Osteoporosis, and Hip Fractures Flashcards
What are some risks for osteoporosis?
Age >65
Thyroid disease (long time use of levothyroxine, can result in osteoporosis, post menopausal
femaleAdvanced age (> 65)
Low body weight
Cigarette smoking
Nontraumatic fracture
Inactive lifestyle
Family history of osteoporosis
Diet low in calcium or vitamin D deficiency
Excessive use of alcohol (>2drinks a day)
Postmenopausal, including premature or surgical menopause
White and Asian American descent
Low testosterone in men
Which drugs can interfere with bone metabolism?
Corticosteroids (prednisone)
Long-term corticosteroid use is a major contributor to osteoporosis.
When a corticosteroid is taken, loss of bone and inhibition of new bone formation occur.
Increases bone loss and stimulates breakdown
Anti-seizure drugs (e.g., valproate [Depakote], phenytoin [Dilantin])
What other influence do these drugs have?
Aluminum-containing antacids
Certain cancer treatments
Antiseizure drugs (e.g., valproate [Depakote], phenytoin [Dilantin]) What other influence do these drugs have?
Anti seizure drugs depress bone marrow, can have low bone marrow, blood count
Aluminum-containing antacids
Certain cancer treatments
Antacids- leads to poor absorption of other meds
Heparin is also a culprit in osteoporosis. Why?
Antidote for Heparin?
detrimental effect of heparin on bone, with an increase in fracture rate.Heparin—Heparin causes bone loss by decreasing bone formation. The few studies of the mechanism of bone loss have revealed decreased bone formation
Protamine Sulfate
Medications and Osteoporosis
Meds can decrease osteoblast function, increase bone resorption, inhibit GI calcium absorption,
What is the gold standard diagnostic test?
Her physician orders a dual-energy x-ray absorptiometry (DEXA Scan).
What is a DEXA scan?
A dexa scan is a measurement of bone mass of spine, femur, forearm, and total body. Allows assessment of bone density with minimal radiation exposure, used to diagnose bone disease and to measure response to treatment. One beam is high energy while the other is low energy. The amount of X-rays that pass through the bone is measured for each beam. This will vary depending on the thickness of the bone. Based on the difference between the two beams, the bone density can be measured.
At what age should a DEXA scan be conducted for a woman? For a man?
65 or older in women
Man - unless having hx or pain, bc there bone is bigger and denser
Diagnostic Studies Osteoporosis
Osteoporosis is a BMD >-2.5 standard deviations below a young adult BMD.
Osteopenia
is a BMD > -1.0 but less than - 2.5 standard deviations below a young adult BMD
What is osteopenia? “Pre osteoporosis”
Osteopenia is a loss of bone mineral density (BMD) that weakens bones. It’s more common in people older than 50, especially women. Osteopenia has no signs or symptoms, but a painless screening test can measure bone strength. Certain lifestyle changes can help you preserve bone density and prevent osteoporosis
Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone among the elderly.
is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone among the elderly.
Osteomalacia causes soft bones due to a lack of
vitamin D.
What other Diagnostic Studies Are Appropriate?
History and physical exam
Hip, vertebra, or wrist fracture Back pain Loss of height Spinal deformities Kyphosis Stooped posture
Quantitative ultrasound
Uses sound waves to evaluate bone mass
May see increased use due to cost effectiveness
x-ray
Osteoporosis 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.
normal, although alkaline phosphatase may be elevated after a fracture.
Blood Tests
Many of the blood tests are used to screen for disease processes that may contribute to osteoporosis
Albumin is affected by alcohol
Albumin can be impacted with liver dx check for elevated ALT and AST! (if 3x’s the normal)
Liver fx study to look for decreased platelets
Look for thyroid problems
Thyroid stimulating hormone
High TSH = hypo
High T3, T4 maybe they are taking too much levothyroxine?
Other tests that might be helpful
CBC
Serum Chem levels
Vitamin D Levels check for
insufficiency, can predispose a patient to osteoporosis
= low mood, low immune, low calcium absorption
Calcium Homeostasis The calcium level in blood is balanced by:
Parathyroid hormone (PTH)
secreted by the parathyroid gland
If calcium level is low – PTH raises calcium level by stimulating osteoclasts to break down bone
Increases calcium resorption from kidneys
Calcitonin hormone
secreted by the thyroid gland
if calcium level is too high – calcitonin moves calcium from the blood and deposits it in bones
Decreases calcium resorption in kidneys
When calcitonin is released in response to high calcium levels, calcium is
not reabsorbed in kidneys and neither is phosphorus.
Which two antagonistic hormones play the major role in calcium homeostasis
PTH and calcitonin
Calcium phosphorus relationship
Calcium high, phosphorus and vice versa
Phosphates (phosphorus) are used clinically to treat the following:
Hypophosphatemia, low levels of phosphorus in the body
Hypercalcemia, high blood calcium levels
Calcium based kidney stones
Phosphates are also used.
Phosphates are also used in enemas as laxatives. Most people get plenty of phosphorus in their diets. Sometimes athletes use phosphate supplements before competitions or heavy workouts to help reduce muscle pain and fatigue, although it’s not clear how much it helps or if it improves performance.
Osteoporosis is
Chronic, progressive metabolic bone disease characterized by Porous bone Low bone mass Structural deterioration of bone tissue Increased bone fragility
More common in women than men for several reasons
Lower calcium intake than men
Less bone mass because of smaller frame
Bone resorption begins earlier and accelerates after menopause.
Etiology and Pathophysiology
In osteoporosis, bone resorption exceeds bone deposition.Wedging and fractures of vertebrae produce gradual loss of height and a humped back known as dowager’s hump or kyphosis.
Occurs most commonly in
Occurs most commonly in spine, hips, and wrist
Bone is continually being deposited by osteoblasts and resorbed by
osteoclasts, a process called remodeling.
Normally, rates of bone deposition and resorption are
Normally, rates of bone deposition and resorption are equal to each other, so that the total bone mass remains constant.
Clinical Manifestations of Osteoporosis
Often termed the….
“silent disease” because there are no symptoms
Since no symptoms, the usual first signs are
back pain and spontaneous fractures
Physiology of Bone Growth
Bone is a living tissue undergoing change
About 10% of skeleton is broken down each year.
OsteoClasts break down (Crush) areas of old or damaged bone
OsteoBlasts Build new bone in those areas
Osteocytes maintain and monitor mineral content
Which picture best represents osteoporosis?
Porous bone is what occurs
What treatment options are available?
Calcium supplementation, bisphosphonates, calcitonin, selective estrogen receptor modulators.
No smoking, get exercise, eat foods with high amounts of calcium.
CAUTION: Risk of massive calcium supplementation, however, can cause too much calcium deposits in the heart.
Biphosphonate: take 1st thing in the a.m. on empty stomach, make sure person is upright after 30 minutes, bc biphosphanate bubbles up and can creep up to esophagus and can cause irritation, give with full glass of water to help with absorption. Can recommend to go for 30 minute walk, helps with weight bearing exercise, pt. gets Vit D.
What lifestyle changes can she make to improve her condition?
Moderate amounts of exercise are important to build up and maintain bone mass. The best exercises are weight-bearing exercises that force the individual to work against gravity. Exercises that are low impact, such as walking, hiking, weight training, and dancing are recommended to avoid stress fractures associated with high-impact activities. Review with her general measures to reduce her risk of falling, including getting up slowly, wearing well-fitting shoes, removing any loose rugs in the house, making sure all of the walkways are kept clear, using grab bars and nonskid mats in the bathroom, and having appropriate lighting, particularly at nighttime.
Overview Collaborative CareFocus on
Proper nutrition Calcium supplements Exercise Prevention of fractures Drug therapy Vertebroplasty Kyphoplasty
Collaborative CareNutrition
Milk Cheese Yogurt Ice cream (soft serve best!) Salmon Seafood Broccoli Spinach
Collaborative CareSupplements
Calcium
1500 mg/day post menopausal women
1000 mg/day premenopausal or post menopausal taking estrogen
2. Supplemental vitamin D may be recommended.
800 units to 1000 units
20 minutes of sunlight daily
3. Calcitonin
inhibits osteoclastic bone resorption interacts with active osteoclasts
Salmon calcitonin (Calcimar)
intramuscular, subcutaneous, and intranasal forms.
When calcitonin is used, calcium supplementation is necessary to prevent secondary hyperparathyroidism.
Collaborative CareDrug Therapy
Bisphosphonates inhibit osteoclast-mediated bone resorption (e.g., etidronate [Didronel], alendronate [Fosamax]).
NATES are our bone building meds
These drugs include etidronate (Didronel), alendronate (Fosamax), pamidronate (Aredia), risedronate (Actonel), clodronate (Bonefos), tiludronate (Skelid), and ibandronate (Boniva).
The nurse is caring for a patient taking alendronate (fosamax). What education should the nurse include in discharge teaching?
Always best to get nutrients from food.
1st thing in morning Empty stomach Upright Full glass of water Go for a walk Jaw pain
Will taking these supplements cure me?”
Prevention and treatment depend on adequate calcium intake.
Increased calcium prevents future loss but will not form new bone.
Exercise and Lifestyle
Weight bearing that force work against gravity is best
Walking, hiking, weight training
Quit smoking
Cut down on alcoho
Collaborative CarePrevention of Fractures
Install grab bars Sit to shower Make your shower less slippery Raise your toilet seat Make the last step stand out Reduce clutter including wires Take care around uneven floor surfaces Keep items within easy reach Use a stepstool.
Drug Therapy Selective estrogen receptor modulators
Raloxifene (Evista) - estrogen
Teriparatide (Forteo)
Portion of parathyroid hormone
First drug to stimulate new bone formation
What factors increase risk of hip fracture in older adults?
Falls Poor balance Limited shock absorbers (Fat, muscles, bulk) Gait Decreased vision and hearing Slow reflexes Hypotension Medication use Loose rugs
Other Factors
Trip over the pets
Evidence Based Practice
Yoga was more effective than a self-care book in improving function and reducing pain for at least several months.
Yoga was no better than stretching classes.
Assist patients in identifying resources and community classes that focus on stretching exercises and yoga and encourage participation. Zumba
Suspected in hip fracture
Leg short with external rotation External rotation
Muscle spasm
Shortening of affected extremity
Severe pain and tenderness in region of the fracture
Hip Fractures-
Disruption or break in continuity of the structure of bone Fracture of proximal third of femur extending up to 5cm below lesser trochanter Intracapsular fracture (femoral neck)
Common in older adults
Due to osteoporosis or trauma
Many develop disabilities requiring long-term care
What are the initial assessments and treatment?
Assessment
Temperature, cap refill, distal pulses, edema, sensation, motor function
Past medical history
X-ray
Pain Management
Analgesics
Muscle relaxants
Positioning
Teaching upmost importance Surgery will take place quickly Exercise unaffected leg Use trapeze bar PT to begin to teach chair transfers
Overall goals of fracture treatment
Anatomic realignment of bone fragments
Immobilization to maintain realignment
Restoration of normal or near-normal function of injured parts
Skin traction (Buck’s Traction)
Used for short-term treatment until surgery is possible Used for 24- 48 hours Traction weights 5 to 10 pounds Application of a pulling force to an injured or diseased part of body or extremity while counter traction pulls in opposite direction Purpose of traction Prevent or ↓ muscle spasm Immobilize joint or part of body ↓ a fracture or dislocation Treat a pathologic joint condition
Care of client in traction
Temp Ropes hang freely do not touch floor Alignment Circulation check 5P's Type of location of fracture Increased fluid intake Overhead trapeze No weights on bed or floor
Surgery is recommended….
Surgical Repair- Fracture Reduction
Open reduction (ORIF)
Correction of bone alignment through surgical incision
Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails
Chief disadvantages
Possibility of infections
Complications associated with anesthesia
Effects of preexisting medical conditions
Nursing Management
Prior to surgery Monitor vital signs Neurovascular checks Maintain proper alignment Monitor Buck’s traction if applicable Medicate for pain/muscle spasms Pre-op teaching
Post op nursing management
Post-op Monitor vital signs Monitor for bleeding Monitor I&O Turn, Cough & Deep Breath Medicate for pain Maintain Abduction Mobilize patient as soon as possible(first post op day) Prevent complications (such as DVT, infection, etc.)
Infection in bone
osteomyelitis, very strong antibiotics to get rid of it, 6 or more weeks on vancomycin or other mycin meds
5 P’s
Pain Paresthesia Paralysis Pulse Pallor
Hip Fracture post op
DVT's Bleeding, swelling, skin breakdown, Atelactasis urinary retention Delayed complications, infection Hypotension
Watch for
severe pain
inability to move the leg
shortening and external rotation of the leg
What teaching is important to provide?
Fall precautions
Avoid flexing more than 90 degrees
Watch for sudden severer pain, a lump in the buttock, limb shortening and external rotation
These are signs of dislocation
Place a large pillow between legs when turning
Avoid turning on affected side until approved by surgeon
You do not want to cause the leg to change position greater than 90. If you narrow angle in hip, then hip joint might come out of their socket. Like the butt sinking into a chair, now legs/knees are greater than 90 degrees, can even ruin the surgery.
Joint Arthroplasty
Replacement or reconstruction of a joint to decrease pain, improve ROM, decrease deformity
Collaborative CareHip Arthroplasty
For posterior approach hip arthroplasties, do not flex greater than 90 degrees
Knees must be kept apart
Avoid bending – get raised toilet seat, grab bars
DVT prophylaxis – extremely important for joint surgeries on lower part of the body
* knees and hips highest risk
May be on warfarin (Coumadin), rivaroxiban (Xarelto), abixaban (Eliquis) for several weeks Hip and knee surgeries are highest risk for DVT’s. Question if heparin is not ordered for example.
