Osteoporosis is an age-related metabolic disease that is defined as low bone mass with a normal ratio of mineral to osteoid, the organic matrix of bone. Approximately 10 million Americans have osteoporosis and another 14 million have low bone mass, or osteopenia. With the aging of the U.S. population, osteoporosis is expected to increase and hip fractures are expected to rise to 750,000 per year by the year 2050. Bone demineralization results in decreased density and subsequent fractures as bone resorption occurs faster than bone formation. The general reduction in skeletal bone mass occurs as bones lose calcium and phosphate, become brittle and porous, and develop an increased susceptibility to fractures. Common sites for fractures are the wrist, hip, and vertebral column.
Osteoporosis can be classified as primary or secondary. Primary osteoporosis is more common and is not associated with an underlying medical condition. Secondary osteoporosis results from an associated underlying condition, such as hyperparathyroidism, or an iatrogenic cause, such as long-term corticosteroid or heparin administration.
The exact cause of osteoporosis is unknown. A mild but prolonged negative calcium balance, resulting from an inadequate dietary intake of calcium, may be an important contributing factor. Declining gonadal adrenal function, faulty protein metabolism because of estrogen deficiency, and a sedentary lifestyle may also contribute. Risk factors that increase the likelihood of osteoporosis also include smoking, advanced age, heavy caffeine consumption, vitamin D deficiency, excess alcohol consumption, long-term heparin or corticosteroid use, and the use of laxatives or antacids. In addition, patients who are postmenopausal are more susceptible to osteoporosis. Patients who have Cushing’s disease or Parkinson’s disease, rheumatoid arthritis, scoliosis, or anorexia or who have had bilateral oophorectomy are also at greater risk. Paradoxically, both a sedentary lifestyle and excessive exercise are thought to be risk factors for osteoporosis.
Nursing care plan assessment and physical examination
Take a careful history of all traumatic injuries, with a particular focus on previous bone fractures. Collect data about risk factors: age, sex, race, body frame, age of menopause onset, diet, patterns of alcohol intake, caffeine use, smoking, medications, concurrent medical conditions, and exercise habits. Inquire about complaints of back pain while lifting or bending, particularly when assessing elderly women. If the patient has vertebral collapse, she or he may describe backache or pain that radiates around the lower trunk and is aggravated by movement.
Diagnosis of osteoporosis is typically made after the patient sustains a vertebral, wrist, or hip fracture. Often, the patient is asymptomatic before admission with a bone fracture. A typical first sign of osteoporosis is vertebral collapse on bending over; sudden lower back pain that radiates around the trunk is a common symptom. Inspection of the vertebral column reveals curvature of the dorsal spine, the classic “dowager’s hump.” Often, the patients report a height reduction of 2 to 3 inches over 20 years. Palpation of the vertebrae that is accompanied by back pain and voluntary restriction of spinal movement are indicative of a compression vertebral fracture, which is the most common type of osteoporotic fracture. The most common area for fracture occurrence is between T-8 and L-3. The radius (Colles’s fracture), hip, and femur are also gently palpated and assessed for pain and fracture.
Assess the patient’s concept of body image and self-esteem if there is severe curvature of the spine. Inquire about the patient’s ability to find clothing to fit, any decrease in social activity, or alterations in sexuality. Evaluate the patient’s home environment; inquire about fall risks in the environment—for example, stairs, waxed floors, and scatter rugs.
Nursing care plan primary nursing diagnosis: Pain (acute) related to fracture.
Nursing care plan intervention and treatment plan
Nonsurgical management is directed to measures that retard bone resorption, form new bone tissue, and reduce the chance of fracture. These goals are often met through pharmacologic therapy. For the patient who has had a fracture, pain medication is prescribed to relieve pain, and a diet high in protein, vitamin C, and iron is recommended to promote bone healing. Orthotic devices are ordered to stabilize the spine and reduce pain.
Consult with the physical therapist to develop an exercise plan that includes weight-bearing and strengthening exercises. Consult with the occupational therapist if self-care assistive devices are needed. Generally, bowling and horseback riding are discouraged. If your assessment indicates that the patient’s home environment places him or her at risk, consult with social services or a public health nurse.
Stress the need for routine exercise of the upper and lower body and a diet high in calcium for all middle-aged and older women. If the patient is placed on estrogen, encourage her to complete monthly breast self-examinations and immediately report any lumps to the physician. Teach the patient to report abnormal vaginal bleeding immediately. Emphasize the need for regular gynecologic exams. Careful monitoring of patient medications with side effects of weakness and dizziness is also warranted.
To prevent falls and other activities that could cause a fracture, a hazard-free environment is required. If the patient is hospitalized, assist the patient during ambulation in a well-lighted room and provide nonskid shoes. Maintain the patient’s activity at the highest level possible. Encourage the patient to perform as many of the activities of daily living as the pain allows. Check the patient’s skin daily for redness, warmth, and new sites of pain, which are all indicators of new fractures. Explain to the patient’s family how easily an osteoporotic patient’s bones can fracture. Check orthotic devices for proper fit, patient tolerance, and skin irritation. If surgery is needed to repair fractures, encourage verbalization of feelings about surgery, change in body image, or inability to cope with the disease progression. The patient may need reassurance to help cope with limited mobility. If possible, arrange for the patient to interact with others who have osteoporosis. Be sure to include the family or significant other in the interactions.
Nursing care plan discharge and home health care guidelines
Reinforce the medication, exercise, and diet plan. Provide a hazard-free environment to prevent falls. Apply orthotic devices correctly. Remove scatter rugs, provide good lighting, and install handrails in the bathroom. Be sure the patient understands all medications, including the dosage, route, action, and side effects. If the patient is placed on estrogen therapy, she needs routine gynecologic checkups to detect early signs of cervical cancer. Consider placement in a nursing home if a patient cannot return home. Communicate the special needs of the patient on the transfer chart. The need for physical or occupational therapy, social work, and homemaking personnel is determined by the home care nurse. Facilitate the procurement of needed orthotic devices or ambulation aids before the patient goes home. The Osteoporosis Foundation provides information to clients regarding the disease and its treatment.