Marie, a 58-year-old spinster, has a stooping posture. She frequently complains about back pain. After a particularly painful episode, she decided to have a consultation. Her laboratory tests and diagnostic studies results showed the progression of osteoporosis.
Osteoporosis is classified as a metabolic bone disorder.
- Osteoporosis occurs when the creation of new bone doesn’t keep up with the removal of old bone.
- Osteoporosis causes bones to become weak and brittle — so brittle that a fall or even mild stresses such as bending over or coughing can cause a fracture.
Osteoporosis may be classified into two types:
- Primary osteoporosis. Primary osteoporosis occurs in women after menopause and in men later in life, but it is not merely a consequence of aging but of failure to develop optimal peak bone mass during childhood, adolescence, and young adulthood.
- Secondary osteoporosis. Secondary osteoporosis is the result of medications or other conditions and diseases that affect bone metabolism.
Osteoporosis is characterized by reduced bone mass, deterioration of bone matrix, and diminished bone architectural strength.
- Reduced total bone mass. Normal homeostatic bone turnover is altered; the rate of bone resorption that is maintained by osteoclasts is greater than the rate of bone formation that is maintained by osteoblasts, resulting in a reduced total bone mass.
- Progression. The bones become porous, brittle, fragile; they fracture easily under stresses that would not break normal bone.
- Postural changes. The postural changes result in relaxation of the abdominal muscles and a protruding abdomen.
- Age-related losses. Calcitonin and estrogen decrease with aging, while parathyroid hormone increases, increasing bone turnover and resorption.
- Consequence. The consequence of these changes is net loss of bone mass over time.
Statistics and Incidences
Osteoporosis is the most prevalent bone disease in the world.
- More than 10 million Americans have osteoporosis and an additional 33.6 million have osteopenia, the precursor to osteoporosis.
- It is projected that one of every two Caucasian women and one of every five men will have an osteoporosis-related fracture at some point in their lives.
- The costs incurred from treating osteoporosis-related fractures in the United States are estimated at $20 billion annually.
- The prevalence of osteoporosis in women older than 80 years is 50%.
- The average 75-year-old woman has lost 25% of her cortical bone and 40% of her trabecular bone.
- With the aging of the population, the incidence of fractures (more than 1.5 million osteoporotic fractures per year), pain, and disability associated with osteoporosis is increasing.
The causes of osteoporosis and their effects on bone include:
- Genetics. Small-framed, nonobese Caucasian women are at greatest risk; Asian women of slight build are at risk for low peak bone mineral density; African American women are less susceptible to osteoporosis.
- Age. Osteoporosis occurs in men at a lower rate and at an older age, as it is believed that testosterone and estrogen are important in achieving and maintaining bone mass, so risk for osteoporosis increases with increasing age.
- Nutrition. A low calcium intake, low vitamin D intake, high phosphate intake, and inadequate calories reduce nutrients needed for bone remodeling.
- Physical exercise. A sedentary lifestyle, lack of weight-bearing exercise, and low weight and body mass index increases the risk for osteoporosis because bones need stress for bone maintenance.
- Lifestyle choices. Too much consumption of caffeine and alcohol, smoking, and lack of exposure to sunlight reduces osteogenesis in bone remodeling.
- Medications. Intake of corticosteroids, antiseizure medications, heparin, and thyroid hormone affects calcium absorption and metabolism.
Common signs and symptoms found in patients with osteoporosis include:
- Fractures. The first clinical manifestation of osteoporosis may be fractures, which occur most commonly as compression fractures.
- Kyphosis. The gradual collapse of a vertebra is asymptomatic, and is called progressive kyphosis or “dowager’s hump” associated with loss of height.
- Decreased calcitonin. Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased.
- Decreased estrogen. Estrogen, which inhibits bone breakdown, decreases with aging.
- Increased parathyroid hormone. Parathyroid hormone increases with aging, increasing bone turnover and resorption.
To prevent primary and secondary osteoporosis, measures such as the following must be implemented:
- Identification. Early identification of at-risk teenagers and young adults could prevent osteoporosis.
- Diet. A diet with increased calcium intake strengthens the bones and avoids fractures.
- Activities. Participation in regular weight-bearing exercises results in excellent bone maintenance.
- Lifestyle. Modifications in lifestyle such as reduced use of caffeine, cigarettes, carbonated softdrinks, and alcohol could improve osteogenesis for bone remodeling.
Assessment and Diagnostic Findings
Osteoporosis may be undetectable on routine x-rays until there has been 25% to 40% demineralization, resulting in radiolucency of the bones.
- Dual-energy X-ray Absorptiometry (DXA). Osteoporosis is diagnosed by DXA, which provides information about BMD at the spine and hip.
- BMD testing. BMD testing is useful in identifying osteopenic and osteoporotic bone and in assessing response to therapy.
- Laboratory studies. Laboratory studies such as serum calcium, serum phosphate, serum alkaline phosphatase, urine calcium excretion, hematocrit, erythrocyte sedimentation rate, and x-ray studies are used to exclude other possible disorders that contribute to bone loss.
Medical management for a patient with osteoporosis include:
- Diet. A diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence, young adulthood, and the middle years, protects against skeletal demineralization.
- Exercise. Regular weight-bearing exercise promotes bone formation, such as a 20-30-minute aerobic exercise, 3x a week, is recommended.
- Fracture management. Osteoporotic compression fractures of the vertebrae are managed conservatively, pharmacologic and dietary treatments are aimed at increasing vertebral bone density, and for patients who do not respond to first-line approaches are treated with percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacrylate bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra).
The first-line medications and other medications used to treat and prevent osteoporosis include:
- Calcium supplements with vitamin D. To ensure adequate calcium intake, a calcium supplement with vitamin D may be prescribed and taken with meals or with a beverage high in vitamin C to promote absorption, but these supplements should not be taken at the same day as biphosphonates.
- Biphosphonates. Biphosphonates that include daily or weekly oral preparations of alendronate or risedronate, monthly oral preparations of ibandronate, or yearly intravenous infusions of zoledronic acid increase bone mass and decrease bone loss by inhibiting osteoclast function.
- Calcitonin. Calcitonin directly inhibits osteoclasts thereby reducing bone loss ans increasing bone mineral density, and is administered by nasal spray or by subcutaneous or intramuscular injection.
- Selective estrogen receptor modulators (SERMs). SERMs such as raloxifene, reduce the risk of osteporosis by preserving bone mineral density without estrogenic effects on the uterus.
- Teriparatide. Teriparatide is a subcutaneously administered anabolic agent that is administered once daily, and as a recombinant PTH, it stimulates osteoblasts to build bone matrix and facilitates overall calcium absorption.
Fractures of the hip that occur as a consequence of osteoporosis are managed surgically through:
- Joint replacement. Joint replacement is a surgery to replace all or part of a joint with a man-made joint called prosthesis.
- Closed or open reduction with internal fixation. Open reduction, internal fixation involves the implementation of implants to guide the healing process of a bone, as well as the open reduction, or setting, of the bone, while closed reduction is a procedure to set or reduce a broken bone without surgery.
Management of a patient with osteoporosis consists of the nursing process.
Health promotion, identification of people at risk for osteoporosis, and recognition of problems associated with osteoporosis form the basis for nursing assessment.
- Health history. The health history includes questions concerning the occurrence of osteopenia and osteoporosis and focuses on family history, previous fractures, dietary consumption of calcium, exercise patterns, onset of menopause, and use of corticosteroids as well as alcohol, caffeine, and smoking.
- Symptoms. Any symptoms the patient is experiencing, such as back pain, constipation, or altered body image, are explored.
- Physical examination. Physical exam may disclose a fracture, kyphosis of the thoracic spine, or shortened stature.
Based on the assessment data, the major nursing diagnoses for a patient who has osteoporosis may include:
- 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.
- Risk for injury: additional fractures related to osteoporosis.
Nursing Care Planning and Goals
Main Article: 8 Fracture Nursing Care Plans
The major goals for the patient may include:
- Knowledge about osteoporosis and the treatment regimen.
- Relief of pain.
- Improved bowel elimination.
- Absence of additional fractures.
Nursing interventions appropriate for a patient with osteoporosis are:
- Promoting understanding of osteoporosis and the treatment regimen. Patient teaching focuses on factors influencing the development of osteoporosis, interventions to arrest or slow the process, and measures to relieve symptoms.
- Relieving pain. Advise the patient to rest in bed in a supine or side-lying position several times a day; the mattress should be firm and nonsagging; knee flexion increases comfort; intermittent local heat and back rubs promote muscle relaxation, and the nurse should encourage good posture and teach body mechanics.
- Improving bowel movement. Early institution of high fiber diet, increased fluids, and the use of prescribed stool softeners help prevent or minimize constipation.
- Preventing injury. The nurse encourages walking, good body mechanics, and good posture plus daily weight-bearing activity outdoors to enhance production of vitamin D.
Expected patient outcomes may include:
- Acquired knowledge about osteoporosis and the treatment regimen.
- Achieved pain relief.
- Demonstrated normal bowel elimination.
- Experienced no new fractures.
Discharge and Home Care Guidelines
At the completion of the home care instruction, the patient or caregiver will be able to implement the following:
- Diet. Identify calcium and vitamin D rich foods and discuss calcium supplements.
- Exercise. Engage in weight-bearing exercise daily.
- Lifestyle. Modify lifestyle choices: avoid smoking, alcohol, caffeine, and carbonated beverages.
- Posture. Demonstrate good body mechanics.
- Early detection. Participate in screening for osteoporosis.
The focus of documentation are:
- Individual findings including learning style, identified needs, presence of learning blocks.
- Plan for learning, methods to be used, and who is involved in the planning.
- Teaching plan.
- Response of client/SO to the learning plan and actions performed.
- Client’s description of response to pain, specifics of pain inventory, expectations of pain management, and acceptable level of pain.
- Current bowel pattern, characteristics of stool, medications and herbals used.
- Dietary intake.
- Exercise and activity level.
- Current physical findings.
- Client’s/caregiver’s understanding of individual risks and safety concerns.
- Availability and use of resources.
- Attainment or progress toward desired outcome.
- Modifications to plan of care.
Practice Quiz: Osteoporosis
Here are some practice questions for this study guide:
In Exam Mode: All questions are shown but the results, answers, and rationales (if any) will only be given after you’ve finished the quiz.
Practice Quiz: Osteoporosis
Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.
Practice Quiz: Osteoporosis
1. Alendronate (Fosamax) is given to a client with osteoporosis. The nurse advises the client to?
A. Take the medication in the morning with meals.
B. Take the medication 2 hours before bedtime.
C. Take the medication with a glass of water after rising in the morning.
D. Take the medication during lunch.
1. Answer: C. Take the medication with a glass of water after rising in the morning.
- C: Alendronate needs to be taken with a glass of water after rising in the morning in order to prevent gastrointestinal effects.
- A, B, D: Not taking Alendronate on the specified time of the day could cause GI upset.
2. A client with osteoporosis is asking the nurse regarding the use of Salmon calcitonin (Miacalcin) nasal spray. The nurse tells the client to do the following, except?
A. Delivery system contains enough medication for at least 30 doses. Discard any unused solution after 30 doses.
B. If you do not feel the spray while using it, repeat the dose on the other nostrils.
C. Miacalcin is usually given as one spray per day into only one of your nostrils.
D. Take extra vitamin D while you are using Miacalcin.
2. Answer: B. If you do not feel the spray while using it, repeat the dose on the other nostrils.
- B: Miacalcin spray delivers a fine mist into the nose. Even if the client does not feel the spray while using it, the medication is still being absorbed by the nasal passages.
- A: Discard any unused solution after 30 doses because spray may not deliver correct dose.
- C: Use the other nostril the next day and continue alternating back and forth for each daily dose.
- D: Vitamin D helps in treating osteoporosis by helping in maintaining healthy bones.
3. Which patient should NOT be prescribed alendronate (Fosamax) for osteoporosis?
A. A female patient being treated for high blood pressure with an ACE inhibitor.
B. A patient who is allergic to iodine/shellfish.
C. A patient on a calorie restricted diet.
D. A patient on bed rest who must maintain a supine position.
3. Answer: D. A patient on bed rest who must maintain a supine position.
- D: Alendronate can cause significant gastrointestinal side effects, such as esophageal irritation, so it should not be taken if a patient must stay in supine position.
- A&B: ACE inhibitors are not contraindicated with alendronate and there is no iodine allergy relationship.
- C: The patient should not eat or drink for 30 minutes after administration and should not lie down.
4. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to:
A. Exercise doing weight bearing activities.
B. Exercise to reduce weight.
C. Avoid exercise activities that increase the risk of fracture.
D. Exercise to strengthen muscles and thereby protect bones.
4. Answer: A. Exercise doing weight bearing activities.
- A: Weight bearing exercises are beneficial in the treatment of osteoporosis.
- B, C, D: Although loss of bone cannot be substantially reversed, further loss can be greatly reduced if the client includes weight bearing exercises along with estrogen replacement and calcium supplements in their treatment protocol.
5. The nurse knows that a 60-year-old female client’s susceptibility to osteoporosis is most likely related to:
A. Lack of exercise.
B. Hormonal disturbances.
C. Lack of calcium.
D. Genetic predisposition.
5. Answer: B. Hormonal disturbances.
- B: After menopause, women lack hormones necessary to absorb and utilize calcium.
- A & C: Doing weight-bearing exercises and taking calcium supplements can help to prevent osteoporosis but are not causes, so answers A and C are incorrect.
- D: Body types that frequently experience osteoporosis are thin Caucasian females, but they are not most likely related to osteoporosis, so answer D is incorrect.
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