Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for osteoporosis and osteopenia
- Describe the diagnostics and laboratory values of osteoporosis and osteopenia
- Apply nursing concepts and plan associated nursing care for patients with osteoporosis and osteopenia
- Evaluate the efficacy of nursing care for patients with osteoporosis and osteopenia
- Describe the medical therapies that apply to the care of osteoporosis and osteopenia
The musculoskeletal system comprises bones, joints, muscles, tendons, and ligaments. Its major function is promoting body mobility, the ability of a patient to change and control their body position. Physical mobility requires sufficient muscle strength and energy, along with adequate skeletal stability, joint function, and neuromuscular synchronization. Anything that disrupts this integrated process can lead to impaired mobility or immobility. Mobility exists on a continuum ranging from no impairment (i.e., the patient can make major and frequent changes in position without assistance) to complete immobility (i.e., the patient is unable to make even slight changes in position without assistance) (Figure 13.2). Functional mobility assessment tools can help determine the level of a patient’s mobility.
Link to Learning
The Johns Hopkins Highest Level of Mobility (JH-HLM) Scale measures the patient’s highest level of mobility achieved.
The bone disease osteoporosis is caused by caused by a significant decrease in bone density and mass. This disease presents a major threat to public health, with almost 54 million Americans affected (International Osteoporosis Foundation, 2023). A decrease in bone mineral density, osteopenia is the precursor condition to osteoporosis; it currently affects nearly 34 million Americans. Females are four times more likely to be affected than males, and the incidence is higher in postmenopausal females (Varacallo et al., 2023). The prevalence of these conditions is significant, as they often result in serious bone fractures, which can pose significant health problems, especially to already at-risk populations such as older adults.
Pathophysiology
The underlying pathophysiology of osteoporosis involves too much resorption, or the breakdown and reabsorption over time of small amounts of minerals from the bone; the minerals are broken down and reabsorbed into the systemic circulation. Without replacement and remodeling of the removed parts, bone weakness and fragility occur, resulting in osteopenia and eventually osteoporosis (Figure 13.3). Risk factors for the development of osteopenia and osteoporosis include
- advanced age,
- certain medical conditions (e.g., cancer, HIV, anorexia nervosa),
- chronic alcohol use,
- cigarette smoking,
- family history of osteoporosis,
- female sex,
- hormonal changes (e.g., low estrogen levels after menopause),
- long-term use of certain medications (e.g., corticosteroids, proton pump inhibitors, antiepileptic medications),
- low body mass index (BMI),
- physical inactivity or prolonged immobility, and
- poor dietary habits (e.g., inadequate calcium, vitamin D, or protein).
Life-Stage Context
Osteoporosis Risk in Older Females
The risk of developing osteoporosis is significantly higher in females when compared to males. Most of this risk is associated with estrogen levels. Estrogen acts as a bone protectant, so when hormonal levels decrease dramatically, such as during menopause, the rate of bone breakdown is accelerated, resulting in the development of osteoporosis (National Health Service, 2022).
Clinical Manifestations
Due to the progressive bone weakness that occurs with osteopenia and osteoporosis, clinical manifestations may not become evident until the individual experiences a bone fracture. The most common fractures associated with osteoporosis include fractures of the hip, lumbar spine, and wrist. Another common clinical manifestation of osteoporosis, especially in older adults, is a loss of height (usually an inch or two) due to kyphosis, or excessive curvature of the upper spine. This occurs secondary to the gradual breakdown of the vertebrae over time, causing the individual to stand with a “hunched over” posture (Figure 13.4). Other clinical manifestations include pain in the lower back and shortness of breath, both related to vertebral body compression (National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2022).
Assessment and Diagnostics
The physical assessment of a patient with osteopenia or osteoporosis often reveals a kyphotic posture, as well as a decrease in total height over the course of several years. This highlights the importance of obtaining baseline measurements and completing accurate documentation so that data collected on subsequent visits may be compared to the earlier assessments. Additionally, it is important to complete a risk assessment for fractures for any patient who has been diagnosed with or is at risk for osteoporosis. A commonly used risk assessment tool is the Fracture Risk Assessment Tool (FRAX), which analyzes risk factors including age, sex, height, weight, family history, and alcohol use, among others. This tool helps calculate the risk for experiencing a bone fracture in patients with osteoporosis and is used to guide treatment planning.
Link to Learning
The Online Fracture Risk Assessment (FRAX) Tool allows a patient to input data directly into the calculator and obtain a risk-assessment score.
Diagnostics and Laboratory Values
There are several diagnostic tests that can be used to confirm a diagnosis of osteopenia or osteoporosis. The gold standard test is the dual-energy x-ray absorptiometry (DEXA or DXA) scan. This procedure uses low-dose–radiation x-rays to determine bone density of the hip, wrist, or spine (Figure 13.5). Once a value is obtained, it is compared to standard values for an individual with similar demographic characteristics to determine the presence and severity of osteoporosis. It is currently recommended that all individuals assigned female at birth who are over the age of 65 have a DXA scan; females with specific risk factors should consider obtaining a scan before the age of 65 so that early intervention and treatment may be initiated (U.S. Preventative Services Task Force, 2018). In the later stages of osteoporosis, regular x-rays may be used to monitor the progression of the disease. While no laboratory values are specific to confirming a diagnosis of osteoporosis, several laboratory tests—such as testing vitamin D, calcium, albumin, and phosphate levels—can be used to rule out other medical conditions.
Nursing Care of the Patient with Osteoporosis and Osteopenia
Nursing care of patients with osteopenia or osteoporosis occurs in many areas, including both outpatient and inpatient settings. Typically, this condition can be managed on an outpatient basis, but there may be a need for inpatient hospitalization, especially in the later stages of the disorder if major bone fractures occur.
Recognizing Cues and Analyzing Cues
First and foremost, nurses must be able to recognize risk factors specific to osteoporosis—such as sex, age, and medical history—when obtaining a complete health history from their patients. Upon recognition of these risk factors, the nurse can make appropriate recommendations and referrals for further testing and treatment as needed. The nurse should also be mindful of physical symptoms of osteoporosis, including kyphosis, loss of height, and patient-reported back pain.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
If any risk factors or physical assessment findings indicate the development of osteoporosis, the nurse will mention them to the provider, and it is likely that further diagnostic testing will be conducted. Once these tests have confirmed the diagnosis of osteoporosis, the nurse will assist in implementing treatment interventions, providing patient education, and ensuring appropriate follow-up appointments. One of the main nursing interventions for patients with osteoporosis is providing education, especially as it relates to lifestyle changes that the patient can make to slow the progression of the disorder. Common nursing interventions for patients with osteoporosis include
- promoting patient independence,
- assisting with activities of daily living (ADLs) as needed,
- encouraging physical mobility as tolerated,
- providing education regarding the importance of calcium and vitamin D intake as well as dietary sources
- referring the patient to a dietician as needed,
- encouraging smoking cessation, and
- implementing fall-risk precautions as needed.
Evaluation of Nursing Care for the Patient with Osteoporosis and Osteopenia
It is important for nurses to follow up with patients to ensure that treatment outcomes are achieved. If they are not, the nurse will work closely with the provider and other members of the health-care team to revise the patient’s plan of care.
Evaluating Outcomes
The nurse will evaluate several outcomes that indicate treatment goals for osteoporosis are being met. These outcomes include
- improved patient knowledge regarding the condition and its associated treatments,
- pain relief (especially in the back), and
- no new bone fractures.
To evaluate these outcomes, the nurse will employ the following strategies:
- conduct pre- and post-education knowledge assessments to determine whether the patient has gained knowledge about their condition and treatments;
- implement a validated pain assessment tool to measure pain intensity before and after pain management interventions; and
- review medical records to track and identify any new fractures or signs of fractures since the initiation of treatment.
Medical Therapies and Related Care
Treatment options for osteopenia and osteoporosis often involve a combination of lifestyle modifications and pharmacological interventions (Table 13.1).
| Treatment | Rationale |
|---|---|
|
Risk factors for osteoporosis should be addressed through lifestyle modifications because most of the risk factors are modifiable. |
| Vitamin supplements (if not enough are obtained from dietary intake) | Calcium and vitamin D may help reduce the risk of bone fractures. |
|
These medications work by inhibiting osteoclasts to slow the progression of osteoporosis. (An osteoclast is a cell that breaks down bones.) |
| Selective estrogen receptor modulators (SERMs) (e.g., raloxifene) | These medications mimic the effects of estrogen in the body to preserve bone marrow density. |
| RANKL inhibitors (e.g., denosumab) | This monoclonal antibody increases bone marrow density and inhibits the action of osteoclasts. |
Link to Learning
Bisphosphonates are typically the first line treatment for osteoporosis, so it is important for nurses to educate patients about their potential side effects and other care conditions. For example, this type of medication should be taken with a full glass of water, and the patient should remain upright for one hour after taking it to prevent upper-GI conditions such as esophagitis and dyspepsia.