osteoporosis/hip fracture and osteoarthritis/joint replacement

osteoporosis

chronic bone loss → decreased bone density

increased fracture risk

primary (postmenopausal) vs secondary causes (history of hyperparathyroidism, long term steroid therapy, sedentary)

diagnosis: dual xray absorptiometry (DXA), T-score <= -2.5
xray recommended for women who turn 40: detects changes

risk factors for osteoporosis

age, female, postmenopausal

low Ca and vit D

smoking (nicotine delays bone healing), alcohol

immobility

long term steroid use

prevention of osteoporosis

Ca and vit D in diet if levels are low

weight-bearing exercise; walking

stop smoking, limit alcohol

adequate protein intake

osteoporosis treatment

bisphosphonates (alendronate): increases body’s ability to absorb Ca from diet

SERMs (raloxifene): preserve and increase bone mineral density

RANKL inhibitor (denosumab): at increased risk for fractures; postmenopausal

parathyroid hormone (teriparatide): increase bone formation

calcium teaching

take Ca supplements with meals; helps absorb

spread throughout day

vit D improves absorption. ex: orange juice, milk

avoid taking with certain meds (iron, antibiotics). take within a 2-4 hour difference

caffeine and sodas can increase excretion

foods high in calcium

yogurt

collards greens, fresh or cooked

turnip greens

sardines in oil

hip fracture overview

common in older adults

high mortality rate

often leads to loss of independence

approximately 30% will die within 1st year post fracture

types of hip fractures

intracapsular (femoral neck) *most common

intertrochanteric *most common

subtrochanteric

risk: avascular necrosis: bone has high supply of blood so when feature → blood loss → bone dies

risk factors for hip fracture

osteoporosis (#1) (low body weight, low physical activity, and smoking all play a role)

falls

vision impairment

medications: diuretics → increases risk for falls at night

environmental hazards; rugs, pets

clinical manifestation for hip fractures

unable to bear weight

shortened leg and external rotation are main things that are seen

pain and bruising (vascular damage)

preoperative care with hip fractures

pain control; opioids, non inflammatory NSAIDs

traction (Buck’s): decreases painful muscle spasms. traction keeps leg in line and pulls out to keep things not pushed together that is causing the muscle spasms

neurovascular checks; pedal pulses distal to injury, cap refill, temp, edema, color, movement

prevent complications: DVT, pressure ulcers, Ortho hypo, pneumonia/atelectasis bc in bed all of the time

ankle fractures increases risk for compartment syndrome

surgical management with hip fractures

open reduction and internal fixation (ORIF): rods, screws. decreases pain, helps be mobile again

prosthesis (hip replacement)

goal: early mobility and decreased complications

if fall again after ORIF, would do total hip replacement

postop nsg care with hip fractures

pain management; opioids

DVT prevention; SQ, anticoagulants and platelets. increased risk for DVTs bc drilling into bone and releases blood and coagulant factors

early mobility

positioning

prevent complications; pneumonia: IS, C&DB

fall prevention

remove hazards (rugs, cords)

adequate lighting

grab bars

proper footwear at home and hospital

medication review; meds that increase fall risk

life alert necklace can help

compartment syndrome

increased pressure in muscle → decreased blood flow in nerves and cells → necrosis → lose extremity

fascia that surrounds muscles can’t expand when pressure increases

sudden severe pain (early sign)

numbness/paralysis (late sign)

surgical emergency; OR, but can do at bedside if pressure is really high

not common with hip, more with lower fractures (tibia, fibula, ankle)

priority nsg focus with fractures

assess mobility and safety

monitor for complications

promote independence; out of bed, walking, PT & OT, assistive devices

educate on prevention

arthritis overview

2 classifications:

osteoarthritis (OA): noninflammatory, degenerative

rheumatoid arthritis (RA): inflammatory, autoimmune

both cause pain and stiffness

osteoarthritis

most common arthritis

degeneration of cartilage and bone

noninflammatory

affects weight-bearing joints (hips, knees, spine)

leads to pain and decreased mobility

risk factors for OA

primary: aging, genetics, weight bearing joints

secondary: obesity, joint injury/overuse

occupation

DM, paget’s disease, sickle cell

clinical manifestations of OA

pain with activity, relieved with rest

stiffness

crepitus

joint enlargement/effusions in knee or fingers

decreased mobility bc of pain

diagnosis of OA

based on history and physical exam

X-rays show joking changes. spine: would have to do MRI

labs usually normal; help for screening other conditions that could cause arthritis

OA treatment overview

conservative measures:

pain management: start with topical/tylenol, then NSAIDs, then opioids. cortisone injections, PT, cryotherapy

maintain mobility; PT

improve QOL

multimodal approach; pain and PT

drug therapy for OA

acetaminophen (first line)

NSAIDs (ibuprofen, celecoxib)

topical agents (Diclofenac)

injections (steroids, hyaluronic acid)

OTC: topical capsaicin

dietary supplements (glucosamine, chondroitin)

medical marijuana (cannabis)

non pharm management for OA

exercise (low impact)

weight loss

heat/cold therapy

regenerative therapies (stem cell therapy, platelet rich plasma)

OA surgical management

total joint arthroplasty (TJA)

indicated when conservative therapy fails

includes hip and knee replacement

contraindications: active infection, progressive inflammation, severe medical problems

preop care for surgery with OA

pt education (prehab)

home preparation

lab work and diagnostic tests

prevent infections and DVT

med review

post op priorities surgery with OA

pain management

infection monitoring

neurovascular checks

early mobility

DVT prevention

post op pain management with surgery OA

multimodal approach

trend away from PCA/opioids; Tylenol (PO) or Ofirmev (IV acetaminophen) Q6h with oxycodone PO Q4h PRN

IV/PCA: basal rate of morphine, hydromorphone, fentanyl. move to PO after 1st day then to NSAIDs

prevent constipation/opioid induced constipation: polyethylene glycol, senna, colace

manage nausea (ondansetron)

non pharm: cryotherapy (ice packs)

post op infection monitoring with OA

monitor for s/s post op infection

VS Q4h for 1 24 hours; esp temp

monitor WBC

older adults: change in mental status may be first sign

prophylactic antibiotics as ordered

incisions: redness, excess/foul-smelling drainage. if drain present: monitor output, amount and character at least q shift

if infection develops: prothesis is removed; temporary “spacer” placed. aggressive long term antibiotic therapy (at least 6 weeks). once infection cleared → procedure to place new prothesis

optimize mobility with total hip replacement (THR)

pain control

PT

exercises (quadricep setting, leg raises, ankle pumps)

post op day 0 or 1 → out of bed to chair; walk with assistance

take it slow 1st time out of bed (dizziness)

instruct how to use assistive device (walker versus crutches)

no bending at hip

optimize mobility with total knee replacement (TKR)

similar THR post op care

pain more intense as compared to THR

dislocation rare; no concerns with hip abduction

continuous passive motion (CPM)

knee precautions: no pillows under knees; no knee gatch, do not hyperextend

hip replacement precautions

direct lateral and posterolateral approach

do not cross legs

do not flex > 90 degrees

use abduction pillow

prevent dislocation: care with turning, avoid twisting body, pillows between legs

s/s severe pain, shortening of affected LE, LE rotation → notify surgeon

knee replacement key points

focus on regaining extension

no pillows under knees

pain often greater than hip replacement

specific concerns: hip vs knee

hip replacement: dislocation, weight bearing restrictions (cemented, non cemented, hybrid)

knee replacement: regaining extension

complications with joint replacements

DVT/PE

infection

bleeding

dislocation (hip)

prosthesis failure

DVT prevention

assess for s/s: pain, tenderness, positive homan’s sign

neurovascular checks Q2-4hr

early ambulation

compression devices (TEDS, SCD)

antiplatelets/coagulants; educate bleeding precautions

early ambulation/leg exercises

priority nsg focus with joint replacements

promote mobility

prevent complications

pain control

pt education