Osteoporosis, and Hip Fractures

Question 1

What are some risks for osteoporosis?

Answer 1

Age >65
Thyroid disease (long time use of levothyroxine, can result in osteoporosis, post menopausal
femaleAdvanced age (> 65)
Low body weight
Cigarette smoking
Nontraumatic fracture
Inactive lifestyle
Family history of osteoporosis
Diet low in calcium or vitamin D deficiency
Excessive use of alcohol (>2drinks a day)
Postmenopausal, including premature or surgical menopause
White and Asian American descent
Low testosterone in men

Question 2

Which drugs can interfere with bone metabolism?

Answer 2

Corticosteroids (prednisone)
Long-term corticosteroid use is a major contributor to osteoporosis.
When a corticosteroid is taken, loss of bone and inhibition of new bone formation occur.

Increases bone loss and stimulates breakdown
Anti-seizure drugs (e.g., valproate [Depakote], phenytoin [Dilantin])
What other influence do these drugs have?
Aluminum-containing antacids
Certain cancer treatments

Question 3

Antiseizure drugs (e.g., valproate [Depakote], phenytoin [Dilantin]) 
What other influence do these drugs have?

Answer 3

Anti seizure drugs depress bone marrow, can have low bone marrow, blood count

Question 4

Aluminum-containing antacids

Certain cancer treatments

Answer 4

Antacids- leads to poor absorption of other meds

Question 5

Heparin is also a culprit in osteoporosis. Why?

Antidote for Heparin?

Answer 5

detrimental effect of heparin on bone, with an increase in fracture rate.Heparin—Heparin causes bone loss by decreasing bone formation. The few studies of the mechanism of bone loss have revealed decreased bone formation

Protamine Sulfate

Question 6

Medications and Osteoporosis

Answer 6

Meds can decrease osteoblast function, increase bone resorption, inhibit GI calcium absorption,

Question 7

What is the gold standard diagnostic test?

Answer 7

Her physician orders a dual-energy x-ray absorptiometry (DEXA Scan).

Question 8

What is a DEXA scan?

Answer 8

A dexa scan is a measurement of bone mass of spine, femur, forearm, and total body. Allows assessment of bone density with minimal radiation exposure, used to diagnose bone disease and to measure response to treatment. One beam is high energy while the other is low energy. The amount of X-rays that pass through the bone is measured for each beam. This will vary depending on the thickness of the bone. Based on the difference between the two beams, the bone density can be measured.

Question 9

At what age should a DEXA scan be conducted for a woman? For a man?

Answer 9

65 or older in women

Man - unless having hx or pain, bc there bone is bigger and denser

Question 10

Diagnostic Studies Osteoporosis

Answer 10

Osteoporosis is a BMD >-2.5 standard deviations below a young adult BMD.

Question 11

Osteopenia

Answer 11

is a BMD > -1.0 but less than - 2.5 standard deviations below a young adult BMD

Question 12

What is osteopenia? “Pre osteoporosis”

Answer 12

Osteopenia is a loss of bone mineral density (BMD) that weakens bones. It’s more common in people older than 50, especially women. Osteopenia has no signs or symptoms, but a painless screening test can measure bone strength. Certain lifestyle changes can help you preserve bone density and prevent osteoporosis

Question 13

Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone among the elderly.

Answer 13

is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone among the elderly.

Question 14

Osteomalacia causes soft bones due to a lack of

Answer 14

vitamin D.

Question 15

What other Diagnostic Studies Are Appropriate?

History and physical exam

Answer 15

Hip, vertebra, or wrist fracture
Back pain
Loss of height 
Spinal deformities 
Kyphosis
Stooped posture

Question 16

Quantitative ultrasound

Answer 16

Uses sound waves to evaluate bone mass

May see increased use due to cost effectiveness

Question 17

x-ray

Answer 17

Osteoporosis often goes unnoticed because it cannot be detected by conventional x-ray until more than 25% to 40% of calcium in the bone is lost.

Question 18

Serum calcium, phosphorus, and alkaline phosphatase levels usually are normal, although alkaline phosphatase may be elevated after a fracture.

Answer 18

normal, although alkaline phosphatase may be elevated after a fracture.

Question 19

Blood Tests

Answer 19

Many of the blood tests are used to screen for disease processes that may contribute to osteoporosis

Question 20

Albumin is affected by alcohol

Answer 20

Albumin can be impacted with liver dx check for elevated ALT and AST! (if 3x’s the normal)

Liver fx study to look for decreased platelets

Question 21

Look for thyroid problems

Thyroid stimulating hormone

Answer 21

High TSH = hypo

High T3, T4 maybe they are taking too much levothyroxine?

Question 22

Other tests that might be helpful

Answer 22

CBC

Serum Chem levels

Question 23

Vitamin D Levels check for

Answer 23

insufficiency, can predispose a patient to osteoporosis

= low mood, low immune, low calcium absorption

Question 24

Calcium Homeostasis The calcium level in blood is balanced by:

Answer 24

Parathyroid hormone (PTH)
secreted by the parathyroid gland
If calcium level is low – PTH raises calcium level by stimulating osteoclasts to break down bone
Increases calcium resorption from kidneys
Calcitonin hormone
secreted by the thyroid gland
if calcium level is too high – calcitonin moves calcium from the blood and deposits it in bones
Decreases calcium resorption in kidneys

Question 25

When calcitonin is released in response to high calcium levels, calcium is

Answer 25

not reabsorbed in kidneys and neither is phosphorus.

Question 26

Which two antagonistic hormones play the major role in calcium homeostasis

Answer 26

PTH and calcitonin

Question 27

Calcium phosphorus relationship

Answer 27

Calcium high, phosphorus and vice versa

Question 28

Phosphates (phosphorus) are used clinically to treat the following:

Answer 28

Hypophosphatemia, low levels of phosphorus in the body Hypercalcemia, high blood calcium levels Calcium based kidney stones

Question 29

Phosphates are also used.

Answer 29

Phosphates are also used in enemas as laxatives. Most people get plenty of phosphorus in their diets. Sometimes athletes use phosphate supplements before competitions or heavy workouts to help reduce muscle pain and fatigue, although it's not clear how much it helps or if it improves performance.

Question 30

Osteoporosis is

Answer 30

``` Chronic, progressive metabolic bone disease characterized by Porous bone Low bone mass Structural deterioration of bone tissue Increased bone fragility ```

Question 31

More common in women than men for several reasons

Answer 31

Lower calcium intake than men Less bone mass because of smaller frame Bone resorption begins earlier and accelerates after menopause.

Question 32

Etiology and Pathophysiology

Answer 32

In osteoporosis, bone resorption exceeds bone deposition.Wedging and fractures of vertebrae produce gradual loss of height and a humped back known as dowager’s hump or kyphosis.

Question 33

Occurs most commonly in

Answer 33

Occurs most commonly in spine, hips, and wrist

Question 34

Bone is continually being deposited by osteoblasts and resorbed by

Answer 34

osteoclasts, a process called remodeling.

Question 35

Normally, rates of bone deposition and resorption are

Answer 35

Normally, rates of bone deposition and resorption are equal to each other, so that the total bone mass remains constant.

Question 36

Clinical Manifestations of Osteoporosis | Often termed the....

Answer 36

“silent disease” because there are no symptoms

Question 37

Since no symptoms, the usual first signs are

Answer 37

back pain and spontaneous fractures

Question 38

Physiology of Bone Growth

Answer 38

Bone is a living tissue undergoing change About 10% of skeleton is broken down each year. OsteoClasts break down (Crush) areas of old or damaged bone OsteoBlasts Build new bone in those areas Osteocytes maintain and monitor mineral content

Question 39

Which picture best represents osteoporosis?

Answer 39

Porous bone is what occurs

Question 40

What treatment options are available? Calcium supplementation, bisphosphonates, calcitonin, selective estrogen receptor modulators. No smoking, get exercise, eat foods with high amounts of calcium. CAUTION: Risk of massive calcium supplementation, however, can cause too much calcium deposits in the heart. Biphosphonate: take 1st thing in the a.m. on empty stomach, make sure person is upright after 30 minutes, bc biphosphanate bubbles up and can creep up to esophagus and can cause irritation, give with full glass of water to help with absorption. Can recommend to go for 30 minute walk, helps with weight bearing exercise, pt. gets Vit D.

Answer 40

What lifestyle changes can she make to improve her condition? Moderate amounts of exercise are important to build up and maintain bone mass. The best exercises are weight-bearing exercises that force the individual to work against gravity. Exercises that are low impact, such as walking, hiking, weight training, and dancing are recommended to avoid stress fractures associated with high-impact activities. Review with her general measures to reduce her risk of falling, including getting up slowly, wearing well-fitting shoes, removing any loose rugs in the house, making sure all of the walkways are kept clear, using grab bars and nonskid mats in the bathroom, and having appropriate lighting, particularly at nighttime.

Question 41

Overview Collaborative CareFocus on

Answer 41

``` Proper nutrition Calcium supplements Exercise Prevention of fractures Drug therapy Vertebroplasty Kyphoplasty ```

Question 42

Collaborative CareNutrition

Answer 42

``` Milk Cheese Yogurt Ice cream (soft serve best!) Salmon Seafood Broccoli Spinach ```

Question 43

Collaborative CareSupplements

Answer 43

Calcium 1500 mg/day post menopausal women 1000 mg/day premenopausal or post menopausal taking estrogen 2. Supplemental vitamin D may be recommended. 800 units to 1000 units 20 minutes of sunlight daily 3. Calcitonin inhibits osteoclastic bone resorption interacts with active osteoclasts Salmon calcitonin (Calcimar) intramuscular, subcutaneous, and intranasal forms. When calcitonin is used, calcium supplementation is necessary to prevent secondary hyperparathyroidism.

Question 44

Collaborative CareDrug Therapy

Answer 44

Bisphosphonates inhibit osteoclast-mediated bone resorption (e.g., etidronate [Didronel], alendronate [Fosamax]).

Question 45

NATES are our bone building meds

Answer 45

These drugs include etidronate (Didronel), alendronate (Fosamax), pamidronate (Aredia), risedronate (Actonel), clodronate (Bonefos), tiludronate (Skelid), and ibandronate (Boniva).

Question 46

The nurse is caring for a patient taking alendronate (fosamax). What education should the nurse include in discharge teaching?

Answer 46

Always best to get nutrients from food. ``` 1st thing in morning Empty stomach Upright Full glass of water Go for a walk Jaw pain ```

Question 47

Will taking these supplements cure me?”

Answer 47

Prevention and treatment depend on adequate calcium intake. Increased calcium prevents future loss but will not form new bone.

Question 48

Exercise and Lifestyle

Answer 48

Weight bearing that force work against gravity is best Walking, hiking, weight training Quit smoking Cut down on alcoho

Question 49

Collaborative CarePrevention of Fractures

Answer 49

``` Install grab bars Sit to shower Make your shower less slippery Raise your toilet seat Make the last step stand out Reduce clutter including wires Take care around uneven floor surfaces Keep items within easy reach Use a stepstool. ```

Question 50

Drug Therapy Selective estrogen receptor modulators

Answer 50

Raloxifene (Evista) - estrogen Teriparatide (Forteo) Portion of parathyroid hormone First drug to stimulate new bone formation

Question 51

What factors increase risk of hip fracture in older adults?

Answer 51

``` Falls Poor balance Limited shock absorbers (Fat, muscles, bulk) Gait Decreased vision and hearing Slow reflexes Hypotension Medication use Loose rugs ```

Question 52

Other Factors

Answer 52

Trip over the pets

Question 53

Evidence Based Practice

Answer 53

Yoga was more effective than a self-care book in improving function and reducing pain for at least several months. Yoga was no better than stretching classes. Assist patients in identifying resources and community classes that focus on stretching exercises and yoga and encourage participation. Zumba

Question 54

Suspected in hip fracture

Answer 54

Leg short with external rotation External rotation Muscle spasm Shortening of affected extremity Severe pain and tenderness in region of the fracture

Question 55

Hip Fractures-

Answer 55

``` Disruption or break in continuity of the structure of bone Fracture of proximal third of femur extending up to 5cm below lesser trochanter Intracapsular fracture (femoral neck) ``` Common in older adults Due to osteoporosis or trauma Many develop disabilities requiring long-term care

Question 56

What are the initial assessments and treatment?

Answer 56

Assessment Temperature, cap refill, distal pulses, edema, sensation, motor function Past medical history X-ray Pain Management Analgesics Muscle relaxants Positioning ``` Teaching upmost importance Surgery will take place quickly Exercise unaffected leg Use trapeze bar PT to begin to teach chair transfers ```

Question 57

Overall goals of fracture treatment

Answer 57

Anatomic realignment of bone fragments Immobilization to maintain realignment Restoration of normal or near-normal function of injured parts

Question 58

Skin traction (Buck’s Traction)

Answer 58

``` Used for short-term treatment until surgery is possible Used for 24- 48 hours Traction weights 5 to 10 pounds Application of a pulling force to an injured or diseased part of body or extremity while counter traction pulls in opposite direction Purpose of traction Prevent or ↓ muscle spasm Immobilize joint or part of body ↓ a fracture or dislocation Treat a pathologic joint condition ```

Question 59

Care of client in traction

Answer 59

``` Temp Ropes hang freely do not touch floor Alignment Circulation check 5P's Type of location of fracture Increased fluid intake Overhead trapeze No weights on bed or floor ```

Question 60

Surgery is recommended….

Answer 60

Surgical Repair- Fracture Reduction Open reduction (ORIF) Correction of bone alignment through surgical incision Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails Chief disadvantages Possibility of infections Complications associated with anesthesia Effects of preexisting medical conditions

Question 61

Nursing Management

Answer 61

``` Prior to surgery Monitor vital signs Neurovascular checks Maintain proper alignment Monitor Buck’s traction if applicable Medicate for pain/muscle spasms Pre-op teaching ```

Question 62

Post op nursing management

Answer 62

``` Post-op Monitor vital signs Monitor for bleeding Monitor I&O Turn, Cough & Deep Breath Medicate for pain Maintain Abduction Mobilize patient as soon as possible(first post op day) Prevent complications (such as DVT, infection, etc.) ```

Question 63

Infection in bone

Answer 63

osteomyelitis, very strong antibiotics to get rid of it, 6 or more weeks on vancomycin or other mycin meds

Question 64

5 P's

Answer 64

``` Pain Paresthesia Paralysis Pulse Pallor ```

Question 65

Hip Fracture post op

Answer 65

``` DVT's Bleeding, swelling, skin breakdown, Atelactasis urinary retention Delayed complications, infection Hypotension ```

Question 66

Watch for

Answer 66

severe pain inability to move the leg shortening and external rotation of the leg

Question 67

What teaching is important to provide?

Answer 67

Fall precautions Avoid flexing more than 90 degrees Watch for sudden severer pain, a lump in the buttock, limb shortening and external rotation These are signs of dislocation Place a large pillow between legs when turning Avoid turning on affected side until approved by surgeon You do not want to cause the leg to change position greater than 90. If you narrow angle in hip, then hip joint might come out of their socket. Like the butt sinking into a chair, now legs/knees are greater than 90 degrees, can even ruin the surgery.

Question 68

Joint Arthroplasty

Answer 68

Replacement or reconstruction of a joint to decrease pain, improve ROM, decrease deformity

Question 69

Collaborative CareHip Arthroplasty

Answer 69

For posterior approach hip arthroplasties, do not flex greater than 90 degrees Knees must be kept apart Avoid bending – get raised toilet seat, grab bars DVT prophylaxis – extremely important for joint surgeries on lower part of the body * knees and hips highest risk May be on warfarin (Coumadin), rivaroxiban (Xarelto), abixaban (Eliquis) for several weeks Hip and knee surgeries are highest risk for DVT’s. Question if heparin is not ordered for example.