Chapter 41: Musculoskeletal Disorders

The recommended adequate intake level of calcium for men 50 to 70 years is _____________ daily.

-1000 mg

Women aged 51 and older and men aged 71 and older is _________ mg daily.

-1200

Postmenopausal women and older adults need to consume approximately ______________ of daily calcium. Quantities larger than this may place patients at heightened risk of renal calculi or cardiovascular disease.

-1200 mg

Peak adult bone mass is achieved between the ages of a ______ and ______ years in both women and men

-18 -25

The prevalence of osteoporosis in women older than 80 years is ________.

-50%

The recommended vitamin D intake for adults up to 70 years of age is _____ IU daily, and ________ IU daily for those over the age of 70

-600 -800

Baseline DEXA testing is recommended for all women older than _____________, for women who are postmenopausal older than _________ with osteoporosis risk factors, and for all people who have had a fracture thought to occur as a consequence of _______________.

-65 years -50 years -Osteoporosis

Medical Management of Osteoporosis:

-A diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence and the middle years, protects against skeletal demineralization. -Regular weight-bearing exercise promotes bone formation. -Women who are postmenopausal and men aged 50 and older should be advised to avoid excessive intake of alcohol. -Those who use tobacco products should be advised to quit

Osteomalacia Gerontologic Considerations:

-A nutritious diet is particularly important in older adults. -Adequate intake of calcium and vitamin D is promoted. -Because sunlight is necessary for synthesizing vitamin D, patients should be encouraged to spend some time in the sun, for at least 10 minutes and up to an hour daily (Vitamin D Council, 2016). -Prevention, identification, and management of osteomalacia in older adults are essential to reduce the incidence of fractures. -When osteomalacia is combined with osteoporosis, the risk of fracture increases.

Common side effects of calcium supplements are _____________________ and _____________________.

-Abdominal distention -Constipation.

Age-related loss begins soon after the peak bone mass is ________________.

-Achieved

Severe renal insufficiency results in ________________. The body uses available _______________ to combat the acidosis, and PTH stimulates the release of skeletal calcium in an attempt to reestablish a physiologic pH. During this continual drain of skeletal calcium, bony fibrosis occurs, and bony cysts form. (Osteomalacia)

-Acidosis -Calcium

Risk Factors of Osteoporosis:

-Alcohol intake of 3 or more drinks daily -Current use of tobacco products -Family history -History of bone fracture during adulthood -Inactive or sedentary lifestyle -Inadequate calcium and vitamin D intake -Low body mass index -Malabsorption disorders (e.g., eating disorder, celiac disease, bariatric surgery) -Men older than 60 years of age -Women who are postmenopausal -Prescribed corticosteroids (e.g., prednisone) for longer than 3 months

Prolonged use of ________________ medication (e.g., phenytoin [Dilantin], phenobarbital) poses a risk of osteomalacia, as does insufficient vitamin D (dietary, sunlight).

-Anticonvulsant

What medications put patients at risk of osteoporosis?

-Anticonvulsants (phenytoin [Dilantin]) -Thyroid replacement agents (levothyroxine [Synthroid]) -Antiestrogens (medroxyprogesterone [Depo-Provera]) -Androgen inhibitors (leuprolide [Lupron]) -Proton pump inhibitors (esomeprazole [Nexium])

Patients with moderate to severe disease may benefit from specific _____________________ therapy. These medications reduce bone turnover, reverse the course of the disease, relieve pain, and improve mobility.

-Antiosteoclastic

Strategies for Preventing Osteoporosis in women who are menopausal and postmenopausal:

-Assess home environment for hazards contributing to falls. -Demonstrate good body mechanics. -Describe appropriate calcium supplements and pharmacologic agents to maintain and enhance bone mass. -Engage in exercise that improves balance to reduce risk of falls. -Review concurrent medical conditions and medications with primary provider to identify factors that contribute to bone mass loss.

Gerontologic Considerations for Paget Disease:

-Because Paget disease tends to affect older adults, patients and their families and caregivers should be educated about how to compensate for altered musculoskeletal functioning with an emphasis on the risk of falls. -The home environment is assessed for safety to prevent falls and to reduce the risk of fracture. -Strategies for coping with a chronic health problem and its effect on quality of life need to be developed. -If age-related hearing loss is exacerbated by Paget disease, alternative communication devices (e.g., text telephone, telecommunication device for the deaf) and home safety alarms may be indicated.

_______________________ are the cornerstone of Paget therapy in that they stabilize the rapid bone turnover. Their use may not suppress all Paget symptoms, but they reduce serum ALP and urinary hydroxyproline levels.

-Bisphosphonates

The consequence of osteoporosis is ________ ______________.

-Bone fracture

The femurs and tibiae tend to _______, producing a ___________ gait. The spine is bent __________ and is __________; the chin rests on the _________. The thorax becomes __________ during respiration. The trunk is flexed on the legs to maintain balance and the arms are bent outward and forward, appearing long in relation to the shortened trunk. (Paget Disease)

-Bow -Waddling -Forward -Rigid -Chest -Immobile

________________, which inhibits bone resorption and promotes bone formation, is ___________. ___________, which inhibits bone breakdown, also ____________ with aging. On the other hand, parathyroid hormone (PTH) ___________ with aging, thus increasing bone turnover and resorption. The consequence of these changes is net loss of bone mass over time. (Osteoporosis)

-Calcitonin -Decreased -Estrogen -Decreases -Increases

If kidney disease prevents activation of absorbed vitamin D, then supplementation requires the activated form _______________.

-Calcitriol).

Strategies for Preventing Osteoporosis for men:

-Characterize risk factors associated with osteoporosis in men, including medications (e.g., corticosteroids, anticonvulsants, aluminum-containing antacids) -Chronic diseases (e.g., kidney, lung, gastrointestinal), and undiagnosed low testosterone levels. -Participate in screening for osteoporosis. -Talk with primary provider about the use of medications (e.g., alendronate) to enhance bone mass or to correct testosterone deficiency.

Strategies for Preventing Osteoporosis for adolescents and young adults:

-Characterize risk factors for osteoporosis. -Consume diet with adequate calcium (1000-1300 mg/day) and vitamin D. -Engage in weight-bearing exercise daily. -Identify calcium- and vitamin D-rich foods. -Modify lifestyle choices—avoid smoking, alcohol, caffeine, and carbonated beverages.

What are the common fractures of osteoporosis? These fractures may be the _______ clinical manifestation of osteoporosis

-Commonly as compression fractures of the thoracic and lumbar spine, hip fractures, and Colles fractures of the wrist. -First

Nursing Intervention: IMPROVING BOWEL ELIMINATION

-Constipation is a problem related to immobility and medications. -Early institution of a high-fiber diet, increased fluids, and the use of prescribed stool softeners help prevent or minimize constipation. -If the vertebral collapse involves the T10-L2 vertebrae, the patient may develop a paralytic ileus. -The nurse therefore monitors the patient's intake, bowel sounds, and bowel activity.

The major defect in osteomalacia is a deficiency of activated vitamin _______, which promotes calcium absorption from the gastrointestinal tract and facilitates mineralization of bone. The supply of calcium and phosphate in the extracellular fluid is ______ and does not move to calcification sites in bones.

-D -Low

Nursing Diagnoses r/t Osteoporosis:

-Deficient knowledge about the osteoporotic process and treatment regimen -Acute pain related to fracture and muscle spasm -Risk for constipation related to immobility or development of ileus (intestinal obstruction) -Risk for injury: additional fractures related to osteoporosis

A family history has been noted, with siblings often ___________ the disease. The cause of Paget disease is _________________.

-Developing -Not known

If osteomalacia is ___________ in origin, the interventions are akin to those discussed previously in the discussion on osteoporosis. Long-term monitoring of the patient is appropriate to ensure stabilization or reversal of osteomalacia. Some persistent orthopedic deformities may need to be treated with braces or surgery (e.g., osteotomy may be performed to correct long bone deformity).

-Dietary

Some patients __________ experience symptoms but only have ___________ deformity. The condition is most frequently identified on x-ray studies performed during a workup for another problem. Sclerotic changes and cortical thickening of the long bones occur. (Paget Disease)

-Do not -Skeletal

Osteoporosis is diagnosed by _________________________, which provides information about BMD at the spine and hip.

-Dual-energy x-ray absorptiometry (DEXA)

Older adults absorb dietary calcium less _____________ and excrete it more ____________ through their kidneys.

-Efficiently -Readily

Assessment and Diagnostic of Paget Disease:

-Elevated serum ALP concentration and urinary hydroxyproline excretion reflect increased osteoblastic activity. Higher values suggest more active disease. -Patients with Paget disease have normal blood calcium levels. -X-rays confirm the diagnosis of Paget disease by revealing local areas of demineralization and bone overgrowth in the characteristic mosaic patterns. -Bone scans demonstrate the extent of the disease. -Bone biopsy may aid in the differential diagnosis with other bone diseases

Osteomalacia may result from:

-Failed calcium absorption or from excessive loss of calcium from the body (e.g., kidney failure). -Gastrointestinal disorders (e.g., celiac disease, chronic biliary tract obstruction, chronic pancreatitis, small bowel resection) in which fats are inadequately absorbed are likely to produce osteomalacia through loss of vitamin D (along with other fat-soluble vitamins) and calcium, the latter being excreted in the feces with fatty acids. -In addition, liver and kidney diseases can produce a lack of vitamin D because these are the organs that convert vitamin D to its active form.

Fracture Mangament r/t Osteoporosis:

-Fractures of the hip that occur as a consequence of osteoporosis are managed surgically by joint replacement or by closed or open reduction with internal fixation.

Peak adult bone mass is achieved between the ages of 18 and 25 years in both women and men and is affected by _____________________, _____________, ________________, _______________, ______________, and ____________________.

-Genetic factors -Nutrition -Physical activity -Medications -Endocrine status -General health

Normal homeostatic bone turnover is altered; the rate of bone resorption that is maintained by osteoclasts is ____________ than the rate of bone formation that is maintained by osteoblasts, resulting in a reduced total bone mass. (Osteoporosis)

-Greater

The incidence of Paget's Disease is slightly ___________ in aging men than in women.

-Greater

____________________________ leads to skeletal decalcification and thus to osteomalacia by increasing phosphate excretion in the urine.

-Hyperparathyroidism

Paget disease is ____________.

-Insidious

Assessment and Diagnosis for Osteomalacia:

-Laboratory studies show low serum calcium and phosphorus levels and a moderately elevated ALP. -Urine excretion of calcium and creatinine is low. -Bone biopsy demonstrates an increased amount of osteoid, a demineralized, cartilaginous bone matrix that is sometimes referred to as prebone.

Most residents of ______________________ facilities have a low BMD and are at risk for bone fracture.

-Long-term care

If osteomalacia is caused by ______________________, increased doses of vitamin D, along with supplemental calcium, are usually prescribed. Exposure to sunlight may be recommended; ultraviolet radiation transforms a cholesterol substance (7-dehydrocholesterol) present in the skin into vitamin D.

-Malabsorption

The degree of bone loss is related to the duration of ______________ therapy. When the drugs are discontinued or the metabolic problem is corrected, the progression is ___________ but restoration of lost bone mass may not occur (see Chart 41-5).

-Medication -Halted

Gerontologic Considerations for preventing injury r/t Osteoporosis:

-Older adults fall frequently as a result of environmental hazards, diminished senses and cardiovascular responses, and responses to medications. -The patient and family need to be included in planning for care and preventive management regimens. -For example, the home environment should be assessed for elimination of potential hazards (e.g., scatter rugs, cluttered rooms and stairwells, toys on the floor, pets underfoot). -A safe environment can then be created (e.g., well-lighted staircases with secure hand rails, grab bars in the bathroom, properly fitting footwear).

As a result of _______________, the skeleton softens and weakens, causing pain, tenderness to touch, bowing of the bones, and pathologic fractures.

-Osteomalacia

On physical examination of a patient with ________________, skeletal deformities (spinal kyphosis and bowed legs) give patients an unusual appearance and a waddling gait. These patients may be uncomfortable with their appearance and are at risk for falls and pathologic fractures, particularly of the distal radius and the proximal femur.

-Osteomalacia

What is the precursor to osteopenia?

-Osteomalacia

_____________________ is a metabolic bone disease characterized by inadequate mineralization of bone.

-Osteomalacia

Failure to develop optimal peak bone mass and low vitamin D levels contribute to the development of __________________ without associated bone loss.

-Osteopenia

________________________ is the most prevalent bone disease in the world.

-Osteoporosis

In ___________ ___________, a primary proliferation of osteoclasts occurs, which induces bone resorption. This is followed by a compensatory increase in osteoblastic activity that replaces the bone. As bone turnover continues, a classic mosaic (disorganized) pattern of bone develops. Because the diseased bone is highly vascularized and structurally weak, pathologic fractures occur. Structural bowing of the legs causes malalignment of the hip, knee, and ankle joints, which contributes to the development of arthritis and back and joint pain.

-Paget Disease

________________ ________________ is a disorder of localized rapid bone turnover, most commonly affecting the skull, femur, tibia, pelvic bones, and vertebrae.

-Paget disease (osteitis deformans)

Medical Management of Paget Disease:

-Pain usually responds to NSAIDs. -Gait problems from bowing of the legs are managed with walking aids, shoe lifts, and physical therapy. -Weight is controlled to reduce stress on weakened bones and misaligned joints. -Asymptomatic patients may be managed with diets adequate in calcium and vitamin D and periodic monitoring. -Fractures, arthritis, and hearing loss are complications of Paget disease. -Fractures are managed according to location. Healing occurs if fracture reduction, immobilization, and stability are adequate. -Severe degenerative arthritis may require total joint replacement; however, the afflicted "soft" bones do not make ideal surgical sites and are thus prone to complications. -Loss of hearing is managed with hearing aids and communication techniques used with people who have hearing impairments.

Nursing Intervention: PROMOTING UNDERSTANDING OF OSTEOPOROSIS AND THE TREATMENT REGIMEN

-Patient education focuses on factors influencing the development of osteoporosis, interventions to arrest or slow the process, and measures to relieve symptoms. -The nurse emphasizes that people of any age need sufficient calcium, vitamin D, and weight-bearing exercise to slow the progression of osteoporosis. -Patient education related to medication therapy as described previously is important. -Patients must understand that having one fracture increases the probability of sustaining another

______________________, ___________________, and _________________ measures are used to reduce the patient's discomfort and pain. (Osteolmalica)

-Physical -Psychological -Pharmaceutical

Nursing Intervention: PREVENTING INJURY

-Physical activity is essential to strengthen muscles, improve balance, prevent disuse atrophy, and retard progressive bone demineralization. -Isometric exercises can strengthen trunk muscles. The nurse encourages walking, good body mechanics, and good posture. -Daily weight-bearing activity, preferably outdoors in the sunshine to enhance the body's ability to produce vitamin D, is encouraged. -Sudden bending, jarring, and strenuous lifting are avoided.

________________ is given by IV infusion; hepatic, kidney, and bone marrow function must be monitored during therapy. Clinical remissions may continue for months after the medication is discontinued.

-Plicamycin (Mithracin)

_________________ has dramatic effects on pain reduction and on serum calcium, ALP, and urinary hydroxyproline levels; however, there are significant side effects.

-Plicamycin (Mithracin)

__________________ is reserved for severely affected patients with neurologic compromise and for those whose disease is resistant to other therapy.

-Plicamycin (Mithracin)

______________________, a cytotoxic antibiotic, may be used to control the disease.

-Plicamycin (Mithracin)

The bones become progressively ________________, _________________, and _____________. They fracture easily under stresses that would not break normal bone.(Osteoporosis)

-Porous -Brittle -Fragile.

Osteomalacia that results from malnutrition (deficiency in vitamin D often associated with poor intake of calcium) is a result of ______________________, __________________, and ___________________. It occurs most frequently in parts of the world where vitamin D is not added to food, where dietary deficiencies exist, and where sunlight is rare

-Poverty -Poor dietary habits -Lack of knowledge about nutrition.

_______________ osteoporosis occurs in women after menopause (usually by age 51) and in men later in life, but it is not merely a consequence of aging.

-Primary

Nursing Assessment r/t Osteoporosis:

-Recognition of risks and problems associated with osteoporosis form the basis for nursing assessment. -The health history focuses on family history, previous fractures, dietary consumption of calcium, exercise patterns, onset of menopause, and the use of certain medications (e.g., corticosteroids), as well as alcohol, smoking, and caffeine intake. -Any symptoms the patient is experiencing, such as back pain, constipation, or altered body image, are explored. -Physical examination may disclose localized pain, kyphosis of the thoracic spine, or shortened stature. -Problems in mobility and breathing may exist as a result of changes in posture and weakened muscles.

How long should someone with osteoporosis exercise?

-Recommendations include 20 to 30 minutes of aerobic, bone-stressing exercise daily

Osteoporosis is characterized by ______________________, _______________________, and _____________________.

-Reduced bone mass -Deterioration of bone matrix -Diminished bone architectural strength.

Nursing Intervention: RELIEVING PAIN

-Relief of back pain resulting from compression fracture may be accomplished by short periods of resting in bed in a supine or side-lying position. -The mattress should be supportive. -Knee flexion increases comfort by relaxing back muscles. -Intermittent local heat and backrubs promote muscle relaxation. -The nurse instructs the patient to move the trunk as a unit and to avoid twisting. -When the patient is assisted out of bed, a trunk orthosis (e.g., lumbosacral corset) may be worn for temporary support and immobilization, although such a device is frequently uncomfortable and is poorly tolerated by many older adults (Cosman et al., 2014). -The patient gradually resumes activities as pain diminishes.

__________________ osteoporosis is the result of medications or diseases that affect bone metabolism.

-Secondary

In most patients, skeletal deformity involves the ______. The skull may ___________, and the patient may report that a hat no longer fits. In some cases, the cranium, but not the face, is ___________. This gives the face a small, ___________ appearance. Most patients with skull involvement have impaired ________ from cranial nerve compression and dysfunction. Other cranial nerves may also be similarly affected. (Paget Disease)

-Skull -Thicken -Enlarged -Triangular -Hearing

Planning and Goals r/t Osteoporosis:

-The major goals for the patient may include knowledge about osteoporosis and the treatment regimen, relief of pain, improved bowel elimination, and absence of additional fractures.

What does a diet rich in calcium and vitamin D include?

-Three glasses of skimmed vitamin D-enriched milk or other foods high in calcium (e.g., cheese and other dairy products, steamed broccoli, canned salmon with bones) daily. -A cup of milk or calcium-fortified orange juice contains about 300 mg of calcium.

Pharmacologic therapy of Osteoporosis:

-To ensure adequate calcium intake, a calcium supplement (e.g., Caltrate, Citracal) with vitamin D may be prescribed and taken with meals or with a beverage high in vitamin C to promote absorption. -The recommended daily dose should be split and not taken as a single dose. -

True or False: Chronic glomerulonephritis, obstructive uropathies, and heavy metal poisoning result in a reduced serum phosphate level and demineralization of bone. (Osteomalacia)

-True

True or False: Early identification of at-risk teenagers and young adults, increased calcium and vitamin D intake, participation in regular weight-bearing exercise, and modification of lifestyle (e.g., reduced use of caffeine, tobacco products, carbonated soft drinks, and alcohol) are interventions that decrease the risk of fractures and associated disability later in life.

-True

True or False: Exercise improves balance, reducing the incidence of falls and fractures.

-True

True or False: It is estimated that the number of hip fractures and their associated costs will at least double by the year 2040 because of the projected aging of the United States population.

-True

True or False: Men are more likely than women to have secondary causes of osteoporosis, including the use of corticosteroids (especially if they receive doses in excess of 5 mg of prednisone daily for more than 3 months) and excessive alcohol intake.

-True

Osteoporosis may be __________________ on routine x-rays until there has been significant demineralization, resulting in radiolucency of the bones

-Undetectable

Tenderness and warmth over bones may be noted due to increased bone ___________. Patients with large, highly vascular lesions may develop high-output cardiac __________ due to the increased vascular bed and metabolic demands (Grossman & Porth, 2014). The pain is mild to moderate, deep, and aching. It increases with __________________. Pain and discomfort may precede skeletal deformities of Paget disease by years and are often wrongly attributed by the patient to old age or ______________. (Paget Disease)

-Vascularity -Failure -Weight bearing -Arthritis

Fracture risk can be estimated using the __________________________________________.

-World Health Organization (WHO) Fracture Risk Assessment Tool (FRAX).