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Osteoporosis Notes 1 of 4

OSTEOPOROSIS

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 Action Age Related Changes


Calcitonin inhibits bone resorption and promotes bone formation Decreases
Estrogen inhibits bone breakdown Decreases
Parathyroid increases bone turnover and resorption Increases
hormone

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
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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
b. Stop smoking - Tobacco Quitline Mississippi: 800-244-9100
c. Moderate consumption of alcohol and caffeine.
d. Regular weight-bearing exercise to promote bone formation (20 – 30 minutes, 3 days/wk or more)
e. Walk out of doors – to get the Vit D from sunlight
f. If taking corticosteroids or anti-seizure meds – need to institute therapies to reverse the development of osteoporosis

5. DX
a. X-rays may identify osteoporosis when there has been a 25% to 40% demineralization.
b. Laboratory studies, including serum calcium and serum phosphate, and radiographs are used to exclude other diagnoses.
c. Quantitative ultrasound (QUS) studies of the heel are used for diagnosis and to predict risk for fracture
d. 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 BMD is -1.0 to -2.5 SD below the young adult reference range.
(Osteopenia)
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 Decreases bone resorption and Caution patient of risks involved in estrogen use.
Replacement Therapy increases bone mass
Estrogen and prog.
calcitonin inhibits bone resorption Assess for allergy to salmon or fish products. Give
Calcimar skin test to any patient with history of allergies.
Give SC or IM or intranasally. (IM is for large
amounts)
selective receptor Estrogen receptor modulator. Administer daily without regard to food.
modulators (SERMs) Increases bone mineral density Monitor for possible long-term effects including
raloxifene (Evista) without stimulating cancer, thrombosis.
endometrium in women. Arrange for periodic blood counts.
Indicated both for prevention
and treatment of osteoporosis.
Biphosphonates Slows normal and abnormal Give in AM with full glass, at least 30 min before
alendronate bone resorption without any beverage, food, or medication and stay upright
(Fosamax) inhibiting bone formation and for 30 minutes - can cause reflux.
risedronate (Actonel) mineralization.
f. Alendronate – is a good alternative to HRT
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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
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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