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Orthopedic 6

Gout (illustration)
Definition
1. monoarticular asymmetrical arthritis
2. characterized by hyperuricemia
Etiology
1. primarily affects men
2. peak incidence 40 to 60 years of age
3. familial tendency
4. abnormal purine metabolism or excessive purine intake results in formation of uric acid crystals which are deposited in the joints and connective tissue.
5. deposits are most often found in the metatarsophalangeal joint of the great toe or in the ankle.
Findings
1. tight, reddened skin over the inflamed joint
2. elevated temperature
3. edema of the involved area
4. hyperuricemia
5. acute attacks commonly begin at night and last three to five days
6. gout attacks may follow trauma, diuretics, increased alcohol consumption, a high purine diet, stress (both psychological and physical) or suddenly stopping of maintenance medications
7. warning signs of flare-up include the exacerbation of previous findings or the development of a new one
8. systemic manifestations may include fever, renal disease, tophus
Diagnostics: lab tests find -
1. increased urinary uric acid following a purine restricted diet
2. hyperuricemia
Management
1. expected outcomes: control symptoms; prevent attacks
2. medical
  1. NSAIDs
  2. colchicine (used when NSAIDs are contraindicated) - enhances the excretion of uric acid
  3. to prevent flareups: antihyperuricemic agents such as allopurinol (lopurin) or probenecid (benemid) - minimize the production of uric acid
  4. heat or cold therapy
3. dietary
  1. avoid purine foods such as meats, organ meats, shellfish, sardines, anchovies, yeast, legumes
  2. control weight
  3. drink less alcohol - all types
Nursing care
1. pain management strategies
2. elevate the affected limb; provide bed rest and immobilize joint
3. avoid pressure or touching of bed clothing on affected joint
4. reinforce dietary management and weight control
5. administer anti-gout medications as ordered
6. increase fluid intake to prevent renal calculi (kidney stones)
Metabolic Bone Disorders
Osteomalacia
1. Definition - delayed mineralization; resulting bone is softer and weaker
2. Pathophysiology - similar to rickets
  1. bones have too little calcium and phosphorus
  2. vitamin D deficiency; possibly inadequate exposure to sunlight
    1. less serum calcium than normal
    2. more parathyroid hormone
    3. more renal phosphorus clearance
1. Findings
  1. accurate client history includes:
    1. generalized muscle and skeletal pain in hips
    2. similar pain in low back
  2. physical examination
    1. gait
      - client unwilling to walk
      - wide stance
      - waddling gait
    2. muscle weakness
    3. bones
      - deformities of weight-bearing bones
      - scoliotic or kyphotic deformities of the spine
      - bones break easily
2. Diagnostic testing
  1. radiographic findings
    1. generalized demineralization
    2. pseudo fractures
    3. bending deformities
  2. laboratory studies
    1. decreased serum calcium
    2. decreased serum phosphorus
    3. alkaline phosphatase level is moderately elevated
3. Management
  1. calcium gluconate
  2. vitamin D daily until signs of healing take place
  3. diet high in protein
  4. ultraviolet radiation therapy
Osteoporosis (illustration)
1. Definition
  1. multifactorial disease results in
    1. reduced bone mass
    2. loss of bone strength
    3. increased likelihood of fracture
  2. types
    1. type one osteoporosis (estrogen related)
    2. type two osteoporosis (related to old age)
2. Etiology/epidemiology
  1. most common metabolic disease of bone
    1. affects an estimated 25 million Americans
    2. contributor of 50% of all adult fractures
  2. onset is insidious
  3. women affected twice as often as men before the age of 70
  4. skeletal changes result from the aging process
  5. bone loss due to
    1. immobilization
    2. lack of gravitational stress
1. Factors related to osteoporotic fractures
  1. low bone density
  2. history of scoliosis
  3. neurological impairment after
    1. CVA
    2. Parkinson's disease
    3. decreased vision from macular degeneration, complications of diabetes, etc.
  4. best indicator of fracture risk in bone densitometry
1. Findings
  1. client history
    1. acute fracture
    2. prior history of a traumatic fracture; no trauma
    3. history of falls
  2. pain
    1. greater when active, less while resting
    2. early in disease, pain in mid to low thoracic spine
  3. anxiety
    1. about further falls/fractures
    2. about ability to perform ADLs
  4. kyphosis- 'Dowager's hump' may reflect multiple spinal fractures
  5. loss of height
    1. two or more inches
    2. usually precedes diagnosis of osteoporosis diagnosis
1. Diagnostics
  1. blood tests
    1. complete blood counts
    2. serum levels
      - calcium
      - phosphate
      - alkaline phosphatase
  2. x-rays
    1. help identify fractures and kyphosis of spine
    2. less useful in the detection of pre-fracture osteoporosis
    3. detect osteoporosis only after 20% bone mineral content is lost
  3. bone densitometry
    1. best means of measuring risk for fracture
    2. quantitative computerized axial tomogram (CAT) measures pure vertebral trabecular bone
    3. dual energy x-ray absorptionometry (DEXA)
      - technique of choice
      - assesses cortical and trabecular bone in spine and hip
      - single photon absorptionometry measures cortical bone in long bones
1. Management
  1. exercise
    1. restorative - aims to increase bone density, decrease risk for fracture
    2. within the client's tolerance
    3. must be maintained throughout life
  2. nutrition
    1. calcium and vitamin D
    2. deficiencies increase risk of fracture
    3. sedentary older adults may need supplements
  3. medication
    1. anti-resorptive agents
      - do not increase bone mass - rather prevent further bone loss
      - estrogen therapy
      - calcitonin (Osteocalcin)
        
        peptide hormone
        powerful inhibitor of osteoclastic bone resorption
        modestly increases bone mass in osteoporosis
      - not shown to decrease osteoporotic fractures
      - expensive
    2. biophosphonates
      - inhibit bone resorption
      - sustained use associated with osteomalacia and Paget's disease
      - alendronate (Fosamax)
        
        100 to 500 times more potent than etidronate
        non-hormonal agent
        highly selective inhibitor
        not associated with detrimental effects of mineralization
        expensive: average $41.70 per day for osteoporosis
    3. bone-forming agents
      - sodium fluoride (Fluoritab)
      - androgens
        
        taken long-term, increases bone mass in osteoporotic women
        but androgens virilize and elevate cholesterol levels

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