Musculoskeletal Problems

Osteomyelitis​-
● Staph. Aureus is the most common
● Indirect entry ​(hematogenous) -​Injury that spreads from
blood to bone​. (​ why vascular bones are the main sites) ​Only 20%
of all cases. Usually associated with infection of 1
microorganism.
○ Most often ​growing bones in boys 12 or
younger.
○ Blunt force trauma
○ Adults w/ ​GI and Respiratory Infection, and/or
Vascular Insufficiency​ ( Diabetes) are at high risk
for primary infection via blood to bone.
○ Highly vascular bones → ​pelvis, vertebrae,
tibia ​= most common sites for adults.
■ Other risk factors in adults are older age,
debilitation, hemodialysis, sickle cell
disease, and IV drug use.
● Direct entry​- It can occur​ w/ an open wound. ​Occurs at
any age but most often adults
○ Penetrating wounds, fractures, surgery , a foreign body
■ implant or an orthopedic prosthetic device (e.g., plate, total joint prosthesis).
○ Feet of patients with diabetes or vascular disease–related ulcers or in the hips or sacrum near a pressure
injury.

● After gaining entry into the blood → microorganisms grow → bones are non-expanding → ⬆ pressure → to
ischemia and vascular compromise of the periosteum.
○ Once ischemia occurs, the bone dies
○ The part of the periosteum that continues to have a blood supply forms new bone called​ involucrum
● The infection spreads through the bone cortex and marrow cavity → ultimately resulting in cortical
devascularization and necrosis..
○ The area of devitalized bone eventually ​separates from the surrounding living bone​, forming ​sequestra.
■ A sequestrum is a piece of devitalised bone that has been
separated from its surrounding bone during the process
of necrosis.In some instances the sequestrum becomes
encased in a thick sheath of periosteal new bone, known
as an involucrum.
○ It is difficult for blood-borne antibiotics or white blood cells
(WBCs) to reach the sequestrum.
○ A sequestrum may become a reservoir for microorganisms that
spread to other sites, including the lungs and brain.
○ If the sequestrum does not resolve on its own or is debrided
surgically, a sinus tract may develop, resulting in chronic, purulent
cutaneous drainage.
Risk Factors
● Immunocompromised
● Diabetics,Vascular Insufficiency
● Those with Orthopedic Prosthetic devices

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● Boys

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Teach patients at risk local and systemic s/s .
Encourage pt to immediately tell HCP about any bone pain, fever, swelling or restricted movement.
DX STUDIES
● Bone or soft tissue biopsy- ​definitive​ to determine the causative microorganism.
● Blood and wound cultures
○ should be done if possible before initiating drug therapy.
● Elevated​ WBC count and erythrocyte sedimentation rate (ESR)
○ Elevated ESR- usually in ​chronic​ infections
○ Elevated C-reactive protein in ​acute​ infections
● X-ray signs
○ Do not appear until 10 days to weeks after the initial clinical symptoms
■ Not good if found because this means the disease has progressed.
● Radionuclide bone scans (gallium and indium)- usually positive in the area of infection.
● CT scans -help identify the extent of the infection
● MRI- more sensitive than CT in detecting bone marrow edema (early indicator of OM​)

Acute osteomyelitis​ ​- initial infection or last less than 1 month.

● Local manifestations
○ constant bone pain that worsens with activity & unrelieved by rest.
○ swelling, tenderness, and warmth at the infection site
○ restricted movement of the affected part.
● Systemic manifestations
○ fever, night sweats, chills, restlessness, nausea, and malaise.
● Later signs
○ drainage from cutaneous sinus tracts or the fracture site.
Treatment: 
● Aggressive, vigorous and prolonged IV antibiotic therapy is the treatment of choice
○ As long as bone ischemia has not yet occurred.
● If antibiotic therapy is delayed → surgical debridement and decompression
● IV antibiotic therapy may be started in the hospital and continued at home for 4 to 6 weeks or as long as 3 to 6
months.
○ the patient will leave with a PICC/CVAD line, teach care!
○ Fluoroscopy X Ray to verify position
○ Strict Sterile technique ; wash your hands before touching
○ Perform dressing changes and cleanse the catheter insertion; A chlorhexidine-based preparation
○ NO BP on that arm
○ Risk for infection
○ Flushing to maintain patency with NS 10 ml. ( also helps prevent incompatibility with other drugs)
● A variety of antibiotics may be prescribed depending on the microorganism.
○ penicillin, nafcillin (Nafcil)
○ neomycin, vancomycin, gentamicin (Garamycin), and tobramycin (Nebcin)
○ cephalexin (Keflex), cefazolin (Ancef), cefoxitin (Mefoxin)
● Oral antibiotic therapy may also be given after acute IV therapy is completed to ensure resolution of the infection.
● DRUG ALERT: Gentamicin (Garamycin)
○ Assess patients for dehydration before starting therapy.
○ Ensure ​renal function testing​ is done before starting therapy, especially in older patients.
○ Assess K, Ca, and Mg
■ Dehydration, Renal and Electrolyte imbalances can ​increase​ risk of toxicity!
○ Monitor ​peak and trough levels​ for therapeutic effect and to minimize renal and inner ear
toxicity.
○ Instruct patient to notify health care provider if any ​visual, hearing, or urinary problems develop

Chronic osteomyelitis- ​persists longer than 1 month or an infection that has failed to respond to the initial course
of antibiotic therapy.
● Is either a continuous, persistent problem (a result of inadequate acute treatment) or a process of exacerbations
and remissions
● Systemic Manifestations:
○ Tend to be diminished
● Local Manifestations:
○ Constant bone pain and swelling and warmth at the infection site
 ● Over time, granulation tissue turns to scar tissue.
○ This avascular scar tissue protects microorganism growth and cannot be penetrated by antibiotics 
● In adults,oral therapy with a​ fluoroquinolone​ (ciprofloxacin [Cipro]) for 6 to 8 weeks may be prescribed instead of
IV antibiotics.
● The patient’s response to drug therapy is ​monitored through bone scans and ESR tests.
● Surgical removal of the poorly vascularized tissue and dead bone and the extended use of antibiotics
● Antibiotic-impregnated ​polymethylmethacrylate bead chains​ may also be implanted → helps combat the infection.
○ P ​ laced inside open fractures to prevent infection. Can also be loaded with gentamicin
● After debridement the wound may be closed and a suction irrigation system inserted.
● Intermittent or constant irrigation with antibiotics
may also be initiated.
● Protect the limb/surgical site with cast or brace.
● Post op-Negative-pressure wound therapy
(vacuum-assisted wound closure)
○ Uses suction to remove drainage and
speed wound healing.The tubing is
connected to a pump, which creates a
negative pressure in the wound bed
● Hyperbaric oxygen with 100% oxygen may be
given as an adjunct therapy in ​refractory cases​ of
chronic osteomyelitis.
○ Stimulates circulation, new bone growth &
healing. Accelerates granulation tissue formation.
○ Hyperbaric O2 therapy (HBOT) is the systemic delivery of 100% O2 at increased
atmospheric pressures (1.5-3x ) to a patient placed in an enclosed chamber. O2 diffuses into the serum,
rather than RBCs, this allows the O2 to move past narrowed arteries and capillaries where RBCs cannot
go and be transported to the tissues.
○ In addition, elevated O2 levels stimulate angiogenesis (the production of new blood vessels), kill
anaerobic bacteria, and increase the killing power of WBCs and certain antibiotics (e.g., fluoroquinolones,
aminoglycosides).
● Muscle flaps or skin grafting provides wound coverage over the dead space (cavity) in the bone
○ Grafts or flaps SHOULD NEVER be placed over an active infection site.
● Bone grafts may help to restore blood flow.
● Amputation of the extremity → bone destruction is extensive, save the patient’s life or to improve quality of life.

ACUTE INTERVENTION
● Some immobilization of the affected limb
○ Splint or traction to decrease pain/further injury
○ Frequent bed rest in the early stages of the acute
infection
● Careful handling to the limb → can increase pain and may
cause a pathologic fracture.
● Assess the patient’s pain.
○ Minor to severe pain may be experienced with muscle
spasms.
● NSAIDS, opioid analgesics, and muscle relaxants
● Encourage non-drug approaches to pain management
○ guided imagery, relaxation breathing.
● Sterile technique for dressing changes; Dressings can be either dry, sterile dressings; dressings saturated in
saline or antibiotic solution; and wet-to-dry dressings.
● Good body alignment and frequent position changes prevent complications associated with immobility and
promote comfort.
○ Flexion contracture of the lower extremity is a common complication of
■ Flex position is common when a patient is in pain , splints/braces to extend joints!
■ Turn patient 1-2q
■ Pressure wound precautions
○ Footdrop can develop quickly due to Achilles tendon contracture if the foot is not correctly supported in a
neutral position ​by a splint or if a splint applies excessive pressure, which can injure the peroneal nerve.
● Teach the patient the potential adverse and toxic reactions from prolonged and high-dose antibiotic therapy (e.g.,
tobramycin, neomycin).
○ Hearing deficit, nephrotoxicity, and neurotoxicity.
 ■ Neurotoxicity → Limb weakness/numbness, cognitive changes or memory loss, vision changes,
headache, behavior changes
○ Cephalosporins ​→ hives, severe or watery diarrhea, blood in stools, and throat or mouth sores.
■ Assess patient’s allergies to penicillin/ Sulfa (specifically Ancef (cefazolin) )
○ Fluoroquinolones ​(ciprofloxacin, levofloxacin ) → ​Tendonitis​;Tendon rupture (especially the Achilles
tendon)​ --​other s/s GI disturbance, neurologic effects (dizziness, headache), rash
○ Lengthy antibiotic therapy can also result in an overgrowth of ​Candida albicans and Clostridium difficile​ in
the genitourinary and gastrointestinal (GI) tract, ​especially in immunosuppressed and older patients.
■ Instruct the patient to report any changes in the oral cavity such as ​whitish yellow, curdlike lesions
or changes in the genitourinary cavity such as any perianal itching or diarrhea.
■ Probiotics to add into their diet. Fiber.
● Other complications include septicemia, ​septic arthritis, ​pathologic fractures, and amyloidosis

Ambulatory Care
● IV antibiotics can be administered to the patient in a skilled nursing facility or home setting.
● If at home, instruct the patient and caregiver on the proper care and management of the venous access device
○ Patients have a CVAD or PICC line inserted for IV use.
● Also teach them how to administer the antibiotic when scheduled and the need for follow-up laboratory testing
● Stress the importance of continuing to take antibiotics after the symptoms have subsided.
● The patient and caregiver may require supplies and instruction in the technique.
● If the osteomyelitis becomes chronic, patients need continued physical and psychological support

Bone Tumors  
Benign Bone Tumors
● Osteochondroma, Osteoclastoma, and Enchondroma
● These types of tumors are often removed by surgery.
Osteochondroma ​-most common primary benign bone tumor.
● Characterized by an o​vergrowth of cartilage and bone near the end of the bone at the growth plate​.
● It is more commonly found in the long bones of the leg, pelvis, or scapula.
● S/S​: painless, hard, immobile mass; lower-than-normal height for age; soreness of muscles in close proximity to
the tumor; one leg or arm longer than the other; and pressure or irritation with
exercise.
○ Patients may also be asymptomatic.
● Diagnosis is confirmed using x-ray, CT scan, and MRI.
● No treatment is necessary for asymptomatic osteochondroma.
○ If the tumor is causing pain or neurologic symptoms because of
compression, surgical resection is usually done.
● Patients should have regular screening examinations for early detection of
malignant transformation

MALIGNANT BONE TUMORS

● Most common;​Osteosarcoma,Chondrosarcoma and Ewing’s sarcoma
● Sarcoma- ​can develop in bone, muscle, fat, nerve, or cartilage.
● Primary malignant tumors occur most often during childhood and young
adulthood.
○ Characterized by rapid metastasis and bone destruction.

Osteosarcoma​ is extremely aggressive and rapidly metastasizes to ​distant​ sites.

● Most common malignant bone tumor affecting children and young adults
● It can also occur, but not as commonly, in older adults.
● It is most often associated with ​Paget’s disease ​and prior radiation
● It usually occurs in the metaphyseal region of the long bones of extremities, particularly in the regions of the​ distal
femur, proximal tibia, and proximal humerus, as well as the pelvis
● S/S​ associated with the gradual onset of pain and swelling, ​especially around the knee​.
● A ​minor injury does not cause the neoplasm​ but may bring the preexisting condition to medical attention.
● Metastasis is present in 10% to 20%cases.
DX Testing
● Tissue biopsy
● Elevation of serum alkaline phosphatase and ​calcium levels
○ Ca high in the blood because of bone breakdown
● Radionuclide bone scans
○ are often done once primary lesion has been ID’d first to
detect metastasis since they may not be visible on a x ray
● Xray, CT, PET scans MRI
Treatment
● Preoperative (neoadjuvant) chemotherapy to decrease tumor size
before surgery.
● Limb salvage procedures are usually considered when there is a
clear (no cancer present) 6- to 7-cm margin surrounding the lesion.
○ Limb salvage is usually contraindicated if there is major
neurovascular involvement, pathologic fracture, infection,
or extensive muscle involvement.
■ Pathological fx include fxs from osteoporosis,
osteomalacia, Paget's disease, osteitis,
osteogenesis imperfecta, benign bone tumours
and cyst
○ Adjunct chemotherapy after amputation or limb salvage
has increased the 5-year survival rate to 70% in people
without metastasis.

Metastatic Bone Cancer

● Occurs as a result of metastasis from a primary tumor located at
another site.
○ Common sites for the primary tumor include breast,
prostate, lungs, kidney, and thyroid.
● Metastatic cancer cells travel from the primary tumor to the bone
via the lymph and blood supply.
○ Commonly found in vertebrae, pelvis, femur, humerus, or
ribs.
● Pathologic fractures at the site of metastasis are common because
of a weakening of the involved bone.
● Metastatic bone lesions may occur at any time (even years later)
following dx and treatment of the primary tumor.
● Metastasis to the bone should be suspected in any pt who has​ local bone pain and a past history of cancer.
● Prognosis depends on the primary type of cancer and any other sites of metastasis
● Surgical stabilization of the bone may be indicated if there is a fracture or the patient is at high risk for a fracture
● Treatment may be palliative and consists of radiation and pain management .

Nursing Management for BONE CANCER 

● Assess the patient for the location and severity of pain.
○ Note weakness caused by anemia and decreased mobility.
● Monitor the site of the tumor for swelling; changes in circulation; and decreased movement, sensation, or joint
function.
● Special attention is required to prevent pathologic fractures or to reduce the complications associated with them.
○ It is important to prevent fractures by careful handling and support of the affected extremity and logrolling
for those on bed rest.

● Treatment for hypercalcemia​ may need to be initiated if bone decalcification occurs

○ Serum levels in ​excess of 12 mg/dL​ can be life threatening.
○ Control of pain and prevention of pathologic fractures.
■ Analgesics, orthopedic supports, and localized radiation help reduce the skeletal pain
○ Prolonged immobilization,--> more bone mineral loss and increased plasma calcium concentration
■ Ambulation and adequate hydration
● Weight bearing helps the bones reasorb some calcium, and fluids dilute calcium and
prevent protein precipitates from causing renal tubular obstruction.
 ○ Primary S/S:
■ ⬆ Levels leads to reduced excitability of both muscles and nerves.
● muscle weakness
■ Renal
● polyuria (​ what's my K level!)​ and nocturia, kidney stones
■ GI
● Anorexia, N +V
○ Metabolic Acidosis
■ Neurologic manifestations such as apathy, depression, fatigue, confusion,and ultimately seizures,
coma
■ Cardiac problems
● ECG changes → cardiac arrest (heart monitor!)
○ Serum calcium levels are affected by a low albumin level.
■ A low albumin level will give a false-normal calcium level.
○ Treated by hydration (3 L/day) and Bisphosphonate therapy.
■ Fluids (isotonic NS) promote urinary excretion of calcium, and decrease kidney stones
● Administering a loop diuretic → ​ furosemide​ [Lasix])
■ Bisphosphonates​ pamidronate [Aredia] zoledronic acid [Zometa]
● Most effective for malignancy hypercalcemia & prevent bone complications in patients
with bone metastasis
● inhibit the action of osteoclasts
○ cells that break down bone and result in calcium release
● DRUG ALERT: ​Zoledronic Acid (Zometa) → Patient should be adequately rehydrated
before administering drugs. → Renal toxicity may occur if IV infusion of drug is
administered in less than 15 min.
■ Synthetic​ ​Calcitonin
● is naturally produced by the thyroid gland and is stimulated by high serum calcium levels.
● It opposes the action of PTH and lowers the serum calcium level by decreasing GI
absorption → increasing calcium deposition into bone, and promoting renal excretion.
● given intramuscularly (IM) or subcutaneously lowers serum calcium levels
○ the intranasal form is not effective​.
○ Other supportive measures include a diet low in calcium calcitonin
○ The patient is often reluctant to participate in exercise or therapeutic activities because of weakness from
the disease and the treatment, fear of falling and fracturing a bone, and fear of pain.
● Provide regular rest periods between activities.
● The pain associated with bone cancer can be severe.
○ Often caused by the tumor pressing against nerves and other organs near the bone.
○ Carefully monitor the patient’s pain → adequate pain medication.
■ New onset of pain can indicated pathologic fx
● Sometimes radiation therapy is used as a palliative therapy to shrink the tumor and decrease the pain.
● Assist the patient and caregiver in accepting the poor prognosis associated with bone malignancies.
● General principles related to cancer nursing are applicable
● Special attention is necessary for the problems of pain and disability, side effects of chemotherapy, and
postoperative care after surgery such as spinal cord decompression or amputation.
● As with all types of cancer, stress the importance of follow-up examinations.
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Lower Back Pain 
● Most often due to a musculoskeletal problem.
● It may be localized or diffuse.
○ Localized​ pain → soreness or discomfort when palpated or pressed on a specific area of the lower back
○ Diffuse​ pain → spread over a larger area and comes from deep tissue layers
● May be radicular or referred.
○ Radicular​ pain is caused by irritation of a nerve root.
■ Not typically isolated to a single location but instead radiates or moves along a nerve distribution
● Sciatica is an example of radicular pain.
○ Referred​ pain is “felt” or perceived in the lower back, but the source of the pain is another location
■ kidneys, lower abdomen
● Low back pain is a common problem because the lumbar region
○ Bears most of the weight of the body
○ Is the most flexible region of the spinal column
○ Contains nerve roots that are vulnerable to injury or disease
○ Has an inherently poor biomechanical structure.
● Risk factors
○ lack of muscle tone and excess body weight, stress, poor posture, cigarette smoking, pregnancy, prior
compression fractures of the spine, spinal problems since birth, and a family history of back pain.
○ Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged
periods of sitting are also associated with low back pain.
○ Health care personnel who engage in patient care–related tasks are at high risk for the development of
low back pain.Lifting and moving patients, excessive time stooping over or leaning forward, and frequent
twisting.
■ BEND WITH YOUR KNEES! Ask for help! Elevate the bed to waist level!
● The causes of low back pain of musculoskeletal origin:
○ acute lumbosacral strain
○ instability of the lumbosacral bony mechanism
○ osteoarthritis of the lumbosacral vertebrae
○ degenerative disc disease
○ herniation of an intervertebral disc.

ACUTE LOW BACK PAIN

● low back pain that lasts 4 weeks or less.
● Most acute low back pain is caused by trauma or some type of activity that causes undue stress
○ often hyperflexion of the lower back.
■ Heavy lifting, overuse of the back muscles while working in the yard, a sports injury, or a sudden
jolt such as a car accident​.
○ Often symptoms do not appear at the time of injury but develop later (usually within 24 hours) because of
a gradual increase in pressure on the nerve by an intervertebral disc.
● Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility or range of motion, or an
inability to stand straight.
DX Testing/Assessment:
● Neurologic
○ Depressed or absent Achilles tendon reflex or patellar tendon reflex;
○ positive straight-leg-raising test, positive crossover straight-leg raising test, positive Trendelenburg test
● Musculoskeletal
○ Tense, tight paravertebral muscles on palpation, ↓ range of motion of spine
● Straight-leg raise
○ Patient is supine and the leg is passively raised to 60 degrees or less.
○ The test is positive if the patient complains of pain along the distribution ( sciatic nerve)
 ○ A positive test indicates nerve root irritation from intervertebral disc prolapse and herniation
■ Usually L4-L5 or L5-S1 level
● MRI and CT scans are generally not done unless trauma or systemic disease
○ Cancer, spinal infection are suspected.
○ Edema may limit MRI findings in acute phase
● Possible Diagnostic Findings Localization of site of lesion or disorder on myelogram, CT scan, or MRI;
determination of nerve root impingement on electromyography
HEALTH PROMOTION
● Proper body mechanics at all times.
○ Healthcare workers → elevate the patient’s bed height, bending at the knees, asking for help in lifting and
moving patients, and using lifting devices.
● Assess the patient’s use of body mechanics and offer advice when the person does activities that could produce
back strain (Table 64-6).
● Some health care providers refer patients with back pain to a program called “Back School.”
○ It is designed to teach the patient how to minimize back pain and avoid repeat episodes of low back pain.
● Advise patients to maintain appropriate body weight.
○ Excess body weight places additional stress on the lower back and weakens the abdominal muscles that
support the lower back.
● Flat shoes or shoes with low heels and shock-absorbing shoe inserts are recommended for women.
● The position assumed while sleeping is also important in preventing low back pain.
○ Tell patients to avoid sleeping in a prone position because it produces excessive lumbar lordosis, placing
excessive stress on the lower back.
○ The patient should sleep in either a supine or side-lying position ​with knees and hips flexed​ to prevent
unnecessary pressure on support muscles, ligaments, and lumbosacral joints.
○ A firm mattress is recommended.
● Teach patients the importance of stopping smoking, since it has been associated with low back pain.
○ One reason for this is that nicotine decreases circulation to the intervertebral discs.
ACUTE INTERVENTION
● If the acute muscle spasms and accompanying pain are not severe and debilitating,
○ NSAIDs (e.g., acetaminophen) and muscle relaxants (e.g., cyclobenzaprine [Flexeril]).
○ Massage and back manipulation, acupuncture, and the application of cold and hot compresses may help
some patients.
● Severe pain may require a brief course of opioid analgesics or corticosteroids
● A brief period (1 to 2 days) of rest at home
○ but most patients do better with a continuation of their regular activities.
○ Prolonged bed rest should be avoided.
● Patients should refrain from activities that aggravate the pain, including lifting, bending, twisting, and prolonged
sitting.
● Most cases of acute low back pain show improvement within 2 weeks and often resolve without treatment.
● Muscle stretching and strengthening exercises may be part of the management plan.
○ Although the actual exercises are often taught by the physical therapist, it is your responsibility to ensure
that the patient understands the type and frequency of exercise prescribed and the rationale for the
program.

AMBULATORY AND HOME CARE.

● The goal of management is to make an episode of acute low back pain an isolated incident.
● If the lumbosacral mechanism is unstable, repeated episodes can be anticipated.
● The lumbosacral spine may be unable to meet the demands placed on it without strain because of factors such as
○ obesity, poor posture, poor muscle support, older age, or trauma.
○ Intervention is aimed at strengthening the supporting muscles by exercise.
● Persistent use of poor body mechanics may also result in repeated episodes of low back pain. If the strain is work
related, occupational counseling may be necessary.
● The frustration, pain, and disability imposed on the patient with low back pain require your emotional support and
understanding care.

CHRONIC LOW BACK PAIN  

● Low back pain that lasts more than 3 months or is a repeated incapacitating episode.
● It is often progressive, and the cause can be difficult to determine.
● Causes include
○ (1) degenerative conditions such as arthritis or disc disease
○ (2) osteoporosis or other metabolic bone diseases
○ (3) prior injury (scar tissue weakens the back)
○ (4) chronic strain on the lower back muscles from obesity, pregnancy, or job related stooping, bending, or
other stressful postures
○ (5) congenital abnormalities in the spine.
Spinal Stenosis​ is a narrowing of the spinal canal (hollow vertical hole that contains the spinal cord).
● Stenosis in the lumbar area of the spine is a common cause of chronic low back pain.
● Spinal stenosis can be caused by either acquired or inherited conditions.
● A common acquired cause is ​osteoarthritis​ in the spine.
○ Arthritic changes (bone spurs, calcification of spinal ligaments, degeneration of discs) narrow the space
around the spinal canal and nerve roots → eventually leading to​ compression.
■ In return inflammation results in pain, weakness, and numbness.
● Other acquired conditions include
○ rheumatoid arthritis, spinal tumors, Paget’s disease, and traumatic damage to the vertebral
column.
● Inherited conditions include
○ congenital spinal stenosis and scoliosis.
 ●Pain associated with lumbar spinal stenosis often ​starts in the lower back and then radiates to the
buttock and leg.
○ It worsens with walking and, in particular, standing without walking.
○ Numbness, tingling, weakness, and heaviness in the legs and buttocks may also be present.
● Hx of the ​pain lessening when the patient bends forward or sits down is often a sign of spinal stenosis.
● In most cases the stenosis slowly progresses
○ does not cause paralysis​.
● Can cause ​Herniated disc​ d/t the narrowing of the spinal canal forcing the disc to bulge.
NURSING MANAGEMENT AND TREATMENT
● Similar to acute low back pain.
● Mild Analgesics/Nsaids
○ Relief of pain and stiffness
● Antidepressants
○ Duloxetine [Cymbalta])
■ may help with pain relief and sleep problems.
● Antiseizure drug
○ Gabapentin (Neurontin)
■ may improve walking and relieve leg symptoms.
● Weight reduction, sufficient rest periods, local heat or cold application, physical therapy, and exercise and activity throughout
the day assist in keeping the muscles and joints mobilized.
● Cold, damp weather aggravates the back pain
○ Can be relieved with rest and local heat application.
● Biofeedback, acupuncture, and yoga may help reduce the pain
● “Back School” can significantly reduce pain and improve body posture for both patients and nurses.
● Minimally invasive treatments
○ epidural corticosteroid injections and implanted devices that deliver pain medication
■ chronic low back pain that is refractory to the usual therapeutic options.
● Surgical intervention may be indicated in patients with severe chronic low back pain who do not respond to conservative care
and/or have continued neurologic deficits
○ (Surgery for low back pain is under intervertebral disc sx)

Intervertebral Disc Disease 

● Involves the deterioration, herniation, or other dysfunction of the intervertebral discs.
Degenerative disc disease (DDD)
● Progressive degeneration results from fluid loss, elasticity, flexibility, and shock-absorbing capabilities in the
intervertebral discs
○ Normal process of aging unless accompanied by pain
● Thinning occurs as the nucleus pulposus (gelatinous center of the disc) starts to dry out and shrink.
○ Limit the ability of the discs to distribute pressure loads between the vertebrae.
○ The pressure then transfers to the annulus fibrosus (strong outside portion of the intervertebral disc),
causing progressive structural deterioration.
● Osteoarthritis of the spine is associated w/ DDD
○ The joints, which are not adequately lubricated, rub against each other, leading to damage of
the protective cartilage and the formation of painful bone spurs
■ complication found in osteoarthritis

Herniated disc ​(slipped disc)

○ a condition in which a spinal disc herniations and bulges outward between the vertebrae
○ With structural damage to the disc the nucleus pulposus may seep through a torn or stretched annulus.
○ The most common sites of herniation are the lumbosacral discs
 ■ specifically L4-5 and L5-S1. Disc herniation may also occur at C5-6 and C6-7.
○ The nucleus pulposus may first bulge and then it can herniate, placing pressure on nearby nerves
○ Can be the result of
■ natural degeneration with age (DDD)
■ repeated stress and trauma to the spine. .
■ spinal stenosis
● in which narrowing of the spinal canal forces the intervertebral disc to bulge.
○ When pressed up against the spinal nerves that emerge from the intervertebral foramen it causes a
“pinched nerve” causing ​radiculopathy
■ radiating pain, numbness, tingling, and diminished strength and/or range of motion

Manifestations
● Lumbar Disc Disease
○ may occur when a disc in the low back area of the spine bulges or herniates from between the bony area
of the spine.
■ causes lower back pain and leg pain and weakness that is made worse by movement and
activity.
■ Radicular pain that radiates down the buttock and below the knee, along the distribution of the
sciatic nerve, generally indicates disc herniation.
○ The straight-leg raising test may be positive, indicating nerve root irritation.
■ Back or leg pain may be reproduced by raising the leg and flexing the foot at 90 degrees.
○ Reflexes may be depressed or absent, depending on the spinal nerve root involved.
○ Paresthesia or muscle weakness in the legs, feet, or toes may occur.
● Cauda Equina
○ This condition is a medical emergency!!!!!
■ Requires surgical decompression to reduce pressure on the nerves
○ Multiple nerve root compressions from a herniated disc, a tumor, or an epidural abscess
■ May be manifested as severe low back pain
 ■ Progressive weakness
■ Increased pain
■ bowel and bladder incontinence.
● Cervical disc disease
○ pain radiates into the arms and the hands, following the pattern of the nerve involved.
■ Similar to lumbar disc disease, reflexes may or may not be present, and the handgrip is often
weak.
○ Because CDD may include shoulder pain and dysfunction , HCP must rule out shoulder disorders as part
of the dx.

DX Studies
● X-rays- structural defects
● Myelogram, MR or CT to localize damage
● Epidural Venogram or Diskogram
● EMG of extremities to determine severity of nerve
irritation or rule out Peripheral Neuropathy

Collaborative Care
● usually first managed with conservative therapy and
limitation of extremes of spinal movement
○ brace, corset, or belt
○ local heat or ice
○ ultrasound and massage, traction, and
transcutaneous electrical nerve stimulation
(TENS).
● Drug therapy to relieve pain includes
○ NSAIDs, Analgesic
○ short-term use of opioids
○ muscle relaxants
○ antiseizure drugs
○ antidepressants.
○ Epidural corticosteroid injections to reduce
inflammation and relieve acute pain.
● If the underlying cause remains, the pain tends to recur.
● Once the symptoms subside → back strengthening
exercises are begun twice a day and continued for life.
● Teach good body mechanics and ​discourage​ extremes of flexion and torsion.
● Most patients heal with a conservative treatment plan after 6 months.

Surgical Therapy
● Surgery for a damaged disc is generally performed when diagnostic tests indicate that the problem is not
responding to conservative treatment and the patient is in constant pain and/or has a persistent neurologic deficit
○ radiculopathy becomes progressively worse, or loss of bowel or bladder control (cauda equina) occurs
● Intradiscal electrothermoplasty​ (IDET)
○ Minimally invasive outpatient procedure to treat back and sciatica pain.
○ Involves inserting a needle into the affected disc with the guidance of an x-ray.
○ A wire is then threaded down through the needle and into the disc and heated → denervates the small
nerve fibers that have grown into the cracks and have invaded are destroyed.
■ The heat also partially melts the annulus fibrosus, which triggers the body to generate new
reinforcing proteins in the fibers of the annulus.
● Radiofrequency discal nucleoplasty​ (coblation nucleoplasty)
○ A needle is inserted into the disc similar to IDET.
○ Instead of a heating wire, a special radiofrequency probe is used.
 ■ The probe generates energy that breaks up the molecular bonds of the gel in the nucleus
pulposus.
○ The result is that up to 20% of the nucleus is removed, which decompresses the disc and reduces the
pressure on both the disc and the surrounding nerve roots.
○ Relief from pain varies among patients.
● Interspinous process decompression system​ (X-Stop)
○ Made of titanium and fits onto a mount that is placed on vertebrae in the lower back.
○ The X-Stop is used in patients with pain due to lumbar spinal stenosis.
○ The device works by lifting the vertebrae off the pinched nerve.
● Laminectomy *****
○ Common and traditional sx for Lumbar Disc Disease
○ It involves the surgical excision of part of the vertebra (referred to as the lamina) to gain access to the
protruding disc to remove it.
○ A minimal hospital stay is usually required after the procedure (1-3 days)
● Diskectomy
○ Surgical procedure to decompress the nerve root.
○ Microsurgical diskectomy
■ standard diskectomy in which the surgeon uses a microscope to allow better visualization of the
disc and disc space during surgery to aid in the removal of the damaged portion.
■ This helps maintain the bony stability of the spine.
○ Percutaneous diskectomy
■ Safe and decreases rehabilitation time.
■ Surgical procedure using a tube that is passed
through the retroperitoneal soft tissues to the
disc with the aid of fluoroscopy.
■ A laser is then used on the damaged portion of
the disc.
■ Small stab wounds are used, and minimal
blood loss occurs during the procedure.
● Charité disc
○ Artificial disc replacement surgery
■ Used to restore movement and eliminate pain.
○ Used in patients with lumbar disc damage associated
with DDD. T
○ Artificial disc is made up of a high-density core
sandwiched between two cobalt-chromium endplates
○ This device is surgically placed in the spine (usually
through a small incision below the umbilicus) after the
damaged disc is removed.
○ The disc allows for movement at the level of the implant.
● The ProDisc-L
○ Another type of artificial lumbar disc that can be used to treat DDD.
● The Prestige cervical disc system​, ​Mobi-C and Secure- C artificial cervical Disc
○ treatment of DDD of the cervical spine.
● Spinal fusion
○ may be performed if the spine is unstable.
○ The spine is stabilized by creating an ​ankylosis​ (fusion) of contiguous vertebrae with a bone graft from
the patient’s fibula or iliac crest (autograft) or from a donated cadaver bone (allograft)
○ Metal fixation with rods, plates, or screws may be implanted at the time of spinal surgery to provide more
stability and decrease vertebral motion.
○ A posterior lumbar fusion may be performed in patients to provide extra support for bone grafting or a
prosthetic device.
 ● Bone morphogenetic protein​ (BMP),
○ genetically engineered protein, used to stimulate bone growth of the graft in spinal fusions.
○ A dissolvable sponge soaked with BMP is implanted into the spine. The protein on the sponge stimulates
the body’s own cells to become active and produce bone.
○ BMP begins the process of fusion, which continues even after the protein and sponge dissolve, leaving
living bone behind.

NURSING MANAGEMENT
● After vertebral disc surgery, postoperative nursing interventions mainly focus on maintaining proper alignment of
the spine until it has healed.
● Depending on the type and extent of surgery and the surgeon’s preference, the patient may be able to dangle the
legs at the side of the bed, stand, or even ambulate the same day of surgery.
● place pillows under the thighs of each leg when supine and between the legs when in the side-lying position to
provide comfort and ensure alignment.
● Reassure the patient that the proper technique is being used to maintain body alignment.
○ The patient often fears turning or any movement that increases pain by straining the surgical area.
● Sufficient staff should be available to move the patient without undue pain or strain on staff members or the
patient.
● Postoperatively, patients require opioids such as morphine IV for 24 to 48 hours.
● Patient-controlled analgesia (PCA) allows for optimal analgesic levels and is the preferred method of continued
pain management during this time.
● Once fluids are being taken, the patient may be switched to oral drugs such as
○ acetaminophen with codeine, hydrocodone (Vicodin), or oxycodone (Percocet).
○ Diazepam (Valium) may be prescribed for muscle relaxation.
● Monitor and document pain management and its effectiveness.
● Because the spinal canal may be entered during surgery, there is potential for cerebrospinal fluid (CSF) leakage.
○ Immediately report a severe headache or leakage of CSF on the dressing.
■ CSF appears as clear or slightly yellow drainage on the dressing.
■ It has a high glucose concentration and is positive for glucose when tested with a dipstick.
■ Note the amount, color, and characteristics of drainage.
● Frequently monitor the patient’s peripheral neurologic signs after spinal surgery.
○ Movement of the arms and the legs and assessment of sensation should be unchanged when compared
with the preoperative status.
○ These assessments are usually repeated every 2 to 4 hours during the first 48 hours after surgery and
compared with the preoperative assessment.
○ Paresthesias, such as numbness and tingling, may not be relieved immediately after surgery.
○ Document any new muscle weakness or paresthesias and report them to the surgeon immediately.
○ Assess extremity circulation using temperature, capillary refill, and pulses.
● Paralytic ileus and interference with bowel function may occur for several days and may manifest as nausea,
abdominal distention, and constipation.
○ Assess whether the patient is passing flatus; has bowel sounds in all quadrants; and has a flat, soft
abdomen.
○ Stool softeners (e.g., docusate [Colace]) may aid in relieving and preventing constipation.
● Adequate bladder emptying may be altered because of activity restrictions, opioids, or anesthesia.
○ If allowed by the surgeon, encourage men to dangle the legs over the side of the bed or stand to urinate.
○ Patients should use the commode or ambulate to the bathroom when allowed to promote adequate
emptying of the bladder.
○ Ensure that privacy is maintained.
○ Intermittent catheterization or an indwelling catheter may be necessary for patients who have difficulty
urinating. Loss of sphincter tone or bladder tone may indicate nerve damage.
○ Monitor for incontinence or difficulty evacuating the bowel or bladder, and report significant findings to the
surgeon immediately.
● In addition to the nursing care appropriate for a patient who has had a laminectomy, there are other nursing
responsibilities if the patient has also had a spinal fusion.
○ Because a bone graft is usually involved, the postoperative healing time is prolonged compared with that
of a laminectomy.
○ Limitations on activity may be necessary over an extended time.
○ A rigid orthosis (thoracic-lumbar-sacral orthosis [TLSO] or chairback brace) is often used during this
period.
○ Some surgeons require that the patient be taught to put it on and take it off by logrolling in bed, whereas
others allow their patients to apply the brace in a sitting or standing position.
■ Verify the preferred method before initiating this activity.
○ If surgery is done on the cervical spine, ​be alert for manifestations of spinal cord edema
● such as respiratory distress and a worsening neurologic status of the upper extremities.
■ After surgery, the patient’s neck may be immobilized in either a soft or hard cervical collar.
■ In addition to the primary surgical site, regularly assess the donor site for the bone graft.
■ The posterior iliac crest is the most commonly used donor site, although the fibula may also be
used.
■ The donor site usually causes greater pain than the spinal fusion area.
■ The donor site is bandaged with a pressure dressing to prevent excessive bleeding.
■ If the donor site is the fibula, neurovascular assessments of the extremity are a postoperative
nursing responsibility.
○ After a spinal fusion the patient may experience some immobility of the spine at the fusion site.
○ Instruct the patient in proper body mechanics and to avoid sitting or standing for prolonged periods.
○ Encourage activities that include walking, lying down, and shifting weight from one foot to the other when
standing.
○ Lifting is usually restricted in the postoperative period after spinal surgery.
○ The patient should learn to mentally think through an activity before starting any potentially injurious task
such as bending or stooping.
○ Any twisting movement of the spine is contraindicated.
○ Patients should use the thighs and knees, rather than the back, to absorb the shock of activity and
movement.
○ A firm mattress or bed board is essential.
Osteomalacia -  
● is caused by a vitamin D deficiency, resulting in decalcification and softening of bones.
● This disease is the same as rickets in children except that the epiphyseal growth plates are closed in the adult.
● Vitamin D is required for the absorption of calcium from the intestine.
● Insufficient vitamin D intake can interfere with the normal mineralization of bone; with little or no calcification, bone
softening results.
● Causes of osteomalacia include
○ lack of exposure to ultraviolet rays (which is needed for vitamin D synthesis),
○ GI malabsorption
○ extensive burns
○ chronic diarrhea
○ Pregnancy
○ Kidney disease, and drugs such as phenytoin (Dilantin).
● Risk Factors
○ Morbidly obese
■ because of inadequate calcium intake, decreased physical activity, vitamin D deficiency,
coexisting chronic diseases (e.g., hyperlipidemia),
■ use of medications associated with these diseases (e.g., cholestyramine [Questran])
○ Residents of long term care settings​ are increase risk due to inadequate sun exposure
○ Peron’s with ​dark skin​ also do not synthesize vitamin d easily as a person with fair skin.
○ Chronic diseases of the ​liver and kidneys, small intestine
○ Long term use of ​anti seizure drugs, phosphate binding antacids ​( Maalox),​ sedatives and muscle
relaxants ​may decrease calcium and vitamin d absorption
● Common manifestations
○ bone pain
○ difficulty rising from a chair, and difficulty walking (usually with waddling gait) .
● Other manifestations include
○ Muscular weakness, especially in the pelvic girdle;
○ weight loss;
○ Progressive deformities of the spine (kyphosis) or extremities.
○ Fractures are common and indicate delayed bone healing.
● Laboratory findings commonly include
■ decreased serum calcium or phosphorus​ levels
■ decreased serum 25-hydroxyvitamin D
■ Elevated serum alkaline phosphatase.
○ X-rays may demonstrate the effects of generalized bone demineralization, especially loss of calcium in
the bones of the pelvis and associated bone deformity.
○ Looser’s transformation zones (ribbons of decalcification in bone found on x-ray) are diagnostic of
osteomalacia.
■ However, significant osteomalacia may exist without changes noted on x-ray.
Collaborative care
● is directed toward correction of the vitamin D deficiency.
● When vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol) are used as supplements, the patient often
shows a dramatic response.
● Calcium salts or phosphorus supplements may also be prescribed.
● Encourage dietary ingestion of eggs, meat, oily fish, and milk and breakfast cereals fortified with calcium and
vitamin D.
● Exposure to sunlight (and ultraviolet rays) is also valuable, along with weight bearing exercise.
○ Teach sun protection
● Patients who have bariatric surgery to treat obesity should be assessed for osteomalacia.
● Any vitamin D deficiencies should be corrected before surgery
Osteoporosis ​or porous bone fragile bone disease
● “​bone “ “pores” higher break down of bone in comparison to new formation = porous bones → decrease
bone density → increase in risk for fractures
● is a chronic, progressive metabolic bone disease characterized by low bone mass and structural deterioration of
bone tissue, leading to increased bone fragility
● known as the “silent thief ” because it slowly and insidiously over many years robs the skeleton of its banked
resources.
● Bones can eventually become so fragile that they cannot withstand normal mechanical stress.
● Osteoporosis is more common in women than in men for several reasons
○ (1) women tend to have lower calcium intake
■ men between 15 and 50 years of age consume twice as much calcium as women
○ (2) women have less bone mass because of their generally smaller frames
○ (3) bone resorption begins at an earlier age in women and is accelerated at menopause
○ (4) pregnancy and breastfeeding deplete a woman’s skeletal reserve unless calcium intake is adequate;
○ (5) longevity increases the likelihood of osteoporosis.
● 1 in 2 women and 1 in 4 men over age 50 will sustain an osteoporosis-related fx during their lifetime.
○ An initial bone scan in women before age of 65.
○ If the results are normal & they are at low risk →
another scan is not needed for 15 years.
○ Testing should start earlier and be done
frequently if a person is at high risk for fractures
■ low body weight, smoker, prior fractures
○ Men should be screened before 70 years old and
by age 50 if at high risk for fractures
■ low body weight, hypogonadism
ETIOLOGY AND PATHOPHYSIOLOGY

● Decreased risk is associated with regular weight-bearing exercise and fluoride, calcium, and vitamin D ingestion.
● Low testosterone levels are a ​major risk factor in men​.
● Peak bone mass (maximum bone tissue) is primarily achieved before age 20.
○ Determined by a combination of heredity, nutrition, exercise, and hormone function.
■ Heredity responsible for up to 70%
● At menopause, women experience rapid bone loss d/t decline in estrogen
○ This rate of loss then slows, matches the rate of bone lost by men 65 to 70 years old.
● Genetic factors → influence not only bone mineral density but also bone size, bone quality, and bone turnover.
● Bone is continuously being deposited by osteoblasts and resorbed by osteoclasts, a process called remodeling.
● Bone resorption exceeds bone deposition in Osteoporosis.
● Specific diseases associated with osteoporosis include
○ inflammatory bowel disease
○ intestinal malabsorption
○ kidney disease
○ rheumatoid arthritis
○ Hyperthyroidism
○ chronic alcoholism
○ cirrhosis of the liver
○ Hypogonadism
○ diabetes mellitus.
● Many drugs can interfere with bone metabolism, including
○ Corticosteroids
■ Long-term corticosteroid use is a major contributor to osteoporosis.
■ So is PPI’s and yet the book did not mention this
○ antiseizure drugs (e.g., divalproex sodium [Depakote], phenytoin)
○ aluminum-containing antacids
○ Heparin
○ Certain cancer treatments
○ excessive thyroid hormones.
○ At the time one of these drugs is prescribed, inform the patient of this possible side effect.

Clinical Manifestations
● Occurs most commonly in the bones of the spine, hips, and wrists.
● The usual first manifestations are back pain or spontaneous fractures.
○ The loss of bone substance causes the bone to become mechanically weakened and prone to either
spontaneous fractures or fractures from minimal trauma.
○ One spinal vertebral fracture d/t osteoporosis has an increased risk of having a second vertebral fracture
w/in 1 year. (spinal vertebral fx is also considered compression fx)
■ Experience back pain, height loss and a slump posture
● Wedging and fractures of the vertebrae produce gradual loss of height and a humped back known as ​kyphosis​, or
“dowager’s hump”
● ** NOTE in osteoporosis there is normal
mineralization. In Osteomalacia there is no
mineralization

Dx Studies
● Often goes unnoticed because it cannot be
detected by conventional x-ray until more
than 25% to 40% of calcium in the bone is
lost.
● Serum calcium, phosphorus, and alkaline
phosphatase levels usually are normal,
although alkaline phosphatase may be
elevated after a fracture.
 ● Bone mineral density (BMD) measurements are typically expressed as the grams of mineral per unit volume.
○ BMD is determined by peak bone mass and amount of bone loss.
● BMD can be measured by
○ Quantitative ultrasound (QUS) and dual-energy x-ray absorptiometry (DXA).
■ QUS measures bone density with sound
waves in the heel, kneecap, or shin.
○ DXA
■ measures bone density in the spine, hips,
and forearm
● the most common sites of
fractures resulting from
osteoporosis
■ Are also useful to evaluate changes in
bone density over time and to assess the
effectiveness of tx.
■ DO NOT TAKE CA BEFORE EXAM
○ Results are compared to the ideal or PBMD of a
healthy 30 year old adult
■ Results are reported as T-scores.
● The T-score is the number of
standard deviations below
average for normal
● A T-score b/t +1 and −1 or higher
indicates normal bone density.
■ a T-score between −1 and −2.5 →
osteopenia
■ T-Sore of −2.5 or lower → ​Osteoporosis
● The greater the negative number
the more severe
■ Z-score can be used instead of a T-score.
● A person is compared with
someone his or her own age and/or ethnic group
● Can be misleading b/c decrease bone density is common
● A Z-score that is less than −2.0 or lower can suggest something other than aging is
causing abnormal bone loss
○ A patient’s risk of fracture from osteoporosis can also be calculated with the Fracture Risk Assessment
(FRAX) tool.The FRAX takes into account BMD and additional clinical factors when assessing fracture
risk.

Collaborative care
● Focuses on proper nutrition, calcium supplementation,
exercise, prevention of falls and fractures, and drugs
● Prevention and treatment of osteoporosis focuses on adequate
calcium intake
○ 1000 mg/day in premenopausal women and
postmenopausal women taking estrogen, and 1500
mg/day in postmenopausal women who are not
receiving supplemental estrogen
○ Foods that are high in calcium content include whole
and skim milk, yogurt, turnip greens, cottage cheese,
ice cream, sardines, and spinach
○ If dietary intake of calcium is inadequate, supplemental
calcium may be recommended.
 ○ Calcium is difficult to absorb in single doses greater than 500 mg.
■ Teach the patient the importance of taking supplemental calcium in divided doses with food.
■ The amount of elemental calcium varies in different calcium preparations
● Vitamin D is important in calcium absorption and function and may also have a role in bone formation.
○ Most people get enough vitamin D from their diet or naturally through synthesis in the skin from exposure
to sunlight, organ meat.
○ Being in the sun for 20 minutes a day is generally enough.
■ However, supplemental vitamin D (800 to 1000 IU) is recommended for postmenopausal women,
older men, those who are homebound, and those who get minimal sun exposure.
● Regular physical activity is important to build up and maintain bone mass.
○ Exercise also increases muscle strength, coordination, and balance.
■ Best exercises are ​weight-bearing exercises​.
● walking, hiking, weight training, stair climbing, tennis, and dancing.
○ Walking is preferred to high-impact aerobics or running, both of which may put
too much stress on the bones, resulting in stress fractures.
○ Walking 30 minutes, three times a week is recommended.
○ Instruct patients to quit smoking and cut down on alcohol intake
○ Loss of bone cannot be significantly reversed
■ But further loss can be prevented if the patient follows a regimen of calcium and vitamin D
supplementation, exercise, and drugs
○ Make an effort to keep patients with osteoporosis ​ambulatory to prevent further loss of bone
○ Treatment may also involve the use of a gait aid as needed and to protect areas of potential pathologic
fractures.
■ A thoracic-lumbar-sacral orthosis (TLSO) brace m
○ Vertebroplasty and kyphoplasty are minimally invasive procedures used to treat osteoporotic vertebral
fractures
■ In vertebroplasty bone cement is injected into the collapsed vertebra to stabilize it, but it does not
correct the deformity.
■ In kyphoplasty, an air bladder is inserted into the collapsed vertebra and inflated to regain
vertebral body height, and then bone cement is injected.
Drug Therapy
● Estrogen therapy after menopause is no longer given as
a primary treatment to prevent osteoporosis
● Lasiks promotes secretion of Ca
■ it is associated with an increased risk of
heart disease and breast and uterine
cancer.
○ If estrogen therapy is being used to treat
menopausal symptoms, it also protects the
woman against bone loss and fractures of the
hip and vertebrae.
○ It is believed that estrogen inhibits osteoclast
activity, leading to decreased bone resorption and preventing both cortical and trabecular bone loss.
● Bisphosphonates
○ inhibit osteoclast-mediated bone resorption, thereby increasing total bone mass and BMD.
■ S/S
● are anorexia, weight loss, and gastritis.
○ Instruct patients on the proper administration of a bisphosphonate to aid in its absorption
○ These precautions have been shown to decrease GI side effects (especially esophageal irritation) and
increase absorption.
○ A rare and serious side effect of bisphosphonates is jaw osteonecrosis (bone death).
○ DRUG ALERT: Bisphosphonates •Instruct patient to •​Take it with a full glass of water. •Take 30
min before food or other medications. •Remain upright for at least 30 min after taking​ (reduce
reflex)
 ○ No peg tube!
○ Alendronate ​(Fosamax)
■ is available as a once-per-week oral tablet.
○ Ibandronate​ (Boniva) and​ risedronate ​(Actonel)
■ are available as once-per-month oral tablets.
○ Zoledronic acid​ (Reclast)
■ is approved for a once-yearly IV infusion and can prevent osteoporosis for 2 years after a single
infusion.
■ Flu-like symptoms may occur for the first few days after administration of the drug.
● Salmon calcitonin​ (Calcimar)
○ available in intramuscular (IM), subcutaneous, and intranasal forms.
○ Administration of the IM or subcutaneous form of the drug at night has been shown to decrease the side
effects of nausea and facial flushing associated with this drug.
○ Nausea does not occur with the nasal spray.
○ If patients are using the nasal form, teach them to alternate nostrils daily.
○ Nasal dryness and irritation are the most frequent side effects.
○ Calcium supplementation is necessary to prevent secondary hyperparathyroidism.
● Selective estrogen receptor modulator (SERM)
○ Raloxifene​ (Evista)
■ mimics the effect of estrogen on bone by reducing bone resorption without stimulating the tissues
of the breast or uterus.
■ In ​postmenopausal ​women significantly increases BMD.
■ Side effects
● leg cramps, hot flashes, and blood clots.
● May decrease breast cancer risk.
■ Similar to tamoxifen, it blocks the estrogen receptor sites of cancer cells.
● Teriparatide​ (Forteo),
○ which is a recombinant form of human parathyroid hormone (PTH)
○ increases the action of​ osteoblasts.
○ Used to treat osteoporosis in men and postmenopausal women at high risk for fractures ​ADVANCE
OSTEOPOROSIS
○ First drug approved for the treatment of osteoporosis that stimulates new bone formation
■ (most drugs prevent further bone loss
○ administered by subcutaneous injection once a day.
○ S/S
■ leg cramps and dizziness.
● Denosumab​ (Prolia)
○ Used for​ postmenopausal​ women with osteoporosis who are at high risk for fractures.
○ It is a monoclonal antibody that binds to a protein (RANKL) involved in the formation and function of
osteoclasts.
○ Given as a subcutaneous injection every 6 months.
● Hydrochlorothiazide​ ( thiazide diuretic)
○ Ca reabsorption in the kidneys. Increase transformation to osteoblast= decrease mineral bone loss
● Medical management of patients receiving corticosteroids includes prescribing the lowest effective dose and
ensuring an adequate intake of calcium and vitamin D, including supplementation when osteoporosis drugs are
prescribed.
○ If osteopenia is evident when taking corticosteroids → treat w/ bisphosphonates
Paget’s Disease- ​Osteitis deformans
● chronic skeletal bone disorder in which excessive bone resorption is followed by replacement abnormal bone
marrow by vascular, fibrous connective tissue
● New bone = larger, disorganized & ​weaker
● Commonly affected areas = pelvis, long bones, spine, ribs, sternum & cranium
● Possible viral etiology
● Up to 40% of people with Paget's disease have a relative with the disorder
● Men​ > women 2:1

Diagnosis:
● X-ray
○ demonstrate that the normal contour of the affected bone is curved and the bone cortex is thickened and
irregular, especially the weight-bearing bones and the cranium.
● Serum chemistry - high alkaline phosphatase
○ levels are markedly elevated (indicating high bone turnover) in advanced forms of the disease.
● Bone scans using a radiolabeled bisphosphonate demonstrate increased uptake in the affected skeletal areas.

Signs & Symptoms:

● Mild forms - may be asymptomatic
● Early Signs
○ Bone pain may develop gradually and cause severe intractable pain
○ Fatigue
○ Progressive development of waddling gait
● Pts complain of becoming shorter and heads becoming bigger
○ Skull thickens and enlarges
■ headache, dementia, visual deficits, loss of hearing
● Increased bone volume in spine puts pressure on spinal cord and compression of nerve roots
○ Paresthesias, weakness,
● Complications
○ Pathologic fx: may be first indication sometimes
○ Osteosarcoma, fibrosarcoma, osteoclastoma

Treatment:
● Limited to symptomatic and supportive care with correction of secondary deformities by surgical intervention or
braces
● Biphosphate Drugs​ - retard bone resorption
○ Alendronate​ ( Fosamax, Binosto)
○ Etidronate​ (Didronel)
💊
○ Ibandronate​ (Boniva)
○ Pamidronate​ ( Aredia)
○ Risedronate​ (Actonel)

💗○ Zoledronic Acid​ (Reclast) - given specifically to build bone

Nursing Parameters
■ Calcium & vitamin D - decrease hypocalcemia (common SE of biphosphate drugs)
■ Monitor drug effectiveness by regular assessment of serum alkaline phosphatase
 ● Calcitonin
○ recommended for patients who cannot tolerate bisphosphonate drugs.
○ Human calcitonin​ (Cibacalcin)
■ inhibits osteoclastic activity, prevents bone resorption, relieves acute symptoms, and lowers the
serum alkaline phosphatase levels.
■ subcutaneous injection.
○ Salmon calcitonin​ can also be used as a subcutaneous or IM injection for treating Paget’s disease.
■ longer halflife and greater milligram potency than human calcitonin.
○ Response to calcitonin therapy is not permanent and often stops when therapy is discontinued.
● Pain is usually managed by NSAIDs.
● Orthopedic surgery for fractures, hip and knee replacements, and knee realignment
● A firm mattress.
● Wear a corset or light brace to relieve back pain and provide support when in the upright position.
○ The patient should be proficient in the correct application of such devices and know how to regularly
examine areas of the skin for friction damage.
● Discourage activities such as lifting and twisting.
● Physical therapy may increase muscle strength.
● Good body mechanics are essential.
● Balanced nutrition program is important in the management of metabolic disorders of bone, especially pertaining
to vitamin D, calcium, and protein, which are necessary to ensure the availability of the components for bone
formation.
● Initiate prevention measures such as patient teaching, use of an assistive device, and environmental changes to
prevent falls and subsequent fractures.
SAFETY ALERT:
● Reduce risk of patient home from falls
● Evaluate environmental fall risk factors
● Identify personal risk factors for falls, including drugs and uncorrected vision
● Take action to address any unidentified risks

Gerontologic Considerations: Metabolic Bone Diseases

● More common in older pt
● Nutrition
● Keep pt active to slow down demineralization
● Prevent pathologic fracture - turn or move pt very slowly
● Supervised exercise program
● Encourage ambulation