1. Metabolic Diseases of the Bone
Paget’s
Gout
Carolyn Morse Jacobs, RN, MSN, ONC

2. Paget’s Disease (osteitis deformans)
Etiology/Pathophysiology
Bone deformities due to abnormal regeneration and reabsorption of bone
Affects pelvis, lone bones, spine, cranium
Cause unknown (hormonal, autoimmune, etc)
Excessive osteoclastic bone reabsorption then osteoblastic bone formation
Bone initially hyperemic (increased blood flow); bone soft; new bone brittle
Common males over 50

3. Paget’s Disease (osteitis deformans)
Manifestations & Complications
Initially aymptomatic
Bone pain; pathologic fractures
Mental changes due to compression of spinal cord (small hat syndrome)
Hearing loss
CV disease (vasodilation of vessels in skin and tissues overlying affected bones)
May lead to osteosarcoma, chondrosarcoma

4. Paget’s Disease Diagnosis Nursing diagnosis Treatment
Increased serum alkaline phosphatase
X-ray shows thickened bone, curved, abnormal structure
Nursing diagnosis
Treatment
Supportive
Calcitonin, EHDP, Mithramycin
Exercises

5. What nursing problems can you identify from this slide?

6. Case study What nursing problem can you identify from this slide?
Musculoskeletal effects (pain long bones, deformities, deformity, pathological fx, compression fx)
Neurological (hearing loss, spinal cord injuries, back pain)
CV (high cardiac output; inc temp over affected extremities)
Metabolic (hypercalcemia, hypercalciuria)
Case study

7. Paget’s disease Diagnostic Tests X-rays (punched out appearance)
Bone scans
CT scans and MRI
Serum alkaline phosphatase increased
Urinary collagen pyridinoline indicated bone resorption

8. Paget’s disease Therapeutic Interventions/Collaborative Care
Pain medications (NSAIDS)
Bisphophonate (retard bone resorption such as Fosamax by ataching to bone surface to inhibit osteoclastic activity)
Calcitonin (inhibit osteoclastic resorption; also anangesic)
Calcium supplements
Surgery: THR; TKR
Nursing Diagnosis
Chronic Pain
Impaired Physical Mobility

9. Gout Etiology/Pathophysiology
Inflammatory response to production or excretion or uric acid resulting in high levels of uric acid in the blood (hyperuricemia)
Caused by disturbed uric acid metabolism
Urate salts deposited in articular, periarticular and subcutaneous tissue
Primary result of genetic defect purine metabolism
Secondary due to increased cell turnover (medications, diseases, leukemia, etc)
? Who gets secondary gout?

10. Gout Urate deposities in synovial fluids cause gouty arthritis
Urate depositis in subcutaneous nodules cause formation of tophi
Normal serum uric acid level men; 2-4 and 6.0 women; higher than 7 mg/dl sodium urate crystals form; deposit in peripheral tissues with low temperatures; areas subject to tissue trauma

11. Manifestations Gout

13. Manifestations & Complications Gout
Stage 1: asymptomatic; hyperuricemic
Stage 2: acute gouty arthritis; affect single joint, unexpected, trauma , stress; high level uric acid; joint hot, red swollen; generally metatarsophalangeal joint great toe.
Stage 3: Chronic Tophaceous; occurs if gout not treated; urate pool increases; develop in multiple areas (especially ear, bursae, toes), compress nerves and erode through tissues.
Kidney disease with untreated gout; kidney stones!

14. Management Gouty Arthritis
Diagnostic Tests
Serum uric aacid elevated (above 7.5 mg/dl)
WBC elevated (if acute)
ESR elevated
24 urineproduction and excretion or uric acid
Analysis of fluid from involved joint
Interventions
Diet: Slight effect; maybe low purine (all meats, seafoods, spinach, avoid alcohol)
Fluids: Liberal 2000cc
Acute: alleviate pain, inflammation
Bedrest: 24 hours after attack
Medications including ASA, NSAID, Colchicine IV or orally (GI symptoms)

15. Medications for Gout Uricosuric Agents
Probenecid (ASA an antagonist); inhibits resportion of uric acid thus increases excretion of uric acid
Sulfinprazone (anturan) to block resorption uric acid
Need high fluid intake, alkaline urine
Xanthine-oxidase inhibitors decrease uric acid production
Allopurinal (zyloprim); may cause agranucytosis
Need high fluid intake, and alkaline urine

16. Priority Nursing Problems and Interventions
Acute Pain
Position for comfort
Protect affected joint from pressure
Knowledge deficit
Instruct patient on medications used to treat/manage disease process
Impaired physical Mobility
Disease control!
Required Resource

17. Osteomyelitis/Septic Arthritis
Inflammation with an Infectious cause.
Osteomyelitis affects the bones; septic arthritis affects the joints.

18. Etiology/Pathophysiology Osteomyelitis
Usually bacterial cause
Most often from direct inoculation or contiguous infection (open wound/adjacent wound)
Hematogenous spread
(older adults, IV drug users, spine affected )
Vascular insufficiency (diabetics, PVD)
Primary agents causing osteomyelitis: Staph, E. coli, Pseudomonas, Klebsiella, salmonella, and Proteus, strep, gonorrhea

19. Development of Osteomyelitis
Bacteria invade bone
Pressure within bone increases
Periosteum elevates and bone DIES
Infected bone separates = sequestrum
Separated periosteum produces new bone = involcrum
Sinus tract forms

20. Figure 39.9 Osteomyellitis

21. Development of Osteomyelitis
Classification of osteomyelitis
Acute
Chronic
Sinus tracts form, bone destruction

22. Etiology/Pathophysiology Septic Arthritis (Joint infection)
Septic arthritis develops when joint space invaded by pathogen
Hematogenous
Direct inoculation
Persistent bacteremia; previous joint damage
Joint infection results in inflammation, synovitis, joint effusion; abscess formation; cause joint destruction
Onset abrupt; pain, stiffness in joint, red, hot and swollen; systemic manifestations
Agents
staph, strep, e-coli, Pseudomonas, gonorrhea, viral, post rubella

23. Osteomyelitis Manifestations/complications
Diagnostic tests
X-ray, no initial bone changes
CT, MRI, radionucleotidetide bone scan. Biopsy
Ultrasound for subperiosteal fluid collection, etc
Culture
Late bone changes with bone destruction
ESR, WBC, CBC
Acute hrs post-surgery
Pain
CV: tachycardia; chills, fever
Integumentary: Swelling, erythemia, lymph node involvement
MS: Pseudoarthrosis involved limb
Chronic
Signs & symptoms chronic infection
Drainage wound perodically

24. Septic Arthritis Manifestations/complications
Signs and symptoms
Medical emergency requiring prompt intervention to preserve joint function!
Extremely painful
Loss of motion
High fever
Less likely to become chronic
Diagnostic tests
Lab studies:
Blood cultures from likely sources
CBC, etc
X-rays show synovial effusion
Arthrocenthesis with culture
Positive, synovial fluid cloudy, high WBC low glucose

25. Synovial inflammation!
Comparison acute rheumatoid arthritis and septic arthritis of the joint!
Purulent exudate!

26. Septic Arthritis (most common in children)

27. Priority Nursing Diagnosis and Interventions Osteomyelitis and Septic Arthritis
Acute: prevent, identify source, short-term antibiotics
Chronic: opt nutrition, splint for support, surgery,hyperbaric O2, muscle flap, long term antibiotics
Nursing Diagnosis
Risk for Infection!
Hyperthermia
Acute Pain
Impaired physical mobility
Potential for injury: fracture (chronic osteomyelitis)
Knowledge deficit
Management Osteomyelitis
Septic Arthritis

28. Avoid the pain and grief of chronic osteomyelitis!
If only I had taken those antibiotics!
Avoid the pain and grief of chronic osteomyelitis!

29. Tuberculosis of Bone and Spine
Source
Signs and symptoms: vertebral collapse, pain, deformity (Potts fx), systemic as night sweats, anemia
Diagnosis
Treatment

30. Test Yourself!
1. Sixty days following her TKR, Ms. K calls her physician to report “a little pain and swelling “ around her knee. What advice would you give her?
a. “That is expected.”
b. “Wait and see what happens.”
c. “Let me check the knee.”
d. “You may need an antibiotic.”

31. Test Yourself!
1.Sixty days following her TKR, Ms. K calls her physician to report “a little pain and swelling “ around her knee. What advice would you give her?
a. “That is expected.”
b. “Wait and see what happens.”
c. “Let me check the knee.” Assessment first; may be an infection!
d. “You may need an antibiotic.”

32. Try these!
2.You are providing instruction to a client on high does of corticosteroids (50 mg/day) for treatment of SLE. Which statements indicate a need for further teaching?
A.“I will stop taking the medication which symptoms resolve.”
B.“I will avoid anyone with an infection.”
C.“ I expect to gain some weight and experience a puffy face.”
D.“ I will take the medications on a daily basis even if I don’t feel well.”
3. The nurse admits a client with a primary diagnosis of metastic CA and probable gout. Which of these lab values suggests the diagnosis of gout?
A. Ca 9mg/dl
B. Uric acid 9.0mg/dl
C. Potassium 4.2 mEq/L
D. Phosphorous 4mEg/l

33. Try these!
2.You are providing instruction to a client on high does of corticosteroids (50 mg/day) for treatment of SLE. Which statements indicate a need for further teaching?
A.“I will stop taking the medication which symptoms resolve.”
B.“I will avoid anyone with an infection.”
C.“ I expect to gain some weight and experience a puffy face.”
D.“ I will take the medications on a daily basis even if I don’t feel well.”
Steroid dosage must be gradually tapered down; others are correct responses
3. The nurse admits a client with a primary diagnosis of metastic CA and probable gout. Which of these lab values suggests the diagnosis of gout?
A. Ca 9mg/dl
B. Uric acid 9.0mg/dl* (at above 7.0 mg/dl sodium urate crystales form and are insoluble; other values are normal )
C. Potassium 4.2 mEq/L
D. Phosphorous 4mEg/l

34. Try more!
4.Which of the following manifestations should cause the nurse the MOST concern after treating a client with osteomyelitis for two days with IV antibiotics?
A.Sudden increase in temperature
B.Complaints of pain at site of infection
C.Application of most heat to infection site by spouse
D.uarding of involved extremity
5.A person who as gout needs to know that both aspirin and thiazide diuretics may cause(a)__________, which will worsen the gout. In addition, if he begins to take probenecid, he should drink at least (b)___________ml of fluids per day to protect his kidneys!

35. Try more!
4.Which of the following manifestations should cause the nurse the MOST concern after treating a client with osteomyelitis for two days with IV antibiotics?
A.Sudden increase in temperature
B.Complaints of pain at site of infection
C.Application of most heat to infection site by spouse
D.Guarding of involved extremity
Sudden increase indicates that antibiotic is not effective; other signs/symptoms are common due to initial pain of osteomyelitis
5.A person with gout needs to know that both aspirin and thiazide diuretics may cause(a) hyperuricemia, which will worsen gout. In addition, if he takes probenecid, he must drink at least (b)3000 ml of fluids per day to protect his kidneys!
Probenecid (Benemid) inhibits renal tubular reabsorption of urates (ineffective when creatinine reduced. ASA inactivates effects of uricosurics and causes urate retention. Adequate fluids necessary (3000 ml) prevent precipitation or uric acid in renal tubules

36. Case study Osteomyelitis
AJ, a rodeo rider suffered a comminuted fracture of his left tibia 20 years ago; had multiple surgical procedures and treatments with antibiotics, but continued to have a draining sinus in the lower leg. His is admitted to the hospital for definitive treatment due to the continued draining sinus, soft tissue swelling and signs of chronic infection.

37. Case study chronic osteomyelitis
What was the most likely “original” cause of AJ’s osteomyelitis? What organism is the most likely culprit?
What risk factors?
Explain the pathophysiology of chronic osteomyelitis?

38. Case study chronic osteomyelitis
What was the most likely “original” cause of AJ’s osteomyelitis? (open comminuted fracture; direct innoculation; maybe complication of surgery) What organism is the most likely culprit? (Staph most common)
What risk factors?(Poor blood supply of tibia, over 50, other unknown factors such smoking, hx diabetes, PVD)
Explain the pathophysiology of chronic osteomyelitis?(Bacteria lodge in bone and multiply, inflammatory and immune system response walls off infection; bone tissue destroyed, pus forms, more edema and congestion, travels to other parts of bone; when gets to outer portion of bone, lifts periosteum, disrupts blood supply; sinus tract forms; Blood and antibiotics unable to reach bone tissue when pressure compromises vascular and arteriolar system; bacteria also covers bone)

39. Case study chronic osteomyelitis
4. What diagnostic tests are typically performed for chronic osteomyelitis?
5. What signs and symptoms would you expect to see in AJ?
6. Describe medications usually employed in the management of chronic osteomyelitis.

40. Case study chronic osteomyelitis
4. What diagnostic tests are typically performed for chronic osteomyelitis? (scans, X-ray, MRI, blood tests (cultures), radionucleotide bone scans to determine if active, ultrasound for subperiosteal fluid collection, ESR, blood and tissue cultures)
5. What signs and symptoms would you expect to see in AJ?(signs chronic infection; sinus tract drainage, limp in invloved extremity, localized tenderness, lymph node swelling, non-healing wound, tachycardia, anorexia, potential for pathological fracture etc)
6. Describe medications usually employed in the management of chronic osteomyelitis.( Culture and sensitivity; 4-6 weeks antibiotics, must revascularize bone, antibiotics directly to area)

41. Case study chronic osteomyelitis
Since conservative treatment was ineffective, surgical intervention was employed.
Debride inflammatory tissue and infected bone; left defect of soft tissue and in tibia (bacterial cultures taken)
Latissimus muscle flat (myocutaneous flap) used to fill defect and supply blood; with muscle attached to anterior tibial artery defect for blood supply; implanted antimicrobial beads

42. Case study chronic osteomyelitis
Patient resource
What are the priority nursing diagnosis for AJ as he recovers?
What teaching is Most important?

43. Case study chronic osteomyelitis
What are the priority nursing diagnosis for AJ as he recovers? (Risk for infection; Hyperthermia; Altered tissue perfusion (post surgery); Impaired physical mobility; Acute pain; Anxiety)
What teaching is Most important? (Complete antibiotics, will go home on IV antibiotic therapy for 4-6 weeks; Will have limited mobility of affected limb; maintain limb in functional position; no weight –bearing to avoid pathological fracture; ROM to prevent flexion contractures; manage pain; optimal nutrition for healing)