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OSTEOPOROSIS
KEY POINTS
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Osteoporosis is the most common metabolic bone
disorder resulting in low bone density.
It occurs when the rate of bone resorption (osteoclast
cells) exceeds the rate of bone formation (osteoblast
cells) resulting in fragile bone tissue
subsequent fractures.
Osteopenia (precursor to osteoporosis), refers to low
bone mineral density for what is expected for the
person’s age and sex.
Peak bone mineral density: age of 30 to 35 years.
After that, bone density decreases, rapidly in
postmenopausal women due to estrogen loss.
Fragile, thin bone tissue is susceptible to fracture.
RISK FACTORS
Age  60
 Postmenopausal estrogen deficiency
 Family Hx
 Thin, lean body build
 Hx of low calcium intake with suboptimal levels
of vitamin D
 Hx of smoking
 Hx of high alcohol intake
 Lack of physical activity/prolonged immobility
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SECONDARY OSTEOPOROSIS
Hyperparathyroidism.
 Long-term corticosteroid use (for example,
asthma).
 Long-term immobility (for example, spinal cord
injury).
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DIAGNOSTIC PROCEDURES AND NURSING
INTERVENTIONS
Radiographs of the spine and long bones reveal
low bone density and fractures.
 Dual energy x-ray absorptiometry (DEXA) is used
to screen for early changes in bone density. This
painless test measures bone mineral density in
the wrist, hip, and vertebral column.
 Serum calcium, vitamin D, phosphorus, and
alkaline phosphatase levels are drawn to rule
out other metabolic bone diseases (Paget’s
disease or osteomalacia).
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ASSESSMENT
Monitor for signs and symptoms.
 Thoracic kyphosis
 Reduced height (postmenopausal)
 Acute back pain after lifting or bending (worse
with activity, relieved by rest)
 Restricted movement
 Fractures
 Fear of falling
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NANDA NURSING DIAGNOSES
 Impaired
mobility
 Imbalanced nutrition: Less than body
requirement
 Risk for falls
 Ineffective health maintenance
NURSING INTERVENTION
NURSING INTERVENTION
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Instruct the client and family regarding dietary calcium food
sources.
Provide information regarding calcium supplementation
(take with food).
Instruct the client of the need for adequate amounts of
protein, magnesium, vitamin K, and other trace minerals
needed for bone formation.
Reinforce the need for exposure to vitamin D (sunlight,
fortified milk).
Assess the home environment for safety (remove throw rugs,
adequate lighting, clear walkways).
Reinforce the use of safety equipment and assistive devices.
Instruct the client to avoid inclement weather (ice or slippery
surfaces).
Clearly mark thresholds, doorways, and steps.
Prevention
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 Teach
the importance of regular, weight-bearing
exercises.
 Introduce the importance of calcium intake to
children to improve peak bone mass.
 Strong adult skeletons are built during childhood.
COMPLICATIONS AND NURSING IMPLICATIONS
Fractures are the leading complication of
osteoporosis.
 Early recognition and treatment is essential.
The nurse should review risk factors for
osteoporosis and falls, assess the client’s
dietary intake of calcium, reinforce daily
exercise including weight-bearing activities, and
ensure proper screening with a DEXA scan.
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TEST YOURSELF
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Which of the following clients is at the greatest
risk for osteoporosis?
 A.
40-year-old man who has asthma
 B. 30-year-old female who jogs daily
 C. 65-year-old female who smokes cigarettes and is
sedentary
 D. 65-year-old male who drinks alcohol excessively
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In providing dietary instructions to a client to
minimize the risk of osteoporosis, the nurse
should recommend which of the following
foods?
 A.
Bread
 B. Yogurt
 C. Chicken
 D. Rice
OSTEOARTHRITIS
KEY POINTS
Osteoarthritis (OA) is a disorder characterized by
progressive deterioration of the articular cartilage.
It is a non-inflammatory (unless localized), nonsystemic disease.
 It is a process where new tissue is produced as a
result of cartilage destruction within the joint.
 The destruction outweighs the production. The
cartilage and bone beneath the cartilage erode
and osteophytes (bone spurs) form, resulting in
narrowed joint spaces
 The changes within the joint lead to pain,
immobility, muscle spasms, and potential
inflammation.
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RISK FACTORS
Age
 Decreased muscle strength
 Obesity
 Possible genetic link
 Early in the disease process of OA, it may be
difficult to distinguish from rheumatoid arthritis
(RA).
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DIAGNOSTIC PROCEDURES AND NURSING
INTERVENTIONS
ESR and high-sensitivity C-reactive protein may
be slightly elevated related to secondary
synovitis.
 X ray can determine structural changes within
the joint.
 CT imaging scan may be used to determine
vertebral involvement
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ASSESSMENT
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Joint pain and stiffness that resolves with rest or inactivity (chief
report)
Pain with joint palpation or ROM (observe for muscle atrophy,
loss of function, client limp when walking, and restricted activity
due to pain)
Crepitus in one or more of the affected joints
Enlarged joint related to bone hypertrophy
Heberden’s nodes enlarged at the distal interphalangeal (DIP)
joints
Inflammation resulting from secondary synovitis, indicating
advanced disease
ASSESS/MONITOR
Pain: Level (0-10), location, characteristics,
quality, and severity
 Degree of functional limitation
 Levels of pain and fatigue after activity
 ROM
 Proper functional/joint alignment
 Home barriers
 Ability to perform activities of daily living (ADLs)
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NANDA NURSING DIAGNOSES
Chronic pain
 Impaired physical mobility
 Activity intolerance
 Self care deficit
 Disturbed body image
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NURSING INTERVENTIONS
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Conservative therapy includes:
Balance rest with activity.
 Use bracing or splints.
 Apply thermal therapies (heat or cold).
 Analgesic therapy.
 Acetaminophen
 NSAIDS
 Topical salicylates
 Glucosamine (rebuilds cartilage)
 Intra-articular injections of glucocorticoids (treat
localized inflammation)
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NURSING INTERVENTIONS
When all other conservative measures fail, the
client may choose to undergo joint replacement
surgery to relieve the pain and improve mobility
and quality of life.
 Osteotomy; remove damaged cartilage and correct
the deformity.
 Instruct the client on the use of analgesics and
NSAIDS prior to activity and around the clock as
needed.
 Balance rest with activity.
 Instruct the client on proper body mechanics.
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INTERVENTION
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Encourage the use of thermal applications: heat to
alleviate pain, ice for acute inflammation.
Encourage the use of complementary and alternative
therapies, including: acupuncture, hypnosis, magnets,…….
Encourage the use of splinting for joint protection and the
use of larger joints.
Encourage the use of assistive devices to promote
independence, including an elevated toilet seat, shower
bench, …………..
Encourage the use of a daily schedule of activities that will
promote independence (high-energy activities in the
morning).
Encourage a well-balanced diet and ideal body weight.
Consult a dietitian to provide meal-planning for balanced
nutrition.
Rheumatoid
Arthritis
KEY POINTS
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RA is a chronic, systemic, progressive inflammatory disease of
the synovial tissue.
It is a bilateral systemic inflammatory disease process involving
multiple joints.
In contrast, osteoarthritis is a unilateral degenerative disease
process of a single joint.
It is classified as an autoimmune process in which antibodies
are formed against synovial tissues, including:
 Synovial membrane.
 Articular cartilage.
 Joint capsule.
 Tendons and ligaments surrounding the joint.
 Involvement of the spine, particularly the cervical joints.
KEY POINTS
The natural course of the disease is one of
exacerbations and remissions.
 Inflammation and tissue damage can cause
severe deformities that greatly restrict function
 Risk Factors
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Female gender
 Age 20 to 50 years
 Genetic predisposition
 Epstein Barr virus
 Stress
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DIAGNOSTIC PROCEDURES AND NURSING INTERVENTIONS
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Rheumatoid Factor (RF) antibody
 Diagnostic for rheumatoid arthritis = 1:40 to 1:60 (normal
≤ 1:20).
 High titers correlate with severe disease.
Antinuclear Antibody (ANA) Titer (antibody produced against
one’s own DNA)
 A positive ANA titer is associated with RA (normal is
negative ANA titer at 1:20 dilution)
Erythrocyte Sedimentation Rate (ESR): Elevated
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20 to 40 mm/hr = mild inflammation.
40 to 70 mm/hr = moderate inflammation.
70 to 150 mm/hr = severe inflammation
Arthrocentesis; Synovial fluid aspiration by needle With RA,
increased white blood cells (WBCs) and RF are present.
ASSESSMENTS
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Clinical findings depend on the area affected by the
disease process:
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Pain at rest and with movement
Morning stiffness
Joint swelling
Joint deformity
Anorexia/weight loss
Fever (generally low grade)
Fatigue
Muscle weakness/atrophy
Assess/Monitor
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Pain (character, intensity, effectiveness of relief measures)
Functional ability
Indications of infection
NANDA NURSING DIAGNOSES
Fatigue
 Impaired physical mobility
 Chronic pain
 Disturbed body image
 Risk for injury
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NURSING INTERVENTIONS
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Apply heat or cold to affected areas as indicated
based on client response.
Morning stiffness (hot shower)
 Pain (heated paraffin)
 Edema (cold therapy)
 Assist with and encourage physical activity to maintain
joint mobility (within the capabilities of the client).
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Teach the client measures to:
Maximize functional activity.
 Minimize pain.
 Conserve energy (pacing activities, rest periods)
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NURSING INTERVENTIONS
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Provide a safe environment.
Facilitate the use of assistive devices.
Remove unnecessary equipment/supplies.
Utilize progressive muscle relaxation.
Monitor the client for signs/symptoms of fatigue.
Refer the client to support groups as appropriate.
Administer medications as prescribed.
 Analgesics
 Anti-inflammatories
 NSAIDs), such as hydroxychloroquine (Plaquenil),
sulfasalazine (Azulfidine)
 Steroids, such as prednisone
 Monitor for fluid retention, hypertension, and renal
dysfunction.
NURSING INTERVENTIONS
Immunosuppressants (may slow the progression
of disease)
 Disease-modifying anti-rheumatic medications
(DMARM)such as hydroxychloroquine,
sulfasalazine, minocycline (slow the progression of
joint damage from rheumatoid arthritis.
 Methotrexate (Rheumatrex)
 Monitor for toxic effects (bone marrow
suppression, increased liver enzymes).
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NURSING INTERVENTIONS
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Biological response modifiers: Inhibit the action of
tumor necrosis factor (TNF); is a cytokine produced
primarily by monocytes and macrophages. It is
found in synovial cells and macrophages in the
tissues.
Do not administer if the client has a serious infection.
 Monitor for injection/infusion reactions.
 Monitor CBC and the client for signs of infection.
 Monitor for medication effectiveness (reduced pain,
increased mobility).
 Teach the client regarding signs/symptoms that need to
be reported immediately (fever, infection).
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COMPLICATIONS AND NURSING IMPLICATIONS
Sjogren’s syndrome (dry eyes, dry mouth, dry
vagina)
 Joint deformity (tendon rupture, secondary
osteoporosis)
 Vasculitis (ischemic organs)
 Cervical subluxation (risk of quadriplegia and
respiratory compromise)
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