REVIEW For EXAM 4

What is osteoporosis?

Bone disease caused by loss of calcium and phosphate from bones, resulting in decreased bone density; causes weakened bones and increased vulnerability to fractures

What is the most common metabolic bone disease in the United States?

Osteoporosis

How is osteoporosis classified?

Localized (associated with focal skeletal lesions) and generalized; further divided into primary and secondary

Primary vs. secondary osteoporosis: what is the difference?

Primary = due to hereditary and environmental factors (estrogen deficiency, aging) / Secondary = caused by an identifiable agent or disease

What diseases/agents can cause secondary osteoporosis?

Hyperparathyroidism, hyperthyroidism, chronic liver disease, corticosteroid excess, inflammatory bowel disease, celiac disease

What are the two primary causes of osteoporosis?

Estrogen deficiency and changes associated with aging

What happens in the pathophysiology of osteoporosis?

Bone resorption accelerates as bone formation decelerates → decreased bone mass; bones become porous and brittle

What hormonal and metabolic risk factors are listed for osteoporosis?

Mild, prolonged negative calcium balance; declining gonadal adrenal function; faulty protein metabolism (caused by estrogen deficiency); amenorrhea, late menarche, early menopause, or postmenopause

What lifestyle risk factors are listed for osteoporosis?

Immobilization or sedentary lifestyle; more than 2 alcoholic drinks/day; smoking; high caffeine intake; diet low in calcium and vitamin D; malnutrition or malabsorption

What medication-related risk factors are listed for osteoporosis?

High doses of thyroid hormones, systemic steroids, or anticonvulsants; corticosteroid drugs; chemotherapy

What demographic risk factors are listed for osteoporosis?

Increased age; being female; White, Mexican-American, or Asian-American ethnicity; family history; weight less than 128 lb (58 kg)

What history-based risk factors are listed for osteoporosis?

Previous fracture; rheumatoid disorder; autoimmune disorder; diabetes; gastrectomy or gastric bypass

What body weight is a risk factor for osteoporosis?

Weight less than 128 lb (58 kg)

How many people in the U.S. have osteoporosis, and how much more likely are adult females to develop it?

About 10 million; adult females are 4 times more likely

At what ages do postmenopausal osteoporosis and age-related osteoporosis occur?

Postmenopausal (estrogen deficiency): females ages 50–70 / Due to aging: most common over age 70

What is the main complication of osteoporosis, and where does it occur?

Bone fractures: vertebrae, femoral neck, and distal radius

Why is osteoporosis often missed until late?

It is asymptomatic; often no apparent history until a fracture occurs

What classic history finding happens when an osteoporosis patient bends down to lift something?

Snapping sound or sudden pain in the lower back

What pain pattern occurs with vertebral collapse in osteoporosis?

Backache and pain that radiates around the trunk to the abdomen; aggravated by movement, jarring, or after a fall

What is a fragility fracture?

A fracture from a fall from standing height or less (in osteoporosis: spine, hip, wrist, humerus, or pelvis)

What are the physical findings of osteoporosis?

Humped back, markedly aged appearance, loss of height >1½" (4 cm), muscle spasms, decreased spinal movement (flexion more limited than extension), fragility fractures

How much height loss is a physical finding of osteoporosis?

More than 1½ inches (4 cm)

In osteoporosis, which is more limited: spinal flexion or extension?

Flexion is more limited than extension

What lab results are NORMAL in osteoporosis?

Calcium (serum and urine), phosphorus, and alkaline phosphatase

What lab results are ELEVATED or DECREASED in osteoporosis?

Elevated: parathyroid hormone, serum osteocalcin / May be decreased: serum vitamin D3 / Bone-specific alkaline phosphatase may be mildly increased if fracture, hyperparathyroidism, Paget disease, or osteomalacia

What is the standard test for measuring bone mineral density?

Dual-energy X-ray absorptiometry (DEXA); shows loss of bone mass

What DEXA T-score is diagnostic of osteoporosis?

A T-score of less than 2.5 standard deviations (below the mean) at any site

What do X-rays show in osteoporosis?

Characteristic degeneration in the lower thoracolumbar vertebrae and evidence of fracture

What does a bone biopsy show in osteoporosis?

Thin, porous, but otherwise normal bone; rules out other diseases that contribute to bone loss

What does a fracture risk assessment identify?

Probability of fracture over a specified period, typically 10 years

What are the general treatment goals/measures for osteoporosis?

Prevent more fractures and bone loss, control pain, reduce/immobilize fractures, supportive/assistive devices, PT/OT, smoking cessation, moderate sunlight, fall prevention, treat underlying conditions

What are the diet recommendations for osteoporosis?

Calcium-rich diet with 800–1,000 IU vitamin D daily (adults over 50); avoid excess phosphoric acid–containing beverages and protein; avoid caffeine; moderate alcohol

How much vitamin D daily is recommended for adults over 50 with osteoporosis?

800–1,000 International Units

What weight-bearing exercise prescription is recommended for osteoporosis?

Weight-bearing exercises (walking, jogging, stair climbing, tai chi) 30 minutes, 3 times weekly

Which bisphosphonates are listed for osteoporosis?

Alendronate sodium, risedronate sodium, zoledronic acid, ibandronate sodium

When is denosumab used for osteoporosis?

Initial therapy for patients at high risk for fracture (e.g., older patients with markedly impaired kidney function), or second-line for patients intolerant of/unresponsive to other therapies

When are anabolic agents used for osteoporosis, and which ones are listed?

For patients at high risk for fracture or unresponsive to bisphosphonates: teriparatide, abaloparatide, romosozumab-aqqg

What is raloxifene used for in osteoporosis?

A selective estrogen receptor modulator (SERM) that inhibits bone resorption and reduces vertebral fracture risk in postmenopausal patients who also need breast cancer prophylaxis

What other medications are listed for osteoporosis besides bisphosphonates, denosumab, anabolics, and SERMs?

Calcitonin salmon; hormone replacement therapy (risks weighed against benefits); calcium and vitamin D supplements

What surgeries are listed for osteoporosis?

Open reduction and internal fixation (ORIF) for fractures, percutaneous vertebroplasty, kyphoplasty

How should bisphosphonates be taken for osteoporosis?

First thing in the morning with a full glass of plain water, before any other food, fluids, or medications; remain upright at least 30 minutes

What are the adverse effects of bisphosphonates listed in the osteoporosis teaching?

Nausea, diarrhea, bone pain, dyspepsia

What should you teach a female osteoporosis patient on hormone replacement therapy?

Monthly breast self-exam and regular Pap tests; report chest pain, dyspnea, or abnormal vaginal bleeding to the practitioner immediately

What key nursing interventions are listed for an osteoporosis patient who is in bed or immobilized?

Frequent position changes, frequent skin inspection for irritation/redness/pressure areas, passive ROM exercises

What should you do when applying heat for an osteoporosis patient?

Inspect the skin before, during, and after heat application to reduce the risk of thermal injury

What should an osteoporosis patient be taught about sleeping and new pain?

Sleep on a firm mattress; immediately report new pain sites and seek care if a fracture is suspected

What should be monitored in a patient with osteoporosis?

Nutritional status, joint mobility/ambulation, pain and effectiveness of interventions, skin integrity, safety, activity/exercise, assistive devices, medication therapy and adverse effects

What is osteoarthritis?

Progressive inflammatory degenerative disease of the diarthrodial joints, especially weight-bearing joints such as the hips and knees

What is osteoarthritis often referred to as?

Degenerative joint disease

What is the most common form of joint disease?

Osteoarthritis

What happens in stage 1 of osteoarthritis?

Cartilage swells from increased production of proteoglycans; eventually joint cartilage deteriorates

What happens in stage 2 of osteoarthritis?

Reactive new bone forms at margins/subchondral areas, chondrocytes break down, cartilage erodes and flakes, irritating the synovial lining

What happens in stage 3 of osteoarthritis?

Cartilage breakdown releases cytokines into synovial fluid; cartilage lining becomes fibrotic and chronic inflammation adds to breakdown

How do cysts form in osteoarthritis?

Synovial fluid leaks into bone defects

What are the causes of osteoarthritis?

Congenital abnormality, endocrine disorders (diabetes mellitus), heredity (possibly), metabolic disorders (chondrocalcinosis), secondary osteoarthritis, traumatic injury, infection

What are the risk factors for osteoarthritis?

Advanced age, female sex, obesity, trauma, muscle weakness, repetitive joint use, previous rheumatoid arthritis, infection, underlying bone disease or deformity, genetics

How does osteoarthritis incidence differ by sex and age?

Equal in adults up to age 55, then more common in females; typically develops after age 40

How many Americans does osteoarthritis affect, and what is it the leading cause of?

Over 30 million; leading cause of disability in adults older than 65

What are the complications of osteoarthritis?

Flexion contractures, subluxation, deformity, ankylosis, bony cysts, gross bony overgrowth, central cord syndrome, nerve root compression, cauda equina syndrome, drug reaction, inability to work/perform previous activities

What type of joint pain is seen in osteoarthritis, and what relieves it?

Deep aching joint pain or tenderness on palpation; pain after exercise or weight bearing; may be relieved by rest

How long does morning stiffness usually last in osteoarthritis?

Less than 30 minutes (in the morning and after exercise)

What other history findings are seen in osteoarthritis?

Aching with weather changes, grating feeling when the joint moves, limited joint movement or dexterity, predisposing traumatic injury

Is there edema or warmth over the affected joint in osteoarthritis?

No edema or warmth over the affected joint

What are the physical findings of osteoarthritis?

Contractures, joint swelling, muscle atrophy, deformity, gait abnormalities, hard nodes on DIP/PIP joints, loss of finger dexterity, spasms, joint instability, decreased ROM with pain at end of range, crepitus

What are Heberden nodes?

Hard, usually painless bony and cartilaginous enlargements on the dorsolateral aspect of the DISTAL interphalangeal (DIP) joints; seen in middle-aged and older adults with OA

What are Bouchard nodes?

Similar to Heberden nodes but less common; appear on the PROXIMAL interphalangeal (PIP) joints

What is the purpose of synovial fluid analysis in osteoarthritis?

Rules out inflammatory arthritis

What do X-rays of an osteoarthritic joint show?

Narrowing of joint space/margin, cystlike bony deposits, sclerosis of subchondral space, joint deformity or articular damage, bony growths at weight-bearing areas, possible joint fusion

What do a radionuclide bone scan and arthroscopy show in osteoarthritis?

Bone scan: normal uptake (rules out inflammatory arthritis) / Arthroscopy: internal joint structures, soft-tissue swelling; rules out inflammatory arthritis, infection, crystal arthropathy

What are the general (nondrug) treatments for osteoarthritis?

Weight reduction if obese; heat and/or cold; ultrasound therapy; PT/OT; assistive devices such as braces; tai chi, massage, acupressure, acupuncture, hydrotherapy, relaxation; VTE prophylaxis if hospitalized for surgery

What are the diet recommendations for osteoarthritis?

Weight-reduction diet if overweight/obese; high-fiber diet if taking opioids; increased omega-3 fatty acids to help reduce inflammation

What is the exercise prescription for osteoarthritis?

Moderate- or high-intensity muscle strengthening of all major muscle groups 2+ days/week; balance exercises; 150 minutes/week of moderate-intensity aerobic activity

What first-line pain medications are used for osteoarthritis?

Acetaminophen; topical or oral NSAIDs (ibuprofen, naproxen, topical diclofenac)

When are opioid analgesics used in osteoarthritis?

Only for short-term treatment of acute pain (e.g., codeine, oxycodone)

What is the limit on intra-articular corticosteroid injections for osteoarthritis?

No more than 4 injections into the joint in 1 year (used for acute flare-ups)

What other medications/injections are listed for osteoarthritis?

Topical capsaicin (knee/hand), intra-articular hyaluronic acid, glucosamine and chondroitin (research inconclusive), colchicine (frequent inflammatory episodes not responding to NSAIDs), platelet-rich plasma injections

What surgeries are listed for osteoarthritis?

Arthroplasty (partial or total), arthrodesis, osteoplasty, osteotomy

How should NSAIDs be taken in osteoarthritis, and what should be reported?

With food to minimize GI distress; report bruising or bleeding (frank or occult)

What adverse effect is possible with topical capsaicin?

Local burning

What joint-specific nursing interventions are listed for osteoarthritis?

Hand: warm soaks, compresses, paraffin dips / Lumbosacral spine: firm mattress / Cervical spine: cervical collar if indicated / Hip: moist heat / Knee: help with ROM exercises

What assistive devices help with self-care in osteoarthritis?

Hook-and-loop closures, grab bars, reaching devices

What should an osteoarthritis patient be taught about rest and morning stiffness?

Need for adequate rest during the day, after exertion, and at night; allow time in the morning for stiffness to resolve

What should be monitored in a patient with osteoarthritis?

Pain level and effectiveness of interventions, joint mobility, muscle strength, activity level, body image and coping

What is Paget disease of bone?

Chronic metabolic bone disorder causing irregular bone formation; new bone is less compacted, more vascular, and more fragile

What is Paget disease also known as?

Osteitis deformans

What skeletal areas does Paget disease affect?

Spine, pelvis, femur, clavicle, long bones of the lower extremities, and skull

What percentage of Paget disease patients develop malignant bone changes?

About 5%

When can Paget disease be fatal?

Particularly when associated with heart failure, bone sarcoma, or giant cell tumors

How is Paget disease of bone different from Paget disease of the breast?

They are different disorders; Paget disease of the breast is a rare breast cancer that appears as a red, scaly crust on the nipple with itching and burning (often misdiagnosed as a skin problem; biopsy confirms)

What happens in the first (lytic) phase of Paget disease?

Bone resorption occurs faster than normal

What happens in the second (mixed lytic and blastic) phase of Paget disease?

Increased bone formation (with abnormalities in the new bone) to keep up with rapid bone breakdown

What happens in the third (sclerotic) phase of Paget disease?

Disorganized, weaker bone forms; excess fibrous connective tissue and blood vessels infiltrate, making bone hypervascular

What is thought to cause Paget disease?

Exact cause unknown; possible familial, environmental, genetic links; thought to be a slow or dormant viral infection (possibly mumps)

What are the risk factors for Paget disease?

Family history and history of viral infection

Who is most likely to get Paget disease?

Typically after age 55, most commonly diagnosed in 60s (rare under 40); slightly more often males; more common in Northern European descent

What are the complications of Paget disease?

Fractures, head enlargement, blindness/hearing loss (tinnitus, vertigo, deafness), OA, sarcoma, HTN, renal calculi, hypercalcemia, gout, heart disease/failure, carpal/tarsal tunnel, spinal stenosis, stroke, vascular steal syndrome, loosening of teeth

What are the history findings of Paget disease?

Possibly asymptomatic; severe persistent bone pain; impaired mobility; pain worse with weight bearing; increased hat size; headaches; gradual hearing and vision loss; chronic back pain

What classic history finding about the head is seen in Paget disease?

Increased hat size (cranial enlargement over frontal and occipital areas)

What musculoskeletal physical findings are seen in Paget disease?

Cranial enlargement, facial deformities/drooping, teeth changes, kyphosis, barrel-shaped chest, asymmetrical bowing of tibia and femur, footdrop, warmth and tenderness over affected sites, acetabular protrusion, fracture

What cardiac and neuro physical findings are seen in Paget disease?

Left ventricular hypertrophy, aortic stenosis (from calcification), peripheral neuropathy