Transcript document

Medical-Surgical
Musculo-Skeletal System
Disorders
Review of Musculo-Skeletal System
Anatomy and Physiology
• Bone – hard tissue that makes up most of the
skeletal system.
Functions: 1. support
2. protection
3. movement
4. storage of calcium and
other ions
5. manufacture of blood cells
Cartilage
• Specialized fibrous connective tissue.
• It provides firm but flexible support for the
embryonic skeleton and part of the adult
skeleton
• Differs from bone in that its matrix has the
consistency of a firm plastic or gristle-like
gel.
• Cartilage cells are called chondrocytes
and are located in tiny spaces that are
distributed throughout the matrix.
Terminologies
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Acrosclerosis
Amputation
Ankylosis
Arthritis
Arthrocentesis
Arthrogram
Arthroplasty
Arthroscopy
Bursitis
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Cast
Dislocation
Electromyogram
Fasciotomy
Fracture
Gangrene
Gout
Halo Device
Kyphosis
Laminectomy
Terminologies
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Lordosis
Myelogram
Orthopedics
Osteomalacia
Osteomyelitis
Prosthesis
Replantation
Rickets
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Sclerodactyly
Scoliosis
Sequestration
Skeletal Traction
Spinal Stenosis
Sprain
Strain
Synovectomy
Tenosynovitis
Acronyms
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AEA
AKA
BEA
BKA
CK
CMS
CPM
DJD
ECG
EEG
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ESR
HNP
IVD
OA
ORIF
RA
RF
SLE
THA
TMJ
TLSO
Joint Structure and Function
• Connective tissue disorders are often
manifested as joint disorders since joint
mobility is dependent on functional
connective tissues.
• Joint is the site at which two or more bones
of the body are joined.
• Joint permits motion and flexibility of the
rigid bone
• Hyoid bone – the only bone in the human
body that does not articulate with at least
one other bone, to which the tongue is
attached.
Ligaments
• Are strong and flexible fibrous bands of
connective tissue that connect bones and
cartilage and support muscles.
• Yellow ligaments and white ligaments
have distinctively different functions.
• Yellow ligaments, located in the vertebral
column, are elastic and allow for
stretching.
• White ligaments, found in the knee, do not
stretch but provide stability.
Joint Structure and Function
• Classification on basis of the extent of
movements:
• Synarthroses – fixed joints
ex. Skull – allow no movement at all
• Amphiarthroses – slightly movable joints
ex. Juncture of the ulna and radius in the
forearm.
• Diarthroses – freely movable joints
ex. Elbows, shoulders, fingers, hips, and knees.
sometimes called synovial joints. They are
encased in a fibrous capsule made of strong
cartilage and lined with synovial membrane
Tendons
• Are composed of very strong and dense
fibrous connective tissue.
• They are in the shape of heavy cords and
anchor muscles firmly to bones.
• Achilles tendon, one of the most prominent
tendon which can be felt at the back of the
ankle just above the heel.
Joint Structure and Function
• Synovial membrane is very smooth, thus
permitting structures to move without
friction.
• Ligaments are tough fibrous cords that
bind the capsule.
• Synovial fluids fills and lubricates the
space in the middle of the joint.
• Bursae permit tendons to sl,ide easily with
movement of the bones.
Definition of Terms
• Orthopedics – specialty of medicine that
examines and treats diseases and injuries
of the musculoskeletal system.
• Orthopedists- Surgeon who specialize in
the area of orthopedics.
• Orthopedic nursing – involves preventing
further complications for clients with
musculoskeletal conditions.
Common Diagnostic Tests Related to
Musculo-Skeletal Disorders
• Diagnostic Tests – nursing clients with
musculoskeletal disorders is likely to
involve preparation for physical
examination, radiographic tests, and other
diagnostic procedures.
• Be sure to explain the actual procedures
to reduce tension or anxiety that clients
may experience.
Laboratory Test
• Diagnostic Studies for Diagnosing
Connective Tissue Disorder.
• Studies help to determine whether a disorder
is inflammatory or non-inflammatory.
• Complete Blood Cell ( CBC) Count
- identifies the total number of blood cells
(WBC’s, RBC’s and platelets as well as
hemoglobin (Hgb) and hematocrit (Hct),
percentage of blood consisting of RBC’s
and RBC indices.
WBC Count – increase in infection, tissue
necrosis, inflammation, may decrease in SLE.
RBC Count – detects and differentiates blood
dyscrasias. Decreased in RA and SLE.
Laboratory Test
• Erythrocyte Sedimentation Rate (ESR) –
Determines presence of inflammation as
in Rheumatoid Arthritis (RA), Rheumatic
Fever, and decreased with osteoarthritis.
Fasting not required. Apply pressure to
venipuncture site. Assess
site for bleeding
• C- Reactive Protein Determination
- Detects active inflammation as in RA and
disseminated lupus erythematosus.
Restrict food and fluids for 4 hours.
Apply pressure to venipuncture site. Assess
site for bleeding
Laboratory Test
• Venereal Disease Research Laboratory
(VDRL) – Measures antibodies to syphilis.
Sometimes decrease in SLE. Fasting not
required. Apply pressure to venipucture
site. Assess for bleeding.
• Rheumatoid Factor ( RF) – Detects antibodies
often present with RA. Fasting not required.
Apply pressure to venipucture
site. Assess for bleeding.
Laboratory Test
• Antinuclear Antibodies (ANA) – Positive in
SLE, systemic sclerosis, Reynaud’s
disease, Sjoren’s sysndrome, and
necrotizing arteritis. Fast for 8 hours.
Apply pressure to venipuncture site.
Assess site for bleeding.
• Creatinine- Assesses renal function.
Increase with SLE, PSS, polyarthritis.
Fasting not required. Apply pressure to
venipuncture site. Assess site for bleeding.
Laboratory Test
• Urine maybe tested also for creatinine and uric
acid level.
• 24- Hour Urine Creatinine
- Measures renal function and status of muscles
diseases. Instruct the patient to collect a 24-hour
urine specimen.
• Urinary Uric Acid ( 24-Hour Collection).
- Measures uric acid metabolism; increase in
gout, liver disease, chronic myelogenous
leukemia, fever.
Requires a 24-hour urine specimen.
Radiologic Studies
• Arthrography – Use contrast medium to
show soft-tissue joint structures. Question
patient about allergy to contrast agent,
seafood, iodine. Tell patient that needle
insertion may cause swelling that last
several days. Assess and document
discomfort, swelling. Instruct patient to
avoid strenuous activity 12-24 hr. after
test. Joint may be wrapped.
Computed Tomography (CT)
• Detec tumors and some spinal fractures.
Tell patient that procedure may be lengthy
(up to 30 min per body part). Patient lies
on a stretcher while a machine scans area
being studied. No post procedure nursing
care required.
Diskography
• Visualizes vertebral disk after contrast
medium injected into disk. Preparation and
post nursing care is same as in
arthrography
Magnetic Resonance Imaging
• Visualizes soft tissue. May detect avascular necrosis ,
disk disease, tumors, osteomyelitis, and torn ligaments.
- tell the patient the procedure is painless;
must lie still for 30 min. or more . Some
equipment has videos that patient can
view to reduce anxiety. Ask whether patient is
claustrophobic. Give sedation if ordered for
agitated
or anxious patients. Remove any metallic object such as
jewelry. Inquire whether patient has any implanted
devices such as cardiac pacemaker or intracranial
aneurysm clips and notify radiologist. Procedure is
contraindicated with some implants. Metal may not a
problem with some newer equipment. No post procedure
care requires. Safety is needed is sedated.
Nuclear Scintigraphy (Bone Scan)
• Detects bone malignancies, osteoporosis,
osteomyelitis and some fractures.
• Contraindicated during pregnancy. Tell patient
that a small amount of radioactive
material will be injected intravenously, then a
scanner will move slowly back and forth over the
body as the patient lies on a stretcher . May take
1 hour procedure is painless except for
venipuncture. Radioactive isotopes are not
harmful except to fetus. Empty bladder
immediately before procedure for comfort and
prevent blocked view of pelvis.
Common Diagnostic Tests Related to
Musculo-Skeletal Disorders
• Radiography (X-Ray)
- is the most common method of
assessing the general state of the bone.
- non-invasively visualizes bones and
other internal structures, so that health
care provider can diagnosed abnormalities
and monitor the effectiveness of
treatments.
- Some types of radiographic exams
requires use of radiographic dyes
Radiography
• Shows density, texture, and alignments of
bones; reveals soft tissue involvement.
Tell patient to expect to lie on an X-ray
table or to stand next to a special device
while films are taken. Remove any
radiopaque objects ( jewelry, etc.), that
can interfere with results. Advise radiology
of patient’s physical limitations r/t moving,
turning, climbing.
Tomography
• Provides details of structure otherwise hidden by
bone.Requires lying in a cylindric
scanner;assess for claustrophobia and inform
radiologist.
• Ultrasonography
- reveals masses or fluid in soft tissue.
• Arthroscopy
- A surgical procedure to visualize a joint
cavity and structure and to obtain fluid
and/or tissue for study. Inform patient that
procedure is performed in operating room
under local or general anesthesia.
Arthrogram
• X-Ray study of the joint ( e.g. Knee or shoulder)
• Radiopaque or radiolucent substance is injected,
and then a sequence of x-rays is taken to
determine the joint’s condition.
Myelogram
• Is an x-ray examination of the spinal cord and
vertebral canal after injection of a contrast
medium or air into the spinal sub-arachnoid
space. Valuable in evaluating spinal cord
abnormalities cause by tumors, herniated
intervertebral disk, or other lesions.
Ultrasound
• Uses sound waves and their echos to
display images –helps to evaluates soft
tissue masses, osteomyelitis, infection,
congenital and acquired pediatric
disorders, bone mineral density, sports
injuries, and fracture healing.
• Non-invasive, inexpensive, readily
available, and safe because it does not
involve ionizing radiation.
Arthrocentesis
• Aspiration of synovial fluid, blood, or pus
from a joint cavity. By examining these
fluids, a health care provider can
diagnosed infections, inflammatory
conditions and bleeding
• Compression dressing is a joint after the
procedure and the joint is rested for 1 day.
Arthroscopy
• Invasive procedure using specialized endoscope design to
view joints.
• Use tiny incision known as stab wound.
• It is a close procedure.
• Performed in OR or same day surgery often under local
anesthesia.
• Arthroscopy use to diagnosed and treat joint disorders.
• E.g. Foreign or loose objects ( piece of cartilage or a bone spur
can be removed.
• Rough and worn joint can be made smoother and more
comfortable.
• Tissue samples can be obtained for biopsy.
• Torn meniscus or ligament can be diagnosed and possibly
repaired.
• Much safer, more comfortable, and more cost effective than
open surgery.
• Post procedure, elevate client’s joint and apply ice to control
edema and pain. Teach client to monitor for s/s of infection.
Biopsy
• Biopsy of bone, tissue, or muscle must be
performed using local anesthesia to
diagnose tumors, infections, muscle
inflammation or arthophy and various
other problems.
• Post procedure , monitor site for bleeding,
swelling, infection or hematoma.
Electromyogram (EMG)
• Test of electrical conductivity, similar to
ECG or the EEG. Provider places fine
needles into the client’s muscle and
measures the electrical impulses within
the muscle, both at rest and during
activity. The provider can then determine
whether or not the client’s muscle respond
appropriately to stimuli.
Commom Medical Treatments
• Joint, bone and muscle disorders often cause
pain and limit movement.
• Common treatments include:
- Heat application e.g. hot soaks or baths
paraffin baths.
- Cold application e.g. cold compress or packs
• Physical Therapy – PROM and AROM
• Massage – if joints are not damage or inflamed,
often helps to soothe aching joints.
• External immobilization – braces, corsets,
splints, cast and traction.
Common Surgical treatments
• Performed to remove or repair damaged
or diseased parts.
• Disorders that require surgery include
fractures, ligament ruptures, arthritic joints,
or accidental limb amputation
• Surgery necessary when fractured joint or
bone cannot heal with external fixation.
• Fracture resulting to multiple fragments
using surgical hardware such as pins,
screws, or plates
Example of surgery:
• Common treatment for client with either
arthritis or severe fractures that may not
heal.
- Joint –replacement surgery
- Arthroplasty
• Amputation surgical choice if a limb is
damage by injury or disease beyond
repair.
Common Therapeutic Measures
• Splint, Cast and Immobilizers
• Use to secure the position of the body parts
being treated.
• Hold the bone in alignment while allowing
enough movement for other parts of the body to
carry out activities of daily living.
Cast- is a solid mold that is used to immobilized a
fracture can be made of plaster of Paris,
fiberglass, thermoplastic resins, thermolabile
plastic and polyester-cotton knit impregnated
with polyurethane.
Common Therapeutic Measures
• Plaster of Paris – anhydrous calcium sulfate
embedded in gauze. Least expensive type of
cast used.
• Dries after about 24 to 72 hours depending on
the size and location.
• Can withstand weight-bearing and other
stresses as long as dry and strong.
• Petaling – short pieces of tape placed over the
edges of the cast to prevent skin irritation by
rough edges and to protect the cast from
moisture and soiling.
Cast – fiberglass
• is a synthetic material used for cast that is lighter
and has shorter drying time than plaster of
Paris.
• Drying time 10 -15 minutes, and can stand
weight-bearing 30 minutes after application.
• Cast split down the front to allow the casting
material and padding to spread.
• Bivalved cast is cut down both sides so that the
front portion can be removed while the back
portion maintain immobilization.
• Windowed cast – opening is cut into the cast to
allow inspection of the body area or to relieve
pressure. Cut out window need to be saved.
4 main groups of cast
• Upper extremity cast – use for breaks in the shoulder,
arm, wrist and hand. Wearing an arm cast should keep
the arm elevated above the heart when lying in bed to
prevent swelling. Arm is kept in a sling for support when
the patient is up.
• Lower extremity- used for breaks in the upper and lower
leg, ankle and foot. A leg cast is used to allow mobility
and maybe used with crutches. Affected leg should be
elevated on several pillows during the first few days after
the break to prevent swelling.
• Cast brace – supports the affected part while allowing
the knee to bend . Applying a cast above and below the
knee and connecting them with hinge.
Body or spica cast
• Used when a fracture is located
somewhere in the trunk of the body. The
body cast encircles the trunk , whereas a
spica cast encase the trunk plus one or
two extremities.
• Body or spica cast severely limit mobility
and may cause complications related to
lack of movement such as skin
breakdown, respiratory problem,
constipation, and joint contractures.
Cast Syndrome
• It is cause by compression of a portion of
the duodenum between the superior
mesenteric artery and the aorta and
vertebral column.
• Sign and symptoms:
- nausea
- abdominal distention
Facts:
• Cast is removed only on physician’s order.
• Cast cutter – use to cut the plaster
• Skin under the cast will be noted tender
and dry and may have crust of dry skin.
• Gently wash the areaand explain that the
skin will regain its normal appearance after
few days.
• Muscle atrophy may be apparent. Assure
the patient that muscle mass will be
restored with use of limb.
Patient teaching plan ( Cast Care)
• Keep plaster cast dry: follow physician’s
instructions regarding wetting synthetic cast.
• Do not remove any padding.
• Do not insert any foreign object inside the
cast.
• Do not bear weight on a new plaster cast for 48
hours ( synthetic , less than an hour.)
• Do not cover the cast with plastic for prolonged
periods.
• Do report swelling, discoloration of toes or
fingers, pain during motion, and burning or
tingling under the cast to health care provider.
Traction
• Exerts a pulling force on a fracture
extremity to provide alignment of the
broken bone fragments.
• It is also use to correct deformity,
decrease muscle spasm, promote rest,
and maintain the position of the diseased
or injured part.
• Applied directly to skin ( skin traction)
• Attached directly to the bone ( skeletal
traction) by means of metal pin or wire.
Skin Traction
• Weight is no more than 5 to 10 lbs to prevent injury to
the skin.
• Buck’s traction – used for hip and knee contractures,
muscles spasms, and alignment of hip fractures.
Skeletal Traction
• provides a strong, steady, continuous pull and can be
used for prolonged periods of time.
• e.g. Gardner-Wells, Crutchfield, and Vinke tongs and a
halo vest, in which pins are inserted into the skull on
either side. Heavier weights can be used with skeletal
traction , usually from 15 – 30 lbs.
Cruthcfield traction and a halo vest are used for
reduction and immobilization of fractures of the cervical
or high thoracic vertebrae.
Complication of tractions
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Impaired circulation
Inadequate fracture alignment
Skin breakdown
Soft tissue injury
Pin track infection and osteomyelitis can
occur
Important points to remember when patients
are in traction
• Weights always hangs freely.
• Be sure the amount of weight used is correct as ordered,
clamps are tight, and ropes moves freely over pulleys.
• Maintain good body alignments so the line of pull is
correct.
• Use padding to prevent trauma to skin where traction is
applied. Report skin breakdown or irritation to the
physician
• Assess affected extremities for temperature, pain,
sensation, motion, capillary refill time and pulses.
• With skeletal traction, assess pin sites for redness,
drainage, or odor which may indicate infection.
Application of Nursing Process on MS
Disorders
• Data collection
• Assess for skeletal
deformity, and body build, note for asymetry, or
deformity.
• Palpate soft tissues, joints and muscles.
• Assess skin temperature and document any
swelling, crepitation, tenderness, or other
abnormality.
• Evaluate the client’s musculoskeletal function,
ROM, muscle strength, balance, and gait.
• Ability and safety in using mobility aids
• Observe client’s emotional response to the
disorder or disease.
Nursing Diagnosis
• Established nursing diagnoses based on
data collected.
Planning and Implementation
• Include clients and their families
• Preventing Disorders of immobility
• Providing comfortable position and proper alignment
• Providing skin care
• Providing adequate nutrition
• Providing activity and exercise
Evaluation
• Periodically evaluate outcome care with client’s families
and members of the healthcare team.
Common Musculoskeletal
Disorders
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Amputation
Chronic Back Pain
Temporomandibular Joint Disorders
Degenerative Disorders
Repetitive Strain Injuries
Inflammatory Disorders
Systemic Disorders with Musculoskeletal
Manifestations
• Gout
• Lupus Erythematosus
• Scleroderma
• Rickets and Osteomalacia
Traumatic Injuries
• Sprains
• Strains
• Dislocations
• Fractures
Hip/Fracture Hip Replacement
• Hip Fractures
• Common in older adults
• Refers to proximal third of the femur which
extends up to 5 cm below the lesser
trochanter.
• Intracapsular fracture - Fx occur within the
the hip joint capsule. ( femoral neck)
Clinical Manifestation
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External rotation.
Muscle spasm
Shortening of the affected extremity and
Severepain and tenderness in the region
of the fracture site.
• Note: Displaced femoral neck fx causes
serious disruption of blood supply to the
femoral head which can result to avascular
necrosis of the femoral head
Collaborative Care
• Surgical repair – preferred method of
managing intracapsular and extracapsular
hip fractures.
• Permits early mobilization of the pt. and
decrease risk of major complications.
• Initial tx- immobility temporary with Buck’s
traction until physical condition stabilize.
• Bucks traction relieves painful muscle
spasm
• Used for 24 to 48 hours maximum
Buck’s Traction
Pre-operative Mgt.
• Consider when planning tx chronic health
problems.
• Appropriate analgesics or muscle relaxant
• Comfortable positioning unless
contraindicated.
• Properly adjusted traction.
• Careful preoperative teaching can affect
mobility.
• Teaching done at the ER
• Consider cognitive abilities.
Preoperative Mgt.
• Teach - Method and frequency of
exercising for the unaffected leg and both
arms.
• Encourage use of overhead trapeze bar
and opposite side rails to assist in
changing position.
• Inform family of weight –bearing status
after surgery.
Post- operative ORIF
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ORIF – open reduction external fixation
Monitoring V/S
Monitoring I and O
Supervise respiratory activities – Deep
breathing exercises, couhing, use of
spirometer.
• Pain medication administration cautiously.
• Observe for dressing and insicion for s/s
bleeding and infection.
Early post operative
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Assess for pt. extremity on
color
Temperature
Capillary refill
Distal pulses
Edema
Sensation
Motor function
Pain
Things to note for
• Pain resulting from poor alignment of
extremity can be reduced by keeping
pillows between the knees
• Sandbag and pillows are used to prevent
external rotation.
• With PT collaboration supervise active
assistance exercises for the affected
extremity.
• Ambulation begins usually between first or
second post-op day day
Complication to monitor
• Non-union avascular necrosis
• Dislocation
• Degenerative arthritis
• Hip Fx can be treated by insertion of
femoral head prothesis.
Measures to prevent Dislocation
• Do not :force hip into greater than 90
degrees of flexion
• Force hip into adduction
• Force hip into internal rotation
• Cross legs
• Put on own shoes or stockings until 8
weeks after surgery without adaptive
device ( use long handled shoe horn.
Measures to prevent Dislocation
• Do:
• Use toilet elevator on toilet seat
• Place chair inside shower or tub and remain
seated while washing on good side or when
supine
• Keep hip neutral when sitting walking or lying
• Notify surgeon if pain, deformity, or loss of
function occurs.
• Inform dentist of presence of prosthesis before
dental work so prophylactic ATB can be given
Osteoporosis
• Osteoporosis is a disease of bones that leads to an
increased risk of fracture. In osteoporosis the bone
mineral density (BMD) is reduced, bone
microarchitecture is disrupted, and the amount and
variety of proteins in bone is altered.
• Osteoporosis is most common in women after
menopause, when it is called postmenopausal
osteoporosis, but may also develop in men, and may
occur in anyone in the presence of particular hormonal
disorders and other chronic diseases or as a result of
medications, specifically glucocorticoids, when the
disease is called steroid- or glucocorticoid-induced
osteoporosis (SIOP or GIOP). Given its influence in the
risk of fragility fracture, osteoporosis may significantly
affect life expectancy and quality of life.
Osteoporosis
• Osteoporosis can be prevented with lifestyle changes and
sometimes medication
• In people with osteoporosis, treatment may involve both. Lifestyle
change includes exercise and preventing falls as well as reducing
protein intake medication includes calcium, vitamin D,
bisphosphonates and several others.
• Fall-prevention advice includes exercise to tone deambulatory
muscles, proprioception-improvement exercises; equilibrium
therapies may be included.
• Exercise with its anabolic effect, may at the same time stop or
reverse osteoporosis. Osteoporosis is a component of the frailty
syndrome.
Pathogenesis
• Imbalance between bone resorption and bone formation.
• The three main mechanisms by which osteoporosis
develops are an inadequate peak bone mass, excessive
bone resorption and inadequate formation of new bone
during remodeling. Hormonal factors strongly determine
the rate of bone resorption; lack of estrogen (e.g. as a
result of menopause) increases bone resorption as well
as decreasing the deposition of new bone that normally
takes place in weight-bearing bones. The amount of
estrogen needed to suppress this process is lower than
that normally needed to stimulate the uterus and breast
gland.
Sign and symptoms
• Signs and symptoms
• Osteoporosis itself has no specific
symptoms; its main consequence is the
increased risk of bone fractures.
Osteoporotic fractures are those that occur
in situations where healthy people would
not normally break a bone; they are
therefore regarded as fragility fractures.
Typical fragility fractures occur in the
vertebral column, rib, hip and wrist.
Risk factors
• Advanced age (in both men and women)
and female sex; estrogen deficiency
following menopause is correlated with a
rapid reduction in bone mineral density.
• Those with a family history of fracture or
osteoporosis,
• Excess alcohol
• Vitamin D deficiency
Risk factors
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Tobacco smoking
Malnutrition
Underweight/inactive - bone remodeling
Excess physical activity
Heavy metals - exposure to cadmium
Diseases and disorders ex. Cushing
syndrome. Hyperparathyroidism and
hypothyroidism.
• Medications – steroids, barbiturates,
phenytoin, barbiturates.
Treatments
• There are several medications used to
treat osteoporosis, depending on gender.
Medications themselves can be classified
as antiresorptive or bone anabolic agents.
Antiresorptive agents work primarily by
reducing bone resorption, while bone
anabolic agents build bone rather than
inhibit resorption. Lifestyle changes are
also an aspect of treatment.
Treatments
• Antiresorptive agents – Bisphosphonates
• Fosamax) 10 mg a day or 70 mg once a week,
risedronate(Actonel) 5 mg a day or 35 mg once a week
and or ibandronate(Boniva) once a month.
• Estrogen analogs
• Estrogen replacement therapy remains a good treatment
for prevention of osteoporosis but, at this time, is not
recommended unless there are other indications for its
use as well.
• Raloxifene
• Calcitonin
• Bone anabolic agents
• Teriparatide (Forteo, recombinant
parathyroid hormone residue
• Calcium salts come as water insoluble and
soluble formulations.
• Sodium fluoride
Prevention
• Methods to prevent osteoporosis include
changes of lifestyle..
• Fall prevention can help prevent
osteoporosis complications.
• Nutrition- Proper nutrition includes a diet
sufficient in calcium and vitamin D
• Patients at risk for osteoporosis (e.g.
steroid use) are generally treated with
vitamin D and calcium supplements and
often with bisphosphonates.