are used for diagnosis and to predict risk for fracture Dual-energy x-ray absorptiometry (DEXA; DXA) 1. provides information about spine and hip bone mass and bone mineral density (BMD). 2. DEXA data are analyzed and reported by T-Scores 3. compared to the number of standard deviations (SD) above or below the average BMD of a young, healthy, Caucasian female. 4. T-Score: WHO Criteria for Osteoporosis in Women Normal

BMD > -1 SD below the young adult reference range

Low Bone Mass (Osteopenia)

BMD is -1.0 to -2.5 SD below the young adult reference range.

Osteoporosis

BMD <-2.5 SD below the young adult reference range.

Severe Osteoporosis

BMD < -2.5 SD below the young adult reference range and the patient has had one or more fractures

5. Fracture risk increases progressively as the SD of the T-score falls below the mean value. 6. MEDICAL MANAGEMENT a. Adequate, balanced diet rich in calcium and vitamin D b. Increased calcium intake in adolescents and elderly, or prescribe a calcium supplement with meals or beverages high in vitamin C c. Regular weight-bearing exercise to promote bone formation d. Weight training stimulates an increased BMD e. Medications Drug Actions Nursing Implications Hormone Replacement Therapy Estrogen and prog. calcitonin Calcimar selective receptor modulators (SERMs) raloxifene (Evista)

Decreases bone resorption and increases bone mass

Caution patient of risks involved in estrogen use.

inhibits bone resorption

Assess for allergy to salmon or fish products. Give skin test to any patient with history of allergies. Give SC or IM or intranasally. (IM is for large amounts) Administer daily without regard to food. Monitor for possible long-term effects including cancer, thrombosis. Arrange for periodic blood counts.

Estrogen receptor modulator. Increases bone mineral density without stimulating endometrium in women. Indicated both for prevention and treatment of osteoporosis. Biphosphonates Slows normal and abnormal alendronate bone resorption without (Fosamax) inhibiting bone formation and risedronate (Actonel) mineralization. f. Alendronate – is a good alternative to HRT

Give in AM with full glass, at least 30 min before any beverage, food, or medication and stay upright for 30 minutes - can cause reflux.

Osteoporosis Notes

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g. Can’t take Vit D & Ca supplements at same time of take as Biphosphonates (Fosamax, Actonel) 7. FRACTURE MANAGEMENT a. Hip Fractures 1. Managed surgically by a. joint replacement b. closed or open reduction with internal fixation 2. Surgery, early ambulation, physical therapy, and adequate nutrition decrease morbidity and improve outcomes. 3. Evaluate client with hip fracture for osteoporosis and treat if indicated. b. Compression Fractures of Vertebra 1. Manage conservatively 2. Additional fractures and progressive kyphosis are common 3. Medication and diet regimens aim to increase vertebral bone density 4. Percutaneous vertebroplasty kyphoplasty is reported to provide rapid acute pain relief and improved quality of life – injection of bone cement into fractured vertebra 8. NURSING PROCESS a. Assessment 1. Health promotion is aimed at identifying risk for and recognition of problems associated with osteoporosis. 2. Interview patient regarding a. family history, b. previous fractures, c. intake of calcium, alcohol, caffeine, cigarettes d. exercise patterns e. onset of menopause f. use of Steroids g. symptoms such as pain, constipation, altered body image b. On Physical Exam observe for fracture, kyphosis of the thoracic spine, or shortened stature. c. Mobility and breathing problems may exist as a result of posture and muscle changes. 9. NSG DX Pain related to physiologic changes, fractures Injury, risk for r/t lack of awareness of environmental hazards Knowledge deficit r/t lack of exposure Social isolation r/t altered state of wellness Denial r/t fear and anxiety of aging Activity Intolerance r/t hip fracture 10. NURSING INTERVENTIONS a. Explain Osteoporosis and Treatment Regimen 1. teach interventions to arrest or slow process 2. measure to relieve symptoms 3. adequate diet 4. supplement Ca & Vit D 5. exercise – weight bearing 6. modify lifestyle – smoking, alcohol, caffeine 7. sunshine 8. Medication teaching a Ca supplements s/e – GI upset, abdominal distention – take w/meals 9. ↑ fluids to reduce RF renal calculi 10. HRT - pt will need periodic breast and endometrial cancer screening 11. Alendronate – requires compliance a. take on empty stomach w/water b. no foods or liquids for 30-60 min c. stay upright for 30-60 min 12. Calcitonin nasal spray – alternate nares daily b. Relieve Pain - Back pain 1. a. rest in bed in supine or side-lying position several times a day 2. firm mattress – non-sagging 3. knee-flexion 4. intermittent local heat and back rubs

Osteoporosis Notes 5. move trunk as a unit – no twisting 6. good posture 7. may wear a lumbar corset when out of bed for temporary support c. Improve Bowel Elimination 1. ↑fiber diet 2. increase fluids 3 stool softeners 4. if vertebral collapse involves the T10-L2 vertebrae – may develop ileus a. monitor intake b. bowel sounds c. bowel activity d. Prevent Injury 1. isometric exercises to strengthen trunk muscles 2. walking 3. good body mechanics 4. good posture 5. daily weight-bearing activity - preferably outdoors to get Vit D 6. NO sudden bending, jarring, strenuous lifting 7. Look at environment – especially w/elderly – RF falls

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