What is Osteoporosis - Essay Example

Rebecca Meharry Monash Osteoporosis 22 Aug 2006 Risk Factors of Osteoporosis: According to the National Osteoporosis Foundation, "Osteoporosis or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures, especially of the hip, spine and wrist, although any bone can be affected" (NOF. 2006). Although it can occur as a result of an endocrine disorder or malignancy, it most often is associated with the aging process. After the maximal bone mass is attained at the age 30, the rate of bone loss for both gender is approximately 0.5% per year, and it increase to approximately 1% per year or more in menopausal women (Barzel. 1996). This is so because, estrogen acts indirectly to suppress bone re-sorption, an action reduced/absent during menopause. Poor nutrition or an age-related decrease in intestinal absorption of calcium because of deficient activation of vitamin D is a culprit of the prevalence of Osteoporosis among elderly. "In the United States, 10 million people already have osteoporosis. Millions more have low bone mass, or osteopenia, placing them at increased risk for more serious bone loss and subsequent fractures" (National Institute of Health. 2006). "Hip fractures are common and are often devastating in the geriatric population" (Koval & Zuckerman. 1994). Other risk factors found to be associated with this disease include, smoking, alcohol ingestion and genetic predisposition. As with the case at hand patient Hunt manifested almost all of the indicated risk factors, having had hysterectomy at the age 45 inducing early menopause, smoking and alcohol consumption and most of all, a history of calcium and Vitamin D deficiency as evidenced by Rickets disease in her childhood. 2. Outline of current osteoporosis management strategies recommended for Patient Hunt: Regular exercise and adequate calcium intake are important factors in preventing this disease. Weight-bearing exercises like jogging, walking, rowing and weight lifting are important in maintaining bone mass. "Studies have indicated that pre-menopausal women need more than 1000mg and post-menopausal women needs 1500mg of calcium daily" (Andrews. 1998). This means that adults should drink 3 to 4 glasses of milk daily or substitute other foods that are high in calcium (Bukata & Rosier. 2000). Calcium supplements and a daily intake of 400-800 IU of Vitamin D is recommended because the latter optimizes calcium absorption and inhibits parathyroid secretion, stimulating calcium re-sorption from the bone (Weinstein & Ullery. 2000). Estrogen Therapy is the single most powerful intervention to reduce the incidence and progression of osteoporosis. If commenced immediately after menopause prevents early-stage bone loss and provides beneficial effects if administered throughout the eight decade of women's years (Gambert Et. Al. 1995). Women with breast cancer, active liver disease, a history of blood clots, or unexplained vaginal bleeding should, under no circumstance, go on HRT (Cooper). Additionally women who have migraine headaches, high triglycerides, gallbladder or chronic liver disease, a history of cancer of the uterus or ovaries, fibroids, history of endometriosis, or a history of exposure to the estrogen DES should go under careful evaluation before even considering HRT (Hueseman, 2002). Active treatment of osteoporosis uses four types of agents; gonadal hormones (estrogen), calcitonin, fluorides and biphosphonates. Calcitonin can be used to decrease osteoclastic activity. Although the risk of endometrial cancer is increased with hormone therapy, risk is reduced with subsequent administration of progestin (Riggs & Melton. 1992). In the cases where fracture is involved, management includes immobilization, pain medication, early ambulation and wound care. Surgical intervention is done for stable fracture fixation that allows early restoration of mobility and functions; this means early weight bearing. Walking and swimming are encouraged. Unsafe conditions that predisposes the person to falls and re-fractures should be corrected and avoided. 3. Types of fracture to the neck of the femur and their corresponding management: The most common fracture to the neck of the femur is classified into three main groups: Subcapital fracture, which occurs across the neck of the femur immediately the head; Transcervical fracture, also occurs across the neck but halfway down the neck, like the subcapital fracture if this fracture is displaced, the head of femur will loose blood supply consequential to degeneration (Koval & Zuckerman. 1994). Management is usually through replacement of the head with a metal plant (Barnes. et.al. 1976). Inter-trochanteric (or peri-trochanteric) fractures where the fracture line runs diagonally begin between two trochanters. The area has an excellent blood supply and the fracture here is unlikely to affect the viability of the head, and this is usually treated by internal fixation (Heetveld et.al. 2005). Still another surgical intervention for femoral neck fracture is through the aid an Austin Moore hip prosthesis that is therefore the "ideal implant for most patients with displaced sub-capital neck fracture that are community ambulators" (Shmidt & Swionkowski. 2002). This is by far the oldest method of intervention using a metallic prosthesis that dates back in 1942 developed and used by the Dr. Austin Moore himself. 4. Difference between skin traction and skeletal traction: Skin traction is a pulling force applied to the skin and soft tissue. It is accomplished by strips of adhesive, flannel, or foam secured to the injured part (Glick. 2001). While skeletal traction is a pulling force applied directly to the bone. Pins wires and tongs are inserted through the skin and subcutaneous tissue into the bone distal to the fracture site. This is commonly used for fractures of the femur, the humerus and the cervical spine. It is also used in maintaining alignment of fractures that are casted and in certain types of reconstructive foot surgery. Skin traction on the other hand uses 5 to 7 lbs weights for the force on the bone (Glick. 2001). Both skin and skeletal traction are types of traction that are used for clinical management of fractures weather for long or short term duration. As with patient hunt, skin traction is applied because it brings together the fractured bone or dislocated joint so that it heals correctly. Care and management of the patient's current condition requires making sure that the area is immobile and stays aligned (Rodrigo. 1986). There is also the pain and discomfort to consider, therefore necessary comfort and analgesia should be the nurses' priority. Proper skin care and hygiene is necessary to avoid soreness and irritation. Both patient and nurse should be alert for any possible tingling in the limb or swelling as this would suggest that circulation is impeded due to tightly wrapped bandage (Fergy, Rush and Wells. 1996). 5. Nursing Management 5.1 Pain management Post operatively, the very first issue to consider in Patient Hunt's case is pain, as noted by Sarton et al., "pain increases breathing; it has been noted that breathing was difficult for Gina so the additional stressor of pain needed to be minimized" (1997). In addition to the increased respiratory strain from labored breathing, pain could limit her mobility. Pain has adverse psychological consequences distinctly interfering with a person's well-being (Lawler, 1997). As purported by Davies "pain increases patient anxiety, fear, sleeplessness, and fatigue" (2000). After a thorough assessment of pain and the patient's threshold, initial pain management can be done with the aid of warm or cold compress. Heat, can relieve chronic pain or stiff muscles while cold or ice packs provides relief by numbing the pain-sensing nerves in the affected area. Cold also helps reduce swelling and inflammation (Feldt. 2000). Another option would be the use of a Transcutaneous Electrical Nerve Stimulation machine that sends electrical impulses to block pain signals. TENS works by putting two electrodes on the affected/painful area where a very mild electrical current is pass thus producing a sensation that prevents pain messages from being transmitted to the brain (Davies. 2000). Relief can last for several hours. Braces, support or traction can also reduce pain by reducing the swelling and restricting movement (Bird. 2003). Since a lot of the pain sensation is psychological, it is very important that other coping measures be exhausted prior to the pharmacologic intervention. It must be noted that relaxation techniques, biofeedback, hypnosis, visual imagery and distraction are among the natural pain killers depending on what works for the patient (Andrews. 2002). Pharmacologic intervention such as analgesics and muscle relaxants, anti depressants and even narcotics for acute pain can be administered with proper clearance from the attending general practitioner (Bird. 2003). Fishman & Berger (2000) noted that pain is an intensely subjective experience, making an individualized intervention even more appropriate. However, as most pain does have biological/physiological sources, it is considered appropriate to approach pain management using pharmacological interventions, too (Field, 1996). 5.2 Mobilisation The primary aim in mobilization is to restore normal functioning and movement of the patient, promotion of wellness with careful consideration of the prevention of possible re-fractures. Thus it must be noted while there may still be postoperative pain possibly experienced by the patient thus requiring restrictions in movement, physiotherapy and early ambulation is necessary to prevent complications like embolism or muscle atrophy (Richards. 1997). So the nurse must work together with the patient to get the latter's cooperation and willingness to move about. The soonest time for patient to resume activities of daily living will prove advantageous in the promotion of good circulation thus promoting faster wound healing, it will also help patient to adjust better to the changes created by either traction or prosthesis. 5.3 Major Complications Fracture blisters are skin bullae and blisters representing areas of epidermal necrosis with separation of epidermis from the underlying dermis by edema fluid. They are seen with more severe twisting types of injuries, but can also occur after excessive joint manipulation, dependent positioning and heat application (ORS. 2006). There is also the possible complication on non union of fractures due to the imperfect or improper implementation of the procedure, owing to more pain and inability of the patient to walk. This is usually managed by keeping the legs between sand bags and encouraging physiotherapy as soon as the pain is no longer an issue for the patient (American Academy of Orthopedic Surgeon. 2000). Another complication would be avascular necrosis or tissue death to the head of femur due to the absence of blood supply to the area further contributed with an internal fixation, where this is usually manifested with pain in the hip, limping and limited range of movement (Ross. 1996). Such complication can be addressed with rest or traction in early stages, while hip replacement is usually indicated in severe cases. As with any other wound, the break in the continuity of the skin usually presents a good portal for bacteria to seep in thus posing a great risk for infection (American Academy of Orthopedic Surgeon. 2000). When this situation remains unattended, may produce localized edema, or infection to spread in the system. With all these, along with pain and restricted movement, may affect the patient's satiety center causing malnutrition. In general, the overall wellness of patient hunt should the primary goal of the nurse to focus upon. Regular check, as to patients comfort as well as the alleviation or relief of pain should be prioritized in order to avoid any anxiety and stress, which is necessary for the patient to resume eating habits, hygiene and activities of daily living. It is also very important for the nurse to monitor medications round the clock, especially with anti infective medicines and others. Regular wound care and dressing should also be maintained to prevent any further complications. 6. Discharge planning Planning should focus on the importance of the adherence to her take home medicines therefore it is important that the patient must understand the importance of each. Rehabilitative care should be encouraged in order to assist patient resume normal daily activities, with clear definitions as to the avoidance of those activities that might pose possible re-fractures (Hilleras Et. Al. 1999). The patient needs to understand that while she may think she is still capable of resuming on her bowling games, the possibility for another accident might cause her to undergo another surgery, which is not ideal for her age. Since patient Hunt is under the care of a local retirement village, the nurse must discuss with the patient's attending caregiver the significance of an accident free environment to prevent the likelihood of a fall (e.i., climbing up and down a stair, etc), as well as working out a nutrition plan that is focused on palliative and restorative purposes. By providing patient hunt with a nutrition plan that is aimed at maintaining bone integrity and boosting her immune system will hasten wound healing (Ahmed. 1992). Adherence to vitamins must be stressed to Patient Hunt, as the likelihood for geriatric patient to forget their daily vitamins is possible (Beynon & Quantock. 1997). With the assistance of a rehabilitative team, physiotherapy must be continued to assist patient resume normal functioning and prevent muscle atrophy. It is noteworthy to mention that there is a greater chance that the patient might experience a low self esteem due to the restrictions brought about by her condition, therefore it is imperative to explain the nature of her condition as well as to arrange (with the help of the local retirement staff) activities that will enhance her coping skills thus improving her enthusiasm and energy level (Allison & Keller. 1997). REFERENCE LIST Journal References: Ahmed, F. E. (1992). Effect of nutrition on the health of the elderly. Journal of the American Dietetic Association, 92(9), 1102-1108. Allison, M., & Keller, C. (1997). Physical Activity in the Elderly: Benefits and Intervention Strategies. The Nurse Practitioner, 22(8), 53-69. Andrews, T. (2002). The management of breathlessness in palliative care. Nursing Standard, 17, 5, 43-52 Andrews, WC. (1998). What's new in preventing and treating osteoporosis. Postgraduate Medicine 104 (4), 89-97. American Academy of Orthopedic Surgeon (2000). Don't let a fall be your last trip. Rosemont, II., Author Barnes, R., Brown, JT., Garden, RS., and Nicoll, EA.Subcapital fractures of the femur. A prospective review.J Bone Joint Surg Br.Feb1976; 58 (1):2-24. Barzel, U.S. (1996). Osteoporosis: Taking a fresh look, Hospital Practice 30 (5), 59-68. Beynon, J. H., & Quantock, C. (1997). Strong bones - The role of calcium and vitamin D. Geriatric Medicine, 27(6), 13-17. Bird, J. (2003). Selection of pain measurement tools. Nursing Standard. 18, 13, 33-39 Bukata, SV., and Rosier, RN. (2000). Diagnosis and Treatment of Osteoporosis, Current Opinion in Orthopedics 11, 336-340. Cooper, Donna R. "Hormone replacement therapy (HRT)." Mediline Plus Medical Dictionary. 03 2004. VeriMed Healthcare. 21 11 2005 Feldt, K. (2000). The checklist of non-verbal pain indicators. Pain Management Nursing. 1, 1, 13-21 Fergy, S.; Rush, S. & Wells, D. (1996) 'Care planning: The role of the nurse' Nursing Times. 92. 37. 5-8. Gambert, SR., Schulz, BM and Hamdy, BC. (1995). Osteoporosis: Clinical features, preventions and treatment. Endocrinology and Metabolic Clinics of North America 24, 317-371. Glick, J.M. "Hip Arthroscopy. The Lateral Approach." Clinics in Sports Medicine 20, no.4 (October 1, 2001): 733-41. Heetveld, MJ., Raaymakers, EL., van Eck-Smit, BL., van Walsum, AD., Luitse, JS.,Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome.J Bone Joint Surg Br.Mar2005; 87 (3): 367-73. Hilleras, P. K., Jorm, A. F., Herlitz, A., & Winblad, B. (1999). Activity patterns in very old people: a survey of cognitively intact subjects aged 90 years or older. Age and Ageing, 28, 147-152. Koval, KJ., and Zuckerman, JD.Hip Fractures: I. Overview and Evaluation and Treatment of Femoral-Neck Fractures.J Am Acad Orthop Surg.May1994; 2 (3):141-149 Lawler, K. (1997). Pain assessment. Professional Nurse Study Supplement, 13, 1, ps5-s8. Richards, RR. (1997). Fat Emboli Syndrome. Canadian Journal of Surgery. 40, 334-339. Riggs, B. and Melton, L. (1992). The prevention and treatment of osteoporosis. New England Journal Medicine 327, 630-627. Ross, D. (1996). Chronic Compartment Syndrome. Orthopedic Nursing. 15 (3), 23-27 Sarton, E., Dahan, A., Teppema, L., Berkenbosch, A., Van den Elsen, M., & Van Kleef, J. (1997). 'Influence of acute pain induced by activation of cutaneous nociceptors on ventilatory control', Anesthesiology, 2, 289-296. Shmidt A.U., Swionkowski M.P. Femoral Neck Fractures, Orthopedic Clin. North Am. 2002 Jan;33(1) 97-116.Viii. Weinstein, L. and Ullery, B.(2000). Age, weight, and estrogen use determine need for osteoporosis screen. American Journal of Obstetrics and Gynecology 183, 547-549. Book References: Davies, DB. (2000). Caring For People in Pain. London: Routledge. Fishman, S. & Bergeir, L. (2000). The War on Pain. Ireland: Newleaf Hueseman, P. (2002). Project Aware. UK: Association of Women for the Advancement of Research and Education. Rodrigo, J. (1986). Traction. In Orthopaedic Surgery: Basic Science and Clinical Science. Boston: Little, Brown and Co. Bibliography: National Institute for Health [NIH]. (2006). Osteoporosis: Information on Senior Health. Retrieve online on August 20, 2006 from National Osteoporosis Foundation [NOF]. (2006). Osteoporosis. Retrieved online August 20, 2006 from Orthopedic Research Society [ORS]. (2006). Femoral Neck Fracture. Retrieved online on August 20, 2006 from http://www.ors.org/web/index.asp National Institute of Arthritis and Musculoskeletal and Skin Disease [NIAMS]. (2006). Osteoporosis: disease management and fractures. Retrieved online on August 21, 2006 from Wright P., and Bashar, HR. (1980). The local response to trauma, In Wilson F.C. (Ed,), The Musculoskeletal System: Basic Process and Disorders (2nd ed., p. 264) Philadelphia: J.B. Lippincott. Read More