Nursing Care and Pathophysiology of Osteoporosis

This lesson is going to cover osteoporosis. We know osteo means bone, right? And porosis kind of sounds like “porous” or “pores” - so that already gives us a hint as to what’s going on.

Osteoporosis is a disease of bone demineralization. As the bone loses its minerals, it decreases in mass or density. What’s the #1 mineral found in bones? Calcium, of course. So what we see is that there’s an increased rate of bone resorption. Resorption is when calcium is pulled from the bones to go into the bloodstream. That happens when there isn’t enough calcium in the blood. The problem is that this resorption process is happening faster than the rate of rebuilding the bone. So, we end up with this overall loss of calcium from the bones and they become very porous. If you see here the normal density of bone, but when the calcium is lost, it’s more air than anything else. It’s like normal bone is like a hardwood, but osteoporosis makes it more like styrofoam. We know hardwood takes a lot of force to break, but styrofoam breaks very easily - so these patients are at very high risk for fracture. Their bones can even just crack without any force at all. Females are at greater risk because the loss of estrogen, especially later in life, causes increased bone resorption. Use of corticosteroids can also cause increased bone resorption. That’s why we see osteoporosis in patients with Cushing’s syndrome - the extra Cortisol makes the bones lose their calcium. And, of course, a calcium deficiency will make the body pull it from the bones.

So when we’re assessing these patients, first we’ll notice that they have one or more of these risk factors. An elderly female patient who doesn’t consume enough calcium and is taking corticosteroids is going to be at very high risk. We’ll also see what’s called Kyphosis of the spine. As these bones lose their density, they become sort of soggy and compressible - remember the styrofoam analogy. So now, the vertebrae under the weight of the patient’s body will start to compress and smoosh down. This causes the patient to bend forward, especially in the thoracic spine - that is called Kyphosis. To compensate, their lumbar spine begins to bend the other way so you see a little bit of Lordosis as well. All of this spinal compression also causes the patient to lose some height, as you can see here. You may even hear old ladies say “I used to be 5’6”, but now I’m 5’3”” I swear my grandmother gets shorter and shorter every time I see her, because she’s 83 and has some osteoporosis. Then, we can also see bone pain or achiness as well as fractures of the hip and pelvis. Remember it doesn’t take much force to break osteoporotic bones, so if the patient were to fall or be in a car accident, there’s a high likelihood for fracture.

As far as medical management, we want to have them increase their calcium intake or take calcium supplements. But they also need to increase their vitamin D intake or supplement Vitamin D, because our bodies cannot absorb calcium without sufficient vitamin D. So, that’s very important. We’ll also give a medication that can help to decrease bone resorption. The most common is Alendronate or Fosamax, as well as Risedronate or Actonel - so this -dronate suffix is your osteoporosis medications. These need to be taken on an empty stomach, at LEAST 30 minutes to an hour before eating. As far as nursing care, we want to encourage weight-bearing exercises, and we can get PT and OT involved. These kind of exercises are going to help increase muscle strength around those bones and improve bone density to prevent fractures. We want patients to use assistive devices if needed and we want to prevent falls at all costs. We want to remove any hazards and make sure they have their call light and belongings close by. And then we’ll educate them on dietary options to increase calcium like dairy products as well as leafy greens.

Now, if the patient does have a hip fracture, what we’ll see when they present is their leg will be shortened and externally rotated like what you see here - this is a classic sign of a hip fracture. These patients usually require traction until they can go to the OR for a hip replacement. We’ll talk more about traction in the fractures lesson. If your patient did have a hip arthroplasty or hip replacement, we need to make sure we’re checking their neurovascular status distally - pulses, numbness and tingling, etc. And then positioning is hugely important with hip fractures. They absolutely must follow these rules or their hip could dislocate or re-fracture. They shouldn’t be abducting their leg - so not going towards midline and especially not crossing midline - so no crossing their legs. No internal rotation. Most times we’ll use a special pillow or wedge between their legs to keep it neutral. They should also never bend at the hips past 90 degrees. So they’ll have to lean back in bed and we also put a special seat on the toilet so it lifts it up some. No bending at the waist, either - so we will get them a little reacher, grabber device so they can pick things up. They may also need help putting on shoes and socks since they can’t bend - so we need to consider that. And then we want to make sure they follow doctor’s orders in terms of weight bearing and use assistive devices for safety. If you want to review different assistive devices, check out Fundamentals module 8.

So our top priority nursing concepts for a patient with osteoporosis are mobility, nutrition, and safety. We want to make sure to prevent falls, and get their calcium and vitamin D intake up!

So, let’s recap quickly - osteoporosis is demineralization of the bone caused by increased resorption of calcium out of the bones. It’s common in women and patients taking steroids. Because of this loss of calcium from bones, the bones become porous and the patients can experience bone pain and kyphosis and are at high risk for fractures. We want to make sure patients are taking in enough Calcium AND Vitamin D because Vitamin D is absolutely necessary to absorb calcium. We want to keep them safe to prevent falls because of the high risk of fracture, and encourage weight bearing exercises to get their strength up. And finally, know that hip fractures are common. If your patient require hip replacement surgery, make sure you’re doing neurovascular checks post-op and putting them in the right positions.

So those are the basics of osteoporosis. Make sure you check out all of the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!