OM VERMA ASSISTANT PROFESSOR RELIANCE INSTITUTE OF NURSING LIMTARA DHAMTARI ( C.G)

1. Topic
OSTEOMALACIA AND OSTEOPOROSIS
PRESENTED BY
OM VERMA
ASSISTANT PROFESSOR
RELIANCE INSTITUTE OF NURSING DHAMTARI (C.G)

2. OSTEOMALACIA AND OSTEOPOROSIS
Osteomalacia is derived from Greek: osteo- which means "bone", and
malacia which means softness. Osteomalacia is the softening of the
bones due to defective bone mineralization. Osteomalacia in children is
known as rickets, and because of this, use of the term osteomalacia is
often restricted to the milder, adult form of the disease. It may show
signs as diffuse body pains, muscle weakness, and fragility of the bones.
A common cause of the disease is a deficiency in vitamin D, which is
normally obtained from the diet and/or sunlight exposure.
Osteomalacia refers to a marked softening of your bones, most often
caused by severe vitamin D deficiency. The softened bones of children and
young adults with osteomalacia can lead to bowing during growth,
especially in weight-bearing bones of the legs. Osteomalacia in older
adults can lead to fractures.Mar 6, 2020
Symptoms: Bone pain; Muscle weakness
Treatments: Vitamin D
According to lippen cott
ETIOLOGY :-
The causes of adult osteomalacia are varied, but ultimately result in a
vitamin D deficiency:
 Insufficient nutritional quantities or faulty metabolism of vitamin
D or phosphorus
 Renal tubular acidosis
 Malnutrition during pregnancy
 Malabsorption syndrome
 Chronic renal failure
 Tumor-induced osteomalacia
 Long-term anticonvulsant therapy
 Coeliac disease

3. SIGN & SYMPTOM:-
 Weak bones
 Bone pain
 Spinal bone pain
 Pelvic bone pain
 Leg bone pain
 Muscle weakness
 Hypocalcemia - see symptoms of hypocalcemia
 Compressed vertebrae
 Pelvic flattening
 Fractures
 Easy fracturing
 Bone softening
 Bending of bones
 Pain
 Bone fractures
CLINICAL FEATURES:-
 Osteomalacia in adults starts insidiously as aches and pains in the lumbar
(lower back) region and thighs, spreading later to the arms and ribs. The
pain is symmetrical, non-radiating and is accompanied by sensitivity in
the involved bones. Proximal muscles are weak, and there is difficulty in
climbing up stairs and getting up from a squatting position.
 Due to demineralization bones become less rigid. Physical signs include
deformities like triradiate pelvis and lordosis. The patient has a typical
"waddling" gait. However, those physical signs may derive from a
previous osteomalacial state, since bones do not regain their original
shape after they become deformed.
 Pathologic fractures due to weight bearing may develop. Most of the
time, the only alleged symptom is chronic fatigue, while bone aches are
not spontaneous but only revealed by pressure or shocks.
 It differs from renal osteodystrophy, where the latter shows
hyperphosphatemia.

4.  PATHOPHYSIOLOGY :-

 The primary defect in osteomalacia is deficiency of activated vitamin
D(calcitriol), which promotes calcium absorption from gastrointestinal
tract & facilitates mineralization of bone. The supply of calcium &
phosphate in the extracellular fluid is low. Without adequate vitamin D,
calcium & phosphate are not moved to calcification sites in bone. It result
from failed calcium absorption or from excessive loss of calcium from
the body.

 Due to deficiency of activated vitamin D(calcitriol)
 Promotes calcium absorption from gastrointestinal tract & 4
facilitates mineralization of bone.
 The supply of calcium & phosphate in the extracellular fluid is
low.
 Without adequate vitamin D calcium & phosphate are not
moved to calcification sites in bone.

 . It result from failed calcium absorption or from excessive loss
of calcium from the body.
OSTEOMALACIA.

5. Assessment & diagnostic findings:-
 Radiographic features – x-ray Osteoporosis Mainly axial skeleton fracture.
 Lab tests- Serum Calcium & Serum phosphate (normal), Alkaline phosphatase
(normal even within 5 days of new fracutre), Urinary Calcium (high or normal),
Bone biopsy (tetracycline labels normal).
MEDICAL MANAGEMENT:-
Generally, people with osteomalacia take vitamin D supplements by mouth for a period of
several weeks to several months. Less commonly, vitamin D is given as an injection or through a
vein in arm. Certain vit. D are.
 Calciferol
 Delta D3
 DHT
 DHT Intensol
 Drisdol
 Hectorol
 Rocaltrol
 Vitamin D
 Zemplar
Prevention:-
 Spend a few minutes in the sun. For most people, 15 minutes of direct sun exposure a couple of
times a week is sufficient for proper vitamin D production.
 Eat foods high in vitamin D. These include foods that are naturally rich in vitamin D,
including oily fish (salmon, mackerel, sardines) and egg yolks. Also look for foods that are
fortified with vitamin D, such as cereal, bread, milk and yogurt.
 Take supplements, if needed. If you don't get enough vitamins and minerals in your diet or if
you have a medical condition affecting the ability of your digestive system to absorb nutrients
properly, ask your doctor about taking vitamin D and calcium supplements.
Complication :- Boken bone particularly in ribs, spine & legs.

6. NURSING PROCESS:-
Assessment :-
 Observe the history of client related to injury, infection, orthopaedic surgery.
 Identify the risk factor (older age, diabetes, long term corticosteroid therapy).
 Observe the signs & symptom ( pain, edema , erythema fever)
 Observe the vital sign because due to osteomalacia the temperature elevation will occur.
Nursing diagnosis:-
 Altered level of comfort related to pain in thighs, legs & back related to disease
condition
Goal :- To reduce pain.
Intervention Rationale
 The affected part may be
immobilized with a splint .
 Monitor the neurovascular status of
the affected extremity.
 Elevated the legs of client.
 Administered analgesic.
To decrese pain & muscle spasm.
To check the condition of client.
To reduce the swelling & discomfort.
To reduce pain.
Evaluation :- pain is reduced.
 Impaired physical mobility related to pain, use of immobilization device & weight
bearing limitation.
Goal :- improved physical mobility within therapeutic limitation.
Intervention Rationale
 Treatmenr regimen restrict activity.
 Encourage to take rest.
 Encourage the patient to participate
in activity of daily living with in
physical limitation.
 Demonstrate safe use of
immobilizing & assistive devices.
The bone is weakened by the infective
process & must be procted by
immobilization devices & by avoidance
of stress on the bone.
To reduce physical mobility.
To promote general well being.
To reduce risk of injury.
Evaluation :- physical mobility is improved.

7.  Risk for injury related to fracture.
Goal :- to reduce the risk of injury.
Nursing intervention Rationale
 To support the extrimities &
handeled jently in during nursing
care.
 Adviced patient to avoid sternous
activity.
 Encourage to take rest.
 Teach to patient how to use assistive
devicessafely & how to strengthen
unaffected extremity.
To prevent injury.
To reduce risk of fracture.
To increase muscle relaxation.
To prevent risk of injury.
Evaluation :- Risk of injury is reduced.
 Deficient knowledge related to treatment regimen.
Goal :- to provide the knowledge to patient
Nursing intervention Rationale
 Taught the patient about
imporatance of strictly
adhering to the therapeutic
regimen of antibiotics &
preventing falls or other
injuries.
 Provide knowledge regarding
medication, dose, frequency ,
administration, rate, safe
storage & handling, adverse
reaction.
 Clear the queries of patient.
To provide the knowledge
to patient regarding
prevention.
To educate about
medication.
To reduce anxiety.
Evaluation :- knowledge is increased.

8. Osteoporosis :-
DEFINITION :-
Osteoporosis is a disease in which there is a decrease bone
density; meaning that for a particular volume of bone there is
too little calcium and phosphorous in bones due to which the
bones becomes fragile and porous.
Osteoporosis is a bone disease that occurs when the body loses too
much bone, makes too little bone, or both. As a result, bones become weak
and may break from a fall or, in serious cases, from sneezing or minor
bumps.
Symptoms: Loss of height
a medical condition in which the bones become weak and are easily
broken
CAUSES :-
 Loss of calcium & protein from bone.
 Excessive use of glucocorticoid.
 Consumption of alchohol & smoking
 Nutrition factor
 Genetic factor
 Kidney stones
 Lack of certain hormones, particularly estrogen in women and
androgen in men. Women,

9. Risk factor :-
Unchangeable risk factors are:
• Gender: being female; women are five times more likely to develop
osteoporosis than men.
• Lack Of Exercise: bedridden people lose bone faster than people who
exercise regularly having a thin, small-boned frame
• Family history of older family members with broken bones or stooped
posture, especially women, which suggests osteoporosis
• History of disordered eating that may have contributed to a loss of
regular menstrual cycles
• An early menopause in women before age 45 due to estrogen deficiency,
either naturally or resulting from surgical removal of the ovaries and not
treated with hormone replacement therapy if you drink alcohol, do so in
moderation
• Get regular weight bearing and resistance exercise
• AVoid excess protein intake
• Avoid extreme dieting that can lead to loss of regular mestrual cycles
• Avoid excessive caffeine.
Progressive vertebral compression fractures

10. At age 55 At age 65 At age 75
SIGN & SYMPTOM:-
 Increased risk of bone fractures.
 fragility fractures. Typical fragility fractures occur in the vertebral
column, rib, hip and wrist.
 The symptoms of a vertebral collapse ("compression fracture") are
sudden back pain, often with radiculopathic pain (shooting pain due
to nerve root compression) and rarely with spinal cord compression
or cauda equina syndrome. Multiple vertebral fractures lead to a
stooped posture, loss of height, and chronic pain with resultant
reduction in mobility.[3]
 Fractures of the long bones acutely impair mobility and may require
surgery. Hip fracture, in particular, usually requires prompt surgery,
as there are serious risks associated with a hip fracture, such as
deep vein thrombosis and a pulmonary embolism, and increased
mortality.
 The increased risk of falling associated with aging leads to fractures
of the wrist, spine and hip.

11. ASSESSMENT & DIAGNOSTIC FINDINGS:-
 Dual energy x-ray absorptiometry(DEXA):- The
DXA (dual-energy X-ray absorptiometry) measures the
bone density of the spine, hip, or total body. With your
clothes on, you simply lie on your back with your legs on a
large block. The X-ray machine moves quickly over your
lower spine and hip area.
 SXA (single-energy X-ray absorptiometry) is performed
with a smaller X-ray machine that measure bone density at
the heel, shin bone, and kneecap. Some machines use
ultrasound waves pulsing through water to measure the
bone density in your heel. You place your bare foot in a
water bath, and your heel fits into a footrest as sound waves
pass through your ankle. This is a simple way to screen
large numbers of people quickly. You might find this type
of screening device at a health fair. Bone loss at the heel
may mean bone loss in the spine, hip, or elsewhere in the
body. If bone loss is found in this test, you might be asked
to have the DXA to confirm the results and get a better
measurement of your bone density
 Laboratory studies (serum calcium, serum phosphate,
serum alkaline phosphate, urine calcium excretion,
erythrocyte sedimentation rate)

12. MANAGEMENT :-
Pharmacological management:-
Medication Common Brands Type of FDA approval in
postmenopausal
WOMEN
Action
Bisphosphonates
Calcitonin
Hormone
Replacement
Therapy* (HRT)
Recombinant
Human
Parathyroid
Hormone (PTH
Selective Estrogen
Receptor
Modulators
(SERMS)
Fosamax®
Actonel®
Boniva®
Reclast®
Miacalcin®
Prempro®
Forteo™
Evista®
Prevention and
treatment
Treatment
Prevention
Treatment
Prevention and
treatment
Makes bone
stronger and less
likely to break.
Slows down bone
resorption or bone
loss
Makes bone
stronger and less
likely to BREAK
Builds new bone
which is less likely
break.
Makes bone
stronger and less
likely to BREAK

13.  Estrogen:For newly menopausal women, estrogen replacement
is one way to prevent bone loss. Estrogen can slow or stop bone
loss. And if estrogen treatment begins at menopause, it can reduce
the risk of hip fracture up to 50%. It may be taken orally or as a
transdermal (skin) patch (for example, Vivelle, Climara, Estraderm,
Esclim, Alora).
o Many women past menopause also choose estrogen replacement
therapy because of its proven usefulness in slowing the progression
of, or preventing, osteoporosis.
o Recent studies question the safety of long-term estrogen use.
Women who take estrogen have an increased risk for developing
certain cancers. Although it was once thought that estrogens confer
a protective effect on the heart and blood vessels, recent studies
have shown that estrogens cause an increase in coronary heart
disease, stroke, and venous thromboembolism (blood clots). Many
women who take estrogens have side effects (such as breast
tenderness, weight gain, and vaginal bleeding). Estrogen's side
effects can be reduced with proper dosing and combination. If you
have had a hysterectomy, estrogen alone is needed. For women with
an intact uterus, progestin is always part of hormone replacement
therapy. Ask your doctor whether estrogen is right for you.
 SERMs: For women who are unable to take estrogen or choose
not to, selective estrogen receptor modulators (SERMs) such as
raloxifene (Evista) offer an alternative. For example, many women
who have first-degree relatives with breast cancer will not consider
estrogen. The effects of raloxifene on bone and cholesterol levels
are comparable to those of estrogen replacement. There appears to
be no estrogen stimulation of the breasts or uterine lining, which
reduces the risk profile of hormone replacement. Raloxifene may
cause hot flashes. Its risk of blood clots is at least comparable to the
risks with estrogen. Tamoxifen (Nolvadex), commonly used in the
treatment of certain breast cancers, also inhibits bone breakdown
and preserves bone mass.

14.  Calcium: Calcium and vitamin D are needed to increase bone mass
in addition to estrogen replacement therapy.
o A daily intake of 1,200-1,500 mg (through diet and supplements) is
recommended. Take calcium supplements in doses of less than 600
mg. Your body can only absorb so much at one time. The best way
may be to take one supplement with breakfast and another with
dinner.
o A daily intake of 800-1,000 IU of vitamin D is needed to increase
bone mass.
 Bisphosphonates: Other treatments for osteoporosis are
available. Bisphosphonate medications taken by mouth include
alendronate, risedronate, etidronate; intravenous medications
include bisphosphonate, zoledronate (Reclast). These drugs
slow down bone loss, and in some cases, they actually increase
bone mineral density. Doctors can measure the effects of these
drugs by obtaining DXAs every year or two and comparing the
measurements.
When taking these drugs, it is important to stand or sit upright
for 30 minutes after swallowing the medication. This helps
decrease the risk of heartburn and ulcers in the esophagus.
After taking bisphosphonates, you must wait 30 minutes to
ingest food, beverages (except water), and other medications,
including vitamins and calcium.
Before beginning to take a bisphosphonate, your doctor will
determine if you have enough calcium in your blood and if your
kidneys are functioning well.
o Alendronate (Fosamax): This medication is used to treat
osteoporosis and to prevent bone loss in women. In clinical trials,
alendronate has been shown to reduce the risk of new spinal and hip

15. fractures by 50%. Gastrointestinal problems, such as nausea, acid
reflux symptoms, and constipation, are the most common side
effects. You must take this medication first thing in the morning
with a large glass of water and not lie down or eat for 30 minutes.
Some women find this restriction difficult. This medication is taken
daily or once a week.
o Risedronate (Actonel): This medication is used for the treatment and
prevention of osteoporosis. Gastrointestinal upset is the most
common side effect. Women with severe kidney impairment should
avoid this drug. Results from a recent study showed that daily
risedronate use can lead to a significant reduction in new vertebral
fractures (62%) and multiple new vertebral fractures (90%) in
postmenopausal women with osteoporosis, compared with a similar
group who did not take this medication.
o Etidronate (Didronel): This drug has been approved by the U.S.
FDA for the treatment of Paget disease, another bone condition.
Doctors have been using this drug successfully in clinical trials to
treat women with osteoporosis.
o Ibandronate (Boniva): This drug is the most recently FDA-approved
bisphosphonate and is used to prevent or treat osteoporosis in
postmenopausal women.
o Zoledronate (Reclast): This is a powerful intravenous
bisphosphonate that is given once a year. This can be especially
beneficial for patients who cannot tolerate oral bisphosphonates or
are having difficulty with complying with the required regular
dosing of oral medications.
 Other hormones: These hormones help regulate calcium and/or
phosphate levels in the body and prevent bone loss.
o Calcitonin (Miacalcin): Calcitonin is a hormone (extracted from
salmon) that slows bone loss and may increase bone density. You

16. may be given this drug as an injection (every other day or two to
three times a week) or as a nasal spray.
o Teriparatide (Forteo): Teriparatide contains a portion of human
parathyroid hormone. It primarily regulates calcium and phosphate
metabolism in bones, which promotes new bone formation and leads
to increased bone density. This drug is given as a daily injection.
Non-pharmacological management:-
Diet: Young adults should be encouraged to achieve normal peak bone mass by
getting enough calcium (1,000 mg daily) in their diet (drinking milk or calcium-
fortified orange juice and eating foods high in calcium such as salmon),
performing weight-bearing exercise such as walking or aerobics (swimming is
aerobic but not weight-bearing), and maintaining normal body weight.
DIETARY REFERENCE INTAKES OF CALCIUM
Age Milligrams
(mg)/day
Number of 8
ounce cups
of milk to
get
recommende
d mg of
calcium
*Tolerable Upper
Intake Level (UL)
mg/day
0-6 months 200 --- 1,000
6-12 months 260 --- 1,500
1-3 years 700 2 1/3 2,500
4-8 years 1,000 3 1/3 2,500
9-18 years 1,300 4 1/3 3,000
Males and
Females
19 - 50 years
1,000 3 1/3 2,500
Males
51- 70 years
1,000 3 1/3 2,000
Females
51 -70 years
1,200 4 2,000

17. Adults
> 70 years
4
1,300 3 3,000
14 - 18
years
19 - 50
years
1,000 31/3
3 1/3
3 1/3
2,500
The current recommendation of the amount of vitamin D an individual
should not consume more than is 4000 IU a day. It is difficult to get too
much vitamin D unless a person is taking a prescription dose of the vitamin.
DIETARY REFERENCE INTAKES OF VITAMIN D
Age International Units (IU) vitamin D per day
1 - 70 years of age 600
> 70 years of age 800
Pregnancy and Lactation
14 - 50 years of age
600
Specialists: People who have spinal, hip, or wrist fractures should be
referred to a bone specialist (called an orthopedic surgeon) for further
management. In addition to fracture management, these people should
also be referred to a physical and occupational therapist to learn ways to
exercise safely. For example, someone with spinal fractures would
avoid touching their toes, doing sit-ups, or lifting heavy weights. Many
types of doctors treat osteoporosis, including internists, generalists,
family physicians, rheumatologists, endocrinologists, and others.

18. Exercise: Lifestyle modification should also be incorporated into your
treatment. Regular exercise can reduce the likelihood of bone fractures
associated with osteoporosis.
o Studies show that exercises requiring muscle to pull on bones causes
the bones to retain, and perhaps even gain, density.
o Researchers found that women who walk a mile a day have four to
seven more years of bone in reserve than women who don't.
o Some of the recommended exercises include weight-bearing
exercise, riding stationary bicycles, using rowing machines,
walking, and jogging.
o Before beginning any exercise program, make sure to review your
plan with your doctor.
o
Prevention
Building strong bones during childhood and adolescence can be the best
defense against developing osteoporosis later. The average woman has
acquired 98% of her skeletal mass by 30 years of age.
There are four steps to prevent osteoporosis. No one step alone is
enough to prevent osteoporosis.
 Eat a balanced diet rich in calcium and vitamin D.
 Engage in weight-bearing exercise.
 Adopt a healthy lifestyle with no smoking or excessive alcohol
intake.
 Take medication to improve bone density when appropriate.

19. COMPLICATION :-
It is a condition that causes abnormally thin bone.
Osteoporosis may be due to not enough calcium
consumption, estrogen deficiency, age, or a
combination of these factors. Because the bone is
thinner, less dense, and more fragile, patients with
osteoporosis are at a higher risk of sustaining a
 Broken bone,
 fracture.