Metabolic Diseases of the Bone

1
Metabolic Diseases of the Bone

• Pagets
• Gout

Carolyn Morse Jacobs, RN, MSN, ONC
2
Pagets 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
Pagets 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
Pagets Disease

• Diagnosis
• 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
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) Metabo
lic (hypercalcemia, hypercalciuria)
Case study
7
Pagets 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
Pagets 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 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

11
Manifestations Gout
12
(No Transcript)
13
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!

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
OsteomyelitisManifestations/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 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

24
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

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

• Interventions
• 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
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 dont 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 dont 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

1. What was the most likely original cause of AJs
   osteomyelitis? What organism is the most likely
   culprit?
2. What risk factors?
3. Explain the pathophysiology of chronic
   osteomyelitis?

38
Case study chronic osteomyelitis

1. What was the most likely original cause of AJs
   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)

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

1. What are the priority nursing diagnosis for AJ as
   he recovers?
2. What teaching is Most important?

43
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)