Osteoporosis

Osteoporosis is a metabolic bone disorder often not restricted to joint areas. Osteopenia (low bone mineral density) is a precursor of osteoporosis. Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone strength. In osteoporosis, the normal homeostatic bone turnover is altered, and the rate of bone resorption is greater than the rate of bone formation resulting in reduced total bone mass.

As a result of osteoporosis, bones progressively become porous, brittle, and fragile, fracture easily under stress, occurs most commonly as compression fx.

This article examines osteoporosis nursing diagnosis and provide a detailed description of Osteoporosis, chronic pain related to osteoporosis nursing diagnosis, causes, risk factors, treatment and management, nursing interventions, and prevention methods. As you read, keep in mind that our professional nursing writers are ready to help with your assignment if you get stuck. All you need to do is place an order with us.

Disclaimer: The information presented in this article is not medical advice; it is meant to act as a quick guide to nursing students for learning purposes only and should not be applied without an approved physician’s consent. Please consult a registered doctor if you’re looking for medical advice.

Osteoporosis is a complex skeletal disease characterized by low bone density and micro defects in bone tissue resulting in increased susceptibility. Fractures caused by osteoporosis affect 1 in 2 women and 1 in 5 men over 50 years old.

Bone strength is due to mineral density, size/shape, bone turnover, micro-architecture. Osteoclasts break down bone, osteoblasts make bone.

• Primary Osteoporosis occurs in women post-menopause and in men later in life. The key risk factors include low estrogen levels and low Vit D levels. Primary Osteoporosis can be subdivided into Post-menopausal primary osteoporosis and Senile primary osteoporosis (old age).
• Secondary Osteporosis this is caused by drugs or medications such as corticosteroids, Dilantin, immunosuppressants

In short, osteoporosis implies reduced bone mass that can be 1° (age-related) or 2° to another condition/drugs. It is imperative to note that If the trabecular bone is affected, crush fractures of vertebrae are common. On the other hand, If cortical bone is affected, long bone fractures are more likely (e.g. femoral neck – a significant cause of death and orthopedic expense).

The Risk factors for osteoporosis include

• Previous fracture – Having had a previous fracture posse a significant risk for osteoporosis.
• Being Female, White, and over the age of 50 >50f >65m for males the risk increases significantly at the age of 65
• Low BMI
• FHx
• Loss of height
• Secondary amenorrhea (caused by anorexia/excessive exercise)
• Smoking
• Alcohol
• Prolonged immobilization
• Low calcium, vitamin D
• Glucocorticoid excess
• Corticosteroid use
• Tamoxifen
• Androgen deprivation treatment
• RA

Furthermore, a more elaborate analysis of Osteoporosis Risk Factors narrows down to the acronym ACCESS

A-lcohol Use
C-orticosteroid Use
C-alcium low
E-strogen low
S-moking
S-edentary lifestyle/s

For Osteoporosis, some factors that predispose individual to a higher risk of osteoporosis include

• small framed, Asian, and Caucasian women at greater risk
• bariatric surgery
• disability
• obesity
• GI diseases
• Menopause
• increased phosphate consumption (soda)
• anorexia
• increased age

Osteoporosis Nursing Presentation

• Back pain – vertebral fracture
• Kyphosis
• Impaired vision – may cause the fall and subsequent fracture
• Impaired gait/balance/weakness – cause the fall & fracture

Osteoporosis Nursing Diagnosis

Investigation

The clinical diagnosis for osteoporosis is;

1. It is imperative to investigate Bone densitometry in an osteoporosis nursing diagnosis by using DEXA

• DEXA – <2.5 indicates osteoporosis, <2.5 + fracture = severe osteoporosis
• (DEXA) – Better to scan hip than the lumbar spine
• BMD (g/cm2) is compared with that of a young healthy adult
• T-score is the number of SD the BMD is from the youthful average
• Each decrease of 1SD in BMD = 2.6x increase in hip fracture risk

Indications for DEXA:

• Previous low-trauma fracture, women 65y+ with 1+ RF for OP
• Prior to giving long-term prednisolone (steroids cause OP by promoting osteoclast bone resorption, reducing muscle mass and reducing Ca absorption in the gut)
• People with osteopenia if low-trauma, non-vertebral fracture
• Bone and bone-remodeling disorders

2. Bloods = Ca, PO4, ALP all normal
3. Consider specific investigations for 2° causes if suggestive history
4. Biopsy is  unreliable  and  unnecessary  with  non-invasive techniques available
5. Note that any person who sustains a fragility fracture (for example Colles’ wrist fracture) also needs assessment with FRAX or QFracture.
   1. FRAX Tool-
      1. Estimates the 10-year risk of fragility fracture
      2. Valid for patients 40-90

• Assesses: Age, sex, weight, height, previous fracture, parental fracture, current smoking, glucocorticoids, RA, secondary osteoporosis & alcohol intake

1. Bone mineral density is optional extra, but improves the accuracy of the results.
2. NICE recommends arranging a DEXA scan if FRAX (without BMD) shows an intermediate result

1. Interpretation of FRAX TOOL results

The QFracture test for an osteoporosis diagnosis should

• Estimates 10-year risk of fragility fracture
• Developed in 2009 based on UK primary care dataset
• Can be used for patients aged 30-99 years
• Does not organize into low/mod/high but gives raw data to be used in conjunction with a clinical picture to determine management

When NICE recommends using BMD assessment (via a DEXA scan) rather than using one of the clinical prediction tools below:

• Before starting treatment which have rapid adverse effects on bone density
• In people under 40 years who have a major risk factor such as the history of multiple fragility fractures, major osteoporotic fracture, or current use of high dose oral or systemic corticosteroids
• More than 7.5 prednisolone or equivalent for 3 MONTHS OR LONGER

When accessing patients following a fragility fracture

Patient >75 years of age:

• If they have a fragility fracture then they are assumed to have osteoporosis and should be started on 1st line therapy (an oral bisphosphonate) without the need for a DEXA scan.
• Oral alendronate 70mg once weekly

Patient <75 years of age:

• If the patient is under 75 then a DEXA scan should be arranged.
• The results should be entered into a FRAX assessment to determine ongoing risk.

Treatment and management of nursing diagnosis for osteoporosis for men

Osteoporosis in Men:

• Alendronic acid and risedronate sodium are recommended as first-line treatments for osteoporosis.
• Zoledronic acid and denosumab are alternatives for men who cannot tolerate bisphosphonates

Prostate Cancer:-

• Men having androgen deprivation therapy for prostate cancer have an increased fracture risk.
• Fracture risk assessment should be considered when starting this therapy.

Hence to sum up, the clinical diagnosis for osteoporosis is; DEXA scan, -dual-energy x-ray absorptiometry with -T scores of 1.0-2.5 indicating a significant risk that requires immediate action. Laboratory- ESR, hematocrit, ALP, serum calcium and phosphate as well as x-ray studies. Below is a summarized nursing intervention for osteoporosis and how to manage chronic pain related to osteoporosis nursing diagnosis

Osteoporosis Plan of Care including nursing interventions for osteoporosis

The osteoporosis plan of care should focus on educating the patient on the dx/tx plan.

• The osteoporosis patient education plan should inform the patient on the diagnosis, specifically on the following nursing interventions for osteoporosis;
  • Primary Osteporosis occurs in women post menopause and in men later in life. The key risk factors include low estrogen levels and low vit D levels. Primary Osteoporosis can be subdivided into Post-menopausal primary osteoporosis and Senile primary osteoporosis (old age).
  • Secondary Osteporosis this is caused by drugs or medications such as corticosteroids, Dilantin, immunosuppressants
  • Exercise-resistance and impact most beneficial in developing and maintaining bone mass. weight bearing
  • Teaching diet -adequate calories and nutrients -Diet plays a critical role in determining the occurrence of osteoporosis, hence the NP should emphasize on (diet goals for an osteoporosis patient)
    • Calcium-1,000-1,300mg/day
    • Vitamin D- 800-1,000mg/day
    • Increase fluid intake
  • Fall prevention – emphasize on fall prevention, conduct a morse fall risk assessment to determine the nursing interventions to prevent falls and prevent chronic pain related to osteoporosis nursing diagnosis

  • 

Treatment and Management of Osteoporosis Nursing Diagnosis nursing interventions for osteoporosis

It is imperative to inform the patient that the Loss of BMD may not be entirely irreversible and develop a pharmacological approach based on Age, number of risk factors and BMD guide the pharmacological approach

Lifestyle measures in treatment and management of osteoporosis – should apply to all (including those at risk but not yet OP), the goals for treatment include;

• Quit smoking and reduce alcohol consumption
• Weight-bearing exercise may increase BMD
• Balance exercises such as tai chi reduce the risk of falls
• Ca and VD-rich diet, and supplements
• The home-based fall-prevention program,  with  visual assessment and a home visit

Pharmacological measures in treatment and management of osteoporosis: (nursing interventions for osteoporosis)

1. Bisphosphonates:
   • Alendronic acid is 1st line (10mg/d or 70mg/w, not if eGFR<35)
   • Use also for prevention in long-term steroid use
   • If intolerant, try etidronate or risedronate
   • Tell PT to swallow pills with plenty of water while remaining upright for >30min and  wait 30min before eating/other drugs
   • SE = photosensitivity, GI upset, esophageal ulcers (stop if  dysphagia/Abdo pain), jaw osteonecrosis
2. Ca/VD:

• Rarely used alone for prophylaxis, as questionable efficacy and some evidence of a small increase in CV risk
• Offer if evidence of deficiency

3. Strontium ranelate  = due  to  increased  risk  of  cardiac problems,  should  only  be  used  in  those  with  severe intolerance to other agents and without CV disease
4. HRT = can prevent (not treat) OP in  post-menopausal women (relative risk of breast cancer and CV)
5. Raloxifene =selective estrogen receptor  modulator (SERM) that acts similarly to  HRT, but  with a  reduced breast cancer risk
6. Teriparatide (recombinant PTH)  =  useful in those  who suffer  further  fractures  despite  treatment  with  other agents (potential increased risk of renal malignancy
7. Calcitonin = may reduce pain after a vertebral fracture
8. Testosterone =  may  help  in  hypogonadal  men  by promoting trabecular connectivity
9. Denosumab = monoclonal Ab to RANK ligand, given SC twice yearly

The key takeaways of Osteoporosis management include Calcium/vitamin D supplementation, Bisphosphonates-Fosamax, Selective estrogen receptor modulators-raloxifene, PTH analogs-Teriparatide, SubQ daily for 2yrs, calcitonin, and Fracture management – Alendronate (Fosamax) chronic pain related to osteoporosis nursing diagnosis

• tx osteoperosis & Pagets
  • bisphosphonate
    -bone resorption inhibitor, slows the breakdown
    -suppresses myelination
    -PO 5-10 mg daily AC.
    -not given at the same time of day as Vit D, calcium
    -Pt must be upright after admin. 30-60 min with a full glass of water
    -side effects: GI symptoms
  • SERMs

-raloxifene (Evista)
-Reduce risk of osteoporosis in postmenopausal women by preserving bone mineral density without estrogen effects on the uterus.
-prevention and tx
-side effects: hot flashes, flu-like symptoms
-contraindicated: hx of VTE

• Calcitonin
  • Inhibits bone reabsorption, normal effect

References 

Osteoporosis Plan of Care Sample

Summary of Osteoporosis Nursing Diagnosis and care plan – a quick guide for student RNs and NPs and nursing interventions for osteoporosis

Frequently Asked Questions on osteoporosis nursing diagnosis

1. If people are intolerant of oral bisphosphonates-what, what alternatives are there? Strontium or raloxifene (60mg OD)
2. Any special counseling to be given to patients who take alendronic acid? Swallow with lots of water, sat upright 30mins before food. i. Remain upright for 30 mins
3. What are the side effects of bisphosphonates?
   • Osteonecrosis of the jaw
   • Oesophagitis/dyspepsia
   • Atypical stress fractures
   • Acute-phase response
4. 4. Why is the movicol given? Tramadol
5. What class of laxative is movicol? Osmotic
6. What may other laxatives be given? And what class do these laxatives fall into? Bulk-forming (e.g., fybrogel) b. Stimulant (senna – sennacot)
7. Naproxen was given to the patient recently for suspected carpal tunnel syndrome anD as an anti-inflammatory-have you any concerns with this being prescribed? PPI needs prescribing
8. 8. What management options are available to help with carpal tunnel syndrome?
   1. Splint
   2. Injection
   3. Decompression
9. What complications can arise after carpal tunnel syndrome operations? Worsen/relapse b. General surgical complications (sepsis, infection, bleeding, etc.)