Transcript Metabolic Diseases of the Bone Paget’s Gout

Metabolic Diseases
of the Bone
•Paget’s
•Gout
Carolyn Morse Jacobs, RN,
MSN, ONC
Paget’s Disease (osteitis deformans)
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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)
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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
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Diagnosis
• Increased serum alkaline phosphatase
• X-ray shows thickened bone, curved, abnormal
structure
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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?
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)
Case study
Paget’s disease
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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
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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
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Nursing Diagnosis
• Chronic Pain
• Impaired Physical Mobility
Gout
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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
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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
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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.
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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.
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Kidney disease with
untreated gout; kidney
stones!
Management Gouty Arthritis
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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
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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
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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
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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 Arthritis
Inflammation with an Infectious cause.
Osteomyelitis affects the bones; septic arthritis affects
the joints.
Etiology/Pathophysiology Osteomyelitis

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Usually bacterial cause
Most often from direct
inoculation or
contiguous infection
(open wound/adjacent
wound)
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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
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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 osteomyelitis
Acute
Chronic
Sinus tracts form,
bone destruction
Etiology/Pathophysiology Septic Arthritis
(Joint infection)

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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
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Onset abrupt; pain, stiffness in joint, red,
hot and swollen; systemic manifestations
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Agents
• staph, strep, e-coli, Pseudomonas,
gonorrhea, viral, post rubella
Osteomyelitis
Manifestations/complications
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Acute 24-48 hrs postsurgery
• Pain
• CV: tachycardia; chills,
fever
• Integumentary:
Swelling, erythemia,
lymph node
involvement
• MS: Pseudoarthrosis
involved limb
Chronic
• Signs & symptoms
chronic infection
• Drainage wound
perodically
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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 Arthritis
Manifestations/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
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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
Synovial
inflammation!
Comparison acute
rheumatoid arthritis
and septic arthritis
of the joint!
Purulent
exudate!
Septic Arthritis (most common in children)
Priority Nursing Diagnosis and
Interventions Osteomyelitis and Septic
Arthritis
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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
If only I had taken
those antibiotics!
Avoid the
pain and grief
of chronic
osteomyelitis
!
Tuberculosis of Bone and Spine
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Source
Signs and symptoms: vertebral
collapse, pain, deformity (Potts fx),
systemic as night sweats, anemia
Diagnosis
Treatment
Test Yourself!
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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?
•
•
•
•
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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
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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
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Sudden increase indicates that antibiotic is not effective; other
signs/symptoms are common due to initial pain of osteomyelitis
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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)