70 Osteoporosis
Overview/pathophysiology
Osteoporosis (“porous bone”) is the most common metabolic bone disease. It is characterized by reduction in both bone mass and bone strength, while bone size remains constant. These changes make bone more brittle and susceptible to fractures. Osteoporosis affects 10 million people in the United States, while 34 million more have low bone mass; 80% of those affected by osteoporosis are women. Osteoporosis is responsible for more than 2 million fractures annually (National Osteoporosis Foundation, 2008). Three types of osteoporosis have been identified: postmenopausal, senile, and secondary.
Assessment
Signs and symptoms:
Because of the insidious onset of osteoporosis, most individuals are not diagnosed until they experience an acute fracture or receive radiographic evidence from x-ray examinations obtained for other conditions (e.g., chest x-ray examination to confirm pneumonia). Vertebral compression fractures can develop gradually, resulting in back discomfort and loss of height. Severe chronic flexion of the vertebral spine (kyphosis or “dowager’s hump”) may inhibit function of multiple organ systems (e.g., gastrointestinal [GI], respiratory). With severe spinal deformities, patient often describes difficulty in obtaining clothes that fit well.
Diagnostic tests
Use of one or more tests is common.
Bone biopsy:
Nursing diagnosis:
Deficient knowledge
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s understanding of the nature of osteoporosis and the potential ineffectiveness of treatment if not initiated until symptoms appear. | Because of the insidious onset of osteoporosis, most individuals are not diagnosed until they experience an acute fracture or receive radiographic evidence from x-rays obtained for other conditions (e.g., chest x-ray to confirm pneumonia). |
| Include instruction on osteoporosis prevention as a routine part of health teaching for children, adolescents, and adults. | Adults need to recognize factors that increase their risk for osteoporosis (e.g., female gender, increasing age, small frame, Caucasian or Asian race). As children and adolescents experience bone growth, their bone quality can be improved through awareness of osteoporosis prevention strategies. |
| Teach patient about proper nutrition in relation to calcium intake. | Appropriate nutrition is the foundation of osteoporosis prevention and treatment, and consistent calcium intake is especially important. A knowledgeable patient is more likely to adhere to prevention and treatment strategies. See Imbalanced Nutrition: Less Than Body Requirements, later, for more information. |
| Ensure that health care provider has recommended or approves use of calcium supplements for patient. | Although calcium is important to bone health, supplementation should be done on the advice of health care provider. Excessive calcium intake can lead to nephrolithiasis in susceptible individuals. |
| Teach patient that, although calcium supplements come in numerous forms, calcium carbonate is the most effective form. Note: Patient taking a proton pump inhibitor (PPI) will need to take calcium citrate, an alternate form of the supplement. | Calcium carbonate (e.g., OsCal) is best absorbed in an acidic environment such as the stomach. It delivers approximately 40% calcium. Bone meal and dolomite should be avoided because they may contain high amounts of lead or other toxic substances. Use of PPIs (e.g., esomeprazole, rabeprazole, lansoprazole) for gastric reflux or other conditions alters the acidic environment of the stomach and affects absorption of calcium carbonate, therefore necessitating use of calcium citrate, which can be absorbed. |
| Teach patient to recognize amount of elemental calcium available in supplements and verbalize the recommended calcium dosage. | Elemental calcium refers to the amount of calcium in a supplement that is available for the body to absorb. Total weight in grams listed on the supplement label will reflect the weight of the calcium plus its binder (carbonate, citrate, lactate, gluconate). Adults 19-50 yr of age should take 1000 mg of calcium daily, and individuals 51 yr and older should take 1200 mg of calcium daily through diet and supplements. |
| Teach patient not to take calcium and iron supplements at the same time. | The two elements bind with each other, and absorption of both will be impaired. |
| Evaluate patient’s medication profile. | Because calcium may reduce absorption of other medications, the nurse should carefully time administration of all medications to ensure maximal absorption. |
| Caution patient to avoid taking more than 500-600 mg of calcium at one time and to spread doses over entire day. | Excessive intake can lead to hypercalcemia, which may cause muscle weakness, constipation, and heart block. |
| Remind patient to drink a full glass of water with each supplement. | Adequate hydration minimizes risk of developing renal calculi. |
| Remind patient of need for sunlight to enable vitamin D activation. | Exposure to sunlight is needed for cutaneous synthesis of vitamin D, but prolonged exposure does not necessarily increase the amount of vitamin D that is synthesized. An average of 15 minutes of exposure to hands, face, arms, and legs typically meets the vitamin D requirement for most people. |
| Instruct patient to avoid vitamin D supplementation if dietary intake is adequate. | Supplements may be needed by institutionalized persons, those living in extreme northern or southern latitudes, and people with limited sun exposure. However, excessive intake is discouraged because of risk of toxicity. Recommended amounts of vitamin D include 200 IU through age 50 yr, 400 IU for ages 51-70 yr, and 600 IU for those 71 yr or older. |
| If hormone replacement therapy (HRT) has been prescribed, explain its purpose, action, and precautions. | HRT is not routinely recommended for treatment of chronic disease and is prescribed only after risks and benefits have been evaluated for each patient. Women are encouraged to talk to their health care providers about personal risks and benefits. Benefits should be weighed against any risk of heart disease, stroke, and breast cancer, and health care providers should identify other prevention and treatment options when appropriate. The Food and Drug Administration also suggests using the lowest possible dose for the shortest period of time to manage symptoms of menopause. |
| Teach patient about possible medications prescribed for treatment of osteoporosis, indications for use, possible side effects, administration time and method, and need for follow-up laboratory tests. | A knowledgeable patient is likely to adhere to the drug therapy and report necessary signs and symptoms to ensure prompt treatment of untoward side effects. |
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