osteo, fractures, & gout

Question 1

T scores

Answer 1

-1 or greater → normal → normal bone mineral density

between -1 and -2.5 → low bone mass → osteopenia

less than or equal -2.5 → “porous bone” → osteoporosis

less than or equal -2.5 with a hx of a fragility fx → severe osteoporosis

Question 2

how do we measure bone mineral density

Answer 2

DEXA scan

results reported with T-score

Question 3

osteoporosis risk factors

Answer 3

aging
female
caucasian &  asian
hx fracture as an adult
family hx
low body weight (<127 lbs)
smoking
alcohol
corticosteroids & immune suppressive drugs

Question 4

other risk factors for osteoporosis

Answer 4

thin and small frame
lack of weight bearing exercises
lack of Ca and vit d
eating disorders, gastric bypass surgery
lack of estrogen/testosterone
excess caffeine

Question 5

FRAX

Answer 5

prediction tool for assessing individual risk of fx
used to provide treatment guidelines
can use dexa scan or other methods

Question 6

3 common fxs caused by osteoporosis

Answer 6

hip
wrist
vertebrae: compression fx

50% of all women greater than 50 years old will have a fx in one of these in their lifetime

Question 7

hip fracture complications

Answer 7

death after a fall (d/t complications r/t immobility)
lifetime risk: 18% women, 6% men
women experience 3/4 of all hip fxs
mortality rate 12-37%
osteoporotic hip fxs are specifically linked to an ↑ risk of mortality

Question 8

clinical presentation of hip fx

Answer 8

sudden onset of hip pain before or after fall
inability to walk
severe groin pain
tenderness
affected leg is externally rotated
affected extremity is shortened
typically no bruising

Question 9

complications of hip fx

Answer 9

infection: UTI’s, PNA

venous thromboembolism

Question 10

osteoporosis primary prevention

Answer 10

calcium (1200-2000mg daily post-menopausal)
vit d (800-1000IU daily)
exercise at least 30 min/3x week

Question 11

osteoporosis treatment

Answer 11

promote bone formation

decrease bone resorption

Question 12

bisphosphonates

Answer 12

1st line treatment for prevention and treatment of osteoporosis

Question 13

alendronate

moa

Answer 13

binds permanently to surfaces of bones
inhibits osteoclasts

↓ fxs by 50% for men & women

bishphosphonate

Question 14

bisphosphonate

SE

Answer 14

GI most common: N/D, discomfort

risk of esophageal ulceration: don’t lie down after taking

Question 15

bisphosphonate
alendronate
nursing implications

Answer 15

• take with water
• don’t lie down for 30 min after taking
• no food, drink, calcium or vitamins for 2 hrs (only 1% bioavailable
• drug holiday - after 5 years take a break to ↓ risk of jaw necrosis & esophageal cancer

Question 16

raloxifene

Answer 16

selective estrogen receptor modulator (SERMs)

Question 17

raloxifene

moa

Answer 17

mimics estrogen
inhibits bone resorption (not as well as bisphosphonates)

it is NOT hormone replacement therapy
only used in post-menopausal women to prevent & treat osteoporosis

Question 18

SERMs

SE and nursing implications

Answer 18

hot flashes, leg cramps

important to take adequate calcium & vit d
d/c at least 72 hrs before and during prolonged immobilization
no tobacco or alcohol
teratogenic
black box - stroke

Question 19

calcitonin-salmon

class & moa

Answer 19

hormone: bone resorption inhibitor (parathyroid agent)

inhibits bone removal by osteoclasts

not a 1st line drug, not used long-term

Question 20

calcitonin-salmon
uses & effects
routes

Answer 20

treatment only
↓spinal fxs by 30% only (have to take 5 yrs to see benefit)

slows down bone loss
increases spinal bone density

may have an analgesic effect in pt that have acute, painful vertebral fxs

SQ, IM, nasal - can cause nasal irritation

Question 21

causes of fractures

Answer 21

traumatic

fatigue - bone subjected to repeated, prolonged stress

pathologic - weakened bone, may break spontaneously, highest risk pop. is the elderly

Question 22

describing a fracture

Answer 22

• name of bone
• location on bone
• orientation of fx
• alignment of fx (displaced v aligned)
• condition of overlying tissue (closed v. open)

Question 23

fracture orientation

Answer 23

• transverse (90 degree to length of bone)
• spiral
• longitudinal (along length)
• oblique (diagonal)
• comminuted (> 1 fx line & more than 2 fragments)
• impacted (jumping from heights, crushing)
• greenstick (bends, doesn’t completely break, common in children)
• stress
• avulsion (fx of patella)

Question 24

clinical manifestations of fractures

Answer 24

P.E.D.

Paid
Edema
Deformity

Question 25

delayed healing

Answer 25

1. delayed union bone pain & tenderness ↑ 3 months - 1 yr after fx risk factors - smoking, malnutrition 2. malunion improper alignment - maybe began wt bearing too soon 3. nonunion no healing 4-6 months post-fx causes: poor blood supply, repetitive stress

Question 26

compartment syndrome

Answer 26

increased pressure within limited anatomic space manifestations: extreme pain, often very rapid onset, assess 5 P's (paresthesia, paralysis, pulselessness, pain, pallor)

Question 27

fat embolism

Answer 27

fat molecule in lung following long bone fx, major trauma typically occurs 24-48 hrs after injury triad of manifestations: hypoxemia altered LOC petechiae - often last sx no treatment - provide supportive care

Question 28

osteomyelitis

Answer 28

acute or chronic pyogenic (pus producing) infection of the bone Staph aureus usual cause Peds- long bones adults - vertebrae, hips

Question 29

risk factors for osteomyelitis

Answer 29

``` recent trauma diabetes - ↓ immune response hemodialysis IV drug use splenectomy PVD ``` DM & PVD → ↑ risk for chronic osteomyelitis

Question 30

2 routes of contamination that cause osteomyelitis

Answer 30

direct - open wound, gunshot, puncture, etc. hematogenous (direct) - from bloodstream (most common) usually occurs in long bones children < 16 y.o. at highest risk

Question 31

clinical manifestations of osteomyelitis

Answer 31

``` Local local tenderness, warmth, redness wound drainage restricted movement spontaneous fx ``` Systemic spiking fevers positive blood cultures ↑ WBCs

Question 32

Tx of osteomyelitis

Answer 32

Broad spectrum nafcillin cefazolin vanco bacteria specific once C&S comes back often IV therapy 4-6 weeks then transfer to PO

Question 33

sources of purine

Answer 33

alcohol - specifically beer organ meat (liver) red meat seafood, shellfish, sardines, scallops

Question 34

waste product of purine metabolism

Answer 34

uric acid

Question 35

gout predisposing factors

Answer 35

``` male genetics diet obesity diuretic therapy and kidney insufficiency ```

Question 36

gouty arthritis patho

Answer 36

elevated uric acid levels → uric acid accumulates in body fluids → formation of uric crystals → deposition in or around joints → inflammation → gouty arthritis often big toe affected

Question 37

gouty arthritis manifestations

Answer 37

Pain - intense - great toe - early morning → peaks 24-48 hrs → 5-10 days for flare up to resolve Inflammation - edema - tenderness - redness Fever Malaise

Question 38

Complications of gout

Answer 38

urate kidney stones

Question 39

pharmacotherapy for gout

Answer 39

ACUTE - NSAIDS - steroids - only if pt can't tolerate NSAIDs or is not responding to them - colchicine - acute and prophylactic PROPHYLACTIC - allopurinol - colchicine - probenecid

Question 40

allopurinol

Answer 40

inhibits production of uric acid (xanthine oxidase inhibitor which ↓ uric acid synthesis) prophylactic only AE: rash, typically well tolerated

Question 41

nursing implications with allopurinol

Answer 41

if gi upset, take with food or milk monitor serum/urine uric acid monitor serum glucose (may cause hypoglycemia) monitor PT/INR of pts on warfarin improve 2-6 weeks

Question 42

colchicine

Answer 42

anti-inflammatory, anti-gout mostly unknown, inhibits leukocyte infiltration (disrupts cell division) gout flares & prophylaxis

Question 43

colchicine | SE & nursing implications

Answer 43

GI effects → stop drug immediately (1st sign of toxicity) PO contra: renal disease Teach pt to avoid: they all inhibit breakdown of drug - ETOH - grapefruit - B12 vitamins substrate of CYP450 system check for other drugs that could interact

Question 44

probenecid

Answer 44

uricosuric agent inhibits reabsorption of uric acid in the kidneys, promoting excretion treats hyperuricemia with gout used alone or in combo with allopurinol when not effective alone

Question 45

probenecid | SE & nursing implications

Answer 45

GI upset - take with food, drink plenty of fluids dizziness, HA kidney/liver impairment - report hematuria, changes in urine output, wt gain/urine retention, jaundice, clay color stools lots of drug interactions