Osteoporosis

I. Definition

- A disorder in which bones lose density and become porous and fragile.- It occurs when the body fails to form enough new bone, when too much old bone is reabsorbed by the body, or both.

II. Synonym Brittle bone disease

III. Types of Osteoporosis1. Primary Osteoporosis - is associated with the process of normal aging. 2. Secondary Osteoporosis - caused by certain lifestyle factors, diseases, or medications.

IV. Causes

Risk factors:a. Personal Characteristics:

Gender (Female) Advance Age White (Fair, thin skin) Estrogen deficiency or menopause Low weight and body mass index Family historyb. Lifestyle: Diet low in calcium and vitamin D Cigarette smoking Use of alcohol and/or caffeine Lack of weight-bearing exercise Lack of exposure to sunshinec. Drug and Disease related:

Aluminum containing antacids Anticonvulsants Heparin Corticosteroids or Cushing s disease Gastrectomy Diabetes Mellitus Chronic Obstructive lung disease Malignancy Hyperthyroidism Hyperparathyroidism Rheumatoid Arthritis

V. Anatomy and PhysiologySpineThe spine or backbone is made of 33 individual bony vertebrae. This spinal column provides the main support for the body, allowing you to stand upright, bend, and twist, while protecting the spinal cord from injury.

Functions of the Spine Protect the spinal cord, nerve roots and several of the bodys internal organs. Provide structural support and balance to maintain an upright posture. Enable flexible motion.

Regions of the SpineTypically, the spine is divided into four main regions: cervical, thoracic, lumbar and sacral. Each region has specific characteristics and functions.

Cervical SpineThe neck region of the spine is known as theCervical Spine. This region consists of seven vertebrae, which are abbreviated C1 through C7 (top to bottom). These vertebrae protect the brain stem and the spinal cord, support the skull, and allow for a wide range of head movement.The first cervical vertebra (C1) is called theAtlas. The Atlas is ring-shaped and it supports the skull. C2 is called theAxis. It is circular in shape with a blunt peg-like structure (called theOdontoid Processor dens) that projects upward into the ring of the Atlas. Together, the Atlas and Axis enable the head to rotate and turn. The other cervical vertebrae (C3 through C7) are shaped like boxes with small spinous processes (finger-like projections) that extend from the back of the vertebrae.

Thoracic SpineBeneath the last cervical vertebra are the 12 vertebrae of theThoracic Spine. These are abbreviated T1 through T12 (top to bottom). T1 is the smallest and T12 is the largest thoracic vertebra. The thoracic vertebrae are larger than the cervical bones and have longer spinous processes.In addition to longer spinous processes, rib attachments add to the thoracic spines strength. These structures make the thoracic spine more stable than the cervical or lumbar regions. In addition, the rib cage and ligament systems limit the thoracic spines range of motion and protect many vital organs.

Lumbar SpineTheLumbar Spinehas 5 vertebrae abbreviated L1 through L5 (largest). The size and shape of each lumbar vertebra is designed to carry most of the bodys weight. Each structural element of a lumbar vertebra is bigger, wider and broader than similar components in the cervical and thoracic regions.The lumbar spine has more range of motion than the thoracic spine, but less than the cervical spine. The lumbar facet joints allow for significant flexion and extension movement but limit rotation.

Sacral SpineTheSacrumis located behind the pelvis. Five bones (abbreviated S1 through S5) fused into a triangular shape, form the sacrum. The sacrum fits between the two hipbones connecting the spine to the pelvis. The last lumbar vertebra (L5) articulates (moves) with the sacrum.Immediately below the sacrum are five additional bones, fused together to form theCoccyx(tailbone).

The Pelvis and the SkullAlthough not typically viewed as part of the spine, the pelvis and the skull are anatomic structures that closely inter-relate with the spine, and have a significant impact on the patients balance.

Spinal CurvesWhen viewed from the front (Coronal Plane) the healthy spine is straight. (A sideways curve in the spine is known as scoliosis.) When viewed from the side (Sagittal Plane) the mature spine has four distinct curves. These curves are described as being either kyphotic or lordotic.A kyphotic curve is a convex curve in the spine (i.e. convexity towards the back of the spine). The curves in the thoracic and sacral spine are kyphotic.A lordotic curve is concave (i.e. concavity towards the back of the spine), and is found in the cervical and lumbar levels of the spine.

Vertebral StructuresAll vertebrae consist of the same basic elements, with the exception of the first two cervical vertebrae.The outer shell of a vertebra is made of cortical bone. This type of bone is dense, solid and strong. Inside each vertebra is cancellous bone, which is weaker than cortical bone and consists of loosely knit structures that look somewhat like a honeycomb. Bone marrow, which forms red blood cells and some types of white blood cells, is found within the cavities of cancellous bone.Vertebrae consist of the following common elements:

Veterbral BodyThe largest part of a vertebra. If looked at from above it generally has a somewhat oval shape. When looked at from the side, the vertebral body is shaped like an hourglass, being thicker at the ends and thinner in the middle. The body is covered with strong cortical bone, with cancellous bone within.

PediclesThese are two short processes, made of strong cortical bone, that protrude from the back of the vertebral body.

LaminaeTwo relatively flat plates of bone that extend from the pedicles on either side and join in the midline.

ProcessesThere are three types of processes: articular, transverse and spinous. The processes serve as connection points for ligaments and tendons.

The 4 articular processes link with the articular processes of adjacent vertebrae to form the facet joints. The facet joints, combined with the intervertebral discs, allows for motion in the spine.The spinous process extends posteriorly from the point where the two laminae join, and acts as a lever to effect motion of the vertebra.

EndplatesThe top (superior) and bottom (inferior) of each vertebral body is coated with anendplate. Endplates are complex structures that blend into the intervertebral disc and help support the disc.

Intervertebral ForamenThe pedicles have a small notch on their upper surface and a deep notch on their bottom surface. When the vertebrae are stacked on top of each other the pedicle notches form an area called the intervertebral foramen. This area is of critical importance as the nerve roots exit from the spinal cord through this area to the rest of the body.

Facet JointsThe joints in the spinal column are located posterior to the vertebral body (on the backside). These joints help the spine to bend, twist, and extend in different directions. Although these joints enable movement, they also restrict excessive movement such as hyperextension and hyper-flexion (i.e. whiplash).Each vertebra has two facet joints. Thesuperior articular facetfaces upward and works like a hinge with theinferior articular facet(below).Like other joints in the body, each facet joint is surrounded by a capsule of connective tissue and produces synovial fluid to nourish and lubricate the joint. The surfaces of the joint are coated with cartilage that helps each joint to move (articulate) smoothly.

Intervertebral DiscsBetween each vertebral body is a "cushion" called anintervertebral disc. Each disc absorbs the stress and shock the body incurs during movement and prevents the vertebrae from grinding against one another. The intervertebral discs are the largest structures in the body without a vascular supply. Through osmosis, each disc absorbs needed nutrients.Each disc is made up of two parts: theannulus fibrosisand thenucleus pulposus.

Annulus FibrosusThe annulus is a sturdy tire-like structure that encases a gel-like center, the nucleus pulposus. The annulus enhances the spines rotational stability and helps to resist compressive stress.The annulus consists of water and layers of sturdy elastic collagen fibers. The fibers are oriented at different angles horizontally similar to the construction of a radial tire. Collagen gains its strength from strong fibrous bundles of protein that are linked together.

Nucleus PulposusThe center portion of each intervertebral disc is a filled with a gel-like elastic substance. Together with the annulus fibrosus, the nucleus pulposus transmits stress and weight from vertebra to vertebra.Like the annulus fibrosus, the nucleus pulposus consists of water, collagen and proteoglycans. However, the proportion of these substances in the nucleus pulposus is different. The nucleus contains more water than the annulus.VI. Pathophysiology

VII. Signs/Symptoms/Complaints

Bone pain or tenderness Fractureswith little or no trauma Loss of height (as much as 6 inches) over time Low back pain due to fractures of the spinal bones Neck paindue to fractures of the spinal bones Stooped posture orkyphosis, also called a "dowager's hump"

VIII. Laboratory and Diagnostic Test

X-ray- These tests will help detect whether any of the bones in the patients spine (vertebrae) have broken or collapsed due to compression fractures.Result: Presence of fractures

Bone Mineral Density (BMD) test Measures how much calcium and other types of minerals are in an area of the bone. This test helps to detectosteoporosisand predict the risk of bone fractures.Result: T score below -2.5 indicates osteoporosis. Normal range: +1 and -1

IX. Medical management

a. Diet Adequate intake of calcium, Vitamin D and Vitamin K

Calciumandvitamin Ddecrease the risk of non-vertebral fractures in those with postmenopausal osteoporosis by approximately 18%.High intake ofvitamin Dreduces fractures in the elderly.Vitamin Kprevents bone loss and/or fractures in those with postmenopausal osteoporosis.

b. Medication: Bisphosphonates Primary drugs used to both prevent and treat osteoporosis in postmenopausal women. Calcitonin It is a medicine that slows the rate of bone loss and relieves bone pain. It comes as a nasal spray or injection. The main side effects are nasal irritation from the spray form and nausea from the injectable form. Teriparatide (Forteo) It is approved for the treatment of postmenopausal women who have severe osteoporosis and are considered at high risk for fractures. Raloxifene (Evista) It is used for the prevention and treatment of osteoporosis. Raloxifene can reduce the risk of spinal fractures by almost 50%.

X. Surgical Management

a. Vertebroplasty It is a minimally invasive procedure used to reinforce vertebrae with compression fractures, which are common in patients with osteoporosis.Vertebroplasty involves injecting an acrylic compound into the collapsed vertebra to stabilize the weakened bone. b. Kyphoplasty It is a minimally invasive procedure that is used to restore the height of the vertebrae and stabilize weakened bone. Kyphoplasty cannot correct established spine deformities and is used in patients who have experienced recent fractures (within 24 months).

XI. Identify nursing problems/ Diagnosis

a. Pain related to bone/fracture discomfortb. Impaired physical mobility related to reduced musculoskeletal stamina.c. Deficient knowledge about the osteoporotic process and treatment regimen

XII. Nursing Care/ Intervention:

Pain related to bone/fracture discomfort Elevate and support injured extremity.Rationale: Promotes venous return, decreases edema, and may reduce pain. Elevate bed covers and keep linens off toes.Rationale: Maintains body warmth without discomfort due to pressure of bedclothes on affected parts. Encourage client to discuss problems related to injury.Rationale: Helps alleviate anxiety. Client may feel need to relive the accident experience. Perform and supervise passive or active ROM exercises.Rationale: Maintains strength and mobility of unaffected muscles and facilitates resolution of inflammation in injured tissues. Provide emotional support and encourage use of stress managements techniquesprogressive relaxation, deep breathing exercises, and visualization or guided imagery; provide therapeutic touch.Rationale: Refocuses attention, promotes sense of control, and may enhance coping abilities in the management of the stress of traumatic injury and pain, which is likely to persist for an extended period.

Impaired physical mobility related to reduced musculoskeletal stamina. Assess degree of immobility produced by injury and/or treatment and note clients perception of immobility.Rationale: Client may be restricted by self-view or self-perception out of proportion with actual physical limitations, requiring information and interventions to promote progress toward wellness. Encourage participation in diversional or recreational activities. Maintain stimulating environmentradio, TV, newspapers, personal possessions, pictures, clock, calendar, and visits from family and friends.Rationale: Provides opportunity for release of energy, refocuses attention, enhances clients sense of self-control and self-worth, and aids in reducing social isolation. Instruct client in active, or assist with passive, ROM exercises of affected and unaffected extremities.Rationale: Increases blood flow to muscles and bone to improve muscle tone; maintain joint mobility; and prevent contractures, atrophy, and calcium resorption from disuse. Assist with and encourage self-care activities such as bathing, shaving, and oral hygiene.Rationale: Improves muscle strength and circulation, enhances client control in situation, and promotes self-directed wellness. Assist with mobility by means of wheelchair, walker, crutches, and/or canes as soon as possible. Instruct in safe use of mobility aids.Rationale: Early mobility reduces complications of bedrest, such as phlebitis, and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and client safety. Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement.Rationale: In the presence of musculoskeletal injuries, early good feeding is needed as nutrients required for healing are rapidly depleted. This can have a profound effect on muscle mass, tone, and strength. Note: Protein foods increase contents in small bowel, resulting in gas formation and constipation. Therefore, gastrointestinal (GI) function should be fully restored before protein foods are increased.

Deficient knowledge about the osteoporotic process and treatment regimen Assess vital signs every 2 hours.Rationale: To determined if theres any alteration with the normal vital signs. Determine clients ability to learn.Rationale: To know the clients level of learning ability. Assess the level of the clients capabilities and the possibilities of situation.Rationale: To know clients coping ability towards the situation. Motivate client by providing information relevant to the situation.Rationale: To help client acquire relevant information. Provide active role for client in learning process.Rationale: May assist with further learning/promote learning at own pace. Explain purpose of activity restrictions and need for balance between activity/rest.Rationale: Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further impairment of cellular perfusion. Instruct client/ family in disease process, progression, what to expect, and answer all questions honestly.Rationale: Promotes optimal learning environment when client show willingness to learn. Family members may assist with helping the client to make informed choices regarding the treatment. Anxiety or large volumes of instruction may impede comprehension and limit learning.XIII. Rehabilitationa. Individualized treatment program Its includes exercise, diet modifications and medication, as well as professional support for pain and depression and peer support.

b. Bracing If the patient gets a spinal fracture, the doctor may recommend a back brace for ashort period of time. As the vertebra or vertebrae heal, a brace will support the spine. With the bones weakened byosteoporosisand by the fracture the back muscles will need extra help to support your body weight during the healing period.