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wvc Ch53muscskel
osteoporosis, osteomyelitis (disorders)
| Question | Answer |
|---|---|
| Osteoporosis is a… | chronic metabolic disease in which bone loss causes decreased density and possible fx. |
| Which bones are most often at risk for fx in osteoporosis? | *hip *spine *wrist |
| Bone Remodeling | process in which bone tissue is constantly undergoing changes |
| Osteopenia | low bone mass |
| Osteoporosis and Osteopenia occur when… | osteoclastic activity is greater than osteoblastic activity->the result is ↓ bone mineral density (BMD) |
| BMD determines… | bone strength and peaks between ages 25 and 30. |
| Before and during BMD peak years, osteoclastic and osteoblastic activity work at… | the same rate |
| After peak years, osteoclastic (bone resorption) activity…. | exceeds osteoblastic activity and bone density ↓ |
| BMD decreases most rapidly in… | postmenopausal women as serum estrogen level ↓ |
| Although estrogen does not build bone, it… | helps prevent bone loss. |
| Trabecular (aka cancellous spongy bone) is… | lost first ->followed by loss of cortical (compact) bone. |
| ______ theories about the pathophysiology of osteoporosis exist… | 2 |
| First theory about development of osteoporosis.. | that osteoporosis may occur as a result of ↑ osteoclastic activity and a ↓ in osteoblastic activity RELATED TO CHANGES IN HORMONE LEVELS AND OTHER DISEASE PROCESSES. |
| Second theory of development of osteoporosis… | thought that osteoblasts may have a shortened life span or may be less efficient in pts with osteopor. |
| Osteoporosis can be classified as… | *generalized or *regional |
| Generalized Osteoporosis | involves many structures in the skeleton and is further divided into 2 categories->Primary and Secondary |
| Primary Osteoporosis | *more common *occurs in postmenopausal women d/t ↓ estrogen *in men in 70s-80s->this type probably caused by a combination of risk factors and genetic changes |
| Risk factors for Primary Osteoporosis | *age 65 ↑women/↑75male *family hx *ethnicity *low body wt/thin build *chronic low Ca+ intake *Estrogen and androgen deficiency *smoking *hi alcohol intake *lack of physical exercise |
| Secondary Osteoporosis | *may result from medical conditions (hyperthyroidism) *long term drug therapy *prolonged immobility tx of this type directed toward cause of osteoporosis |
| Causes of Secondary Osteoporosis: | *Diabetes *Hyperthyroidism *Hyperparathyroidism *Cushing’s *RA *Cirrhosis *HIV/AIDS *Prolonged immobilization |
| Regional Osteoporosis | *example of a secondary disease *occurs when limb is immobilized r/t fx, injury, paralysis for longer than 8-12 wks. |
| Osteoporosis occurs more often in… | thin, lean-built European-american and asian women |
| _________ __________ exercise reduces bone resorption (loss) and stimulates bone formation… | weight bearing exercise |
| Relationship of osteoporosis and nutrition is well established… | *excess caffeine=Ca+ loss in urine because soda has phosphorus in the carbonated beverage and the equilibrium between P+ and Ca+ is not maintained. |
| Diet lacking enough Ca+ and Vit. D stimulates… | parathyroid gland to produce parathyroid hormone (PTH) which triggers release of Ca+ from bony matrix. |
| Activated Vit. D is needed for… | Ca+ uptake in the body |
| What also contributes to low serum Ca+ levels in body? | malabsorption of nutrients in the GI tract. |
| Protein deficiency may also reduce… | bone density because 50% of serum Ca+ is protein bound and protein is needed t use calcium. |
| Excessive alcohol and tobacco use are other risks for osteoporosis because they promote… | acidosis which in turn ↑ bone loss. |
| Alcohol also has a direct toxic effect on bone tissue by… | ↓ bone formation and ↑ bone resorption |
| Osteoporosis also occurs in young adults who… | *are athletes *have eating disorders (anorexia/bulimia) *low body wt *absent menstruation *crash dieting |
| Most common type of fx in osteoporosis cases… | vertebral fx |
| Teaching about osteoporosis should begin… | with young women who begin to lose bone after 30 yrs of age. |
| The focus of osteoporosis prevention is to… | ↓ modifiable risk factors->ex: teach pts to include enough Ca+ intake into their diet through dairy and dark green, leafy veggies, teach them to read food labels for sources of Ca+ content. |
| More teaching to pts… | *explain importance of sun exposure or adequate Vit. D in diet *limit amount of carbonated beverages *importance of exercise (weight- bearing to build bone tissue) *avoid activities that cause jarring |
| What is important in the prevention, early detection, and tx of osteoporosis? | a complete health hx with assessment of risk factors |
| What needs to be an included assessment in obtaining a health history… | a fall risk assessment |
| Fall risk factors include… | *delirium *dementia *immobility *muscular weakness *Hx of falls *visual or hearing deficits *current drugs |
| Dowager’s hump aka… | kyphosis of the dorsal spine |
| When performing a physical assessment include… | *palpation of vertebral column *height/wt measurements (compare with old) *assessment of pain |
| Pain with osteoporosis is worse with… | activity and is relieved by rest. |
| Back pain accompanied by tenderness and voluntary restrictions of spinal movement suggests… | one or more compression vertebral fractures |
| Movement restriction and spinal deformity may result in… | *constipation *abdominal distention *reflux esophagitis *respiratory compromise in severe cases |
| Osteoporosis can result in… | suffering, deformity, and disability that can affect a pts well-being and life satisfaction |
| Quality of life for pts with osteoporosis may be further impacted by… | *px *insomnia *depression *fallophobia * |
| When doing a psychosocial assessment on a pt with osteoporosis, make sure to assess… | a pts concept of body image because their social interactions, sexuality and self-esteem may be compromised d/t deformities such as kyphosis. |
| Also it is important to teach the pt with osteoporosis to be… | extremely cautious about activities, and as a result, the threat of fx can create anxiety and fear and result in further limitation of social and physical activities.-->assess for these feelings. |
| Laboratory Assessment Findings for osteoporosis… | biochemical markers that provide info about bone resorption and formation activity.-->used to monitor effectiveness of tx for osteoporosis. |
| Increased levels of biochemical markers indicate… | risk for osteoporosis and are found in pts with osteoporosis |
| A battery of tests can be performed to rule out SECONDARY OSTEOPOROSIS such as… | *measurement of serum Ca+, Vit. D, and P+. *Serum protein measurements *thyroid fxn tests |
| Use of Imaging Assessment in osteoporosis: | *Convential X-ray *Dual X-ray absorptiometry *QCT * |
| Conventional X-ray shows… | of spine and long bones shows ↓ bone density but only after 25-40% bone loss has occurred as well as fx shown. |
| Dual X-ray absorptiometry (DXA)… | most commonly used screening and diagnostic tool for measuring bone mineral density (BMD) and T-score is calculatedspine and hip most often assesseda painless scan that emits less radiation than chest x-ray |
| The BEST tool currently available for a definite diagnosis of osteoporosis… | DXA |
| (QCT) Quantitative computed tomography | also measures bone densityanalyzes trabecular and cortical bone separately and is esp. sensitive to changes in vertebral columnthis test more sensitive than DXA and exposes pt to more radiation. |
| The most common Nsg Dx that apply to pts with osteoporosis: | *Risk for falls *Impaired Physical Mobility *Acute pain and/or chronic pain *Potential for fractures r/t weak, porous bone |
| What kind of interventions are used in pts with osteoporosis? | *Nutrition Therapy *Exercise *Lifestyle changes *Drug therapy *Surgical intervention |
| Nutrition Therapy | nutrional considerations are the same as if trying to prevent osteoporosis: adequate amounts of *protein *Mg+ *Vit. K *trace minerals needed for bone formation |
| Additionally in nutritional therapy, Ca+ and Vitamin D should be… | increased |
| People who are lactose intolerant can ingest a variety of… | soy and rice products that are fortified with Ca+ and Vit. D or they are added in fruit juices, bread, cereal products. |
| A variety of nutrients are needed to maintain bone health and the promotion of a SINGLE nutrient will… | NOT prevent or treat osteoporosis. |
| Exercise Intervention | important in the prevention and management of osteoporosis. Also plays a vital role in px management, cardiovascular fxn and improved sense of well-being. |
| A physical therapist may prescribe what for osteoporosis pts? | excercises for strengthening abdominal and back muscles(improve posture, ect.) , deep breathing, pectoral stretching to increase lung capacity. |
| It is the nurses role to… | encourage active ROM excercises which improve joint mobility and increase muscle tone. Swimming also improves allover muscle exercise. |
| In addition to excercises for muscle strengthening, a general _________ ___________ exercise program should be implemented… | weight bearing->walking 30 min three to five times a week is the single most effective exercise for osteoporosis prevention. |
| Lifestyle Change Interventions | *avoid tobacco/alcohol *careful to prevent falls and other activities that could cause fx *teach pt about importance of having hazard-free environment (no rugs,ect.) |
| Drug Therapy Interventions: | *Ca+/Vit. D supplements *Estrogen/Hormone Therapy *bisphosphonates *selective estrogen receptor modulators (SERM’s) *Calcitonin *Combo of several drugs to tx/prevent osteop. |
| Estrogen and combination hormone therapy | least expensive but increase health risks for women->Estrogen Replacement Therapy (ERT) or Hormone Replacement Therapy estrogen and progesterone) (HRT) |
| Long term effects of ERT and HRT: | increase women’s risk of cardiovascular disease, breast cancer, and venous thromboembolism (VTE) |
| ERT/HRT should be used… | in a low dose for a short duration of tx.-->hormones SHOULD NOT be used only for prevention of osteoporosis. |
| Parathyroid Hormone | teriparatide (rDNA origin)*a parathyroid agent *brand name Forteo *a bone building agent approved for TX of osteoporosis in postmenopausal women with hi risk of fx. *stimulates new bone formation *given subq *may experience dizziness/leg cramping |
| Calcium and Vitamin D | OTC drugs such as Os-Cal, CitracalCa+supplements should be taken with 6-8 oz. of water and is best to divide the daily dose with at least 1/3 taken in evening. *Vit. D 400-800 u/day |
| Vitamin D is vital for… | optimal calcium absorption in the intestines. |
| Hypocalcaemia can cause… | serious damage to urinary system. |
| Bisphosphonates | *slow bone resorption by binding to crystal elements in bone(trabecular) *Most common drugs used for osteoporosis |
| Examples of Bisphosphonates: | *Alendronate (Fosamax) *Risedronate (Actonel) *Ibandronate sodium (Boniva)all 3 of these drugs available in oral form but boniva also IV |
| Bisphosphonates are commonly used in… | prevention and treatment of osteoporosis in postmenopausal women and hypocalcaemia associated with cancer. |
| Oral BP’s are commonly associated with… | esophagitis (inflammation of the esophagus) |
| d/t espophagitis what are some measures to take when taking BP’s? | *take drug early in morning *take with 8oz. water *wait 30 minutes in an upright position before eating |
| Pts with what ailments should not take BP’s? | *those with poor renal fxn *hypocalcaemia *gatroesophageal reflux disease (GERD) |
| What is a problem associated in pts taking BP’s? | osteonecrosis (jaw bone death)teach pts to have an oral assessment and preventive dentistry before beginning BP therapy. |
| Selective Estrogen Receptor Modulators (SERM’s)… | designed to mimic estrogen in some parts of body while blocking its effect elsewhere Raloxifene (Evista) |
| Raloxifene (Evista) is used to… | treat and prevent osteoporosis in postmenopausal women. |
| Effects of Raloxifene (Evista): | *↑ BMD *↓bone resorption *↓incidence of osteoporotic vertebral fx |
| Raloxifene (Evista) should not be used in women who… | have a hx of thromboembolism. |
| Calcitonin | a thyroid hormone that inhibits osteoclastic activity, thus ↓bone loss. Used in the tx of osteoporosis and also has analgesic effect after vertebral fx, thereby promoting early recovery. |
| Calcitonin, which can be derived from salmon, can be given… | *subcutaneously *intranasally (Miacalcin) |
| The nasal route is preferred because… | *it improves drug adherence *decreases side affects *is convenient |
| However, the effect of salmon calcitonin may decrease after use of… | 2 or more years, so pt needs to d/c for a time. |
| It is important to teach a pt taking Miacalcin to… | alternate nares to prevent mucosal irritation which is a common side effect.. Drug must also be refrigerated. |
| Androgens | *successful in ↓ bone resorption(particularly in older men) and ↑ bone growth *when given to postmenopausal women, they cause masculine traits and may lead to liver disease. |
| Example of Androgen: | testosterone propionate (Testex) |
| Surgical Interventions for Osteoporosis | *Vertebroplasty *Kyphoplastyminimally invasive procedures used to tx vertebral body compression and fx. |
| Vertebroplasty: | the injection of bone cement into the vertebral body to reduce a fx or fill the space created by osteoporosis |
| Kyphoplasty: | the use of a balloon in the vertebral body to contain bone cement. |
| Focus on Osteomyelitis | |
| Osteomyelitis: | a bone infection caused by bacteria, viruses and fungi. |
| Bone infection can result in… | *chronic recurrence of infection *Loss of function/mobility *amputation *even death. |
| The invasion of one of the pathogenic microorganisms stimulates… | the inflammatory response in bone tissuecauses ↑ vascular leak and edema often involving surrounding tissuesvessels in the area become thrombosed an release exudates (pus) into bony tissueischemia occursresults in necrotic bone. |
| The area of the necrotic bone then will then… | seperate from the surrounding bone tissue and sequestrum is formed. |
| Sequestrum | prevents bone healing and causes superimposed infection often in form of bone abscesscycle of inflammation repeats itself as this new infection presents. |
| Osteomyelitis is categorized as… | *exogenous or *endogenous |
| Exogenous Osteomyelitis | where infectious microbes enter from outside the body in an open fx or wound |
| Endogenous Osteomyelitis | Infectious microbes are carried by the bloodstream from other areas of infection in the body. Aka hematogenous osteomyletitis |
| A third category of Osteomyelitis: Contiguous Osteomyelitis: | where bone infection results from skin infection of adjacent tissues. |
| Osteomyelitis can further be divided into two major types: | *acute osteomyletitis *chronic osteomyelitis |
| Acute hematogenous infection results from | bacteremia, underlying disease, or nonpenetrating trauma…aka a UTI in older men that often spread to lower vertebrae. |
| Pts at risk for Osteomyelitis … | *those with long term IV catheters *pts undergoing long term hemodialysis *IV drug users |
| _________ infections of the GI tract may spread to the bone… | SalmonellaSalmonellosis (pts with sickle cell disease) |
| Causes of Contiguous Osteomyelitis in facial bones: | *poor dental hygiene *periodontal (gum) infection |
| Regardless of the source of infection, many infections are caused by… | Staphylococcus aureus-->tx of infection may be further complicated by MRSA |
| What causes acute osteomyelitis? | penetrating trauma by direct inoculationanimal bites, puncture wounds, bone surgery |
| Most common offending organism in acute osteomyelitis? | pseudomonas aeruginosa (gram-negative) |
| Chronic osteomyelitis may occur when… | a bone infection is misdiagnosed or inadequately treated.-->about ½ of these cases also caused by gram-negative bacteria. |
| Although bacteria are the most common causes of osteomyelitis… | viruses and fungal organisms also may cause infection. |
| What is the most common type of osteomyelitis? | hematogenous osteomyelitis and is more common in children. |
| What conditions increase the risk and complicate effective tx for osteomyelitis? | *malnutrition *alcoholism *diabetes *kidney/liver disease *immunosupressing disorders |
| What are common sites for infection? | *bone tissues in vertebrae and long bones |
| Key features of Acute Osteomyelitis: | *fever usually above 101 *swelling around infected area *erythema of infected area *tenderness *bone px that is constant, localized, and pulsating, intensifies with movement |
| Key features of Chronic Osteomyelitis: | *Ulceration of the skin *Sinus tract formation *localized px *drainage from affected area. |
| A pt with osteomyelitis often has… | elevated WBC count, usually 2x’s the normal count, but in chronic form, normal or slightly levels may be present. |
| The erythrocyte sedimentation rte (ESR) may be ________ early in the course of the disease but raises as condition progresses… | normal |
| What test is performed to identify the type of offending organism creating in bacteremia infection? | Both aerobic and anaerobic blood cultures |
| What is also extremely helpful in dx of osteomyelitis? | *Bone scan using technetium or gallium *MRI |
| Special treatment protocol depends on… | type and number of microbes present in the infected tissue |
| To reverse acute osteomyelitis | *antimicrobial (antibiotic) therapy *Contact precautions *IV antimicrobial therapy prescribed for several weeks |
| It is important that when a nurse administers the antimicrobials that.. | they give the drugs at specifically prescribed times so that therapeutic serum levels are achieved. |
| It is important to teach the pt and family members that the drugs need to be… | taken until the prescription is done to prevent superbugs. |
| Optimal drug regimen for chronic osteomyelitis | *prolonged therapy for 3 or more mos. *peripherally inserted central catheter for drug administration *oral therapy for weeks or months. |
| Drugs may also be needed to tx __________ in osteomyelitis… | pain |
| Hyperbaric Oxygen (HBO) Therapy | a treatment to increase tissue perfusion and promote healing in pts with chronic osteomyelitis.--> used in conjunction with high dose drug therapy and surgical debridement |
| Surgical techniques used to minimize the disfigurement as a result of severe, chronic osteomyelitis… | *sequestrectomy *grafts *microvascular bone transfers |
| Sequestrectomy | performed to debride necrotic bone and allow revascularization of tissue. |
| The excision of dead and infected bone often results in a sizable cavity, in which case a __________ may be needed… | graft->used to repair bone defects. |
| Microvascular bone transfers | used when infected bone is extensively resected and is reserved for larger skeletal defects.-->most common donor sites are pts fibula and iliac crest. |
| After surgery for one of the surgical interventions, the nurse must assess postoperatively for… | patients neurovascular status: *pain *movement *sensation *warmth *temperature *distal pulses *capillary refill |
| The nurse wants to check for neurovascular compromise such as… | *pain that can’t be controlled *paresis or paralysis (weakness or inability to move) *paresthesias (abnormal, tingling feeling) *pallor and pulselessnes |
| If a bony defect is small, a _________ _____________ may be the only surgery required… | muscle flapused to tx chronic osteomyelitis when soft tissue does not fill in the dead space. |
| The muscle flap provides… | wound coverage and enhances blood flow to promote healing. |
| As a last resort, the effected limb with osteomyelitis may need to be… | amputated |
| For all of the surgical procedures and their recovery phases, long-term ___________ treatment is necessary… | antimicrobial |
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wvc
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