Osteoporosis Nursing Care Plan & Management

 Description

1. 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.
2. Bone demineralization results in the loss of bone mass, leading to fragile and porous bones and subsequent fractures.
3. Greater bone resorption than bone formation occurs
4. Occurs most commonly in the wrist, hip, and vertebral column.
5. Osteoporosis can occur postmenopausally or as a result of a metabolic disorder or calcium deficiency.
6. Client may be asymptomatic until the bones become so weak that a sudden injury causes a fracture.

Causes

• 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.

Risk Factors

Modifiable

1. Cigarette smoking
2. Excessive use of alcohol
3. Insufficient intake of calcium
4. Sedentary lifestyle

Non- modifiable

1. Early menopause
2. Family history
3. Female gender
4. Increasing age
5. Thin, small frame
6. White (European descent) or Asian race

Assessment

1. Possibly asymptomatic
2. Back pain after lifting, bending, or stooping
3. Back pain that increases with palpation
4. Pelvic or hip pain, especially with weight bearing
5. Problems with balance
6. Decline in height from venebral compression
7. Kyphosis of the dorsal spine.
8. Constipation, abnormal distention, and respiratory impairment as a result of movement restriction and spinal deformity
9. Pathological fractures
10. Appearance of thin, porous bone on x-ray film.

Primary Nursing Diagnosis

• Pain (acute) related to fracture

Diagnostic Evaluation

• Bone mineral density (BMD) reported as a T-score:
• (Osteopenia: T-score of –1 to –2.5 SD Osteoporosis: T-score of <–2.5 SD Severe osteoporosis: T-score of <–2.5 SD with fragility fracture(s)). BMD is the best predictor of fracture risk.
• Dual energy x-ray absorptiometry (DXA) reveals bone loss >3%.
• Bone x-rays shows bone loss( cannot determine bone loss until 25%–40% has occurred).
• Other Tests: Complete blood count, chemistry screening, thyroid-stimulating hormone level, urinalysis, serum protein electrophoresis, serum and urine calcium levels, vitamin D level, serum phosphorus levels, alkaline phosphatase, computed tomography (CT) scan

Medical Management

• Adequate, balanced diet rich in calcium and vitamin D
• Increased calcium intake in adolescents and elderly, or prescribe a calcium supplement with meals or beverages high in vitamin C.
• Regular weight-bearing exercise to promote bone formation (20-30 minutes aerobic exercises 3 days/week)
• Other medications; the bisphosphonates alendronate (Fosamax), risedronate (Actonel), and ibandronate, selective receptor modulators (SERMs), raloxifene (Evista), calcitonin

Pharmacologic Highlights

• Calcium supplements (1000–1500 mg/day PO; 1500 recommended for postmenopausal women and men over 50) to prevent bone loss and supplements calcium.
• Alendronate (Fosamax) [Bone resorption inhibitor; similar preparations with different doses are risedronate (Actonel),etidronate (Didronel),and ibandronate (BONIVA)] to prevent bone loss and inhibits bone resorption.
• Estrogen hormone such as conjugated estrogen (Provera) is given to prevent bone loss and reduces number of fractures; needs to be initiated within 3–5 yr of menopause; long-term therapy is no longer recommended when menopausal symptoms abate.
• Other Drugs: Androgens, calcitonin, and vitamin D metabolites may be ordered to decrease bone resorption. Analgesics may also be needed to manage the pain.

Nursing Interventions

1. Assess risk for injury.
2. Provide a safe and hazard-free environment, and assist the client to identify hazards in the home environment.
3. Use side rails to prevent falls.
4. Move the client gently when turning and repositioning.
5. Encourage ambulation; assist with ambulation if the client is unsteady.
6. Instruct in the use of assistive devices such as a cane or walker.
7. Provide range of motion exercises.
8. Instruct the client in the use of good body mechanics.
9. Instruct the client in exercises to strengthen abdominal and back muscles to improve posture and provide support for the spine.
10. Instruct the client to avoid activities that can cause vertebral compression.
11. Apply a back brace as prescribed during an acute phase to immobilize the spine and provide spinal column support.
12. Encourage the use of a firm mattress.
13. Provide a diet high in protein, calcium, vitamins C, D and iron.
14. Encourage adequate fluid intake to prevent calculuses.
15. Advise the client to avoid alcohol and coffee.
16. Administer estrogen or androgens to decrease the rate of bone resorption as prescribed.
17. Administer calcium, vitamin D, and phosphorus as prescribed for bone metabolism.
18. Administer calcitonin as prescribed to inhibit bone loss.
19. Administer analgesics, muscle relaxants, and anti-inflammatory medications as prescribed.

Documentation Guidelines

• Physical findings of musculoskeletal assessment: Pain, mobility, numbness, curvature of the spine
• Response to pain medications
• Reaction to exercise plan and orthotic devices

Discharge and Home Healthcare 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.

Exam

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Nursing Care Plan

Nursing Diagnosis

Impaired Physical Mobility

May be related to

• Bone loss
• Pain
• Fracture
• Inability to bear weight

Possibly evidenced by

• Spontaneous fracture

Desired Outcomes

• Patient will maintain functional mobility as long as possible within limitations of disease process.
• Patient will have a few, if any, complications related to immobility as disease condition progresses

Nursing Interventions

• Assess patient’s functional ability for mobility and note changes.
  • Rationale: Identifies problems and helps to establish a plan of care.
• Provide range of motion exercises every shift. Encourage active range of motion exercises.
  • Rationale: Helps to prevent joint contractures and muscle atrophy.
• Reposition patient every 2 hours and prn.
  • Rationale: Turning at regular intervals prevents skin breakdown from pressure injury.
• Apply trochanter rolls and/or pillows to maintain joint alignment.
  • Rationale: Prevents musculoskeletal deformities.
• Assist patient with walking if at all possible, utilizing sufficient help. A one or two-person pivot transfer utilizing a transfer belt can be used if patient has weight-bearing ability.
  • Rationale: Preserves patient’s muscle tone and helps prevent complications of immobility.
• Use mechanical lift for patients who cannot bear weight, and help them out of bed at least daily.
  • Rationale: Provides change of scenery, movement, and encourages participation in activities.
• Avoid restraints as possible.
  • Rationale: Inactivity created by the use of restraints may increase muscle weakness and poor balance.
• Instruct family regarding ROM exercises, methods of transferring patients from bed to wheelchair, and turning at routine intervals.
  • Rationale: Prevents complications of immobility and knowledge assists family members to be better prepared for home care.
• Assess degree of immobility produced by injury or treatment and note patient’s perception of immobility.
  • Rationale: Patient may be restricted by self-view or self-perception out of proportion with actual physical limitations, requiring information or interventions to promote progress toward wellness.
• Encourage participation in diversional or recreational activities. Maintain stimulating environment (radio, TV, newspapers, personal possessions, pictures, clock, calendar, visits from family and friends).
  • Rationale: Provides opportunity for release of energy, refocuses attention, enhances patient’s sense of self-control and self-worth, and aids in reducing social isolation.
• Instruct patient or assist with active and passive ROM exercises of affected and unaffected extremities.
  • Rationale: Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures or atrophy and calcium resorption from disuse
• Encourage use of isometric exercises starting with the unaffected limb.
  • Rationale: Isometrics contract muscles without bending joints or moving limbs and help maintain muscle strength and mass. Note: These exercises are contraindicated while acute bleeding and edema is present.
• Provide footboard, wrist splints, trochanter or hand rolls as appropriate.
  • Rationale: Useful in maintaining functional position of extremities, hands and feet, and preventing complications (contractures, footdrop).
• Place in supine position periodically if possible, when traction is used to stabilize lower limb fractures.
  • Rationale: Reduces risk of flexion contracture of hip.
• Instruct and encourage use of trapeze and “post position” for lower limb fractures.
  • Rationale: Facilitates movement during hygiene or skin care and linen changes; reduces discomfort of remaining flat in bed. “Post position” involves placing the uninjured foot flat on the bed with the knee bent while grasping the trapeze and lifting the body off the bed.
• Assist with self-care activities (bathing, shaving).
  • Rationale: Improves muscle strength and circulation, enhances patient control in situation, and promotes self-directed wellness.
• Provide and assist with mobility by means of wheelchair, walker, crutches, canes as soon as possible. Instruct in safe use of mobility aids.
  • Rationale: Early mobility reduces complications of bed rest (phlebitis) and promotes healing and normalization of organ function. Learning the correct way to use aids is important to maintain optimal mobility and patient safety.
• Monitor blood pressure (BP) with resumption of activity. Note reports of dizziness.
  • Rationale: Postural hypotension is a common problem following prolonged bed rest and may require specific interventions (tilt table with gradual elevation to upright position).
• Reposition periodically and encourage coughing and deep-breathing exercises.
  • Rationale: Prevents or reduces incidence of skin and respiratory complications (decubitus, atelectasis, pneumonia).
• Auscultate bowel sounds. Monitor elimination habits and provide for regular bowel routine. Place on bedside commode, if feasible, or use fracture pan. Provide privacy.
  • Rationale: Bed rest, use of analgesics, and changes in dietary habits can slow peristalsis and produce constipation. Nursing measures that facilitate elimination may prevent or limit complications. Fracture pan limits flexion of hips and lessens pressure on lumbar region and lower extremity cast.
• Encourage increased fluid intake to 2000–3000 mL per day (within cardiac tolerance), including acid or ash juices.
  • Rationale: Keeps the body well hydrated, decreasing risk of urinary infection, stone formation, and constipation
• Provide diet high in proteins, carbohydrates, vitamins, and minerals, limiting protein content until after first bowel movement.
  • Rationale: In the presence of musculoskeletal injuries, nutrients required for healing are rapidly depleted, often resulting in a weight loss of as much as 20 to 30 lb during skeletal traction. 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.
• Increase the amount of roughage or fiber in the diet. Limit gas-forming foods.
  • Rationale: Adding bulk to stool helps prevent constipation. Gas-forming foods may cause abdominal distension, especially in presence of decreased intestinal motility.
• Consult with physical, occupational therapist or rehabilitation specialist.
  • Rationale: Useful in creating individualized activity and exercise program. Patient may require long-term assistance with movement, strengthening, and weight-bearing activities, as well as use of adjuncts (walkers, crutches, canes); elevated toilet seats; pickup sticks or reachers; special eating utensils.
• Initiate bowel program (stool softeners, enemas, laxatives) as indicated.
  • Rationale: Done to promote regular bowel evacuation.
• Refer to psychiatric clinical nurse specialist or therapist as indicated.
  • Rationale: Patient or SO may require more intensive treatment to deal with reality of current condition, prognosis, prolonged immobility, perceived loss of control.