MSEM14S.pdf

11/27/23, 4:59 AM Realizeit for Student Summary Osteoporosis is a major health problem throughout the world. Despite the serious consequences of osteoporosis and fractures, many people with low bone mass and those with osteoporosis are unaware of it, and as a result are not taking preventive actio...

11/27/23, 4:59 AM Realizeit for Student Summary Osteoporosis is a major health problem throughout the world. Despite the serious consequences of osteoporosis and fractures, many people with low bone mass and those with osteoporosis are unaware of it, and as a result are not taking preventive actions and are receiving no treatment. Nurses have a major role in prevention, assessment, and teaching related to osteoporosis. The most common sites of fracture are the hip, spine, and wrist. Although osteoporosis and fracture are commonly thought of as limited to post-menopausal women, such fractures also occur at an earlier age in women and in men as well. Osteoporosis can occur at younger ages in individuals who did not achieve optimal bone mass during childhood and adolescence for a variety of causes, for example: poor nutrition, underlying disease, prolonged immobility, and extreme exercise leading to amenorrhea. Osteoporosis is characterized by low bone mass or density and structural deterioration of bone tissue, leading to bone fragility and an increased risk of fractures of the hip, spine, wrist, and other bones. Bone density is determined by peak bone mass and the amount of bone loss. Peak bone mass refers to an individual’s maximum bone density and strength. Patients with osteoporosis or low bone mass are generally treated, if they are diagnosed and treated at all, in outpatient settings. However, because of the high prevalence of osteoporosis, many hospitalized patients are likely to have low bone mass or osteoporosis but are often unaware of it and are often untreated. The role of nurses in caring for patients with osteoporosis or at risk for osteoporosis, regardless of setting, includes enhancing patients’ knowledge about osteoporosis and promoting behavior change. Osteoporosis may be classified into two types: Primary osteoporosis: Primary osteoporosis occurs in women after menopause and in men later in life, but it is not merely a consequence of aging but of failure to develop optimal peak bone mass during childhood, adolescence, and young adulthood. Secondary osteoporosis: Secondary osteoporosis is the result of medications or other conditions and diseases that affect bone metabolism. Common signs and symptoms found in patients with osteoporosis include the following: Fractures: The first clinical manifestation of osteoporosis may be fractures, which occur most commonly as compression fractures. Kyphosis: The gradual collapse of a vertebra is asymptomatic and is called progressive kyphosis or “dowager’s hump” associated with loss of height. Decreased calcitonin: Calcitonin, which inhibits bone resorption and promotes bone formation, is decreased. Decreased estrogen: Estrogen, which inhibits bone breakdown, decreases with aging. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 1/5 11/27/23, 4:59 AM Realizeit for Student Increased parathyroid hormone: Parathyroid hormone increases with aging, increasing bone turnover and resorption. Nursing interventions include the following: providing patient education across the lifespan about bone health and prevention of osteoporosis and fractures, including discussing strategies to ensure bone health in adolescents as well as young adults and older patients assessing patients’ risk for low bone density or osteoporosis providing education to patients with or at risk of osteoporosis and their families about pharmacologic and non-pharmacologic treatment strategies educating patients and their family caregivers about the risk for falling and strategies to prevent falls at home assessing the risk factors for falls and implementing strategies during a patient’s hospitalization to decrease the risk of falls and fracture in those with or at risk for osteoporosis providing nursing care for patients at risk for complications of osteoporosis; and promoting adherence to medication and lifestyle changes Treatment of osteoporosis is focused on calcium and vitamin D supplementation to prevent fractures and bisphosphonates. Osteoarthritis is the most common form of arthritis and is commonly described as ‘wear and tear’ or degenerative arthritis. Osteoarthritis (OA) is the most frequently disabling among joint disorders. Osteoarthritis, or sometimes called osteoarthrosis, is a degenerative joint disease even though inflammation may be present. It is the most common among the joint disorders and also the most disabling. OA is both overdiagnosed and trivialized; it is frequently overtreated or undertreated. The functional impact of OA on the quality of life, especially elderly patients, is often ignored. Classification Osteoarthritis is classified into two classifications, yet the distinction between the two of them is always unclear. Primary, or idiopathic OA, has no prior event or disease related to it. Secondary OA results from previous joint injury or inflammatory disease. Pathophysiology Osteoarthritis may be thought of as the result of many factors that, when combined, predispose the patient to the disease. Mechanical injury: OA starts from an injury of the articular cartilage, subchondral bone, and synovium. Chondrocyte response: Factors that initiate chondrocyte response include previous joint damage, genetic and hormonal factors, and others. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 2/5 11/27/23, 4:59 AM Realizeit for Student Cytokines: After the chondrocyte response, the release of cytokines occurs. Stimulation of enzymes: Proteolytic enzymes, metalloproteases, and collagenase are stimulated, produced, and, released. Damage: The resulting damage predisposes to damage further as the chondrocyte is triggered to respond again. Understanding of osteoarthritis has been greatly expanded beyond what was previously thought of as simply “wear and tear” related to aging and the causes include: Increased age: Most elderly people experience osteoarthritis because the ability of the articular cartilage to resist microfracture with repetitive loads diminishes with age. Obesity: Obese people easily wear out their weight-bearing joints because of their increased weight. Previous joint damage: Having previous joint damage predisposes the patient to secondary OA. Repetitive use: Repetitive use due to occupational or recreational factors also causes OA. Clinical Manifestations Most common joints affected are weight bearing joints and those that are used most often, and the onset of the disease is slow, usually affecting those over 40 years of age. Its effects are limited to the joints unlike other forms of arthritis that may affect other body systems such as rheumatoid arthritis (RA). Osteoarthritis has primary signs and symptoms, and that includes: Pain: An inflamed synovium causes the pain, stretching of the joint capsule or ligaments, irritation of the nerve endings in periosteum over osteophytes, trabecular microfracture, intraosseous, hypertension, bursitis, tendinitis, and muscle spasm. Stiffness: Stiffness, which is mostly experienced in the morning or upon awakening, usually lasts less than 30 minutes and decreases with movement. Functional impairment: Functional impairment results from pain on movement and limited motion caused by structural changes in the joints. Nursing management of the patient with osteoarthritis includes both nonpharmacological and pharmacologic approaches. Nursing assessment for OA focuses mainly on history and physical assessment. Physical assessment of the area over the affected joint may reveal tender and enlarged joints. Patient history should note of any past injury to the joints, as this is a risk factor for OA. The management of OA is best achieved with a holistic approach that includes a multidisciplinary team, where the patient is at the center of the decision making process. Effective communication and team management should occur between patient, medical practitioner, nurse, medical specialists, https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 3/5 11/27/23, 4:59 AM Realizeit for Student allied health and community services. Treatment of osteoporosis is focused on calcium and vitamin D, and bisphosphonates. Gout The public and many health care professionals have long regarded fibromyalgia as a mental health disease; therefore, the symptoms are “made up” and not “real”. Many of the contributing factors may be related to the mind but the symptoms are “real” and debilitating. Fibromyalgia is a biopsychosocial syndrome and all aspects of the disease must be treated to alleviate symptoms and promote quality of life for the patient. Nurses are an important part of the treatment team and can focus advocating for the patient as well as patient and family education. Research is ongoing and can provide answers to the many questions about fibromyalgia (fibromyalgia-syndrome-fms) Gout is a disorder of purine metabolism that primarily occurs in adult males and causes joint inflammation. Elevated plasma uric acid concentrations (hyperuricemia) cause deposits of urate crystals in joint spaces causing severe, repeated attacks of arthritis. Uric acid in the form of urate (a byproduct of the metabolism of purines) is a chemical present in all body tissues and many foods. The body is continually metabolizing purines, breaking them down and reusing or excreting the byproducts. Most urate is excreted renally. The body maintains a stable balance between production and excretion, keeping the serum uric acid level between 4 mg/dL and 6.8 mg/dL. Hyperuricemia, variably defined as a serum uric acid level greater than either 6.8 mg/dL or 7.0 mg/dL, occurs when either the kidneys cannot excrete enough urate or too much urate is being produced for the kidneys to handle effectively. Not everyone with hyperuricemia develops gout. Clinical gout begins with an acute episode of intense, painful arthritis possibly triggered by alcohol ingestion, trauma, surgery, drug use, dietary excess, or infection. The first episode is usually monoarticular and associated with few other symptoms. Most have increasingly frequent, longer lasting, and more severe inflammatory episodes as time progresses. Episodes may become polyarticular and eventually resolve incompletely. This leads to a chronic, erosive, and deforming arthritis that slowly progresses to a crippling disease on which acute exacerbations are superimposed. There is evidence that hyperuricemia accompanying chronic gout is related to an increase in myocardial infarction, stroke, kidney failure, metabolic syndrome, and overall mortality. Gout is likely caused by the interaction of several factors outside of the few patients with genetic disease. The most important factors include a metabolic cluster of obesity, insulin resistance, hypertension, hyperlipidemia, diet, medication use, and conditions that increase uric acid production or decrease uric acid excretion. Teaching self-care measures to decrease the risk of acute episodes and avoid long-term complications is highly influential on the patient's quality of life and clinical outcome. All patients https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 4/5 11/27/23, 4:59 AM Realizeit for Student should be informed regarding gout and its treatment (including the risks and benefits of drug therapy), how to prevent and handle episodes, and the importance of lifestyle and dietary issues related to gout. Patients should also understand how comorbid conditions, including hypertension and diabetes mellitus, could affect gout and its treatment. Osteoarthritis and gout are symptomatically managed for pain control with aspirin, NSAIDs including propionic acid derivatives ibuprofen, oxicam derivatives meloxicam, acetic acid derivatives indomethacin, COX-2 inhibitor celecoxib. Gout is treated with uric acid lowering agents, nonpurine agents, and multiple life style changes. Multiple nursing implications are included with these drug classifications for safe patient administration and avoidance of adverse effects. In general, intake of calcium should not exceed 2500 mg from all sources. The upper intake level for vitamin D is 1000 mg/d (4000 international units/d). Calcium deficiency commonly occurs in the elderly because of long-term dietary deficiencies of calcium and vitamin D, impaired absorption of calcium from the intestine, lack of exposure to sunlight, and impaired liver or kidney metabolism of vitamin D to its active form. Postmenopausal women are at high risk for osteoporosis. Both men and women who take corticosteroids are at risk for osteoporosis. Prostaglandins produced by COX-1 are important in regulating homeostasis and are associated with platelet aggregation and protective effects on the stomach and kidneys. Drug-induced inhibition results in gastric ulceration, renal dysfunction, and diminished blood clotting. Prostaglandins produced by COX-2 are associated with pain and inflammation. Drug-induced inhibition results in therapeutic effects of analgesia and anti-inflammatory activity. People with hypersensitivity to aspirin should not take NSAIDs due to the risk of cross-sensitivity to other antiprostaglandin drugs. The use of gastroprotective drugs such as antacids, H2 blockers, and proton pump inhibitors may be indicated to prevent upper GI bleeding with chronic use of nonselective NSAIDs. A BLACK BOX WARNING states that patients who take meloxicam are at risk for cardiovascular events and GI bleeding. Allopurinol, which inhibits the synthesis of uric acid, is the drug of choice for people with gout due to “overproduction” of uric acid. Colchicine is the only antigout drug with anti-inflammatory effects; it is useful for treating acute attacks. Probenecid is effective in treating people with gout who “underexcrete” uric acid. During treatment for gout, the nurse encourages patients to increase fluid intake to 2000 mL/d to prevent renal calculi. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IT%2f2%2bt0zmWpgA%2fttBl%2bYliu9txYeiNyhjGIrXvrN… 5/5