Osteoporosis (OP) is a loss of bone density, leading to increased bone brittleness and fragility. The main concern with osteoporosis is the increased risk of fractures since the bones are porous and weak.
Osteoporosis may not cause symptoms and patients may be unaware until they experience a fracture, sometimes from a very minor injury. It can occur in any bone, but most fractures occur in the wrists, hips, and spine.
In this article:
- Pathophysiology
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Impaired Physical Mobility
- Risk for Falls
- Risk for Injury
Pathophysiology
The bone remodeling process includes osteoclasts, which remove old bone tissue, and osteoblasts, which deposit new tissue. Both cells work together to maintain bone strength. In osteoporosis, an imbalance occurs, with the resorption of old bone exceeding the formation of new bone.
Our bones undergo the remodeling process throughout our lives, but peak bone mass is reached around age 30, and then we begin to lose bone mass faster than it is created. This is why osteoporosis is most common in older adults. However, there is a rare type of osteoporosis called juvenile osteoporosis that affects children and adolescents.
Nursing Process
Nurses can begin conversations with older adult patients about getting screened for osteoporosis. Nurses can also identify at-risk patients and educate them on prevention and safety measures.
Nursing care for osteoporosis includes ensuring the patient adheres to their medication regimen and proper nutrition or supplementation, participates in exercise and employs safety strategies to prevent falls and fractures.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to osteoporosis.
Review of Health History
1. Let the patient describe their general symptoms.
Osteoporosis does not typically cause symptoms, but the patient may report a change in height or posture or lower back pain if the spine is affected.
2. Determine risk factors.
Nonmodifiable risk factors of OP include the following:
- Age over 50
- Female gender
- White or Asian ethnicity
- A smaller, thinner frame
- Family history of osteoporosis
- Low levels of estrogen or testosterone
Women are at a greater risk for OP than men due to various reasons:
- Women generally have lower calcium intake than men
- Women have less bone mass due to their often smaller frames
- Bone resorption begins earlier in women and becomes rapid during menopause
- Pregnancy and breastfeeding utilize a woman’s calcium reserves
- Longevity increases the risk of the development of osteoporosis (women often live longer than men)
3. Track the patient’s medical history.
Note the following conditions that can cause secondary osteoporosis, such as:
- Autoimmune disorders (rheumatoid arthritis, Crohn’s disease, lupus)
- GI conditions (celiac disease or inflammatory bowel disease)
- Hematologic conditions (multiple myeloma, leukemia, or sickle cell disease)
- Endocrine disorders (diabetes or thyroid conditions)
- Kidney or liver disease
- Anorexia nervosa
- Cancer
- HIV/AIDS
4. Identify gaps in the patient’s lifestyle.
The following lifestyle choices increase the risk of OP:
- Cigarette smoking
- Sedentary lifestyle
- Excessive alcohol intake
- Lack of sunlight exposure (source of vitamin D)
5. Assess the patient’s diet.
Patients who do not consume enough calcium and vitamin D are at risk for osteoporosis. Both are essential as vitamin D helps the body absorb calcium.
6. Review the patient’s medications.
The following medications can interfere with the rebuilding of bone over time or speed up bone loss:
- Diuretics
- Corticosteroids
- Anticoagulants
- Proton pump inhibitors
- Antiseizure medications
- Chemotherapy
7. Assess for a history of fractures.
Most patients do not experience symptoms of OP, and the first indication may be a fracture, even from a minor injury like bending or twisting.
Physical Assessment
1. Assess the musculoskeletal status.
Assess the range of motion and strength of joints to identify potential weaknesses. Assess the patient for kyphosis or a hunchback appearance due to abnormal curving of the spine, as this is an indicator of OP.
2. Track the patient’s height.
Measure the height at each visit and track changes over time. Older adults may exhibit a decline in height as a sign of OP.
3. Assess for underlying causes.
Laboratory tests are used to identify or rule out causes of OP. Tests may include:
- Complete blood count to evaluate for anemia or sickle cell disease
- Serum chemistry levels, specifically calcium, phosphate, magnesium, and alkaline phosphatase
- Liver function tests to assess for chronic alcohol use
- Thyroid-stimulating hormone levels as dysfunction is associated with OP
- Vitamin D level
Diagnostic Procedures
1. Prepare the patient for a bone density test.
A bone mineral density (BMD) test is an X-ray that measures the strength of bones and diagnoses osteoporosis.
2. Evaluate for fractures.
A plan radiograph (X-ray), CT scan, or MRI may be ordered to reveal bone damage and fractures from osteoporosis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient suffering from osteoporosis.
1. Administer medications as prescribed.
Bisphosphonates are the most common medications prescribed to patients with osteoporosis at higher risk for fractures. Medication examples include:
- Alendronate
- Risedronate
- Ibandronate
- Zoledronic acid
Other medications may include selective estrogen receptor modulators for postmenopausal women that act like estrogen without some of the serious side effects. However, some women may require estrogen and hormone therapy. Parathyroid hormone analogs and RANKL inhibitors (most commonly denosumab) are injection medications for postmenopausal women or men at high risk for fractures.
2. Stress the importance of exercise.
Encourage physical activities and exercise that strengthen bones and muscles. Weight-bearing exercises and strength training have been shown to decrease the rate of fractures.
3. Encourage lifestyle modifications.
Smoking increases bone loss, while alcohol reduces new bone formation. Additionally, alcohol can impair balance, leading to falls. Advise the patient to limit alcohol intake and smoking cessation.
4. Promote safety.
Preventing falls is paramount to reducing fractures in OP. Educate on the following strategies:
- Keep the living environment free of electrical cords and throw rugs
- Wear low-heeled shoes with non-slip soles
- Place grab bars in the bathroom/shower and stairways
- Use a cane or assistive device as needed
- Collaborate with an occupational therapist if adaptive equipment is needed
5. Promote adequate dietary intake or supplements as advised.
Adequate dietary intake of calcium and vitamin D is essential for bone health. Provide the patient with a list of food sources. If indicated, instruct on calcium and vitamin D supplementation. Remind patients that sunlight is another source of vitamin D.
6. Limit or discontinue medications.
Long-term steroid therapy may be necessary for certain autoimmune conditions but has the adverse effect of interfering with bone health. Discuss the option of decreasing the dose or discontinuing if possible.
7. Educate teenagers and young adults on bone health.
Bone health begins in childhood. Children, adolescents, and young adults can decrease their risk of OP through habits such as consuming a diet high in calcium and vitamin D, participating in physical activities, and getting daily sunlight.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for osteoporosis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for osteoporosis.
Acute Pain
Osteoporosis does not typically cause pain, but patients with fractures resulting from OP will exhibit pain.
Nursing Diagnosis: Acute Pain
Related to:
- Limited range of motion
- Vertebral compression
- Fracture
As evidenced by:
- Pain with ambulation
- Altered gait pattern
- Tenderness with percussion
- Guarding behavior
- Positioning to ease pain
Expected outcomes:
- Patient will report decreased pain intensity and improved comfort.
- Patient will demonstrate strategies to improve posture and positioning to ease pain.
Assessment:
1. Conduct a comprehensive pain assessment.
The nurse can percuss the spine, provide passive range of motion, and observe ambulation to evaluate for pain in the wrist, hip, vertebra, or pubic bone. Have the patient rate their pain on a numeric scale.
2. Monitor for underlying fractures.
OP does not typically cause pain unless fractures occur, which may be the presenting sign of the disease process. The nurse can assist with X-rays to assess for fractures contributing to pain symptoms.
Interventions:
1. Administer pain medications as indicated.
Pain medications like OTC acetaminophen or NSAIDs are often prescribed for fractures from OP. Narcotics are reserved for severe pain.
2. Encourage the use of braces and orthotics.
Braces and orthotics can help reduce pressure on the fracture site to relieve pain.
3. Collaborate with physical therapy.
OP can result in vertebral compression fractures, causing a hunched posture and kyphosis, which may be uncomfortable. A physical therapist can assist the patient with exercises to improve posture and body alignment.
4. Encourage the use of nonpharmacologic pain relief methods.
Nonpharmacologic pain relief methods like moist heat or transcutaneous electrical nerve stimulation (TENS) may temporarily relieve pain.
Deficient Knowledge
Deficient knowledge about osteoporosis, its prognosis, complications, and available treatment options can lead to the development of preventable fractures.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinformation
- Inadequate knowledge of resources
- Inadequate participation in care planning
- Inadequate access to resources
- Inadequate commitment to learning
- Inadequate interest in learning
- Inadequate awareness of resources
As evidenced by:
- Nonadherence to bone density testing
- Inaccurate follow-through of instructions
- Inaccurate statements about a topic
- Development of fractures
Expected outcomes:
- Patient will verbalize understanding of the disease process, complications, and treatment regimen.
- Patient will demonstrate lifestyle modifications and adhere to the treatment regimen.
Assessment:
1. Assess the patient’s knowledge about osteoporosis, its complications, and treatment options.
This will determine additional information needed and correct any misconceptions about the disease if the patient has any.
2. Assess the patient’s motivation to learn and their support system.
Assessment of the patient’s motivation and ability to learn will guide teaching. A support system can be included to reinforce instructions.
Interventions:
1. Instruct on strength training.
Strength training is the best form of exercise to strengthen bones and muscles and prevent fractures.
2. Instruct on foods high in calcium.
Nutrition plays an important role in osteoporosis. Adequate calcium intake, which increases with age, supports strong bones. Calcium-rich foods include dairy products, broccoli, salmon, and fortified cereals and breads. Calcium supplements may be needed for some patients.
3. Teach the patient about vitamin D supplements.
Vitamin D is important because it allows the body to absorb calcium. Vitamin D can be obtained through milk, supplements, and sunlight exposure.
4. Provide information about support and community groups.
Online support groups can offer additional information about healthy living with osteoporosis.
Impaired Physical Mobility
Patients with osteoporosis can experience impaired physical mobility since their bones are susceptible to fracture. This can impair their ability to move freely and may result in back pain, hunched posture, and lost height.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Disease process
- Bone loss
- Fracture
- Bone pain
As evidenced by:
- Decreased range of motion
- Decreased strength
- Difficulty turning
- Engages in substitutions for movement
- Slowed movement
- Uncoordinated movement
Expected outcomes:
- Patient will maintain functional mobility with or without the use of mobility aids.
- Patient will participate in physical therapy as prescribed.
Assessment:
1. Assess the patient’s functional mobility.
Assess for any difficulties with ambulation or performing ADLs.
2. Assess the patient’s risk factors.
Older age, female sex, use of certain medications, sedentary lifestyle, and diet history can predispose the client to osteoporosis.
Interventions:
1. Encourage the patient to perform range of motion exercises.
Range of motion exercises prevents immobility, including joint contractures and muscle atrophy in patients with osteoporosis.
2. Consult with a physical therapist.
Physical therapy and rehabilitation programs can help provide an appropriate exercise regimen based on the patient’s current condition.
3. Assist with self-care activities.
Allow the patient to perform some self-care activities with minimal supervision to promote patient control over the situation and self-directed wellness.
4. Review lifestyle choices.
Excessive alcohol consumption, tobacco use, and a sedentary lifestyle increase the risk of osteoporosis. Discuss ways to improve lifestyle habits if the client is interested.
Risk for Falls
Osteoporosis weakens the bones and contributes to spinal changes, resulting in poor balance and posture changes, increasing the risk of falls.
Nursing Diagnosis: Risk for Falls
Related to:
- Loss of bone mass
- Disease process
- Low bone density
- Muscle weakness
- Impaired mobility
- Impaired balance
- Spinal changes
- Sedentary lifestyle
- Older age
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free from falls.
- Patient will demonstrate interventions to help reduce the risk of falls.
Assessment:
1. Assess the patient’s strength and mobility.
Osteoporosis may be apparent in patients with a stooped posture, kyphosis, or loss of height from spinal changes, though many patients are unaware of their bone loss. Assess the patient’s gait pattern, range of motion, balance, and posture for signs of abnormalities.
2. Evaluate the patient’s activity level.
Older adults with OP may have a fear of falling since falls can result in fractures. This may cause them to limit their activity and have a sedentary lifestyle, which is counterproductive to preserving bone strength.
Interventions:
1. Encourage exercise to improve strength and balance.
Weight-bearing exercise is one of the most important strategies to protect against bone loss. Even low-impact exercise like walking is beneficial. Incorporating balance exercises can give the patient more confidence against falls.
2. Encourage the use of assistive devices.
Assistive devices like walkers and canes can provide additional support against falls, especially in patients with a stooped posture or vertebral changes.
3. Refer the patient to physical and occupational therapy.
Physical and occupational therapy can help plan appropriate rehabilitative interventions to promote bone and muscle strength and reduce the risk of falls.
4. Instruct on ways to fall-proof the home.
Instruct on potential hazards in the home or ways to make their living environment safer, such as:
- Removing clutter
- Keeping pathways clear
- Installing handrails
- Utilizing lights inside and outside
- Using non-skid mats in the shower/bathroom
5. Consider a life alert system.
There is no cure for OP, though medications and lifestyle changes can help prevent further bone loss. Some patients are more at risk, which only increases as the patient ages. The patient may feel safer at home, especially if they live alone, with a system that allows them to call for help if a fall occurs.
Risk for Injury
Patients with osteoporosis develop porous and weaker bones, increasing the risk of fractures and injuries.
Nursing Diagnosis: Risk for Injury
Related to:
- Disease process
- Bone fracture
- Bone pain
- Weak bones
- Sedentary lifestyle
- Vitamin D deficiency
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will remain safe and free from injuries.
- Patient will demonstrate behaviors that decrease the risk of injuries.
Assessment:
1. Assess factors that can contribute to increased risk for injury.
Some risk factors can be modified to decrease the chances of the patient experiencing injuries.
2. Review recent lab work.
Review recent bone density tests, vitamin D, and calcium levels that predispose the patient to injury.
Interventions:
1. Instruct and administer medications.
Bisphosphonates like alendronate or zoledronic acid slow bone loss and reduce the risk of fractures. Denosumab injections improve bone density results and reduce the incidence of fractures.
2. Provide and teach the use of assistive aids.
Assistive aids like walkers, canes, grab bars, shower benches, toilet risers, and more can reduce the incidence of falls and fractures.
3. Improve environmental safety.
Osteoporosis typically affects the elderly, who may have problems with vision. Instruct on removing throw rugs, using night lights, and hiding cords that could be potential fall hazards..
4. Refer the patient to occupational therapy.
Occupational therapists can recommend equipment, footwear, and tips to improve safety in the home and outside.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care. 9th Edition. Donna D. Ignatavicius, MS, RN, CNE, ANEF. 2018. Elsevier, Inc.
- Meyer, F., König, H., & Hajek, A. (2019). Osteoporosis, fear of falling, and restrictions in daily living. Evidence from a nationally representative sample of community-dwelling older adults. Frontiers in Endocrinology, 10, 646. https://doi.org/10.3389/fendo.2019.00646
- Osteoporosis. Cleveland Clinic. Reviewed: April 27, 2020. From: https://my.clevelandclinic.org/health/diseases/4443-osteoporosis
- Osteoporosis. Mayo Clinic. Reviewed: August 21, 2021. From: https://www.mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968
- Osteoporosis. National Institute on Aging. Reviewed: November 15, 2022. From: https://www.nia.nih.gov/health/osteoporosis
- Osteoporosis Overview. NIH Osteoporosis and Related Bone Diseases National Resource Center. Reviewed: October 2019. From: https://www.bones.nih.gov/health-info/bone/osteoporosis/overview
- Osteoporosis – Diagnosis and treatment – Mayo Clinic. (2023, September 7). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved March 2024, from https://www.mayoclinic.org/diseases-conditions/osteoporosis/diagnosis-treatment/drc-20351974
- What are osteoporosis warning signs? (2023, July 20). Cleveland Clinic. Retrieved March 2024, from https://my.clevelandclinic.org/health/diseases/4443-osteoporosis
- Whitaker Elam, R. E. (2024, February 20). Osteoporosis workup: Approach considerations, laboratory studies, biochemical markers of bone turnover. Diseases & Conditions – Medscape Reference. Retrieved March 2024, from https://emedicine.medscape.com/article/330598-workup#showall
