MSEM142.pdf

11/27/23, 4:52 AM Realizeit for Student Metabolic Bone Disorders Medical Management A diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence and the middle years, protects against skeletal demineralization. Such a diet includes three glasses of skim...

11/27/23, 4:52 AM Realizeit for Student Metabolic Bone Disorders Medical Management A diet rich in calcium and vitamin D throughout life, with an increased calcium intake during adolescence and the middle years, protects against skeletal demineralization. Such a diet includes three glasses of skimmed vitamin D–enriched milk or other foods high in calcium (e.g., cheese and other dairy products, steamed broccoli, canned salmon with bones) daily. A cup of milk or calcium-fortified orange juice contains about 300 mg of calcium. The recommended adequate intake level of calcium for men 50 to 70 years is 1000 mg daily, and for women aged 51 and older and men aged 71 and older is 1200 mg daily (USPSTF, 2018). Some researchers are challenging these levels as too low for patients with low baseline values, while others express concern of administering higher dosages, noting that they are associated with adverse events (e.g., renal calculi). The recommended vitamin D intake for most adults, which can be acquired from food or supplements, is between 400 and 1000 IU daily; however optimal vitamin D intake is influenced by a patient’s age and sex (ASBMR, 2020). Regular weight-bearing exercise promotes bone formation. Recommendations include 20 to 30 minutes of aerobic, bone-stressing exercise daily (e.g., not swimming). Weight training stimulates an increase in BMD. In addition, exercise improves balance, reducing the incidence of falls and fractures. Women who are postmenopausal and men aged 50 and older should be advised to avoid excessive intake of alcohol. Those who use tobacco products should be advised to quit. However, additional research is needed to better understand the relationship between smoking and bone health (Strozyk, Gress, & Brietling, 2018). Current guidelines recommend that hormone therapy with estrogen not be used for primary prevention of bone loss in women who are postmenopausal (USPSTF, 2017). Fracture Management Fractures of the hip that occur as a consequence of osteoporosis are managed surgically by joint replacement or by closed or open reduction with internal fixation (e.g., hip pinning). Osteoporotic compression fractures of the vertebrae are managed conservatively. Patients with these findings should be referred to an osteoporosis specialist. Most patients who experience these fractures are asymptomatic and do not require acute care management; for those who experience pain, acute care management is indicated as outlined in the following Nursing Process section. Percutaneous vertebroplasty or kyphoplasty (injection of polymethylmethacrylate [PMMA] bone cement into the fractured vertebra, followed by inflation of a pressurized balloon to restore the shape of the affected vertebra) can provide rapid relief of acute pain and improve quality of life, but might contribute to other complications resulting from https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 1/7 11/27/23, 4:52 AM Realizeit for Student alterations in spinal mechanics. These procedures are contraindicated in the presence of infection, multiple old fractures, and certain coagulopathies. The use of vertebroplasty is highly contested in the medical literature (De Leacy, Chandra, Barr, et al., 2020). Nursing Process The Patient With a Spontaneous Vertebral Fracture Related to Osteoporosis Assessment Recognition of risks and problems associated with osteoporosis form the basis for nursing assessment. The health history focuses on family history, previous fractures, dietary consumption of calcium, exercise patterns, onset of menopause, and the use of certain medications (e.g., corticosteroids), as well as alcohol, smoking, and caffeine intake. Any symptoms the patient is experiencing, such as back pain, constipation, or altered body image, are explored. Physical examination may disclose localized pain, kyphosis of the thoracic spine, or shortened stature. Problems in mobility and breathing may exist as a result of changes in posture and weakened muscles. Nursing Diagnoses Based on the assessment data, major nursing diagnoses may include the following: Lack of knowledge about the osteoporotic process and treatment regimen Acute pain associated with fracture and muscle spasm Risk for constipation associated with immobility or development of ileus (intestinal obstruction) Risk for injury: additional fractures associated with osteoporosis Planning and Goals The major goals for the patient may include knowledge about osteoporosis and the treatment regimen, relief of pain, improved bowel elimination, and absence of additional fractures. TABLE 36-1 Medication Selected Osteoporosis Medications Therapeutic Effects and Indications Key Nursing Considerations https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 2/7 11/27/23, 4:52 AM Realizeit for Student Adequate calcium and vitamin D intake is needed to assure maximum effect; however, these supplements should not be taken at the same time as the bisphosphonates Side effects include gastrointestinal symptoms, including dyspepsia, nausea, Inhibit osteoclasts, causing Bisphosphonates decreased bone loss and increased bone mass flatulence, diarrhea, and constipation Adverse effects may include esophageal or gastric ulcers, osteonecrosis of the jaw, and atypical femur fractures; these effects may be mitigated by instituting a 1–2 yr drug-free holiday in patients with mild osteoporosis after 4–5 yrs of treatment, and in patients with higher fracture risk after 10 yrs of treatment https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 3/7 11/27/23, 4:52 AM Realizeit for Student Administer PO, either daily or weekly Advise patient to take in AM on Alendronate Risedronate Treatment of osteoporosis in women who are postmenopausal Treatment of osteoporosis in men, and in women and men taking corticosteroids empty stomach with 250 mL of water while sitting upright and to remain upright for at least 30 min Effects of alendronate may be diminished in older adult patients who take proton pump inhibitors Ibandronate Treatment of osteoporosis in women who are postmenopausal IV dosing may be good option for patients either intolerant of PO bisphosphonates or nonadherent to prescribed therapy May be given PO monthly or IV every 3 mo Administer IV once yearly for osteoporosis treatment or once every 2 yrs for osteoporosis prevention Zoledronic acid Treatment of osteoporosis in women who are postmenopausal Treatment of osteoporosis in men and in both men and women taking corticosteroids for at least 12 mo This is the most potent bisphosphonate and is associated with acute kidney injury; therefore it is contraindicated in patients with creatinine clearances less than 35 mL/min or in patients with chronic kidney disease Estrogen Promotes estrogenic effects on Administer PO once daily. May Agonist/Antagonist bone, preserving BMD, with be given in tandem with https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 4/7 11/27/23, 4:52 AM Realizeit for Student (formerly called concomitant antiestrogenic selective estrogen effects on the uterus and receptor modulator breasts calcium and vitamin D Side effects include hot flashes and leg cramps [SERM]) Prevention and treatment of osteoporosis in women who are postmenopausal, particularly those with breast cancer May also reduce the risk of breast cancer in patients at risk Raloxifene Monoclonal antibody that Adverse effects include VTE formation Given once every 6 mo SQ increases BMD and reduces the porosity of cortical bone by Side effects include skin inhibiting the effects of TNF on rashes osteoclasts, inhibiting their activity RANKL Inhibitor Treatment of osteoporosis in men and women who are postmenopausal at high risk of fracture; also indicated for women with osteoporosis and breast cancer receiving aromatase inhibitors and for men with osteoporosis and prostate cancer receiving gonadotropin-reducing hormones Denosumab Adverse effects include hypocalcemia, cellulitis, osteonecrosis of the jaw, and atypical femur fracture Note: when treatment with denosumab is stopped, loss of BMD can be rapid; other drugs should be started to mitigate this response Synthetic parathyroid hormone which increases bone strength PTH Analogue and density Teriparatide Treatment of osteoporosis in men and women who are postmenopausal at high risk of fracture Must be refrigerated Daily self-administered SQ injections for up to 2 yrs Nursing Interventions Promoting Understanding of Osteoporosis and the Treatments Regimen https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 5/7 11/27/23, 4:52 AM Realizeit for Student Patient education focuses on factors influencing the development of osteoporosis, interventions to arrest or slow the process, and measures to relieve symptoms. The nurse emphasizes that people of any age need sufficient calcium, vitamin D, and weight-bearing exercise to slow the progression of osteoporosis (Drezner, 2019). Patient education related to medication therapy as described previously is important. Patients must understand that having one fracture increases the probability of sustaining another. Relieving Pain Relief of back pain resulting from compression fracture may be accomplished by short periods of resting in bed in a supine or side-lying position. The mattress should be supportive. Knee flexion increases comfort by relaxing back muscles. Intermittent local heat and backrubs promote muscle relaxation. The nurse instructs the patient to move the trunk as a unit and to avoid twisting. When the patient is assisted out of bed, a trunk orthosis (e.g., lumbosacral corset) may be worn for temporary support and immobilization, although such a device is frequently uncomfortable and is poorly tolerated by many older adults. The patient gradually resumes activities as pain diminishes. Improving Bowel Elimination Constipation is a problem related to immobility and medications. Early institution of a high-fiber diet, increased fluids, and the use of prescribed stool softeners help prevent or minimize constipation. If the vertebral collapse involves the T10–L2 vertebrae, the patient may develop a paralytic ileus. The nurse therefore monitors the patient’s intake, bowel sounds, and bowel activity. Preventing Injury Physical activity is essential to strengthen muscles, improve balance, prevent disuse atrophy, and retard progressive bone demineralization. Isometric exercises can strengthen trunk muscles. The nurse encourages walking, good body mechanics, and good posture. Daily weight-bearing activity, preferably outdoors in the sunshine to enhance the body’s ability to produce vitamin D, is encouraged. Sudden bending, jarring, and strenuous lifting are avoided. Gerontologic Considerations Older adults fall frequently as a result of environmental hazards, diminished senses and cardiovascular responses, and responses to medications. The patient and family need to be included in planning for care and preventive management regimens. For example, the home environment should be assessed for elimination of potential hazards (e.g., scatter rugs, cluttered https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 6/7 11/27/23, 4:52 AM Realizeit for Student rooms and stairwells, toys on the floor, pets underfoot). A safe environment can then be created (e.g., well-lighted staircases with secure handrails, grab bars in the bathroom, properly fitting footwear). Adequate nurse–patient ratios are also critical for fall prevention in inpatient settings (Brent et al., 2018). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 7/7