Metabolic Diseases of the Bone

•Paget’s

•Gout

Carolyn Morse Jacobs, RN, MSN, ONC

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

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

Paget’s Disease

Diagnosis• Increased serum alkaline phosphatase• X-ray shows thickened bone, curved, abnormal

structure

Nursing diagnosis Treatment

• Supportive• Calcitonin, EHDP, Mithramycin• Exercises

What nursing problems can you identify from this slide?

What nursing problem can you identify from this slide?

Case study

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)

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

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

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?

Gout

Urate deposities in synovial fluids cause gouty arthritis

Urate depositis in subcutaneous nodules cause formation of tophi

Normal serum uric acid level 3-4-7.0- 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

Manifestations Gout

Manifestations & Complications Gout Manifestations

• 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!

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)

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

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

Osteomyelitis/Septic ArthritisInflammation with an Infectious cause.

Osteomyelitis affects the bones; septic arthritis affects the joints.

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

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

Figure 39.9 Osteomyellitis

Development of Osteomyelitis

Classification of osteomyelitisAcute

Chronic

Sinus tracts form, bone destruction

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

OsteomyelitisManifestations/complications

Acute 24-48 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

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

Septic ArthritisManifestations/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

Comparison acute rheumatoid arthritis and septic arthritis of the joint!

Purulent exudate!

Synovial inflammation!

Septic Arthritis (most common in children)

Priority Nursing Diagnosis and Interventions Osteomyelitis and Septic Arthritis

Nursing Diagnosis• Risk for Infection!• Hyperthermia• Acute Pain• Impaired physical

mobility• Potential for injury:

fracture (chronic osteomyelitis)

• Knowledge deficit

Interventions• Acute: prevent, identify

source, short-term antibiotics

• Chronic: opt nutrition, splint for support, surgery,hyperbaric O2, muscle flap, long term antibiotics

Management Osteomyelitis

Septic Arthritis

Avoid the pain and grief of chronic osteomyelitis!

If only I had taken those antibiotics!

Tuberculosis of Bone and Spine

Source Signs and symptoms: vertebral

collapse, pain, deformity (Potts fx), systemic as night sweats, anemia

Diagnosis Treatment

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.”

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.”

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

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

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!

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

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.

Case study chronic osteomyelitis

1. What was the most likely “original” cause of AJ’s osteomyelitis? What organism is the most likely culprit?

2. What risk factors?

3. Explain the pathophysiology of chronic osteomyelitis?

Case study chronic osteomyelitis

1. 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)

2. What risk factors?(Poor blood supply of tibia, over 50, other unknown factors such smoking, hx diabetes, PVD)

3. 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)

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.

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)

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

Case study chronic osteomyelitis

1. What are the priority nursing diagnosis for AJ as he recovers?

2. What teaching is Most important?

Patient resource

Case study chronic osteomyelitis

1. 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)

2. 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)