Notes

MY NOTES ON OSTEOPOROSIS FROM TEGRITY
Osteoporosis
also called porus bone
Osteoporosis is a disorder in which there is a reduction of total bone mass. Chronic and progressive. leads to bone fragility. they can eventually become so fragile that they cannot withstand normal mechanical stress, weight bearing (lifting can cause a fracture, coughing (fractured ribs). Caused by inadequate ca intake, excessive ca loss from bones, or poor ca absorption. It's a ca malfunction. Ca is what gives bones strength. Excessive risk of fractures, especially the wrist, hip, and vertebral column.
Osteoporosis is more difficult to treat than to prevent.
Difficult to regain former level of functioning following an osteoporosis-related fracture because you don't have as much bone mass. When you're trying to recover with osteoporosis, it won't heal properly.
It's important to identify those at risk.

Risk factors
-more common in women (women have lower ca intake, and smaller frame=less bone mass, resorption begins at an earlier age is accelerated during menopause, pregnancy/breastfeeding, longer life span (disease of elderly)
-advancing age (>65)
-white or Asian ethnicity
-low body weight
-current cigarette smoking
-nontraumatic fracture usually (indicates low bone mineral density)
-sedentary lifestyle
-postmenopausal
-family history
-diet low in ca and vitamin d
-excessive use of alcohol (more than two drinks/day)
-low testosterone level in men
-specific diseases (inflammatory bowel disease, intestinal malabsorption, kidney disease, rheumatoid arthritis, hyperthyroidism, chronic alcoholism/serousis of liver, diabetes, and hypogonadism (decreased in sexual hormones))
-drugs that interfere with bone metabolism (steroids, anti seizure drugs, aluminum-containing antacids, heparin, some cancer drugs, and excessive thyroid hormones, long term cortiocosteroid use (Major))

Typically, peak bone mass is obtained by age 20. It is determined by a combination of factors
-hereditary
-nutrition
-exercise
-hormone function
Bone loss from midlife (ages 35-40) in inevitable, but rate varies. at menopause, women experience rapid bone loss when estrogen declines at its sharpest. Then the rate slows and eventually matches the rate of bone loss by men at 65-70 years old. You inherit bone mass, size, quality, and turnover (remodeling). Bones is continually being remodeled until old age. In osteoporosis, bone resorption exceeds bone deposition.

What to assess for
-usually no signs or symptoms until they've lost enough that they get a fracture
-most commonly in spine, hips, and wrist
-usual first manifestation is back pain or spontaneous fracture (no trauma)
-one vertebral fracture increases the risk of having a second within a year.
-gradual loss of height
-Dowager's hump (kyphosis)

Nursing Diagnoses
-pain
-risk for injury
-altered body image

Diagnostic screening
-initial bone scan in women before age of 65
-if normal, repeat every 15 years
-earlier and more frequently if high risk
-men screened before age 70
-by age 50 if high risk

Diagnostic Studies
Osteoporosis often goes unnoticed (no symptoms) cannot be detected by conventional x ray until more than 25-40% of calcium from bone is gone, so an x ray does no good until it's really late. serum levels are usually normal because the calcium lost from the bone goes into the bloodstream.
-Bone mineral density (BMD)
determined by peak bone mass and amount of bone loss
-Quantitative Ultrasound (QUS)
-measures bone density in heel, kneecap, or shin
-Dual-Energy x ray absorptiometry (DXA)
-measures bone density in the spine, hips, and forearm
-helps evaluate changes over time
-Reported at T-score
-Number of standard deviations below average
-Greater than or equal to -1 indicates normal bone density.
Osteopenia (bone loss more than normal but not yet osteoporosis) is a t score between -1 and -2.5.
Osteoporosis is a t score less than -2.5

Treat if
-t score is less than -2.5
-t score between -1 and -2.5 with additional risk factors
-prior history of hip or vertebral fracture

Fracture Risk Tool (FRAX) Fracture Risk Assessment
takes into account bone mineral density and additional factors when assessing pt at risk.
-assess fracture risk and gives a 10 year probability of a fracture
-developed by world health organization (who)
-based on individual patient models
-integrates the risk associated with clinical risk factors as well as bone mineral density at the femoral neck
-by country
-by race
http://www.shef.ac.uk/FRAX/tool.aspx

The nurse is gonna focus on proper nutrition, calcium supplements as ordered, exercise, prevention of fractures, and drug therapy.
Prevention and treatment focused on adequate ca. 1000mg/day in premenopausal women and in postmenopausal women taking estrogen
1500mg/day in postmenopausal women who are not taking estrogen
if your dietary intake is not adequate, there are supplements. ca is difficult to absorb in doses greater than 500mg, so it has to be taken in divided does and with food.
Foods high in cal: milk, cheese, ice cream, cottage cheese, yogurt, spinach and turnip greens, dark green leafy vegetables, sardines, fish with bone in it (salmon)
Vitamin D is important in calcium absorption, but most people get enough, so it is usually not added. the sun also provides you with vitamin D (20 minutes/day) you can get supplemental if needed (800-1000)

Nursing Interventions
-weight bearing exercise. regular physical activity is important to build and maintain bone mass. increases muscle strength, coordination and balance(decrease risk for fall)
-best is walking (30 minutes 3x/week). not high impact (running) risk of joint injury/stress fractures
-quit smoking
-decrease alcohol intake (not excessive)
-treatment of existing osteoporosis
Bone loss cannot be reversed, but you can help prevent further bone loss. You want to try to make sure they remain ambulatory. You may want them to use a cane or walker because of the risk of fracture. If they've had one fracture (non traumatic) then their risk of having another is greater. Sometimes the hcp will prescribe a back brace to help prevent further vertebral fractures.
Vertebroplasty and kyphoplasty are surgical procedures
Vertebroplasty: bone cement is injected into collapsed vertebrate. stabilized and corrects deformity.
kyphoplasty: an air bladder (sac of air) is inserted into collapsed vertebrae and inflated. That regains height. Then they used bone cement.

Drug Therapy
-Bisphosphonates. inhibits bone loss. Increase total bone mass and bon mineral density. widely used to treat this disorder. Common side effects: anorexia, weight loss, and gastritis. pt teaching: take them with a full glass of water and they need to take this 30 minutes before meals or other medications and remain upright for 30 minutes after taking so it is all the way out of the esophagus. decreases gi side effects, especially esophageal irrition. also increase absorption. rare but serious side effect is jaw osteonecrosis (bone death in jaw). Fosamax 1x/week, Actonel and Boniva 1x/month, Reclast 1x/year IV infusion and can prevent osteoporosis for two years following, so it has to be repeated every two years. may cause flu like symptoms for the first few days after administration.
-Calcitonin. Normally secreted by the thyroid gland. It inhibits bone osteoplastic bone resorption. salmon calcitonin is derived from salmon, Calcimar, can be given IM, SQ, or intranasal.
it can cause nausea and facial flushing, so we give it IM and SQ at night to decrease facial flushing. If the pt is using nasal spray, the side effects do not occur. If your pt is on the nasal spray, teach them to alternate nostrils daily. Nasal dryness and irritation is the most common side effect of nasal spray. When the patient is using the calcitonin, they also must have a calcium supplement to prevent hyperparathyroidism.
-Selective estrogen receptor modulators {SERM} (not given primarily)
-Raloxifene (Evista)
-Reduces bone resorption
-mimics the effect of estrogen on bone by reducing bone resorption, but it does not stimulate uterus or breasts like estrogen
-side effects: leg cramps, hot flashes, and blood clots and they claim it may decrease breast cancer risk
-Teriparatide (Forteo)
-form of human parathyroid hormone
-increases action of osteoblasts (bone building cells)
-SQ 1x/day
-Side effects: leg cramps and dizziness
-Denosumab (Prolia)
-antibody that binds to a protein involved in the formation/function of osteoclasts and is a SQ every 6 months
-monoclonal antibody for postmenopausal women
-SQ every 6 months
-management of pt receiving cortiocosteroids
give them lowest effective dose for the shortest amount of time that we can to be effective. Make sure they have an adequate cal and vitamin d intake, and if bone mineral density tests shows the pt has lost bone mass, we are going to start the bisphosphonates.

Safety Measures
-flat, broad heel shoes
-bed in low position
-cane or walker close by
-adequate lighting
-removed throw rugs, electrical cords
-pathways clear of clutter
-nonskid floor wax
-install bars along tub, beside toilet
-nonskid mat or strips in tub
-use hand help shower head and sit while bathing
-teach them these safety measures and evaluate the effectiveness

QUESTIONS
1.) What is osteoporosis?
a disorder in which there is a reduction of total bone mass. Chronic and progressive.
2.) What causes osteoporosis?
Caused by inadequate ca intake, excessive ca loss from bones, or poor ca absorption.
3.) What are the risk factors for osteoporosis?
Risk factors
-more common in women (women have lower ca intake, and smaller frame=less bone mass, resorption begins at an earlier age is accelerated during menopause, pregnancy/breastfeeding, longer life span (disease of elderly)
-advancing age (>65)
-white or Asian ethnicity
-low body weight
-current cigarette smoking
-nontraumatic fracture usually (indicates low bone mineral density)
-sedentary lifestyle
-postmenopausal
-family history
-diet low in ca and vitamin d
-excessive use of alcohol (more than two drinks/day)
-low testosterone level in men
-specific diseases (inflammatory bowel disease, intestinal malabsorption, kidney disease, rheumatoid arthritis, hyperthyroidism, chronic alcoholism/serousis of liver, diabetes, and hypogonadism (decreased in sexual hormones))
-drugs that interfere with bone metabolism (steroids, anti seizure drugs, aluminum-containing antacids, heparin, some cancer drugs, and excessive thyroid hormones, long term cortiocosteroid use (Major))
4.) What do you assess for if you suspect osteoporosis?
-usually no signs or symptoms until they've lost enough that they get a fracture
-most commonly in spine, hips, and wrist
-usual first manifestation is back pain or spontaneous fracture (no trauma)
-one vertebral fracture increases the risk of having a second within a year.
-gradual loss of height
-Dowager's hump (kyphosis)
5.) What are some possible nursing diagnoses when dealing with a patient who has osteoporosis?
-pain
-risk for injury
-altered body image
6.) What does a patient need to know about osteoporosis screening?
-initial bone screen in women before age of 65
-if normal, repeat every 15 years
-earlier and more frequently if high risk
-men screened before age 70
-by age 50 if high risk
7.) How do you diagnose osteoporosis?
-Bone mineral density (BMD)
determined by peak bone mass and amount of bone loss
-Quantitative Ultrasound (QUS)
-measures bone density in heel, kneecap, or shin
-Dual-Energy x ray absorptiometry (DXA)
-measures bone density in the spine, hips, and forearm
-helps evaluate changes over time
-Reported at T-score
-Number of standard deviations below average
-Greater than or equal to -1 indicates normal bone density.
Osteopenia (bone loss more than normal but not yet osteoporosis) is a t score between -1 and -2.5.
Osteoporosis is a t score less than -2.5
8.) When do you begin treatment?
-t score is less than -2.5
-t score between -1 and -2.5 with additional risk factors
-prior history of hip or vertebral fracture
9.)What is the FRAX and what does it do?
Fracture Risk Assessment
takes into account bone mineral density and additional factors when assessing pt at risk.
-assess fracture risk and gives a 10 year probability of a fracture
-developed by world health organization (who)
-based on individual patient models
-integrates the risk associated with clinical risk factors as well as bone mineral density at the femoral neck
-by country
-by race
10.) What do we teach a patient with a risk for or diagnosis of osteoporosis about their diet and nutritional needs?
Prevention and treatment focused on adequate ca. 1000mg/day in premenopausal women and in postmenopausal women taking estrogen
1500mg/day in postmenopausal women who are not taking estrogen
if your dietary intake is not adequate, there are supplements. ca is difficult to absorb in doses greater than 500mg, so it has to be taken in divided does and with food.
Foods high in cal: milk, cheese, ice cream, cottage cheese, yogurt, spinach and turnip greens, dark green leafy vegetables, sardines, fish with bone in it (salmon)
Vitamin D is important in calcium absorption, but most people get enough, so it is usually not added. the sun also provides you with vitamin D (20 minutes/day) you can get supplemental if needed (800-1000)
11.) What are some nursing interventions for osteoporosis?
-weight bearing exercise. regular physical activity is important to build and maintain bone mass. increases muscle strength, coordination and balance(decrease risk for fall)
-best is walking (30 minutes 3x/week). not high impact (running) risk of joint injury/stress fractures
-quit smoking
-decrease alcohol intake (not excessive)
-treatment of existing osteoporosis
Bone loss cannot be reversed, but you can help prevent further bone loss. You want to try to make sure they remain ambulatory. You may want them to use a cane or walker because of the risk of fracture. If they've had one fracture (non traumatic) then their risk of having another is greater. Sometimes the hcp will prescribe a back brace to help prevent further vertebral fractures.
12.) What are some surgical treatment options for osteoporosis?
Vertebroplasty and kyphoplasty are surgical procedures
Vertebroplasty: bone cement is injected into collapsed vertebrate. stabilized and corrects deformity.
kyphoplasty: an air bladder (sac of air) is inserted into collapsed vertebrae and inflated. That regains height. Then they used bone cement.
13.) What are the drug therapies for osteoporosis?
-Bisphosphonates. inhibits bone loss. Increase total bone mass and bon mineral density. widely used to treat this disorder. Common side effects: anorexia, weight loss, and gastritis. pt teaching: take them with a full glass of water and they need to take this 30 minutes before meals or other medications and remain upright for 30 minutes after taking so it is all the way out of the esophagus. decreases gi side effects, especially esophageal irrition. also increase absorption. rare but serious side effect is jaw osteonecrosis (bone death in jaw). Fosamax 1x/week, Actonel and Boniva 1x/month, Reclast 1x/year IV infusion and can prevent osteoporosis for two years following, so it has to be repeated every two years. may cause flu like symptoms for the first few days after administration.
-Calcitonin. Normally secreted by the thyroid gland. It inhibits bone osteoplastic bone resorption. salmon calcitonin is derived from salmon, Calcimar, can be given IM, SQ, or intranasal.
it can cause nausea and facial flushing, so we give it IM and SQ at night to decrease facial flushing. If the pt is using nasal spray, the side effects do not occur. If your pt is on the nasal spray, teach them to alternate nostrils daily. Nasal dryness and irritation is the most common side effect of nasal spray. When the patient is using the calcitonin, they also must have a calcium supplement to prevent hyperparathyroidism.
-Selective estrogen receptor modulators {SERM} (not given primarily)
-Raloxifene (Evista)
-Reduces bone resorption
-mimics the effect of estrogen on bone by reducing bone resorption, but it does not stimulate uterus or breasts like estrogen
-side effects: leg cramps, hot flashes, and blood clots and they claim it may decrease breast cancer risk
-Teriparatide (Forteo)
-form of human parathyroid hormone
-increases action of osteoblasts (bone building cells)
-SQ 1x/day
-Side effects: leg cramps and dizziness
-Denosumab (Prolia)
-antibody that binds to a protein involved in the formation/function of osteoclasts and is a SQ every 6 months
-monoclonal antibody for postmenopausal women
-SQ every 6 months
-management of pt receiving cortiocosteroids
give them lowest effective dose for the shortest amount of time that we can to be effective. Make sure they have an adequate cal and vitamin d intake, and if bone mineral density tests shows the pt has lost bone mass, we are going to start the bisphosphonates.
14.) What are some safety measures you can teach a patient with osteoporosis?
-flat, broad heel shoes
-bed in low position
-cane or walker close by
-adequate lighting
-removed throw rugs, electrical cords
-pathways clear of clutter
-nonskid floor wax
-install bars along tub, beside toilet
-nonskid mat or strips in tub
-use hand help shower head and sit while bathing
-teach them these safety measures and evaluate the effectiveness