Osteomalacia is a condition characterized by the softening of bones due to defective bone mineralization. This nursing diagnosis focuses on the care and management of patients with osteomalacia, a condition that can significantly impact a patient’s quality of life and overall health.
Causes (Related to)
Osteomalacia can result from various factors interfering with the body’s ability to properly mineralize bone tissue. The following are common causes of osteomalacia:
- Vitamin D deficiency: The most common cause, often due to inadequate dietary intake, limited sun exposure, or malabsorption disorders.
- Phosphate deficiency: Can be caused by certain kidney disorders or excessive use of phosphate-binding antacids.
- Calcium deficiency: Often due to dietary insufficiency or malabsorption issues.
- Certain medications: Long-term use of anticonvulsants or aluminum-containing antacids can interfere with vitamin D metabolism.
- Chronic kidney disease: This can lead to impaired vitamin D activation and phosphate retention.
- Liver disease: This may affect vitamin D metabolism.
- Celiac disease and other malabsorption syndromes: Can impair the absorption of vitamin D and other nutrients essential for bone health.
Signs and Symptoms (As evidenced by)
Patients with osteomalacia may present with a variety of signs and symptoms. During a physical assessment, a nurse may observe the following:
Subjective: (Patient reports)
- Bone pain, particularly in the lower back, hips, and legs
- Muscle weakness
- Difficulty walking or a waddling gait
- Fatigue
- Joint pain
Objective: (Nurse assesses)
- Bone deformities, especially in weight-bearing bones
- Fractures, particularly stress fractures
- Muscle spasms or tetany
- Decreased muscle tone
- Abnormal gait or posture
- Laboratory findings:
- Low serum calcium levels
- Low serum phosphate levels
- Elevated alkaline phosphatase levels
- Low 25-hydroxyvitamin D levels
- Imaging studies showing decreased bone density or pseudofractures
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for patients with osteomalacia:
- The patient will report a reduction in bone and muscle pain.
- The patient will demonstrate improved muscle strength and mobility.
- The patient will maintain or improve bone density as evidenced by follow-up imaging studies.
- The patient will have serum calcium, phosphate, and vitamin D levels within normal ranges.
- The patient will demonstrate proper technique in taking prescribed supplements and medications.
- The patient will verbalize understanding of dietary requirements for calcium and vitamin D.
- The patient will report increased energy levels and improved quality of life.
Nursing Assessment
Nursing assessment is crucial in identifying a patient’s specific needs for osteomalacia. The following steps should be included in the assessment:
Obtain a comprehensive health history:
- Focus on dietary habits, sun exposure, and any gastrointestinal or kidney disorders history.
- Inquire about current medications, particularly long-term use of anticonvulsants or antacids.
Perform a physical examination:
- Assess for bone tenderness, especially in the spine, pelvis, and legs.
- Evaluate muscle strength and tone.
- Observe gait and posture for any abnormalities.
Review laboratory results:
- Check serum calcium, phosphate, alkaline phosphatase, and 25-hydroxyvitamin D levels.
- Assess parathyroid hormone (PTH) levels, which may be elevated in osteomalacia.
Examine imaging studies:
- Review X-rays, bone scans, or DEXA scans for signs of decreased bone density or pseudofractures.
Assess pain levels:
- Use a standardized pain scale to evaluate the severity and location of bone pain.
Evaluate nutritional status:
- Assess dietary intake of calcium, vitamin D, and other essential nutrients.
- Screen for signs of malnutrition or malabsorption.
Assess fall risk:
- Conduct a fall risk assessment due to the increased fracture risk in osteomalacia.
Evaluate psychosocial impact:
- Assess the patient’s understanding of the condition and its impact on daily life.
- Screen for signs of depression or anxiety related to chronic pain or limited mobility.
Nursing Interventions
Nursing interventions for patients with osteomalacia focus on managing symptoms, improving bone health, and preventing complications. Here are key interventions:
Administer prescribed medications and supplements:
- Ensure proper administration of vitamin D supplements, calcium, and any other prescribed medications.
- Educate the patient on the importance of consistent medication adherence.
Provide pain management:
- Administer pain medications as ordered.
- Teach non-pharmacological pain management techniques such as positioning and relaxation exercises.
Implement fall prevention strategies:
- Assess the patient’s environment for fall risks.
- Teach the patient about the proper use of assistive devices if prescribed.
- Encourage wearing appropriate footwear and using handrails.
Promote proper nutrition:
- Collaborate with a dietitian to develop a meal plan rich in calcium and vitamin D.
- Educate the patient on food sources high in these nutrients.
Encourage safe sun exposure:
- Teach the patient about the importance of controlled sun exposure for vitamin D synthesis.
- Advise on safe sun exposure practices to balance vitamin D production with skin cancer prevention.
Assist with mobility and exercise:
- Collaborate with physical therapy to develop a safe exercise program.
- Encourage weight-bearing exercises as tolerated to improve bone strength.
Provide education:
- Teach the patient about osteomalacia, its causes, and management strategies.
- Instruct on the importance of follow-up appointments and regular bone density screenings.
Nursing Care Plans
The following nursing care plans address common issues associated with osteomalacia. Each plan includes a nursing diagnosis statement, related factors, nursing interventions with rationales, and desired outcomes.
Care Plan 1: Chronic Pain
Nursing Diagnosis: Chronic Pain related to bone demineralization secondary to osteomalacia as evidenced by patient reports of persistent bone pain, rated 7/10 on pain scale, and observed guarding behavior.
Related Factors:
- Bone demineralization
- Microfractures
- Muscle weakness
Nursing Interventions and Rationales:
- Assess pain characteristics (location, intensity, quality) using a standardized pain scale q4h and PRN.
Rationale: Regular pain assessment helps evaluate the effectiveness of pain management strategies and guides treatment adjustments. - Administer prescribed analgesics as ordered and evaluate their effectiveness.
Rationale: Proper pain medication management can significantly improve the patient’s comfort and quality of life. - Teach and encourage non-pharmacological pain management techniques such as relaxation exercises, guided imagery, and positioning.
Rationale: Non-pharmacological methods can complement medication in pain management and promote patient autonomy in symptom control. - Collaborate with physical therapy to develop a gentle exercise program that doesn’t exacerbate pain.
Rationale: Appropriate exercise can help strengthen muscles, support bones, and potentially reduce pain over time. - Provide a comfortable, supportive mattress and pillows to reduce pressure on painful areas.
Rationale: Proper support can alleviate pressure on painful bones and improve comfort during rest.
Desired Outcomes:
- The patient will report pain levels reduced to 3/10 or less on the pain scale within 48 hours.
- The patient will demonstrate using at least two non-pharmacological pain management techniques by discharge.
- Within one week, the patient will report improved sleep quality and the ability to perform daily activities with minimal pain interference.
Care Plan 2: Risk for Falls
Nursing Diagnosis: Risk for Falls related to muscle weakness and bone fragility secondary to osteomalacia as evidenced by unsteady gait and history of near-falls.
Related Factors:
- Muscle weakness
- Bone fragility
- Altered gait
- Impaired balance
Nursing Interventions and Rationales:
- Conduct a comprehensive fall risk assessment using a standardized tool on admission and daily.
Rationale: Regular assessment helps identify specific risk factors and guides individualized fall prevention strategies. - Implement fall prevention measures such as keeping the bed in low position, ensuring call light is within reach, and maintaining a clutter-free environment.
Rationale: These environmental modifications can significantly reduce the risk of falls. - Assist the patient with mobility and transfers as needed, encouraging the use of assistive devices if prescribed.
Rationale: Proper assistance and use of assistive devices can prevent falls during movement. - Educate the patient and family on fall prevention strategies and the importance of calling for assistance.
Rationale: Patient and family education promotes active participation in fall prevention. - Collaborate with physical therapy to implement a strength and balance training program.
Rationale: Improving muscle strength and balance can reduce fall risk over time.
Desired Outcomes:
- The patient will remain free from falls during hospitalization.
- The patient will demonstrate proper use of assistive devices and call for assistance when needed by discharge.
- The patient will show improved balance and strength as evidenced by physical therapy assessments within two weeks.
Care Plan 3: Impaired Physical Mobility
Nursing Diagnosis: Impaired Physical Mobility related to bone and muscle weakness secondary to osteomalacia as evidenced by difficulty in ambulation and performing activities of daily living.
Related Factors:
- Bone pain
- Muscle weakness
- Fear of falling
Nursing Interventions and Rationales:
- Assess the patient’s current level of mobility using a standardized functional assessment tool.
Rationale: Accurate assessment guides the development of an appropriate mobility plan. - Assist the patient with gradual mobilization, starting with in-bed exercises and progressing to ambulation as tolerated.
Rationale: Gradual progression helps build strength and confidence while minimizing the risk of injury. - Teach and encourage the patient to perform range-of-motion exercises for all joints q2h while awake.
Rationale: Regular movement helps maintain joint flexibility and prevents stiffness. - Collaborate with occupational therapists to identify and teach adaptive techniques for daily living activities.
Rationale: Adaptive techniques can improve independence and reduce the risk of injury during daily activities. - Provide emotional support and encouragement to help overcome fear of movement.
Rationale: Emotional support can increase the patient’s confidence and willingness to engage in mobility activities.
Desired Outcomes:
- The patient will demonstrate improved mobility as evidenced by increased distance walking and reduced assistance needed within one week.
- The patient will perform basic activities of daily living with minimal assistance by discharge.
- The patient will express increased confidence in mobility and decreased fear of falling within two weeks.
Care Plan 4: Imbalanced Nutrition: Less than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to inadequate intake of calcium and vitamin D secondary to osteomalacia as evidenced by low serum calcium and vitamin D levels, and reported poor appetite.
Related Factors:
- Inadequate dietary intake of calcium and vitamin D
- Malabsorption issues
- Lack of knowledge about nutritional requirements
Nursing Interventions and Rationales:
- Assess the patient’s dietary and eating habits through a 24-hour recall or food diary.
Rationale: Understanding current dietary patterns helps in developing a personalized nutrition plan. - Collaborate with a dietitian to develop a meal plan rich in calcium and vitamin D.
Rationale: A tailored meal plan ensures adequate intake of essential nutrients for bone health. - Administer prescribed calcium and vitamin D supplements as ordered.
Rationale: Supplements can help correct nutritional deficiencies when dietary intake is insufficient. - Educate the patient on food sources rich in calcium and vitamin D and strategies for incorporating them into their diet.
Rationale: Knowledge of nutrient-rich foods empowers the patient to make healthier choices. - Monitor serum calcium and vitamin D levels regularly and report significant changes to the physician.
Rationale: Regular monitoring helps evaluate the effectiveness of nutritional interventions and guide treatment adjustments.
Desired Outcomes:
- The patient will demonstrate improved serum calcium and vitamin D levels within the normal range within two weeks.
- The patient will verbalize understanding of the importance of calcium and vitamin D in their diet by discharge.
- The patient will report increased appetite and consumption of calcium and vitamin D-rich foods within one week.
Care Plan 5: Deficient Knowledge
Nursing Diagnosis: Deficient Knowledge related to lack of information about osteomalacia and its management as evidenced by patient’s verbalization of misunderstandings and questions about the condition.
Related Factors:
- Lack of exposure to information about osteomalacia
- Misinterpretation of information
- Cognitive limitations
Nursing Interventions and Rationales:
- Assess the patient’s knowledge and understanding of osteomalacia, its causes, and management.
Rationale: Understanding the patient’s baseline knowledge helps tailor education to their needs. - Provide education about osteomalacia, including its causes, symptoms, treatment options, and long-term management.
Rationale: Comprehensive education helps the patients to participate in their care and make informed decisions actively. - Use various teaching methods (verbal explanations, written materials, videos) to accommodate different learning styles.
Rationale: Varied teaching methods can enhance understanding and retention of information. - Teach the patient about medication adherence, proper nutrition, and follow-up care.
Rationale: Understanding the importance of these factors can improve treatment compliance and outcomes. - Encourage the patient to ask questions and express concerns about their condition and treatment.
Rationale: Open communication helps address misconceptions and reinforces understanding.
Desired Outcomes:
- The patient will verbalize an accurate understanding of osteomalacia, its causes, and management strategies by discharge.
- The patient will demonstrate proper technique in taking prescribed medications and supplements by discharge.
- The patient will articulate the importance of follow-up care and regular bone density screenings within one week.
References
- Bhan, A., Rao, A. D., & Rao, D. S. (2010). Osteomalacia as a result of vitamin D deficiency. Endocrinology and Metabolism Clinics of North America, 39(2), 321-331.
- Fukumoto, S., Ozono, K., Michigami, T., Minagawa, M., Okazaki, R., Sugimoto, T., … & Matsumoto, T. (2015). Pathogenesis and diagnostic criteria for rickets and osteomalacia–proposal by an expert panel supported by the Ministry of Health, Labour and Welfare, Japan, the Japanese Society for Bone and Mineral Research, and the Japan Endocrine Society. Journal of Bone and Mineral Metabolism, 33(5), 467-473.
- Herdman, T. H., & Kamitsuru, S. (Eds.). (2018). NANDA International nursing diagnoses: Definitions & classification 2018-2020. Thieme.
- Holick, M. F. (2017). The vitamin D deficiency pandemic: Approaches for diagnosis, treatment and prevention. Reviews in Endocrine and Metabolic Disorders, 18(2), 153-165.
- Lips, P., van Schoor, N. M., & Bravenboer, N. (2013). Vitamin D-related disorders. Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism, 613-623.
