Metabolic Bone Metabolic Bone DisordersDisorders

ObjectivesObjectives Differentiate metabolic bone disorders by Differentiate metabolic bone disorders by

etiology, treatment and outcome.etiology, treatment and outcome. Outline common nursing diagnoses, Outline common nursing diagnoses,

outcome criteria and interventions for outcome criteria and interventions for common metabolic bone disorders.common metabolic bone disorders.

Bone Cell TypesBone Cell Types OsteoblastOsteoblast

Forms bone & mineralization of Forms bone & mineralization of matrixmatrix

OsteocyteOsteocyte Transformed osteoblastTransformed osteoblast Maintains bone found in matrixMaintains bone found in matrix

OsteoclastOsteoclast Breaks down bone salts Breaks down bone salts Responsible for bone Responsible for bone

reabsorptionreabsorption

Bone Cell MnemonicsBone Cell Mnemonics

OsteoOsteobblastslasts ““BBaby bone cells”aby bone cells” ““BBuilding uilding BBlocks”locks”

OsteoOsteoclclastsasts ““ClClean up” cellsean up” cells

OsteoOsteocycytestes ““CyCycle” of bonecle” of bone

Question #1: Which statement is Question #1: Which statement is true of osteoblasts?true of osteoblasts?

a. They transform osteocytes a. They transform osteocytes into osteoblasts.into osteoblasts.

b. They maintain cells within b. They maintain cells within the bone matrix.the bone matrix.

c. Osteoblasts form bone c. Osteoblasts form bone cells within matrix.cells within matrix.

d. Osteoblasts break down d. Osteoblasts break down bone salts.bone salts.

Answer #1. Which statement is Answer #1. Which statement is true of Osteoblasts?true of Osteoblasts?

c. Osteoblasts form bone cells within matrix.c. Osteoblasts form bone cells within matrix.

Rationale:Rationale: Osteoblasts are “bone builders”; Osteoblasts are “bone builders”; the other responses are related to the other responses are related to functions of other bone cell types.functions of other bone cell types.

Bone Remodeling Bone Remodeling ProcessProcess

Osteoclast Form ation

Activate Precursors

Horm onal, Biochem icalPhysiological Indicators

PHASE I

Creates Cavities inCortical & Cancellous Bone

OsteoclastsResorb Bone

PHASE II

Create New BoneIn Form ed Cavities

OsteoblastsForm Bone

PHASE III

Hormonal RegulationHormonal Regulationof Bone Metabolismof Bone Metabolism

Thyroid glandThyroid gland Thyroxine, triodothronine & calcitoninThyroxine, triodothronine & calcitonin Regulated by TSH / TRH & calcitonin by Regulated by TSH / TRH & calcitonin by

plasma levels of calciumplasma levels of calcium

Parathyroid glandParathyroid gland Parathormone PTH (protein hormone)Parathormone PTH (protein hormone) Regulated by serum ionized calcium levelsRegulated by serum ionized calcium levels

Hormonal RegulationHormonal Regulationof Bone Metabolismof Bone Metabolism

Anterior pituitary glandAnterior pituitary gland ACTH / TSH / FSH / LH / ProlactinACTH / TSH / FSH / LH / Prolactin Regulated by hypothalamusRegulated by hypothalamus

Adrenal cortexAdrenal cortex Glucocortcoids / mineralcorticoids & Glucocortcoids / mineralcorticoids &

androgensandrogens

EstrogenEstrogen Increased osteoblast activityIncreased osteoblast activity Retention of calcium and phosphateRetention of calcium and phosphate

Question #2: Which hormone is the Question #2: Which hormone is the most important for regulating most important for regulating serum calcium levels because it serum calcium levels because it acts directly on bone and kidneys?acts directly on bone and kidneys?

a. Parathyroid hormone.a. Parathyroid hormone.

b. Growth hormone.b. Growth hormone.

c. Calcitonin.c. Calcitonin.

d. Adrenal corticosteroids.d. Adrenal corticosteroids.

Answer #2: Which hormone is the Answer #2: Which hormone is the most important for regulating most important for regulating serum calcium levels because it serum calcium levels because it acts directly on bone and kidneys?acts directly on bone and kidneys?

a. Parathyroid Hormone.a. Parathyroid Hormone.

RationaleRationale: As noted earlier, : As noted earlier, this hormone acts this hormone acts directly on bone and directly on bone and kidneys kidneys

HyperparathyroidismHyperparathyroidism Mainly two typesMainly two types

Primary- cause unknown but thought to be Primary- cause unknown but thought to be familial and characterized by excessive secretion familial and characterized by excessive secretion of PTHof PTH

Secondary-usually due to disease state such as Secondary-usually due to disease state such as renal failure which causes decrease in ionized renal failure which causes decrease in ionized serum calcium levelsserum calcium levels

Excess Secretion of PTHExcess Secretion of PTH Interrupts metabolism of calcium / phosphate / Interrupts metabolism of calcium / phosphate /

BoneBone

Hyperparathyroidism- PathophysiologyHyperparathyroidism- Pathophysiology

Although primary/secondary cause either Although primary/secondary cause either hypo or hypercalcemia, end result remains hypo or hypercalcemia, end result remains elevated levels of PTH which causes elevated levels of PTH which causes eventual hypercalcemia and multisystem eventual hypercalcemia and multisystem problemsproblems

HyperparathyroidismHyperparathyroidism PrimaryPrimaryResults in: Results in:

HypercalcemiaHypercalcemia

CausesCauses

Adenoma / Adenoma / CarcinomaCarcinoma

Genetic / Multiple Genetic / Multiple Endocrine DisorderEndocrine Disorder

SecondarySecondaryResults in initialResults in initial

hypocalcemia followed hypocalcemia followed by hypercalcemiaby hypercalcemia

CausesCauses

Chronic Renal Chronic Renal Failure / Failure / Malabsorption Malabsorption Syndromes / Vitamin Syndromes / Vitamin D DeficiencyD Deficiency

HyperparathyroidismHyperparathyroidism Clinical manifestationsClinical manifestations

•Bones – Demineralization due to Bones – Demineralization due to excessive osteoclast and osteocyte excessive osteoclast and osteocyte activityactivity•Kidneys – renal calculi, UTIKidneys – renal calculi, UTI•GI– Anorexia / NV, pancreatitis, GI– Anorexia / NV, pancreatitis, peptic ulcers, constipation, peptic ulcers, constipation, hypergastrinemiahypergastrinemia•Psychiatric issuesPsychiatric issues•Muscle weakness, myalgiasMuscle weakness, myalgias

HyperparathyroidismHyperparathyroidism DiagnosticsDiagnostics

All other causes of hypercalcemia must be All other causes of hypercalcemia must be eliminated firsteliminated first

6 month history of symptoms of hypercalcemia6 month history of symptoms of hypercalcemia Kidney stones, hypophosphatemia, Kidney stones, hypophosphatemia,

hypochloremiahypochloremia Serum Calcium Levels - Serum Calcium Levels - >10mg/dl >10mg/dl PTH Assay – PTH Assay – ↑↑11°° Radioactive Iodine Uptake Test - Radioactive Iodine Uptake Test - ↓↓

Subclinical / Post- Partum / Acute ThyroiditisSubclinical / Post- Partum / Acute Thyroiditis Urinary Calcium – Urinary Calcium – ↑↑(24 Hr Specimen)(24 Hr Specimen) DEXA Bone Density - DEXA Bone Density - ↓↓

HyperparathyroidismHyperparathyroidism Clinical ManagementClinical Management

Adequate HydrationAdequate Hydration Increase urinary excretion of Ca++ with Increase urinary excretion of Ca++ with

diureticsdiuretics Drugs that decrease resorption of Ca++ by Drugs that decrease resorption of Ca++ by

bone-biphosphates, calcitoninbone-biphosphates, calcitonin

SurgerySurgery Parathyroidectomy – Parathyroidectomy – NOTNOT Often Often

RecommendedRecommended Leaves ½ of one Lobe of the ParathyroidLeaves ½ of one Lobe of the Parathyroid Remove AdenomaRemove Adenoma

Question #3: Ms. Jones is a 60-year-old Question #3: Ms. Jones is a 60-year-old female who presents in the Clinic with a 6 female who presents in the Clinic with a 6 month history of frequent renal stones, month history of frequent renal stones, abdominal pain, muscle aches and several abdominal pain, muscle aches and several fractures of her metatarsals. The nurse would fractures of her metatarsals. The nurse would suspect:suspect:

a. Gout.a. Gout.

b. Hyperparathyroidism.b. Hyperparathyroidism.

c. Hypoparathyroidism.c. Hypoparathyroidism.

d. Paget’s Disease.d. Paget’s Disease.

Answer # 3: Ms. Jones is a 60-year-old female Answer # 3: Ms. Jones is a 60-year-old female who presents in the Clinic with a 6 month who presents in the Clinic with a 6 month history of frequent renal stones, abdominal history of frequent renal stones, abdominal pain, muscle aches and several fractures of pain, muscle aches and several fractures of her metatarsals. The nurse would suspect:her metatarsals. The nurse would suspect:

b. Hyperparathyroidism.b. Hyperparathyroidism.

RationaleRationale: As defined : As defined earlier, these are earlier, these are common s/s of common s/s of hyperparathyroidismhyperparathyroidism

Question #4: In order to confirm this Question #4: In order to confirm this diagnosis, diagnostic testing needs to be diagnosis, diagnostic testing needs to be performed. As the Nurse you know:performed. As the Nurse you know:a. a. That you can rely on one blood sample That you can rely on one blood sample

to give complete results.to give complete results.b. The patient will need blood work, b. The patient will need blood work,

DEXA scans, and 24 hour urine DEXA scans, and 24 hour urine samplessamples

c. That you can rely on urine testing c. That you can rely on urine testing alone.alone.

d. The tests will most likely bed. The tests will most likely beinconclusive.inconclusive.

Answer #4: In order to confirm this Answer #4: In order to confirm this diagnosis, diagnostic testing needs to be diagnosis, diagnostic testing needs to be performed. As the Nurse you know:performed. As the Nurse you know:b. You will need to have results of serum b. You will need to have results of serum

Ca++, phosphate, magnesium, Ca++, phosphate, magnesium, bicarbonate levels as well as a DEXA bicarbonate levels as well as a DEXA scan and a 24 hour urine for excreted scan and a 24 hour urine for excreted Ca++Ca++

Rationale: Rationale: DEXA scan shows DEXA scan shows demineralization of bone, 24 hour urine demineralization of bone, 24 hour urine shows excess Ca++, and abnormal shows excess Ca++, and abnormal serum levels of trace elementsserum levels of trace elements

Question #5: Mrs. Jones is diagnosed with Question #5: Mrs. Jones is diagnosed with hyperparathyroidism. As the nurse doing the hyperparathyroidism. As the nurse doing the patient teaching, you are aware that patient teaching, you are aware that adequate hydration is essential in adequate hydration is essential in preventing:preventing:a. Constipation.a. Constipation.

b. Hypercalcemia.b. Hypercalcemia.

c. Alteration in fluid balance.c. Alteration in fluid balance.

d. All of the above.d. All of the above.

Answer #5: Mrs. Jones is diagnosed with Answer #5: Mrs. Jones is diagnosed with Hyperparathyroidism. As the nurse doing Hyperparathyroidism. As the nurse doing the patient teaching, You are aware that the patient teaching, You are aware that adequate hydration is essential in adequate hydration is essential in preventing:preventing:

d. d. All of the above.All of the above.

Rationale: Rationale: Adequate Adequate

hydrationhelps to prevent constipation, hydrationhelps to prevent constipation,

hypercalcemia and fluid hypercalcemia and fluid

balance alterationsbalance alterations

HypoparathyroidismHypoparathyroidism Decreased Secretion of PTHDecreased Secretion of PTH

Most commonly caused by injury to Most commonly caused by injury to parathyroid gland during surgeryparathyroid gland during surgery

Can also be caused by hypomagnesemiaCan also be caused by hypomagnesemia PathophysiologyPathophysiology

Bones – Bones – Mineralization Mineralization Bone Resorption Bone Resorption Hypocalcemia / Hypocalcemia / Intestinal Ca+ Absorption Intestinal Ca+ Absorption Metabolic Alkalosis (Mild)Metabolic Alkalosis (Mild) Parkinson-like SymptomsParkinson-like Symptoms

HypoparathyroidismHypoparathyroidism Clinical PresentationClinical Presentation

Mental FatigueMental Fatigue Abdominal PainAbdominal Pain Patient History of AlcoholismPatient History of Alcoholism

Physical ExaminationPhysical Examination Muscle Spasm / Tetany / ExcitabilityMuscle Spasm / Tetany / Excitability Deep Tendon Reflexes Deep Tendon Reflexes Dry Skin / Hair Loss / Dry Skin / Hair Loss / Weakened Tooth EnamelWeakened Tooth Enamel

HypoparathyroidismHypoparathyroidism

DiagnosticsDiagnostics Serum Calcium Levels – Serum Calcium Levels –

DECREASEDDECREASED Serum Phosphorus – INCREASEDSerum Phosphorus – INCREASED Low Vitamin D LevelsLow Vitamin D Levels Urinary Calcium –DECREASED Urinary Calcium –DECREASED X-Rays X-Rays

Increased Bone DensityIncreased Bone Density

HypoparathyroidismHypoparathyroidism Clinical ManagementClinical Management

Acute conditionAcute conditionMEDICAL EMERGENCYMEDICAL EMERGENCYPrevent larygneal spasms- administer IV Prevent larygneal spasms- administer IV

Ca++ gluconate/carbonate STAT!Ca++ gluconate/carbonate STAT! Chronic conditionChronic condition

Lifetime Vitamin D therapyLifetime Vitamin D therapyCalcium supplementation- 1 to 3 gm/dayCalcium supplementation- 1 to 3 gm/dayMuscle relaxants to control muscular Muscle relaxants to control muscular

spasmsspasmsDrugs to reduce GI absorption of Drugs to reduce GI absorption of

phosphorousphosphorous

Osteomalacia (Adult Rickets)Osteomalacia (Adult Rickets)

Inadequate and delayed mineralization Inadequate and delayed mineralization of osteoid in mature compact and of osteoid in mature compact and spongy bonespongy bone

Major deficit is in Vitamin D , which is Major deficit is in Vitamin D , which is required for Ca++ uptake in intestinesrequired for Ca++ uptake in intestines

Decreased Ca++ stimulates PTH, which Decreased Ca++ stimulates PTH, which does increase Ca++, but also increases does increase Ca++, but also increases phosphate excretion by kidneyphosphate excretion by kidney When phosphate levels too low, When phosphate levels too low,

mineralization cannot occurmineralization cannot occur

Osteomalacia (Adult Rickets) con’tOsteomalacia (Adult Rickets) con’t

EtiologyEtiology More prevalent in extreme preemies, elderly, those More prevalent in extreme preemies, elderly, those

following strict macrobiotic vegetarian diets and following strict macrobiotic vegetarian diets and persons on anticonvulsant Rxpersons on anticonvulsant Rx

Pancreatic insufficiencyPancreatic insufficiency Hepatobiliary diseasesHepatobiliary diseases

Lack of bile salts decreases absorption of Vit DLack of bile salts decreases absorption of Vit D Malabsorption syndromesMalabsorption syndromes HyperthyroidismHyperthyroidism Rare in US due to fortification of foodsRare in US due to fortification of foods Common in GB and Middle Eastern CountriesCommon in GB and Middle Eastern Countries

OsteomalaciaOsteomalacia Clinical PresentationClinical Presentation

Generalized body aches /LBP as well as Generalized body aches /LBP as well as hip painhip pain

Lower extremity pain & deformityLower extremity pain & deformity Physical examinationPhysical examination

Scoliosis / kyphosis of spineScoliosis / kyphosis of spineDeformities of weight bearing bonesDeformities of weight bearing bonesMuscle weakness leading to classic Muscle weakness leading to classic

waddling gaitwaddling gaitGeneralized MalaiseGeneralized Malaise

OsteomalaciaOsteomalacia DiagnosticsDiagnostics

Serum Ca++ –Serum Ca++ –↓ or ↓ or NormalNormal Serum inorganic Phosphate Serum inorganic Phosphate ↑↑> 5.5 > 5.5 Vitamin D Vitamin D ↓↓ BUN & creatinine ↑BUN & creatinine ↑ Alkaline Phosphatase & PTH Alkaline Phosphatase & PTH ↑↑ Bone bx to determine aluminum levelsBone bx to determine aluminum levels X-Rays X-Rays

DemineralizationDemineralization PseudofracturesPseudofractures Bowing of long bonesBowing of long bones

OsteomalaciaOsteomalacia Clinical ManagementClinical Management

Correcting serum Ca++ & phosphorousCorrecting serum Ca++ & phosphorous Chelating bone aluminum if neededChelating bone aluminum if needed Suppressing hyperthyroidismSuppressing hyperthyroidism Supplement with Vitamin DSupplement with Vitamin D Administer Ca++ carbonate to Administer Ca++ carbonate to ↓ ↓

hyperphosphatemiahyperphosphatemia Renal dialysis/transplant for renal Renal dialysis/transplant for renal

osteodystrophyosteodystrophy Correction of associated intestinal disordersCorrection of associated intestinal disorders

Question #6: X-rays of a Question #6: X-rays of a patient with Osteomalacia patient with Osteomalacia would reveal:would reveal:

a. Increased bone a. Increased bone density.density.

b. Stress fractures.b. Stress fractures.

c. Normal joint c. Normal joint alignment.alignment.

d. Demineralization.d. Demineralization.

Answer #6: X-rays of a patient Answer #6: X-rays of a patient with Osteomalacia would with Osteomalacia would reveal:reveal:

d. Demineralization.d. Demineralization.

Rationale:Rationale: As calcium As calcium and phosphorus levels and phosphorus levels are decreased,are decreased,

demineralization can be demineralization can be noted on x-ray noted on x-ray

OsteoporosisOsteoporosis Most common metabolic bone disease

Reduction of bone mass density (BMD) fractures

Estrogen deficiency leads to a rapid in BMD

Rapid bone loss may occur Up to 20% during the first 5-7 years

post-menopause Surgically induced menopause

Results in severe decrease in BMD regardless of age

OsteoporosisOsteoporosis

Accelerated Bone Loss

Loss of T rabecular Bone

Decreased Levels of Estrogen

10-15 Years Postm enopause

Predom inantly in Fem ales

Type I - Postm enopausal

Non-Accelerated Bone Loss

Loss of Cortical & T rabecular Bone

Related to NutritionDecreased Physical Activity

Com m on After Age 70

Affects M ales & Fem ales

Type II - Senile

Loss of Cortical & T rabecular Bone

Result of Disease ProcessOr M edical T reatm ent

Occurs At Any Age

Affects M ales & Fem ales

Secondary

Osteoporosis – Risk FactorsOsteoporosis – Risk Factors

InheritedInherited Gender / EthnicityGender / Ethnicity Body compositionBody composition Gyn considerationsGyn considerations

Family HistoryFamily History Hx. Of osteoporosisHx. Of osteoporosis

Medical ConditionsMedical Conditions Rheumatoid arthritisRheumatoid arthritis Thyroid / Liver DzThyroid / Liver Dz Spinal cord injurySpinal cord injury

BehavioralBehavioral Physical activity levelPhysical activity level Nutritional statusNutritional status Lifestyle habitsLifestyle habits

MedicationsMedications Thyroid replacementThyroid replacement Corticosteroid useCorticosteroid use AntacidsAntacids Long term anti-Long term anti-

convulsant useconvulsant use

OsteoporosisOsteoporosis Clinical PresentationClinical Presentation

Attire Ill fitting clothesAttire Ill fitting clothes HeightHeight Recent loss of Recent loss of

heightheight Spine (Posture)Spine (Posture) KyphosisKyphosis Chest/ AbdomenChest/ Abdomen Chest resting on Chest resting on

protruding abdomenprotruding abdomen GaitGait Slow reciprocal – Slow reciprocal –

Wide base stanceWide base stance

OsteoporosisOsteoporosis Differential DiagnosisDifferential Diagnosis

Urinary calcium - Urinary calcium - ↑↑ in secondary in secondary osteoporosisosteoporosis

Biochemical markers of bone resorptionBiochemical markers of bone resorptionUrinary pyridinoline- Urinary pyridinoline- ↑↑ for a variety of for a variety of

metabolic bone diseasesmetabolic bone diseases X-RaysX-Rays

↑↑ ddensity often not seen until 50% lossensity often not seen until 50% loss DEXA DEXA

Hip / Lumbosacral spine -Hip / Lumbosacral spine -↑↑

Osteoporosis – Fracture Osteoporosis – Fracture RiskRisk

• Essential to ALL groups Post-menopausal & elderly MOST at risk

for fracture• Bone strength depends on

Mass Architecture Bone Quality

• BMD Testing Bone Mass Measurement Act

OsteoporosisOsteoporosis Nutritional supportNutritional support

Calcium intake levelsCalcium intake levelsRDA based on ageRDA based on age

Co-FactorsCo-FactorsVitamin DVitamin DSerum 1,25-dihydroxyvitamin D3Serum 1,25-dihydroxyvitamin D3

ExerciseExercise Weight bearing exercise 2-3 x weekWeight bearing exercise 2-3 x week

Recommended Daily Calcium Recommended Daily Calcium IntakeIntake

0

200

400

600

800

1000

1200

1400

1600

0-6mos.

6-12mos.

1-5 yrs 5-10yrs

11-24yrs

25-50yrs

+65yrs

RDA

Suggested

Anti-Resorptive MedicationAnti-Resorptive Medication EstrogenEstrogen

Prevents bone resorptionPrevents bone resorption Most commonly usedMost commonly used Start within 3 Yrs of menopauseStart within 3 Yrs of menopause Positive effect of calcium absorption & Positive effect of calcium absorption &

calcitonincalcitonin risk of endometrial cancer – prisk of endometrial cancer – progesterone rogesterone

MUST be added if no hysterectomyMUST be added if no hysterectomy Oral / Transdermal Oral / Transdermal New data shows no change in CV riskNew data shows no change in CV risk

Anti-Resorptive MedicationAnti-Resorptive Medication

CalcitoninCalcitonin Inhibits osteoclasts – prevents bone Inhibits osteoclasts – prevents bone

resorptionresorption Tx. postmenopausal osteoporosisTx. postmenopausal osteoporosis Males & femalesMales & females In conjunction with calcium & Vitamin DIn conjunction with calcium & Vitamin D Analgesic propertiesAnalgesic properties Intranasal administrationIntranasal administration

Anti-Resorptive MedicationAnti-Resorptive Medication

BisphosphonatesBisphosphonatesNon-Hormonal agentNon-Hormonal agent Highly selective osteoclast inhibitorHighly selective osteoclast inhibitor Indicated for treatment & prevention & Indicated for treatment & prevention &

osteoporosis in menosteoporosis in men BMD 2 standard dev. below norm for BMD 2 standard dev. below norm for

young adultsyoung adults SE – GI disorders / Esophageal & SE – GI disorders / Esophageal &

gastric ulcersgastric ulcers

Anti-Resorptive MedicationAnti-Resorptive Medication

SERM - Selective Estrogen Receptor SERM - Selective Estrogen Receptor ModulatorModulator Indicated for preventionIndicated for prevention Enhances beneficial effects of estrogen Enhances beneficial effects of estrogen

without increasing risks to breast / without increasing risks to breast / uterusuterus

Caution use in patients at risk for DVT Caution use in patients at risk for DVT

Bone Forming AgentsBone Forming Agents

Slow-Release calcium fluorideSlow-Release calcium fluoride Stimulate osteoblast activityStimulate osteoblast activity New bone matrix remains brittleNew bone matrix remains brittle Not effective with severe Not effective with severe

demineralizationdemineralization Must have adequate calcium intakeMust have adequate calcium intakeSee Handout for medicationsSee Handout for medications

OsteoporosisOsteoporosis Surgical intervention for vertebral Surgical intervention for vertebral

fracturesfractures VertebroplastyVertebroplasty

High pressure injection of bone High pressure injection of bone cement through pedicles to vertebral cement through pedicles to vertebral bodybody

Contraindicated in severe vertebral Contraindicated in severe vertebral body collapsebody collapse

OsteoporosisOsteoporosis Surgical intervention for vertebral fracturesSurgical intervention for vertebral fractures

KyphoplastyKyphoplastyBone tamp through cortical window Bone tamp through cortical window Inflation of bladder in vertebral bodyInflation of bladder in vertebral bodyInjection of bone cement under LOW Injection of bone cement under LOW

PRESSUREPRESSURE

OsteoporosisOsteoporosis PhysiologicalPhysiological

Decreased respiratory functionDecreased respiratory functionKyphotic deformityKyphotic deformity

GI/Bowel alterationGI/Bowel alterationProtrusion of abdomenProtrusion of abdomenMedicationsMedications

Self-care deficitsSelf-care deficits

OsteoporosisOsteoporosis PsychologicalPsychological

Low self-esteemLow self-esteem DepressionDepression Social isolationSocial isolation

Retreat from activitiesRetreat from activities Sleep disturbancesSleep disturbances

Physical/Psychological componentPhysical/Psychological component

Ms. Rice Is a 56 year old woman. She presents to Ms. Rice Is a 56 year old woman. She presents to the GYN for her annual check-up. A detailed the GYN for her annual check-up. A detailed

nursing history reveals the following:nursing history reveals the following:

Ht: 5’5” (5’6” last yr) Wt: 126 lbs. Ht: 5’5” (5’6” last yr) Wt: 126 lbs. Race: CaucasianRace: Caucasian

Medical HistoryMedical History LMP 4 years earlierLMP 4 years earlier Thyroidectomy 10 yrsThyroidectomy 10 yrs Mild OA rt. kneeMild OA rt. knee

Current Meds/SupplementsCurrent Meds/Supplements Synthroid Synthroid Calcium 1000 mgs.Calcium 1000 mgs.

Case Study con’tCase Study con’t

Social HistorySocial History Non-smokerNon-smoker Infrequent ExerciseInfrequent Exercise

Family History:Family History: Mother Mother

OsteoporosisOsteoporosis

Question #7: Of the identified risk Question #7: Of the identified risk factors, which would be considered to factors, which would be considered to be modifiable?be modifiable?

a. Use of thyroid replacement a. Use of thyroid replacement

medications.medications.

b. Exercise level.b. Exercise level.

c. Family history of osteoporosis.c. Family history of osteoporosis.

d. Loss of height.d. Loss of height.

Answer #7: Of the identified risk Answer #7: Of the identified risk factors, which would be considered to factors, which would be considered to be modifiable?be modifiable?

b. Exercise level.b. Exercise level.

RationaleRationale: While Ms. Rice: While Ms. Rice

can control amount of can control amount of

exercise, she cannotexercise, she cannot

modify other factors. modify other factors.

Question #8: The nurse should assess Question #8: The nurse should assess Ms. Rice’s dietary intake of calcium to Ms. Rice’s dietary intake of calcium to be sure she is getting a suggested daily be sure she is getting a suggested daily intake of:intake of:

a. 800 mgs. Daily.a. 800 mgs. Daily.

b. 1000 mgs. Daily.b. 1000 mgs. Daily.

c. 1500 mgs. Daily.c. 1500 mgs. Daily.

d. Calcium is not required as d. Calcium is not required as

she is post-menopausal.she is post-menopausal.

Answer #8: The nurse should assess Answer #8: The nurse should assess Ms. Rice’s dietary intake of calcium to Ms. Rice’s dietary intake of calcium to be sure she is getting a suggested be sure she is getting a suggested daily intake of:daily intake of:

c. 1500 mgs. daily.c. 1500 mgs. daily.

RationaleRationale: Noting age and history,: Noting age and history,

Ms. Rice’s dietary intake of Ms. Rice’s dietary intake of

calcium should be the same as calcium should be the same as

an adolescentan adolescent

Question # 9: Ms. Rice has a DEXA Test. It Question # 9: Ms. Rice has a DEXA Test. It demonstrates demonstrates BMD 2.5 St. Dev. She has been BMD 2.5 St. Dev. She has been advised to start taking medication. As part of advised to start taking medication. As part of the patient education, the nurse understands the patient education, the nurse understands that:that:

a. Estrogen can be started at any time post-a. Estrogen can be started at any time post-menopause and retain the same level of menopause and retain the same level of effectiveness.effectiveness.

b. Calcium alone is effective in increasing BMD.b. Calcium alone is effective in increasing BMD.

c. SERMs c. SERMs risk of breast & uterine cancer. risk of breast & uterine cancer.

d. Bisphosphonates are osteoclast inhibitors d. Bisphosphonates are osteoclast inhibitors

& are effective anti-resorptive agents.& are effective anti-resorptive agents.

Answer #9: Ms. Rice has a DEXA test. It Answer #9: Ms. Rice has a DEXA test. It demonstrates demonstrates BMD 2.5 St. Dev. She has been BMD 2.5 St. Dev. She has been advised to start taking medication. As part of advised to start taking medication. As part of the patient education, the nurse understands the patient education, the nurse understands that:that:

d. Bisphosphonates are osteoclast inhibitors d. Bisphosphonates are osteoclast inhibitors

& are effective anti-resorptive agents.& are effective anti-resorptive agents.

RationaleRationale: As per previous discussion, other : As per previous discussion, other statements are incorrectstatements are incorrect

Paget’s DiseasePaget’s Disease Osteitis DeformasOsteitis Deformas Bone resorption Bone resorption bone formation bone formation

develop large irregularly shaped bones develop large irregularly shaped bones with poor mineralization with poor mineralization thick brittle thick brittle bonesbones

EtiologyEtiology Slow progressing diseaseSlow progressing disease Often occurs between 50-70 yearsOften occurs between 50-70 years Familial tendency in malesFamilial tendency in males Usually asymptomaticUsually asymptomatic

Paget’s DiseasePaget’s Disease Clinical PresentationClinical Presentation

Deep aching sensation Deep aching sensation with weight with weight bearingbearing

Pain - mild to severe unrelated to activityPain - mild to severe unrelated to activity May have bony deformities – skullMay have bony deformities – skull Loss of heightLoss of height

Physical ExaminationPhysical Examination Kyphosis / Bowing of long bonesKyphosis / Bowing of long bones Conductive hearing lossConductive hearing loss Fracture healing is impairedFracture healing is impaired Complications – CHF / Paget’s sarcomaComplications – CHF / Paget’s sarcoma

Paget’s DiseasePaget’s Disease DiagnosticsDiagnostics

Serum alkaline phosphatase -Serum alkaline phosphatase -↑↑ Urinary hydroxyproline - Urinary hydroxyproline - ↑↑ Serum/ urinary citrate – Serum/ urinary citrate – ↑↑ Serum uric acid – Serum uric acid – ↑↑in < 50%in < 50% X-RaysX-Rays

Early localized demineralizationEarly localized demineralizationLater bony overgrowth – irregularLater bony overgrowth – irregularMosaic patternMosaic pattern

Bone scanBone scanMetabolic activity- Metabolic activity- ↑↑

Paget’s DiseasePaget’s Disease Clinical ManagementClinical Management

AsymptomaticAsymptomatic Monitor patientMonitor patient

SymptomaticSymptomatic NSAIDsNSAIDs Calcitonin – relieve bone painCalcitonin – relieve bone pain BisphosphonatesBisphosphonates

Ambulation with assistive devicesAmbulation with assistive devices

Surgical InterventionSurgical Intervention Correction of malalignment / fracturesCorrection of malalignment / fractures

Question #10: Paget’s Disease Question #10: Paget’s Disease is characterized by: is characterized by:

a. Decreased bone formation.a. Decreased bone formation.

b. Decreased bone resorption.b. Decreased bone resorption.

c. Mosaic patterned bone c. Mosaic patterned bone growth.growth.

d. Accelerated bone healing.d. Accelerated bone healing.

Answer #10: Paget’s Disease is Answer #10: Paget’s Disease is characterized by:characterized by:

c. Mosaic patterned bone c. Mosaic patterned bone growth.growth.

RationaleRationale: Decreased bone : Decreased bone formation, bone resorption formation, bone resorption and accelerated bone healing and accelerated bone healing produce a mosaic pattern of produce a mosaic pattern of growth growth

SummarySummary Bone cell typesBone cell types Hormonal regulation of bone formationHormonal regulation of bone formation

Causes & consequences of Causes & consequences of // levels of levels of hormoneshormones

SolutionsSolutions Dietary considerations (note: cause & solution)Dietary considerations (note: cause & solution) Exercise patterns (note: cause & solution)Exercise patterns (note: cause & solution) MedicationsMedications

Hormonal / Non-hormonal / vitaminsHormonal / Non-hormonal / vitaminsSurgical intervention (note: rx. for effect / Surgical intervention (note: rx. for effect /

cause)cause)