N124IN Spring 2013

 Pathophysiology/Etiology Bacteria invades bone and soft tissues nearby  Inflammation, ischemia occur  Necrosis occurs in bone tissue Modes of entry by bacteria  Direct inoculation  Contiguous spread  Hematogenous spread

 Signs/symptoms Acute osteomyelitis  Fever  Local inflammation signs (tenderness, redness, heat, pain, swelling) Chronic osteomyelitis  Ulceration  Drainage  Localized pain

 Diagnostic Tests Increased WBC count Increased ESR Bone biopsy May have positive blood culture MRI, X-ray, CT scan

 Therapeutic Measures Long-term antibiotic therapy Drainage Splinting Surgery to remove necrosis of bone tissue/place healthy bone tissue Amputations

 Nursing Care Educate patient on IV antibiotic therapy  Side effects, toxicity, interactions, precautions  Home health care nurse may be necessary Use sterile technique when working with wound, if present  Educate patient on wound care/dressing changes if applicable

 Pathophysiology Imbalance in bone remodeling process years old: bone density peaks  After this age, bone breakdown rate is greater than bone building rate  Causes bones to be porous inside and weaker  Can result in fractures

 Types/Risk Factors Primary: not related to another disease or health condition  Aging  Female  Caucasian/Asian/Hispanic/Latino  Fracture history/family history  Small bones/petite  Postmenopausal  Decreased testosterone/estrogen in males  Decreased calcium/vitamin D intake  Increased caffeine/protein/sodium intake  Sedentary lifestyle  Excessive alcohol intake  Smoking

 Types/Risk Factors, cont. Secondary: caused by medical condition/procedure  Hyperparathyroidism  Renal dialysis  Steroids  Antiseizure meds  Sleeping meds  Antacids with aluminum  Hormones for endometriosis  Cancer meds  Extended immobility

 Prevention Positive health habits and nutritional intake prior to age 30  Proper calcium and vitamin D intake  Weight-bearing/muscle-strengthening exercises  Decreased alcohol consumption  Not smoking

 Signs/symptoms Fracture Kyphosis Height decrease Back pain

 Diagnostic Tests Computed Tomography Ultrasound Dual-energy x-ray absorptiometry (DEXA) Decreased serum calcium/vitamin D Increased serum phosphorus Alkaline phosphatase levels may be increased

 Therapeutic Measures No cure Reduce Risk Factors Medications  Calcium supplements  Vitamin D

 Therapeutic Measures, cont. Medications, cont.  Antiresorptive drugs  Bisphosphonates  Prevent, slow osteoporosis progress  Ex: alendronate (Fosamax), risedronate (Actonel),  Synthetic thyroid hormone  Decreases bone loss  Ex: Calcitonin (Fortical, Miacalcin)  Selective estrogen receptor modulator (SERM)  Increases bone mass  Ex: Raloxifene (Evista)  Estrogen therapy  Prevents bone loss related to menopause  Bone-forming drugs  Teriparatide (Forteo)  Increases osteoblast action and number: increases bone mass

 Therapeutic Measures, cont. Diet  Increase calcium/vitamin D intake  Calcium:  years: 1000 mg/day  >50 years: 1200 mg/day  Vitamin D:  years: 400 IU  >70 years or with low sunlight: 600 IU

 Therapeutic Measures, cont. Exercise  Weight-bearing exercise  Stimulates building of bones  Resistance exercise

 Fall prevention Assess home environment Educate patient family on creating environment that will help prevent falls  No rugs  No slippery floors  No uneven areas  Clutter free Proper shoes Provide walker or cane

 Nursing Care Educate on prevention Pain relief Symptom care Education on medication

 Pathophysiology 3 phases  Active  Osteoclasts increase and cause bone deformity and destruction  Mixed  Osteoblasts create new bone, but it is disorganized  Inactive  Occurs when osteoblast activity surpasses osteoclast activity  Bone is sclerotic with high vascularity Common bones: spine, femur, skull, pelvis

 Etiology Unknown cause Usually runs in families Could be related to latent viral infection from young adulthood

 Signs/Symptoms Usually no symptoms, especially when only one bone is affected Pain Dependent on bone(s) Other medical conditions can occur  Ex: heart failure

 Diagnostic Tests X-rays Bone scans Increased serum alkaline phosphatase (ALP) Bone biopsy

 Therapeutic Measures No cure Controlled by meds  NSAIDs  Bisphosphonates  Synthetic thyroid hormone Exercise Surgery

 Nursing Care Pain relief Symptom care Educate

 Malignant tumors can be: Primary: originating in bone Metastatic: originating in other area of body and moving to bone  Pathophysiology unique to bone cancer type  Unknown cause

 Primary Malignant Tumors Osteosarcoma/osteogenic sarcoma  Most fatal tumor of bones  Usually metastasizes to lungs in 2 years of diagnosis/treatment  Typically involves people years old and boys more than girls  Site of origin: typically long bones of arms, legs  Signs: pain/swelling, lump, limp  Diagnostic tests: X-ray, bone biopsy, CT scan, bone scan, MRI  Treatments: chemotherapy, surgical removal with bone grafting or amputation

 Primary Malignant Tumors, cont. Ewing’s sarcoma  Bone tumor that is most malignant  Signs/symptoms: local pain/swelling, low-grade fever, leukocytosis, anemia  Often affects pelvis and legs in children and younger men

 Primary Malignant Tumors, cont. Chondrosarcoma  Cartilaginous cell cancer  Better prognosis  Typically occurs in middle-aged and elderly

 Metastatic Bone Disease Bone-seeking cancers: primary malignant tumors in prostate, breast, lung, thyroid gland Once metastasized, numerous bone sites are usually found Important concerns: pathological fractures, severe pain

 Signs/symptoms Primary tumors:  Local swelling  Pain  Tender mass Metastatic disease  Diffuse severe pain  Can cause disability

 Diagnostic Tests X-ray CT scan Bone scan Bone biopsy MRI Increased ALP Increased ESR

 Therapeutic Measures Dependent on tumor type and extent Primary bone tumors  Surgery  Chemotherapy/radiation Metastatic bone disease  No surgery  External radiation  Palliation

 Nursing Care Assist patient with diagnosis Refer patient to appropriate resources Appropriate care with chemotherapy/radiation Postoperative care

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