NUR 211 Unit 2 Study Guide Revised

Osteoporosis NUR 211 Unit 2 Study Guide Revised =chronic condition that results in deterioration of bone tissue and density, increasing a patient’s risk for fractures. It is the most common bone disease in humans and creates a major public health concern for the future. =”Silent Disease” Bone remodeling = the constant replacing of older bone with newer bone Osteoclasts = break down bone by adhering to the surface of bone and secreting acids and enzymes directly into the bone cavity Osteoblasts = rebuild bone by synthesis and mineralization of the new bony matrix within the bone cavity Osteopenia = bone loss; bone resorption is greater than bone rebuilding in a decreased bone mineral density; before osteoporosis Medical Management Diagnosis A. Annual height measurement B. Bone Mineral Density (BMD) testing 1. Women over 65 or men over 70 years 2. Postmenopausal women and men 50-69 with high risk factors a. DEXA = dual-energy x-ray absorptiometry ; precise measurements; highlight areas for future fracture risk Normal BMD within 1 SD of young normal adult, T-score -1.0 or higher Low bone mass or osteopenia BMD between 1 and 2.5 SD’s lower than that of a young normal adult. T-score between 1.0 and -2.5 Osteoporosis BMD more than 2.5 SD’s lower than that of a young normal adult, T-score -2.5 or lower b. Quantitative computed tomography (QCT) = measures volumetric bone density of the spine and hip and can identify cortical and trabecular bones distinctly. Used for research and diagnostic management -NOT screening c. Biochemical Markers = bone-specific alkaline phosphate, osteocalcin, N-telopeptide and C-telopeptide, serum & urine calcium, Vit D, phosphorous, hematocrit, ESR, d. FRAX = calculates a 10 year probability for hip and any one of four major osteoporotic fractures bet 40-89 years. Treatment A. Prevention and early screening B. Weight loss C. Muscle-strengthening exercises and weight-bearing exercises D. Avoid smoking and excessive alcohol intake E. Calcium + Vitamin D supplements Calcium 1,200 mg /day -give with food in divided doses with 6-8 oz of water -can cause GI upset -monitor for constipation & hypercalcemia Vitamin D 800-1000 international units / day -Toxicity can occur: weakness, fatigue, nausea, constipation, kidney stones Milk and milk products Fortified milk & cereals Figs Egg yoks Fish with bones Saltwater fish Greens Liver Red and white beans Sunlight 15 min /day Medications A. Bisphosphonates 1. Fosamax (alendronate) = admin daily or weekly on an empty stomach 30 min before food or meds and remain sitting up for 30 minutes after admin as risk for esophagitis and esophageal ulcers can occur 2. Boniva (ibandronate) = monthly tablet or IV infusion every 3 months – admin on empty stomach and remain sitting up for 30 minutes after admin as risk for esophagitis and esophageal ulcers can occur Manifestations Dowager’s hump (kyphosis) Fear of falling Loss of height (2-3 in) Previous fractures Back pain BMD more than 2.5 SD’s (standard deviations) lower than that of a young adult Pain with activity – relief with rest T-score -2.5 or lower Restriction of movement Hormonal Influences A. Calcitonin (thyroid hormone) – decreases bone resorption by inhibiting osteoclast activity B. Estrogen - replaces estrogen lost due to menopause or surgical removal of ovaries and should be given with progesterone in clients who sill have their uterus. 1. Estrace = assists with bone remodeling and osteoclastic activity; varies methods of admin; risk for MI, stroke, breast and endometrial cancers, PE, DVT. Perform monthly breast exams C. Parathyroid hormone Diet A. Dietary sources such as Vitamin D fortified milk, cereals, egg yolks, saltwater fish, liver, and kale B. Sunlight for 15 min / day C. Supplements of calcium and vitamin D Nursing Diagnosis A. Risk for trauma B. Impaired physical mobility C. Acute / chronic pain D. Nutrition, imbalance: less than body requirements Interventions A. Admin meds B. Encourage activity for ADL’s and exercise: walking is effective C. Assistive devices as applicable D. Safety measures E. Encourage weight reduction F. Vitamin D and calcium supplements Fibromyalgia = chronic pain disorder of soft connective tissues that is characterized by widespread pain and other symptoms such as insomnia, fatigue, stiffness, and cognitive dysfunction. Diagnosis For the diagnosis of fibromyalgia : the patient must experience 11 out of 18 specified locations (tender points) and have widespread pain, which involves pain on both sides of the body and above and below the waist. Assessment is done by applying 4 kg of pressure to the specific points. Treatment Nonpharmacological Physical therapy Strength training Aerobic exercise Cognitive behavioral therapy education Self-management Pharmacological This meds can alter the chemical make-up of the brain to block over-activity of nerve cells Other meds can be given to help with sleep and pain Serotonin Cymbalta -antidepressant to help with pain & promote sleep Norepinephrine Elavil Lyrica (pregabalin) – anti-seizure med to reduce pain Prozac Manifestations Fatigue Arthralgia and myalgia Headache Abdominal pain/painful menstrual cramps Decreased desire to participate in activity Nonrestorative sleep Anxiety Widespread pain Insomnia stiffness Cognitive dysfunction “fibro-fog” Increased sensitivity to heat, cold, pressure Numbness in hands and feet Restless leg syndrome depression Nursing Diagnosis A. Chronic pain related to the disease process B. Ineffective coping skills r/t chronic pain C. Depressed mood r/t chronic pain D. Ineffective sleep patterns r/t chronic pain Interventions A. Assessments 1. Vital signs (pain may alter – increased heart and BP) 2. Affect – depression due to chronic pain 3. Pain – ineffective treatment B. Actions 1. Admin meds a. NSAID’s – inflammation b. Antidepressants – manage depression, promote sleep, and help control pain by inhibiting reuptake of neurotransmitters c. Anti-seizure meds – may modify the release of neurotransmitters through action on calcium channels 2. Provide heating pad for painful muscles and cold packs for painful joints Teaching A. Take meds as prescribed B. Participate in regular exercise C. Teach effective coping skills D. Assist with referring for sleep study E. Assist with referring to mental health F. Assis with referring to OT / PT Osteoarthritis = progressive deterioration of the articular cartilage. Noninflammatory (unless localized), nonsystemic disease = disease that affects the joint as a whole because of biological, chemical, and viscoelastic changes within the joint. =cartilage, synovium, subchondral bone, synovial fluid, ligaments, periarticular muscle, and sensory nerves are altered by osteoarthritis = Serum Calcium 9 – 10.5 Manifestations Progressive aching / pain overtime Decreased ROM Tenderness to Touch **Morning stiffness for 30 minutes Swelling Crepitus (cracking sound) Deformity of joints Instability (unsteady gait) Pain with activity improves with rest Pharmacology Acetaminophen (Tylenol) Mild to moderate pain -Max 4,000 mg /day (include all meds) -inhibits prostaglandin synthesis, a modulator of inflammatory response & blocking the generation of a pain impulses. Side Effects: hepatic toxicity esp. with alcohol use; potentiation of warfarin NSAIDs Celecoxib Naproxen Ibuprofen Mild to moderate pain unresponsive to acetaminophen or severe pain -nonselectively inhibit cyclooxygenase, an isoenzyme responsible for the production of prostaglandins -inhibition of inflammation and pain -adverse effect : GI bleeding and ulceration Side Effects: nephrotic toxicity, GI bleeding, anticoagulation Warning: May cause an increased risk of serous cardiovascular thrombotic events, myocardial infarction, stroke, renal insufficiency Multiple sclerosis = autoimmune, chronic neurological disorder in which the nerves of the CNS (brain & spinal cord) degenerate. =building up of scar tissue (sclerosis) or plaques that form during demyelination (destruction of myelin sheath) Pathophysiology -It begins with a breakdown of the blood-brain barrier that allow immune cells (T lymphocytes) to infiltrate and attack the myelin. -The immune system attacks the brain and spinal cord (CNS) -Breakdown of the myelin sheath Manifestations movement fatigue P. 824 Mental changes, decreased concentration, attention deficit, memory loss Movement, sensation, thinking all impaired due to nerve degeneration. Depends on which nerves are affected dizziness Limb weakness, loss of coordination and balance Loss of sensation, speech impediment, tremors or dizziness Depression & unstable mood Visual disturbances, blurred vision, color distortions, vision loss, eye pain Muscle spasms, fatigue, numbness, tingling and prickling pain Pharmacology Corticosteroids Prednisone, cortisone, hydrocortisone, Solu-Medrol Mimic the effects of hormones produced in the adrenal glands; decrease inflammation by blocking the production of substances that trigger allergic and inflammatory reactions (prostaglandins) Antispasmodic / anticholergic (Muscle relaxer) Oxybutynin chloride (Ditropan) Inhibits transmission of impulses through parasympathetic nerve fibers Complications muscle stiffness or spasm paralysis Mental status changes depression seizures **Problems with bladder, bowel, sexual function (catheter needed: lost nerve sensation to control) Nursing Diagnosis -Impaired physical mobility r/t neuromuscular impairment secondary to demyelination -Self-care deficit r/t reduced neurotransmission and impaired physical mobility secondary to demyelination -Impaired coping, depression r/t the chronic, progressive nature of the disease Assessments Actions Neuromuscular function ( new symptoms ) Encourage ROM exercises (↑venous return, prevent stiffness, maintain muscle strength and endurance) Vision / Eye Movement (demyelination of cranial nerves) Admin interferon beta 1-b (Betaseron) Skin Integrity (immobility promotes skin breakdown) Admin corticosteroids during exacerbation Ability to perform ADL’s (eval for assistive devices) Implement safety measures Bowel and bladder function (impaired innervation) Patch each eye daily as needed in pts with visual deficits or diplopia (improves vision and balance) Parkinson’s Disease = progressive neurodegenerative disease of the CNS manifesting primarily in motor dysfunction. Decreases amount of dopamine and increased amount of acetylcholine→ overstimulation of basal ganglia → acetylcholine dominates → smooth muscle control difficult Discernable Manifestations (4 Cardinal) 1. Resting tremors 2. Muscle rigidity 3. Slowness of movement (bradykinesia) 4. Postural instability ( loss of movement – akinesia) 5. Weakness, Fatigue, Mask-like face, shuffling gait, uncoordinated movements, widening gait and ORTHOSTATIC HYPOTENSION Diagnosis Dr. looks for at least 2 or more cardinal symptoms with asymmetrical presentation. Treatment / Medications A. Anticholinergics 1. Cogentin ** (benztropine) -anticholinergic -adjunctive tx for PD -blocks cholinergic activity in the CNS -restores natural balance of neurotransmitters in the CNS -Reduction of rigidity and tremors -Adverse Effects: confusion, depression, dizziness, hallucinations, headache, sedation, blurred vision, dry eyes, constipation, dry mouth -Admin with food or immediately after meals to minimize gastric irritation. May be crushed. -Teach: dizziness, frequent mouth rinses, ORTHSTATIC HYPOTENSION, report symptoms, avoid cold medicines, antacids, antidiarrheals (within 1-2 hr of med) 2. Artane B. Dopamine-Receptor Agonists 1. Requip 2. Mirapex 3. Carbidopa/Levodopa (Sinemet) ** -dopamine agonist -Levodopa is converted to dopamine in the CNS, where it serves as a neurotransmitter -Carbidopa, a decarboxylase inhibitor, prevents peripheral destruction of levodopa -Adverse Effects: GI hemorrhage, GI ischemia, GI obstruction, GI perforation, hepatotoxicity, pancreatitis, ORTHOSTATIC HYPOTENSION, depression, involuntary movements, constipation, N/V -Interactions: MAOI’s, antihypertensives, anticholinergics