Term
-Osteomylitis
-What is it? (besides a really bad infection) |
|
Definition
| Osteomyelitis is a severe infection of the bone, bone marrow, and surrounding soft tissue. The most common infecting microorganism is Staphylococcus aureus. A variety of microorganisms can cause osteomyelitis1 (Table 64-1). Aerobic gram-negative bacteria alone or mixed with gram-positive organisms are often found. The widespread use of antibiotics in conjunction with surgical treatment has significantly reduced the mortality rate and complications associated with osteomyelitis. |
|
|
Term
| -How can you develop osteomyelitis? Direct |
|
Definition
| Direct entry osteomyelitis can occur at any age when there is an open wound (e.g., penetrating wounds, fractures) and microorganisms gain entry to the body. Osteomyelitis may also occur in the presence of a foreign body such as an implant or an orthopedic prosthetic device (e.g., plate, total joint prosthesis). After gaining entrance to the bone by way of the blood, the microorganisms then lodge in an area of bone in which circulation slows, usually the metaphysis. The microorganisms grow, resulting in an increase in pressure because of the nonexpanding nature of most bone. This increasing pressure eventually leads to ischemia and vascular compromise of the periosteum. Eventually the infection passes through the bone cortex and marrow cavity, ultimately resulting in cortical devascularization and necrosis. Once ischemia occurs, the bone dies. The area of devitalized bone eventually separates from the surrounding living bone, forming sequestra. The part of the periosteum that continues to have a blood supply forms new bone called involucrum (Fig. 64-1). |
|
|
Term
| -How can you develop osteomyelitis? Indirect |
|
Definition
| The infecting microorganisms can invade by indirect or direct entry. The indirect entry (hematogenous) of microorganisms most frequently affects growing bone in boys younger than 12 years old, and is associated with their higher incidence of blunt trauma. The most common sites of indirect entry in children are the distal femur, proximal tibia, humerus, and radius.2 Adults with vascular insufficiency disorders (e.g., diabetes mellitus) and genitourinary and respiratory infections are at higher risk for a primary infection to spread via the blood to the bone. The pelvis, tibia, and vertebrae, which are vascular-rich sites of bone, are the most common sites of infection. |
|
|
Term
| Have an understanding of the pathophysiology of osteomyelitis (for instance what is a sequestra and how does the sinus tract develop and where is it?) |
|
Definition
Once formed, a sequestrum continues to be an infected island of bone, surrounded by pus. It is difficult for blood-borne antibiotics or white blood cells (WBCs) to reach the sequestrum. A sequestrum may enlarge and serve as a site for microorganisms that spread to other sites, including the lungs and brain. If the necrotic sequestrum is not resolved naturally or surgically, it may develop a sinus tract, resulting in chronic, purulent cutaneous drainage.
Chronic osteomyelitis is either a continuous, persistent problem (a result of inadequate acute treatment) or a process of exacerbations and remissions (Fig. 64-2). Over time, granulation tissue turns to scar tissue. This avascular scar tissue provides an ideal site for continued microorganism growth and is impenetrable by antibiotics. |
|
|
Term
| -What does the patient with osteomyelitis “look” like – what are the signs and symptoms? |
|
Definition
Acute osteomyelitis refers to the initial infection or an infection of less than 1 month in duration. The clinical manifestations of acute osteomyelitis are both systemic and local. Systemic manifestations include fever, night sweats, chills, restlessness, nausea, and malaise. Local manifestations include constant bone pain that is unrelieved by rest and worsens with activity; swelling, tenderness, and warmth at the infection site; and restricted movement of the affected part. Later signs include drainage from sinus tracts to the skin and/or the fracture site.
Chronic osteomyelitis refers to a bone infection that persists for longer than 1 month or an infection that has failed to respond to the initial course of antibiotic therapy. Systemic signs may be diminished, with local signs of infection more common, including constant bone pain and swelling, tenderness, and warmth at the infection site. |
|
|
Term
| -What are the lab and diagnostic studies that help to diagnose the problem? |
|
Definition
| A bone or soft tissue biopsy is the definitive way to determine the causative microorganism. The patient's blood and/or wound cultures are frequently positive for the presence of microorganisms. An elevated WBC count and erythrocyte sedimentation rate (ESR) may also be found. Radiologic signs suggestive of osteomyelitis usually do not appear until 10 days to weeks after the appearance of clinical symptoms, by which time the disease will have progressed. Radionuclide bone scans (gallium and indium) are helpful in diagnosis and are usually positive in the area of infection. Magnetic resonance imaging (MRI) and computed tomography (CT) scans may be used to help identify the extent of the infection, including soft tissue involvement.3 |
|
|
Term
| -What are the treatment and the collaborative care options for osteomyelitis? |
|
Definition
Vigorous and prolonged intravenous (IV) antibiotic therapy is the treatment of choice for acute osteomyelitis, as long as bone ischemia has not yet occurred. Cultures or a bone biopsy should be done if possible before drug therapy is initiated. If antibiotic therapy is delayed, surgical debridement and decompression are often necessary.
Patients are often discharged to home care or a skilled nursing facility with IV antibiotics delivered via a central venous catheter or peripherally inserted central catheter. IV antibiotic therapy may initially be started in the hospital and continued in the home for 4 to 6 weeks or as long as 3 to 6 months. A variety of antibiotics may be prescribed depending on the microorganism. These drugs include penicillin, nafcillin (Nafcil), neomycin, vancomycin, cephalexin (Keflex), cefazolin (Ancef), cefoxitin (Mefoxin), gentamicin (Garamycin), and tobramycin (Nebcin). |
|
|
Term
DRUG ALERT
Gentamicin (Garamycin) |
|
Definition
•Instruct patient to notify health care provider if any visual, hearing, or urinary problems develop.
•Assess patient for dehydration before starting therapy. |
|
|
Term
| More info. tx of osteomyelitis |
|
Definition
In adults with chronic osteomyelitis, oral therapy with a fluoroquinolone (ciprofloxacin [Cipro]) for 6 to 8 weeks may be prescribed instead of IV antibiotics. Oral antibiotic therapy may also be given after acute IV therapy is completed to ensure resolution of the infection. The patient's response to drug therapy is monitored through bone scans and ESR tests.
Treatment of chronic osteomyelitis includes surgical removal of the poorly vascularized tissue and dead bone and the extended use of antibiotics. Antibiotic-impregnated polymethylmethacrylate bead chains may also be implanted at this time to aid in combating the infection. After debridement of the devitalized and infected tissue, the wound may be closed, and a suction irrigation system is inserted. Intermittent or constant irrigation of the affected bone with antibiotics may also be initiated. Protection of the limb or surgical site with casts or braces is frequently done. Negative pressure (Wound VAC) over the site of the infection may be used to draw the wound together (see Chapter 13).
Hyperbaric oxygen with 100% oxygen may be given as an adjunct therapy in refractory cases of chronic osteomyelitis.4 This therapy is thought to stimulate circulation and healing in the infected tissue (see Chapter 13). Orthopedic prosthetic devices, if a source of chronic infection, must be removed. Muscle flaps or skin grafting provide wound coverage over the dead space (cavity) in the bone. Bone grafts may help to restore blood flow. Amputation of the extremity may be indicated when there is extensive bone destruction and it may be necessary to also preserve the person's life and/or improve quality of life.
Long-term and mostly rare complications of osteomyelitis include septicemia, septic arthritis, pathologic fractures, and amyloidosis. |
|
|
Term
| -What are the priority nursing interventions for this patient? Think acute interventions (hint pg 1623) |
|
Definition
Some immobilization of the affected limb (e.g., splint, traction) is usually indicated to decrease pain. Carefully handle the involved limb and avoid excessive manipulation, which increases pain and may cause pathologic fracture. Assess the patient's pain. Minor to severe pain may be experienced with muscle spasms. Nonsteroidal antiinflammatory drugs (NSAIDs), opioid analgesics, and muscle relaxants may be prescribed to provide patient comfort. Encourage nonpharmacologic (e.g., guided imagery, hypnosis) approaches to pain (see Chapters 8 and 10).
Dressings are used to absorb the exudate from draining wounds and to debride devitalized tissue from the wound site when removed. Types of dressings used include dry, sterile dressings; dressings saturated in saline or antibiotic solution; and wet-to-dry dressings. Handle soiled dressings carefully to prevent cross-contamination of the wound or spread of the infection to other patients. Sterile technique is essential when changing the dressing.
The patient is frequently on bed rest in the early stages of the acute infection. Good body alignment and frequent position changes prevent complications associated with immobility and promote comfort. Flexion contracture, especially of the hip or knee, is a common sequel of osteomyelitis of the lower extremity because the patient frequently positions the affected extremity in a flexed position to promote comfort. The contracture may then progress to a deformity. Footdrop can develop quickly in the lower extremity if the foot is not correctly supported in a neutral position by a splint or if there is excessive pressure from a splint, which can injure the peroneal nerve. Instruct the patient to avoid any activities such as exercise or heat application that increase circulation and swelling and serve as stimuli to the spread of infection. Uninvolved joints and muscles should continue to be exercised.
Teach the patient the potential adverse and toxic reactions associated with prolonged and high-dose antibiotic therapy. These reactions include hearing deficit, fluid retention, and neurotoxicity, which can occur with the aminoglycosides (e.g., tobramycin, neomycin), jaundice, colitis, and photosensitivity from the extended use of the cephalosporins (e.g., cefazolin).5 Tendon rupture (especially the Achilles tendon), can occur with use of the fluoroquinolones (e.g., ciprofloxacin [Cipro], levofloxacin [Levaquin]). Peak and trough blood levels of most antibiotics must be carefully monitored throughout the course of therapy to avoid adverse effects. Lengthy antibiotic therapy can also result in an overgrowth of Candida albicans and Clostridium difficile in the genitourinary and oral cavities, especially in immunosuppressed and older patients. Instruct the patient to report any whitish, yellow, curdlike lesions to the health care provider.
The patient and family are often frightened and discouraged because of the serious nature of the infection, the uncertainty of the outcome, and the cost and lengthy course of treatment. Continued psychologic and emotional support is an integral part of nursing management. A nursing care plan for the patient with osteomyelitis is available on the Evolve website for this chapter. |
|
|
Term
| What are the long term and home care issues for these patients? |
|
Definition
With the introduction of various intermittent venous access devices, IV antibiotics can be administered to the patient in a skilled nursing facility or home setting. If at home, instruct the patient and caregiver on the proper care and management of the venous access device. Also teach how to administer the antibiotic when scheduled and the need for follow-up laboratory testing. Stress the importance of continuing to take antibiotics after the symptoms have subsided. Periodic home nursing visits provide the caregiver with support, which helps to reduce anxiety. If there is an open wound, dressing changes are often necessary. The patient and caregiver may require supplies and instruction in the technique.
If the osteomyelitis becomes chronic, patients need physical and psychologic support for a prolonged period. They may become suspicious and angry toward the health care providers when treatment plans do not result in a cure. Well-informed patients are better able to participate in decisions and cooperate in treatment plans. |
|
|
Term
| What is the basic etiology and pathophysiology of Low Back pain? |
|
Definition
Low back pain is common and has probably affected about 80% of adults in the United States at least once during their lifetime. Backache is second only to headache as the most common pain complaint. In persons under age 45, low back pain is responsible for more lost working hours than any other medical condition, and it is estimated that the total annual cost exceeds $50 billion annually.14 Low back pain is a common problem because the lumbar region (1) bears most of the weight of the body, (2) is the most flexible region of the spinal column, (3) contains nerve roots that are vulnerable to injury or disease, and (4) has an inherently poor biomechanical structure.
Several risk factors are associated with low back pain, including lack of muscle tone and excess body weight, poor posture, cigarette smoking, and stress. Jobs that require repetitive heavy lifting, vibration (such as a jackhammer operator), and prolonged periods of sitting are also associated with low back pain. Low back pain is most often due to a musculoskeletal problem. The causes of low back pain of musculoskeletal origin include (1) acute lumbosacral strain, (2) instability of the lumbosacral bony mechanism, (3) osteoarthritis of the lumbosacral vertebrae, (4) degenerative disk disease, and (5) herniation of an intervertebral disk. |
|
|
Term
| -What is acute low back pain? |
|
Definition
Acute low back pain lasts 4 weeks or less. Acute low back pain is usually associated with some type of activity that causes undue stress (often hyperflexion) on the tissues of the lower back. Often symptoms do not appear at the time of injury but develop later because of a gradual increase in pressure on the nerve by an intervertebral disk. Few definitive diagnostic abnormalities are present with nerve irritation and muscle strain. One test is the straight-leg raise. This test is positive for lumbar disk herniation when radicular pain occurs. MRI and CT scans are generally not done unless trauma or systemic disease (e.g., cancer, spinal infection) is suspected.
If the acute muscle spasms and accompanying pain are not severe and debilitating, the patient may be treated on an outpatient basis with a combination of the following: (1) analgesics, such as NSAIDs; (2) muscle relaxants (e.g., cyclobenzaprine [Flexeril]); (3) massage and back manipulation; and (4) the alternating use of heat and cold compresses.15 Severe pain may require a brief course of opioid analgesics.
A brief period (1 to 2 days) of rest at home may be necessary for some people, with most patients doing better with a continuation of their regular activities. Prolonged bed rest should be avoided.16 All patients during this time should refrain from activities that aggravate the pain, including lifting, bending, twisting, and prolonged sitting. Most cases show improvement within 2 weeks. |
|
|
Term
| -What is the nursing management of acute low back pain (think acute interventions)? |
|
Definition
The primary nursing responsibilities in acute low back pain are to assist the patient to maintain activity limitations, promote comfort, and educate the patient about the health problem and appropriate exercises. Other nursing interventions are summarized in eNCP 64-2 on the Evolve website for this chapter.
Muscle stretching and strengthening exercises may be part of the management plan. Although the actual exercises are often taught by the physical therapist, it is your responsibility to ensure that the patient understands the type and frequency of exercise prescribed, as well as the rationale for the program. |
|
|
Term
| PATIENT AND CAREGIVER TEACHING GUIDE Low Back Problems DO NOT |
|
Definition
•Lean forward without bending knees.
•Lift anything above level of elbows.
•Stand in one position for prolonged time.
•Sleep on abdomen or on back or side with legs out straight.
•Exercise without consulting health care provider if having severe pain.
•Exceed prescribed amount and type of exercises without consulting health care provider. |
|
|
Term
| PATIENT AND CAREGIVER TEACHING GUIDE Low Back Problems DO |
|
Definition
•Prevent lower back from straining forward by placing a foot on a step or stool during prolonged standing.
•Sleep in a side-lying position with knees and hips bent.
•Sleep on back with a lift under knees and legs or on back with 10-inch-high pillow under knees to flex hips and knees.
•Exercise 15 min in the morning and evening regularly; begin exercises with 2- or 3-min warm-up period by moving arms and legs, alternate relaxing and tightening muscles; exercise slowly with smooth movements.
•Carry light items close to body.
•Maintain appropriate body weight.
•Use local heat and cold application.
•Use a lumbar roll or pillow for sitting. |
|
|
Term
| Prevention of Low Back Pain |
|
Definition
•Maintain healthy weight.
•Do not sleep in a prone position.
•Sleep on side with knees flexed and a pillow between the knees.
•Avoid cigarette smoking and tobacco products.
•Obtain regular physical activity, including strength and endurance training.
•Use proper body mechanics to avoid low back strain (e.g., when lifting heavy objects, bend at the knees, not at the waist, and stand up slowly while holding object close to your body). |
|
|
Term
| -What is chronic low back pain? |
|
Definition
Chronic back pain lasts more than 3 months or is a repeated incapacitating episode. The causes of chronic low back pain include degenerative disk disease, lack of physical exercise, prior injury, obesity, structural and postural abnormalities, and systemic disease. Osteoarthritis (OA) of the lumbar spine is found in patients over 50, whereas chronic back pain in younger patients with OA usually involves the thoracic or lumbar spine. Discomfort is increased following periods of inactivity, particularly on awakening or after long periods of sitting.
Spinal stenosis is a narrowing of the vertebral canal or nerve root canals caused by the movement of bone into the space. The stenosis typically results from traumatic or degenerative changes to the spine such as osteoarthritis. When it occurs in the lumbar area of the spine, it is a common cause of chronic or recurrent low back pain. Compression of the nerve roots can result, with subsequent disk herniation. The pain associated with lumbar spinal stenosis often starts in the low back and then radiates to the buttock and leg.19 It worsens with walking and, in particular, standing without walking. |
|
|
Term
| -What is the nursing management for chronic low back pain? |
|
Definition
Treatment regimens for chronic back pain are much the same as for acute low back pain. These include a reduction in the pain associated with daily activities, a formal back pain program, and ongoing medical care. Cold, damp weather aggravates the back pain, but this can be relieved with rest and local heat application. Relief of pain and stiffness by the use of mild analgesics, such as NSAIDs, is integral to the daily comfort of the individual with chronic low back pain. Weight reduction, sufficient rest periods, local heat or cold application, and exercise and activity throughout the day help to keep the muscles and joints mobilized. Antidepressants may help with pain relief and sleep problems.20
Minimally invasive treatments, such as epidural corticosteroid injections and implanted devices that deliver pain medication, may be used for patients with chronic back pain who are refractory to the usual therapeutic options.
Surgical intervention may be indicated in patients with severe chronic low back pain who do not respond to conservative care and/or have continued neurologic deficits. (Surgery for low back pain is discussed on pp. 1630 to 1631.) |
|
|
Term
| Intervetebral lumbar disk damage |
|
Definition
| An intervertebral disk is interposed between the vertebrae from the cervical axis to the sacrum. |
|
|
Term
| -What is degenerative disk disease? |
|
Definition
| Structural degeneration of both the lumbar and cervical disk is often caused by degenerative disk disease (DDD) (Fig. 64-5). This progressive degeneration is a normal process of aging, and results in the intervertebral disks losing their elasticity, flexibility, and shock-absorbing capabilities.21 Thinning of the disks occurs as the nucleus pulposus (gelatinous center of the disk) starts to dry out and shrink. Compression of the nerve roots and cord may then occur. Damage to the spine by DDD contributes to osteoarthritis of the spine by the formation of osteophytes (bone spurs). |
|
|
Term
| -What is a herniated disk? |
|
Definition
| An acute herniated intervertebral disk (slipped disk) can be the result of natural degeneration with age or repeated stress and trauma to the spine. The nucleus pulposus may first bulge and then it can herniate, placing pressure on nearby nerves. The most common sites of rupture are the lumbosacral disks, specifically L4-5 and L5-S1. Disk herniation may also occur at C5-6 and C6-7. Disk herniation may be the result of spinal stenosis, in which narrowing of the spinal canal creates a bulging of the intervertebral disk. |
|
|
Term
| -What does disk damage “look” like – the signs and symptoms that the patient may tell you? |
|
Definition
| The most common feature of lumbar disk damage is low back pain. Radicular pain that radiates down the buttock and below the knee, along the distribution of the sciatic nerve, generally indicates disk herniation. (Specific manifestations for lumbar disk herniation are summarized in Table 64-7.) The straight-leg raise test may be positive, indicating nerve root irritation. Back or leg pain may be reproduced by raising the leg and flexing the foot at 90 degrees. Low back pain from other causes may not be accompanied by leg pain. Reflexes may be depressed or absent, depending on the spinal nerve root involved. Paresthesia or muscle weakness in the legs, feet, or toes may be reported by the patient. Multiple nerve root (cauda equina) compression due to a herniated disc or spinal surgery may be manifested as bowel and bladder incontinence or impotence. This condition is a medical emergency. |
|
|
Term
| -How do we diagnose disk damage? |
|
Definition
| X-rays are done to note any structural defects. A myelogram, MRI, or CT scan is helpful in localizing the damaged site. An epidural venogram or diskogram may be necessary if other methods of diagnosis are unsuccessful. An EMG of the extremities can be performed to determine the severity of nerve irritation, or to rule out other pathologic conditions such as peripheral neuropathy. |
|
|
Term
| Collaborative Care Disk Damage |
|
Definition
| The patient with suspected disk damage is usually managed first with conservative therapy (Table 64-8). This includes limitation of extremes of spinal movement (brace, corset, or belt), local heat or ice, ultrasound and massage, traction, and transcutaneous electrical nerve stimulation (TENS). Drug therapy includes NSAIDs, short-term opioids, and muscle relaxants. Epidural corticosteroid injections may be effective in reducing inflammation and relieving acute pain. If the underlying cause remains, the pain tends to recur. Conservative treatment can result in a healing over of the damaged area if not due to DDD, with a concomitant decrease in pain. Once the symptoms subside, back strengthening exercises are begun twice a day and are encouraged for a lifetime. Teach the patient the principles of good body mechanics. Extremes of flexion and torsion are strongly discouraged. |
|
|
Term
| -Have a basic understanding of how we repair disk damage surgery. |
|
Definition
| Surgery for a damaged disk is generally indicated when diagnostic tests indicate that the problem is not responding to conservative treatment and the patient is in consistent pain and/or has a persistent neurologic deficit. |
|
|
Term
| intradiscal electrothermoplasty (IDET) |
|
Definition
| minimally invasive outpatient procedure that may help in treating back and sciatica pain.22 The procedure involves the insertion of a needle into the affected disk with the guidance of an x-ray. A wire is then threaded down through the needle and into the disk. The wire is then heated, which denervates the small nerve fibers that have grown into the cracks and have invaded the degenerating disk. The heat also partially melts the annulus, which triggers the body to generate new reinforcing proteins in the fibers of the annulus. |
|
|
Term
| radiofrequency discal nucleoplasty (coblation nucleoplasty) |
|
Definition
| Another outpatient technique is radiofrequency discal nucleoplasty (coblation nucleoplasty). A needle is inserted into the disk similar to IDET. Instead of a heating wire, a special radiofrequency probe is used. The probe generates energy that breaks up the molecular bonds of the gel in the nucleus. The result is that up to 20% of the nucleus is removed, which decompresses the disk and reduces the pressure on both the disk and the surrounding nerve roots. Relief from pain varies among patients. |
|
|
Term
| interspinous process decompression system (X Stop) |
|
Definition
| This device is made of titanium and fits onto a mount that is placed on vertebrae in the lower back. The X Stop is used in patients with pain due to lumbar spinal stenosis. The device works by lifting the vertebrae off the pinched nerve. The effect is similar to and less invasive than a laminectomy. |
|
|
Term
|
Definition
| The most common and traditional surgical procedure for lumbar disk disease is a laminectomy. It involves the surgical excision of part of the posterior arch of the vertebra (referred to as the lamina) to gain access to part of or the entire protruding disk to remove it. A minimal hospital stay is usually required after the procedure. |
|
|
Term
|
Definition
| another common type of surgical procedure that may be performed to decompress the nerve root. Microsurgical diskectomy is a version of the standard diskectomy in which the surgeon uses a microscope to allow better visualization of the disk and disk space during surgery to aid in the removal of the damaged portion. This helps to maintain the bony stability of the spine. |
|
|
Term
|
Definition
| an outpatient surgical procedure using a tube that is passed through the retroperitoneal soft tissues to the lateral border of the disk with local anesthesia and the aid of fluoroscopy. A laser is then used on the damaged portion of the disk. Small stab wounds are used, and minimal blood loss occurs during the procedure. The procedure is effective and safe and decreases rehabilitation time. |
|
|
Term
|
Definition
| used in patients with lumbar disk damage associated with DDD.23 This artificial disk is made up of a high-density core sandwiched between two cobalt-chromium endplates (Fig. 64-6). This device is surgically placed in the spine through a small incision below the umbilicus after the damaged disk is removed. The disk allows for movement at the level of the implant. The Prodise-L is another type of artificial lumbar disc that can be used to treat DDD. |
|
|
Term
| Prestige cervical disc system |
|
Definition
| has recently been approved for treatment of DDD of the cervical spine and is indicated in patients with single-level disease. The surgical procedure is similar to that for the artificial lumbar disc.24 The goals of artificial disc replacement surgery are to restore movement and eliminate pain. |
|
|
Term
|
Definition
| may be performed if an unstable bony mechanism is present. The spine is stabilized by creating an ankylosis (fusion) of contiguous vertebrae with a bone graft from the patient's fibula or iliac crest or from a donated cadaver bone. Metal fixation with rods, plates, or screws may be implanted at the time of spinal surgery to provide more stability and decrease vertebral motion. A posterior lumbar interbody fusion may be performed in patients to provide extra support for bone grafting or a prosthetic device. Bone morphogenetic protein (BMP), a genetically engineered protein, can be used as an adjunct to autologous bone graft in spinal fusions has increased, although the costs associated with BMP have limited its use.25 |
|
|
Term
|
Definition
| Osteomalacia in the United States is an uncommon disease of adult bone associated with vitamin D deficiency, resulting in decalcification and softening of bone. This disease is the same as rickets in children except that the epiphyseal growth plates are closed in the adult. Vitamin D, with its complex actions and method of synthesis, is required for the absorption of calcium from the intestine. Insufficient vitamin D intake can interfere with the normal mineralization of bone, causing failure or insufficient calcification of bone, which results in bone softening |
|
|
Term
| Osteomalacia etiologic factors |
|
Definition
| in the development of osteomalacia include lack of exposure to ultraviolet rays (which is needed for vitamin D synthesis), gastrointestinal (GI) malabsorption, extensive burns, chronic diarrhea, pregnancy, kidney disease, and drugs such as phenytoin (Dilantin). |
|
|
Term
| Osteomalacia common clinical features |
|
Definition
| localized bone pain, difficulty rising from a chair, and difficulty walking. Other clinical manifestations include low back and bone pain; progressive muscular weakness, especially in the pelvic girdle; weight loss; and progressive deformities of the spine (kyphosis) or extremities. Fractures are common and demonstrate delayed bone healing when they occur. |
|
|
Term
| Osteomalacia laboratory findings |
|
Definition
| decreased serum calcium or phosphorus levels, decreased serum 25-hydroxyvitamin D, and elevated serum alkaline phosphatase. X-rays may demonstrate the effects of generalized bone demineralization, especially loss of calcium in the bones of the pelvis and the presence of associated bone deformity. Looser's transformation zones (ribbons of decalcification in bone found on x-ray) are diagnostic of osteomalacia. However, significant osteomalacia may exist without changes noted on x-ray. |
|
|
Term
| Collaborative care of osteomalacia |
|
Definition
| directed toward correction of the vitamin D deficiency. Vitamin D3 (cholecalciferol) and vitamin D2 (ergocalciferol) can be supplemented, and the patient often shows a dramatic response. Calcium salts or phosphorus supplements may also be prescribed. Dietary ingestion of eggs, meat, oily fish, and milk and breakfast cereals fortified with calcium and vitamin D is encouraged.29 Exposure to sunlight (and ultraviolet rays) is also valuable, along with weight-bearing exercise. |
|
|
Term
|
Definition
| Osteoporosis, or porous bone (fragile bone disease), is a chronic, progressive metabolic bone disease characterized by low bone mass and structural deterioration of bone tissue, leading to increased bone fragility |
|
|
Term
| Who does osteoporosis effect |
|
Definition
| more common in women than in men for several reasons: (1) women tend to have lower calcium intake than men throughout their lives (men between 15 and 50 years of age consume twice as much calcium as women); (2) women have less bone mass because of their generally smaller frame; (3) bone resorption begins at an earlier age in women and is accelerated at menopause; (4) pregnancy and breastfeeding deplete a woman's skeletal reserve unless calcium intake is adequate; and (5) longevity increases the likelihood of osteoporosis. |
|
|
Term
CULTURAL AND ETHNIC HEALTH DISPARITIES
Osteoporosis |
|
Definition
• •White and Asian American women have a higher incidence of osteoporosis than African American women.
• •African American women have 10% more bone mass than non–African American women.
• •Hispanic women have a lower incidence of osteoporosis than white women.
• •Postmenopausal women are at the highest risk for osteoporosis regardless of ethnic group.
Women over 65 years old should be routinely screened for osteoporosis. Screening should begin by age 60 for women at increased risk of osteoporotic fractures. No general recommendations for screening have been made for women who are younger than 60 years old, or for women age 60 to 64 who are not at increased risk for osteoporosis.33 |
|
|
Term
| -Have a good understanding of the etiology and pathophysiology of osteoporosis. |
|
Definition
Peak bone mass (maximum bone tissue) is mainly achieved before age 20. It is determined by a combination of four major factors: hereditary, nutrition, exercise, and hormone function. Heredity may be responsible for up to 70% of a person's peak bone mass. Bone loss from midlife (age 35 to 40 years) onward is inevitable, but the rate of loss varies. At menopause, women experience rapid bone loss when the decline in estrogen production is the sharpest. This rate of loss then slows, and eventually matches the rate of bone lost by men 65 to 70 years old.
Bone is continually being deposited by osteoblasts and resorbed by osteoclasts, a process called remodeling. Normally the rates of bone deposition and resorption are equal to each other so that the total bone mass remains constant. In osteoporosis, bone resorption exceeds bone deposition. Although resorption affects the entire skeletal system, osteoporosis occurs most commonly in the bones of the spine, hips, and wrists. Over time, wedging and fractures of the vertebrae produce gradual loss of height and a humped back known as “dowager's hump,” or kyphosis. The usual first signs are back pain or spontaneous fractures. The loss of bone substance causes the bone to become mechanically weakened and prone to either spontaneous fractures or fractures from minimal trauma. A person who has one spinal vertebral fracture due to osteoporosis has a 25% chance of having a second vertebral fracture within 1 year.35 |
|
|
Term
| drugs that interfere with bone metabolism |
|
Definition
| Many drugs can interfere with bone metabolism, including corticosteroids, antiseizure drugs (e.g., divalproex sodium [Depakote], phenytoin [Dilantin]), aluminum-containing antacids, heparin, certain cancer treatments, and excessive thyroid hormones.34 At the time a drug is prescribed, inform the patient of this possible side effect. Long-term corticosteroid use is a major contributor to osteoporosis. When a corticosteroid is taken, there is a loss of bone and inhibition of new bone formation. |
|
|
Term
| Why is osteoporosis called the “silent disease”? |
|
Definition
| known as the “silent thief” because it slowly and insidiously over many years robs the skeleton of its banked resources. Bones can eventually become so fragile that they cannot withstand normal mechanical stress.32 Osteoporosis is often called the “silent disease” because bone loss occurs without symptoms. People may not know they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a hip, vertebral, or wrist fracture. Collapsed vertebrae may initially be manifested as back pain, loss of height, or spinal deformities such as kyphosis or severely stooped posture. |
|
|
Term
| RISK FACTORS FOR OSTEOPOROSIS |
|
Definition
• •Advanced age (>65 yr)
• •Female gender
• •Low body weight
• •White or Asian ethnicity
• •Current cigarette smoking
• •Nontraumatic fracture
• •Inactive lifestyle
• •Family history of osteoporosis
• •Diet low in calcium or vitamin D deficiency
• •Excessive use of alcohol (>2 drinks/day)
• •Postmenopausal, including premature or surgical menopause
• •Long-term use of corticosteroids, thyroid replacements, heparin, long-acting sedatives, or antiseizure medications |
|
|
Term
| What is a “dowager’s hump” or kyphosis and how is it related to and prevented in osteoporosis? What prevention/promotion activities can be done to screen for spine changes? |
|
Definition
Over time, wedging and fractures of the vertebrae produce gradual loss of height and a humped back known as “dowager's hump,” or kyphosis. The usual first signs are back pain or spontaneous fractures. The loss of bone substance causes the bone to become mechanically weakened and prone to either spontaneous fractures or fractures from minimal trauma. A person who has one spinal vertebral fracture due to osteoporosis has a 25% chance of having a second vertebral fracture within 1 year.35
Kyphosis caused by osteoporosis and spinal fractures is also preventable. You need to keep your bones strong and healthy to avoid osteoporosis. By doing things such as eating foods rich in calcium and other vital nutrients, you will be doing your body—and bones—good. There are many other things you can do to prevent osteoporosis; it's one of the most preventable diseases. Osteoporosis Prevention is full of more tips on how to have healthy bones. |
|
|
Term
| Please have a good understanding of the lab and diagnostic studies that are utilized with osteoporosis. |
|
Definition
• History and physical examination
• Serum calcium, phosphorus, alkaline phosphatase, and vitamin D levels
• Bone mineral densitometry
• •Dual-energy x-ray absorptiometry (DEXA)
• •Quantitative ultrasound (QUS) |
|
|
Term
| More on dx studies for osteoporosis |
|
Definition
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. Serum calcium, phosphorus, and alkaline phosphatase levels usually are normal, although alkaline phosphatase may be elevated after a fracture.
Bone mineral density (BMD) measurements are typically used to assess the mass of bone per unit volume, or how tightly the bone is packed. (BMD measurements are presented in Table 62-7.) Types of BMD include quantitative ultrasound (QUS) and dual-energy x-ray absorptiometry (DEXA). QUS measures bone density with sound waves in the heel, kneecap, or shin. One of the most common BMD studies is DEXA, which measures bone density in the spine, hips, and forearm (the most common sites of fractures resulting from osteoporosis).35 DEXA studies are also useful to evaluate changes in bone density over time and to assess the effectiveness of treatment.
DEXA results are frequently reported as T-scores.36 The T-score is the number of standard deviations below the average for normal bone density. A T-score of ≥ −1 indicates normal bone density. Osteoporosis is defined as a BMD of ≤−2.5 (at least 2.5 standard deviations) below the mean BMD of young adults. Osteopenia is defined as bone loss that is more than normal (a T-score between −1 and −2.5), but not yet at the level for a diagnosis of osteoporosis. Over 14 million women over age 50 have osteopenia. Bone biopsy can be used to differentiate the diagnosis of osteoporosis from osteomalacia. |
|
|
Term
|
Definition
| Osteopenia refers to bone mineral density (BMD) that is lower than normal peak BMD but not low enough to be classified as osteoporosis. Bone mineral density is a measurement of the level of minerals in the bones, which shows how dense and strong they are. If your BMD is low compared to normal peak BMD, you are said to have osteopenia. Having osteopenia means there is a greater risk that, as time passes, you may develop BMD that is very low compared to normal, known as osteoporosis. |
|
|
Term
| -What is the priority nursing and collaborative management of the disease? osteopenia |
|
Definition
Collaborative Therapy
Diet high in calcium (see Table 64-15)
Calcium supplements (see Table 64-16)
Vitamin D supplements
Exercise program
calcitonin (Calcimar)
Bisphosphonates (e.g., alendronate, etidronate)
Selective estrogen receptor modulator (e.g., raloxifene, teriparatide)
Vertebroplasty
Kyphoplasty |
|
|
Term
| Collaborative care of osteoporosis |
|
Definition
| focuses on proper nutrition, calcium supplementation, exercise, prevention of fractures, and medications. |
|
|
Term
| Although loss of bone cannot be significantly reversed, further loss can be prevented if the patient follows a regimen of what, and what medications? |
|
Definition
| calcium and vitamin D supplementation, exercise, and certain medications (e.g., alendronate [Fosamax], raloxifene [Evista]) if indicated. Make an effort to keep patients with osteoporosis ambulatory to prevent further loss of bone substance as a result of immobility. |
|
|
Term
| More osteoporosis tx info |
|
Definition
| Treatment may also involve the use of a gait aid as needed and to protect areas of potential pathologic fractures. For example, a thoracic-lumbar-sacral orthosis (TLSO) brace may be used to maintain the spine in proper alignment after a fracture or treatment of a vertebral fracture. (Fractures are discussed in Chapter 63.) |
|
|
Term
| Vertebroplasty and kyphoplasty |
|
Definition
| minimally invasive procedures that are used to treat osteoporotic vertebral fractures (see Chapter 63). In vertebroplasty, bone cement is injected into the collapsed vertebra to stabilize it, but it does not correct the deformity. In kyphoplasty, an air bladder is inserted into the collapsed vertebra and inflated to regain vertebral body height and then bone cement is injected.37 |
|
|
Term
| What do we want the patient to do to increase calcium intake? |
|
Definition
| Prevention and treatment of osteoporosis focuses on adequate calcium intake (1000 mg/day in premenopausal women and postmenopausal women taking estrogen and 1500 mg/day in postmenopausal women who are not receiving supplemental estrogen). If dietary intake of calcium is inadequate, supplemental calcium may be recommended. Foods that are high in calcium content include whole and skim milk, yogurt, turnip greens, cottage cheese, ice cream, sardines, and spinach (Table 64-14). The amount of elemental calcium varies in different calcium preparations (Table 64-15). Calcium supplementation inhibits age-related bone loss. |
|
|
Term
| -Why is Vitamin D important to a disease that is of the bones? |
|
Definition
| Vitamin D is important in calcium absorption and function and may have a role in bone formation. Most people get enough vitamin D from the diet or naturally through synthesis in the skin from exposure to sunlight. Being in the sun for 20 minutes a day is generally enough. However, supplemental vitamin D (800 to 1000 IU) is recommended for postmenopausal women, older adults, those who are homebound, and those who get minimal sun exposure. |
|
|
Term
| -Why is exercise important? |
|
Definition
| Moderate amounts of exercise are important to build up and maintain bone mass. Exercise also increases muscle strength, coordination, and balance. The best exercises are weight-bearing exercises that force an individual to work against gravity. These exercises include walking, hiking, weight training, stair climbing, tennis, and dancing. Walking is preferred to high-impact aerobics or running, both of which may put too much stress on the bones resulting in stress fractures. Walking 30 minutes, three times a week, is recommended. Instruct patients to quit smoking and cut down on alcohol intake to decrease the likelihood of losing bone mass |
|
|
Term
| Estrogen replacement therapy after menopause |
|
Definition
| no longer given as primary treatment to prevent osteoporosis due to the associated increased risk of heart disease and breast and uterine cancer.38 If estrogen is being used to treat menopausal symptoms, it will also protect the woman against bone loss and fractures of the hip and vertebrae. It is believed that estrogen inhibits osteoclast activity, leading to decreased bone resorption and preventing both cortical and trabecular bone loss. |
|
|
Term
|
Definition
| is secreted by the thyroid gland and inhibits osteoclastic bone resorption by directly interacting with active osteoclasts. Salmon calcitonin (Calcimar) is available in intramuscular, subcutaneous, and intranasal forms. The nasal form is easy to administer, and patients should be taught to alternate nostrils daily. Nasal dryness and irritation are the most frequent side effects. Administration of the intramuscular or subcutaneous form of the drug at night has been shown to decrease the side effects of nausea and facial flushing. Nausea does not occur with the nasal spray. When calcitonin is used, calcium supplementation is necessary to prevent secondary hyperparathyroidism. |
|
|
Term
| selective estrogen receptor modulator, such as raloxifene (Evista) |
|
Definition
| The drugs mimic the effect of estrogen on bone by reducing bone resorption without stimulating the tissues of the breast or uterus. Raloxifene in postmenopausal women significantly increases BMD. Side effects included leg cramps, hot flashes, and blood clots. Raloxifene may decrease breast cancer risk; similar to tamoxifen, it blocks the estrogen receptor sites of cancer cells.40 |
|
|
Term
|
Definition
| used to treat osteoporosis in men and postmenopausal women at high risk for fractures. Teriparatide is a portion of human parathyroid hormone (PTH) and works by increasing the action of osteoblasts. Teriparatide is the first drug approved for the treatment of osteoporosis that stimulates new bone formation. Most drugs used to treat osteoporosis prevent further bone loss. Teriparatide is administered by subcutaneous injection once a day.41 Side effects can include leg cramps and dizziness. This drug is expensive, and long-term use (more than 2 years) may slightly increase the risk for osteosarcoma. |
|
|
Term
|
Definition
| may be used for postmenopausal women with osteoporosis who are at high risk for fractures. It inhibits osteoclast formation and function. It is given as a subcutaneous injection every 6 months. |
|
|
Term
| -Why is it important to know if a patient is on: Corticosteriods, Dilantin, Anti-seizure drugs? |
|
Definition
| Because these drugs result in reduction of bone mass. |
|
|
Term
| Please understand the importance of these drugs for the treatment of osteoporosis: Biophosphonates (Boniva) (Actonel) (Fosamax) |
|
Definition
| Bisphosphonates inhibit osteoclast-mediated bone resorption, thereby increasing total bone mass and BMD by 5%. These drugs include etidronate (Didronel), alendronate (Fosamax), pamidronate (Aredia), risedronate (Actonel), clodronate (Bonefos), tiludronate (Skelid), and ibandronate (Boniva). Common side effects are anorexia, weight loss, and gastritis. Instruct patients on the proper administration of a bisphosphonate to aid in its absorption (see Drug Alert). These precautions have been shown to decrease GI side effects (especially esophageal irritation) and increase absorption. A rare and serious side effect is jaw osteonecrosis (bone death), which occurs mostly in patients with advanced cancer. The etiology of this side effect is unknown. Alendronate is available as a once-per-week oral tablet. Ibandronate and risedronate are available as a once-per-month oral tablet. Zoledronic acid (Reclast) is approved for a once-yearly IV infusion and can prevent osteoporosis for 2 years after a single infusion. Flu-like symptoms may occur for the first few days following administration of the drug. In recent trials, zoledronic acid significantly improved disease-free survival in women with estrogen-responsive early-stage breast cancer. |
|
|
Term
| pt taking Bisphosphonates Instruct pt to |
|
Definition
•Take with full glass of water.
•Take 30 minutes before food or other medications.
•Remain upright for at least 30 minutes after taking. |
|
|
