Care of Patients with Musculoskeletal Problems

3 drugs for osteoporosis

1. Meds with high calcium and vit D supplement, like Oscal and Citracal -- 1/3 of the dose should be given at bedtime, and other 2/3 doses during day 2. Bisphosphonates - (Fosamax and Reclast) given on empty stomach 3. Estrogen agonist (Evista) - may cause DVT

Interprofessional Collaborative Care for Osteoporosis

:-Fall Risk Assessment -Diagnostic Testing (Serum calcium should be between 9.0 and 10.5 mg/dL & vitamins D2 +D3 levels should be between 25 and 80 ng/mL) -Imaging 1. Dual x-ray absorptiometry DXA: Screening and diagnostic tool for measuring bone mineral density (BMD) 3. CT-based absorptiometry: volume of bone density and strength of the vertebral spine and hip (more radiation than traditional DXA) 3. Vertebral imaging: performed using lateral spine x-rays or lateral vertebral fracture assessment (VFA), which is available as part of most DXA systems 4. MRI: provides information about yellow bone marrow content(adipose/fat is higher in osteoporosis), diffusion, and PERFUSION to the bone.

Height in Osteoporosis

A normal spine at age 40 years of age and osteoporotic changes at ages 60 and 70 years. These changes can cause a loss of as much as 6 inches in height and can result in the so-called DOWAGER'S HUMP in the upper thoracic vertebrae.

CM of osteomyelitis

ACUTE: Bone pain and fever(101F); infected bone swells and is tender when palpated; erythema and heat; vascular compromise is severe; impaired comfort; lack of adequate perfusion CHRONIC: foot ulcers, sinus tract formation, localized pain, drainage from affected area

During a community education program the nurse is asked about the risk of a woman breaking a bone due to osteoporosis after age 50. The nurse knows which of the following is the risk? A.1 in 2 women B.1 in 5 women C.1 in 7 women D.1 in 10 women

ANS: A One in two women over the age of 50 will break a bone because of osteoporosis. A woman's risk of breaking a hip due to osteoporosis is equal to her risk of breast, ovarian, and uterine cancer combined. Women have lighter, thinner bones than men. Many women also lose bone quickly after menopause. Up to one in four men over the age of 50 will break a bone because of osteoporosis. A man older than age 50 is more likely to break a bone due to osteoporosis than he is to get prostate cancer.

Which assessment data would the nurse expect in a patient diagnosed with osteomalacia? A.Lack of Vitamin D B.Decreased bone mass C.Lack of estrogen D.Elevated blood sugar

ANS: A Osteomalacia is the loss of bone related to lack of vitamin D which causes bone softening. Vitamin D is needed for calcium absorption in the small intestines. As a result of Vitamin D deficiency, normal bone building is disrupted, and calcification does not occur to harden the bone. Decreased bone mass (osteopenia) occurs with osteoporosis. Lack of estrogen (post-menopausal) is associated with osteoporosis. Elevated blood sugar would not be anticipated with osteomalacia.

A patient has just been diagnosed with Dupuytren's contracture. Which statement by the nurse is most appropriate? A."This condition will improve with time." B."The cause of this condition is aging." C."The fourth and fifth fingers are most often affected." D."This condition is never bilateral in nature."

ANS: C Dupuytren's contracture, or deformity, is a slowly progressive thickening of the palmar fascia, resulting in flexion contracture of the fourth (ring) and fifth (little) fingers of the hand. The third or middle finger is occasionally affected. Although Dupuytren's contracture is a common problem, the cause is unknown. It usually occurs in older Euro-American men, tends to occur in families, is most common in diabetics, and can be bilateral. The condition affects a layer of tissue that lies under the skin of your palm. Knots of tissue form under the skin — eventually creating a thick cord that can pull one or more fingers into a bent position.

Osteomyelitis treatment

Antimicrobial Therapy 1. Blood culture 2. Contact precaution (typically caused by MRSA) 3. Irrigate wound, IND 4. hyperbaric oxygen (HBO) therapy: hyperbaric chamber or portable device used to treat & increase tissue PERFUSION for patients with chronic, unremitting osteomyelitis

The patient is diagnosed with possible osteoporosis. Which diagnostic tests should the nurse anticipate will be ordered? (Select all that apply.) A.Sodium B.Phosphorus C.Serum calcium D.Thyroid function tests E.Dual x-ray absorptiometry (DXA)

B, C, D, E

The patient is diagnosed with osteoporosis. Which intervention by the nurse would be appropriate? A.Teach her to cut down on her cigarette smoking. B.Recommend walking for 30 minutes three to five times a week. C.Suggest a diet that is high in protein and calcium but low in vitamin D. D.Tell her to include high-impact activities, such as running, in her exercise regimen.

B. Recommend walking for 30 minutes three to five times a week. The single most effective exercise for osteoporosis is walking 30 minutes three to five times a week. Patients should include increased vitamin D along with calcium in the diet. Smoking should be avoided, as should high-impact exercises, which may cause vertebral compression fractures.

Which patient statement about self-care indicates a need for further teaching by the nurse? A."I am going to swim at the YWCA." B."Low-fat yogurt is on my grocery list." C."My husband is getting rid of our throw rugs." D."Joining a bowling team will help me exercise."

D."Joining a bowling team will help me exercise." Bowling should be avoided for patients with osteoporosis because it can contribute to compression fractures. Swimming, eating yogurt, and eliminating throw rugs in the house are all appropriate considerations for the patient with osteoporosis.

Characteristics of Osteomalacia

Definition: Bone softening caused by lack of calcification Primary etiology: Lack of vitamin D Radiographic findings: Fractures Calcium level: Low or normal Phosphate level: Low or normal Parathyroid hormone: High or normal Alkaline phosphatase: High

Characteristics of Osteoporosis

Definition: decreases bone mass caused by multiple factors Primary etiology: Lack of calcium and estrogen or testosterone Radiographic findings: Osteopenia (bone loss), fractures Calcium level: Low or normal Phosphate level: Normal Parathyroid hormone: Normal Alkaline phosphatase: Normal

Risk factors for osteoporosis

Hx: low-trauma fractures seen in hips, wrist, and spine (most commonly) Genetics: more common in Women, older than 60 years old, parental history of osteoporosis, especially mother Culture: Higher in Asians and Caucasians Diet: High Fat, Low calcium/vitamin D, Excessive Alcohol, Lack of physical exercise or prolonged immobility Others: Menopause, Thinner Figure, Oral contraceptive use, Smoking

Osteomyelitis causes

Infection in bony tissue Caused by bacteria, virus, or fungi from exogenous (wound) versus endogenous (sepsis, UTI, gets into the blood and then bone)

Planning and Implementation for Osteoporosis

Safety precautions Medications (Ca2+ and Vitamin D supplement when 1/3 of dose is taken at bedtime, bisphosphonate on empty stomach, estrogen agonist but side effects include DVT) Surgical management (when problem with spine and PT is shrinking in size, surgeons perform kyphoplasty &vertebroplasty in which the bones are cemented so it causes PT to have decreased mobility) Collaborative health care team roles Community resources Patient Teaching

Osteoporosis

chronic disease of CELLULAR REGULATION in which bone loss causes significant decreased density and possible fracture "silent disease" or "silent thief"

priority problem for patients with osteoporosis or osteopenia

fractures due to weak, porous bone tissue.

Osteomalacia

loss of bone related to lack of vitamin D, which causes bone softening.

Primary osteoporosis

more common and occurs in postmenopausal women and in men in their seventh or eighth decade of life.

Secondary osteoporosis

other medical conditions: •Diabetes mellitus• Hyperthyroidism• Hyperparathyroidism• Cushing's syndrome• Growth hormone deficiency • Metabolic acidosis• Female hypogonadism• Rheumatoid arthritis• Prolonged immobilization • Bone cancer• Cirrhosis• HIV/AIDS •Long-term corticosteroid use

bone mineral density (BMD)

process of tissue that is constantly undergoing changes (osteoclastic & osteoblastic) determines bone strength and peaks between 25 and 30 years of age. Before and during the peak years, osteoclastic activity and osteoblastic activity work at the same rate. After the peak years, bone-resorption activity exceeds bone-building activity, and bone density decreases. BMD decreases most rapidly in postmenopausal women as serum estrogen levels diminish.

Cellular Regulation of Osteoporosis

Ø Osteomalacia (loss of bone due to low vitamin D) Ø Bone Remodeling & Bone Reabsorption (higher osteoclasts than osteoblasts) Ø Osteopenia (low bone mass) Ø Bone Mineral Density (Low)