Metabolism

A patient with a musculoskeletal injury is instructed to increase dietary calcium. Which of the following statements by the nurse is appropriate?

"You need to increase the amount of vitamin D in your diet."

Bone Density Test Scores

-1 and above- normal -1--2.5- Oteopenia -2.5 or less- osteoporosis

Physical exercise- sedentary, lack of weight-bearing exercise, low weight and body mass

Bone needs stress for bone maintenance

Lifestyle Changes

Caffeine, alcohol, smoking, lack of exposure to sunlight- reduces osteogenesis in bone remodeling

Which of the following inhibits bone resorption and promotes bone formation?

Calcitonin

Which of the following inhibits bone resorption and promotes bone formation?

Calcitonin Explanation: Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased in osteoporosis. Estrogen, which inhibits bone breakdown, decreases with aging.

Which medication directly inhibits osteoclasts thereby reducing bone loss and increasing bone mass density (BMD)?

Calcitonin (Miacalcin)

Genetics

Caucasian or asian, female, family history, small frame- predisposes to low bone mass

Which group is at the greatest risk for osteoporosis?

Caucasian women Small-framed, nonobese Caucasian women are at greatest risk for osteoporosis. Asian women of slight build are at risk for low peak BMD. African American women, who have a greater bone mass that Caucasian women, are less susceptible to osteoporosis. Men have a greater peak bone mass and do not experience sudden estrogen reduction.

Diagnostic Tests

DEXA - Dual-energy X-ray Absorptiometry FRAX - Fracture Risk Assessment tool Labs Calcium Vit D Serum Phosphate- if high, decreases bone density Serum Alkaline Phosphatase Urine Calcium

Nursing Diagnosis

Deficient Knowledge about osteoporosis process and treatment regimen Acute Pain r/t fracture and muscle spasm Risk for Constipation Risk for Injury; fractures

RN Role

Educate, Exercise(weight bearing and balance), Diet Supplements, Calcium rich foods, Smoking Cessation, Alcohol in moderation, Recommend Bone density scans

Manifestations

Loss of height Progressive curvature of the spine Low back pain Fractures of forearm, spine, and hip Vertebral collapse Dorsal Kyphosis and cervical lordosis

Nutrition

Low calcium intake, low vitamin D intake, high phosphate intake (carbonated beverages), inadequate calories- reduces nutrients needed for bone remodeling

Medications- corticosteroids, anti seizure medications, heparin, thyroid hormone Co-morbidity- anorexia, hyperthyroidism, malabsorbtion syndrome, renal failure

affects calcium absorption and metabolism

The nurse is reviewing the medication administration record of the client. Which of the following medications would lead the nurse to suspect that the client is at risk for osteoporosis?

aloxifene (Evista) Explanation: Raloxifene (Evista) is used for the prevention and treatment of osteoporosis.

A drug of choice for the treatment of postmenopausal osteoporosis

Alendronate

A pt is taking biphosphonate, which should be taught? a. Take Vit D, calcium, and hormone replacement b. to restrict fluids c. to take drug with food for the day with a full glass of water d. to stay upright for 30 minutes after taking drug e. to take with meals to avoid GI upset f. to avoid exercise to prevent bone fracture

B, D

Medical Management - Medications

Bisphosphonates- slow or block bone resorbtion alendronate (Fosamax), Risedronate ( Actonate), Ibandronate (Boniva)- Zoledronic acid (Reclast)- PO & IV Calcitonin (Miacalcin) Selective Estrogen Receptor Modulators (SERM's) Raloxifene (Estiva) Recombinate PTH- Men/women- subQ daily for 2-3yr Teriparatide (Forteo)

Medical Management - Diet

Milk and milk products are the best sources of calcium (virtually impossible to achieve adequate calcium without dairy products) Salmon, Sardines, clams, Oysters, Turnips. Mustard, greens, Broccoli, cauliflower, kale, Legumes, Dried Fruit, Calcium fortified foods (orange juice, grape juice, margarine, breakfast bars)

Three cell types located in the bone are responsible for 'remodeling' , 'resorption' and 'osteogenesis

Osteoblasts - responsible for bone formation Osteocytes - mature bone cells involved in bone maintenance Osteoclasts - responsible for dissolving and resorbing bone

Age

Postmenopausal, advanced age, low testosterone in men, decreased calcitonin- hormones (estrogen, calcitonin, and testosterone) inhibit bone loss

Which of the following positions should be avoided in severe back pain?

Prone Explanation: A prone position should be avoided because it accentuates lordosis (inward curvature of the spine). Lumbar flexion is increased by elevating the head and thorax 30 degrees using pillows or a foam wedge and slightly flexing the knees supported on a pillow. Alternatively, the patient can assume a lateral position with knees and hips flexed (curled position) with a pillow between the knees and legs and a pillow supporting the head.

Which of the following is a risk-lowering strategy for osteoporosis?

Smoking Cessation

A nurse is performing discharge teaching for an elderly client with osteoporosis. Which instruction about taking a calcium supplement should the nurse include?

Take the supplement with meals or with orange juice. Explanation: Calcium supplements, such as Caltrate or Citracal, are over-the-counter medications. They should be taken with meals or with a beverage high in vitamin C

Kyphosis

also called roundback or Kelso's hunchback, is a condition of overcurvature of the thoracic vertebrae (upper back).

FRAX

is a fracture risk assessment tool (computer software) developed by the World Health Organization (WHO). FRAX calculates a person's absolute fracture risk or estimates of the chance of breaking a bone (eg, hip, spine) within the next 10 years. It can also help pinpoint those people who might benefit from taking an osteoporosis medicine. Both the National Osteoporosis Foundation and International Society for Clinical Densitometry have included FRAX in their recommended guidelines utilized by clinicians.

Lordosis

is the inward curvature of a portion of the lumbar and cervical vertebral column.[1] Two segments of the vertebral column, namely cervical and lumbar, are normally lordotic, that is, they are set in a curve that has its convexity anteriorly (the front) and concavity posteriorly (behind),

The U.S. Preventive Services Task Force (USPSTF)

recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures (Go to Clinical Considerations for discussion of women at increased risk). Rating: B Recommendation. Rationale: The USPSTF found good evidence that the risk for osteoporosis and fracture increases with age and other factors, that bone density measurements accurately predict the risk for fractures in the short-term, and that treating asymptomatic women with osteoporosis reduces their risk for fracture. The USPSTF concludes that the benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or presence of other risk factors. The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures. Rating: C Recommendation. Rationale: The USPSTF found fair evidence that screening women at lower risk for osteoporosis or fracture can identify additional women who may be eligible for treatment for osteoporosis, but it would prevent a small number of fractures. The USPSTF concludes that the balance of benefits and harms of screening and treatment is too close to make a general recommendation for this age group.

Osteoporosis

A metabolic bone disorder resulting in loss of bone density Osteopenia - thinning of bone matrix Osteoporosis - significant loss of bone matrix Caused by an imbalance of the processes that influence bone growth and maintenance

Foods that suppress or affect Calcium

Alcohol, Caffeine, Diet soda, Spinach, Rhubarb, Swiss Chard, Beets