Support those Bones

The Rehabilitation Hospital of South Jersey is promoting and maintaining bone health, one patient at a time

By MaryClare Schafer, MS, RN, ONC, CIC, CLNC

Recognizing the growing importance of promoting bone health, President George W. Bush declared 2002-2011 as the "Decade of the Bone and Joint." In conjunction with that, the first Surgeon General's report on bone health and osteoporosis was released in 2004. The report illustrates the large burden bone disease places on our country, and identifies relevant scientific data on bone health, encouraging health professionals to assess, treat and educate patients on bone health.

The Rehabilitation Hospital of South Jersey (RHSJ), Vineland, is taking this a step further, by identifying bone health as a focused initiative for all patients admitted to the acute care rehab facility. Special emphasis is placed on osteoporosis prevention, bone-health maintenance and the treatment of those with osteopenia or osteoporosis.

The focus on individualized education is a key component that enables the patient to take charge of his or her bone health, and LPNs play an important role in this endeavor.

ABOUT OSTEOPOROSIS

Osteoporosis is a "silent" disease that weakens the bones and is usually diagnosed only after fracture has occurred. Common fracture sites are the spine, hip, ribs, wrist and pelvis. There can be significant social and psychological ramifications by creating a great financial and emotional burden both for the individual and the family.

Statistically, approximately 10 million Americans have bone disease and 18 million more are at risk for low bone mass. One in 2 women and 1 in 8 men are at risk of sustaining an osteoporosis-related fracture in their lifetime, which can cause chronic pain, disfigurement and even lifelong disability.

In the U.S., there are more than 1.5 million fractures annually, including more than 700,000 vertebral compression fractures and 300,000 hip fractures. As a consequence of an osteoporosis-related hip fracture, 24 percent will die of complications such as pressure ulcers, pulmonary emboli, pneumonia, urinary tract infections, depression and failure to thrive. Of those who survive, one-third will require long-term care. Vertebral compression fractures, which are not as easily diagnosed and treated, often become a source of chronic pain and disfigurement. As a nation, osteoporosis creates a financial burden of approximately $13.8 billion annually.

RISK FACTORS

Understanding risk factors and lifestyle behaviors is essential in the battle against osteoporosis. Certain risk factors — heredity, body type, age, gender and ethnic background — cannot be changed.

Throughout childhood and young adulthood, bone strength is established primarily through a calcium-rich diet and weight-bearing exercise. Peak bone mass is generally established between ages 25-30. Beyond age 30, it is essential to continue with a calcium-rich diet and a regular exercise regimen; otherwise a slow, gradual deterioration of the core bone matrix occurs.

For women, the loss of estrogen at menopause accelerates the process of bone loss, since estrogen is a receptor site for calcium and therefore a protective factor for bone tissue. Ethnicity is a key factor in that Asians, Caucasians and those of Northern European heritage are 2-3 times more likely to develop osteoporosis than African Americans and Hispanics.

Lifestyle considerations that can be changed include dietary patterns, exercise regimens and use of alcohol, tobacco and caffeine. Perhaps the two most influential lifestyle factors are diet and exercise.

Sufficient calcium intake is crucial for bone health, yet research studies have indicated that the average American diet provides for only half the recommended daily intake of calcium. Vitamin D is the calcium "gatekeeper," acting to enhance calcium absorption from the intestine and to increase calcium and phosphate reabsorption in the renal tubules.

Weight-bearing exercise, such as walking, is the second most influential lifestyle factor. For those who use wheelchairs, resistance exercises for the upper body and passive resistive exercises for the lower extremities will help achieve exercise goals. In addition to increasing bone density, muscle strength and tone adds support and balance to the skeleton, reducing the risk of falls.

Alcohol and caffeine interfere with calcium absorption, therefore contributing to a weakened bone structure. Nicotine is also harmful to the skeleton, as it interferes with healthy circulation to bone tissue.

A PROACTIVE APPROACH

One of RHSJ's missions is to increase bone health awareness among patients, families, employees and the community.

Aside from the primary injury or disease process that is addressed in acute rehab, prevention, treatment and management of chronic and comorbid conditions, such as osteoporosis and diabetes, are also a focus for staff as part of the rehab process, so that the patient's strength, mobility and independence are maximized. In turn, quality of life is improved tremendously.

The role of the LPN in this process is valuable. For example, unless contraindicated, we have adopted standards of providing calcium and vitamin D supplementation to all of our patients on admission. LPNs are actively involved in medication teaching regarding the use of calcium supplements and antiresorptive drugs such as Fosamax (alendronate). Teaching includes the proper usage of a particular drug or supplement as well as possible side effects and drug interactions.

LPNs are also an integral part in RHSJ's efforts to ensure patient safety, offering input into the decision-making process regarding safety measures and assisting with family and patient teaching.

All patients admitted to RHSJ post-fracture undergo density testing to determine if the break was caused by bone loss. Those without fractures, but who exhibit risk factors, also undergo density screening. A copy of the screening result is forwarded to the patient's primary physician for follow-up upon discharge.

The LPN assists in educating the patient on prevention, maintenance or treatment options, depending on the results of the screening. Topics include diet, exercise, lifestyle changes (such as smoking cessation) and medication usage. For those who have established osteoporosis, LPNs are involved in instructing them how to "fall-proof" their homes. This teaching includes simple ways to make the home safer, such as having adequate lighting in hallways at night and eliminating loose cords and/or throw rugs.

FRAGILITY PRECAUTIONS

A unique concept developed by nurses in the RHSJ program is "fragility precautions" for patients with bone loss. This measure enables staff to more appropriately meet the Joint Commission's 2006 patient safety goals, specifically targeting the reduction of patient harm resulting from falls.

The policy on fragility precautions includes both staff and patient/family education initiatives regarding contributing factors to bone loss. A patient's comorbidities are considered part of the assessment in determining if he should be placed on fragility precautions. Diabetes mellitus, hyperparathyroidism, lupus and renal disease are conditions that cause secondary osteoporosis. Key approaches to care include staff interventions such as instituting fall precautions, logrolling techniques and avoiding the use of gait belts for transfers. We've also recently acquired friction-reducing patient transfer devices (drapes placed under the patient who is deemed fragile) which provide for an easier transfer.

Patient and family education also involves interventions such as proper body mechanics and fall-proofing. A healthy lifestyle is reinforced, and education is provided regarding medications and having a DEXA (dual energy X-ray absorptiometry) scan performed on a regular basis.

Our nursing department has four subcommittees with focuses on patient education, policy and procedure, performance improvement and staff development. LPN staff members are a valued, integral part of these committees and their day-to-day involvement with the patient at the bedside is an asset when addressing patient education needs, medication issues and other topics geared toward improving delivery of care.

NURSING ORIENTATION

To educate nurses in this care philosophy, RHSJ offers a comprehensive nursing orientation program which combines classroom with preceptorships on the unit. Nursing orientees are provided classroom instruction on skeletal health and the impact it has on rehab and beyond. In addition to orthopedic topics — joint replacement, fracture care, compartment syndrome and deep venous thrombosis — a special emphasis is placed on osteoporosis because of the disease's chronicity and mental and physical anguish it can cause.

When a patient is admitted to the facility, the RN performing the admission assessment discusses the need for fragility precautions with the physiatrist.

The RN and LPN on the team provide patient education concerning bone health as a component of the individual care plan and medication teaching regarding calcium and vitamin D supplements, as well as prescribed medications. The entire nursing staff and all newly hired nurses and assistants attend a 4-hour body mechanics training class that includes appropriate transfer techniques for patients diagnosed with bone loss, in addition to techniques to protect themselves from injury.

BONE MINERAL DENSITY SCREENING

Bone density screening, a simple, quick, painless procedure, is a key method of determining a person's bone strength and risk of developing osteoporosis. At RHSJ, bone density screening is ordered on admission for patients with bone-loss risk, and/or who have had fractures prior to admission and have never been tested.

If an individual has a positive reading for either osteopenia or osteoporosis, a recommendation is made to the primary physician for follow-up with a DEXA scan. This is a comprehensive study that measures bone mass specifically in the hip and spine.

The patient with a normal density screen is provided with preventive information on diet, exercise and lifestyle behaviors. For patients deemed to be osteopenic, education is provided regarding the maintenance of current density and the prevention of further bone loss. For patients who screen positive for osteoporosis, extensive education is provided to also include fall-proofing the home and the appropriate use of medications.

RAISING PUBLIC AWARENESS

Since October 2003, RHSJ has held an annual "Bone Run, Walk and Roll for Osteoporosis and Disability Awareness."

The nursing and therapy staff organize a health fair each year for all event visitors and participants, offering free blood pressure and cholesterol screening, as well as free bone density screenings. In conjunction with the screenings, education is provided regarding individual bone health and nutrition issues.

Community feedback has been positive and the event has been instrumental in promoting bone health on a wide-scale basis.

Resources

U.S. Department of Health and Human Services. (2004). Bone health and osteoporosis: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General.

National Osteoporosis Foundation. (2005). Washington, DC, http://www.nof.org

MaryClare Schafer is the orthopedic clinical specialist and infection control coordinator at the Rehabilitation Hospital of South Jersey, Vineland.