Paget’s Disease

Paget’s Disease Nursing Care Plans Diagnosis and Interventions

Paget’s Disease NCLEX Review Care Plans

Nursing Study Guide on Paget’s Disease

Paget’s disease of bone is a chronic disease of the skeleton and is the second most common bone disease with osteoporosis taking the first spot.

In healthy bone, bone remodeling removes old pieces of bone and replaces them with new fresh bone. Paget’s disease changes the bone remodeling process resulting in abnormally shaped, weak, and brittle bones.

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The body of a person with Paget’s disease may generate new bone in abnormal locations or remove old bone from its intended areas. This can lead to bone weakness, bone pain, deformities, arthritis, and fractures. When it occurs in an area where nerves pass through the bone, such as the spine and skull, the bone overgrowth can compress and damage nerve, causing pain, weakness or tingling in the arm or leg.

A person with Paget’s disease is at a very high risk for fracture, and healing may take a long time due to the errors in the process of bone renewal. Paget’s disease commonly affects approximately 2-3% of the population over the age of 55.

Paget’s disease can affect any bone in the skeleton but it most commonly appears in the pelvis, spine, long bones of the limbs, and skull. Paget’s disease can be present in just one or several bones and it may also affect the entire bone or just a part of it.

Signs and Symptoms of Paget’s Disease

  • Bone Pain – commonly affected areas are pelvis, spine, skull, shoulders, and legs
    • is usually dull or aching pain
    • it is felt deep within the affected part of the body
    • the pain is constant
    • is at its worst at night
    • affected area may also feel warm
  • Joint pain, stiffness, and swelling -especially in the hips, back, and knees
  • Nerve Problems
    • pain travelling from the spine to the legs
    • pain travelling from the neck to arms and chest
    • numbness or tingling in the affected limbs
    • partial loss of movement in the affected limbs
    • problems in balance
    • loss of bladder or bowel control
  • Enlargement and bowing of femurs and lower legs
  • Enlargement of the skull around the forehead

Progression of the disease may lead to other signs and symptoms such as:

  • Further bowing of the affected limbs
  • A waddling manner of walking (gait)
  • Pain and inflammation of the joints (arthritis)
  • Fractures of affected bones
  • Muscle and sensory disturbances

Skull involvement may manifest these symptoms:

  • Development of hearing loss
  • Loss of vision
  • Hydrocephalus or the accumulation of excessive cerebrospinal fluid in the skull that increases pressure on the tissues of the brain.

Causes and Risk Factors of Paget’s disease

The cause of Paget’s disease is still unknown, but researchers still study whether it may be partially due to heredity or could be activated through exposure to a virus.

The risk factors for Paget’s disease include:

  • Age
  • Sex (men are more commonly affected than women)
  • National origin (common in those who come from England, Scotland, central Europe, and Greece)
  • Family history of Paget’s disease

Complications of Paget’s disease

  1. Fractures and deformities. Affected bones are broken easily, and extra blood vessels in deformed bones can cause more bleeding during repair surgeries. There is bowing of leg bones which can affect the ability to walk.
  2. Osteoarthritis. Misshapen bones can increase the amount of pressure and stress on nearby joints, which causes osteoarthritis.
  3. Neurological problems. When Paget’s disease occurs in an area where nerves pass through the bone, such as the skull and spine, the bone overgrowth can compress and damage the nerve that causes pain, weakness or tingling in an arm or leg or even hearing loss.
  4. Heart failure. In severe cases of Paget’s disease, the heart needs to work harder to pump blood to the affected areas of the body and this increased workload can result in heart failure.
  5. Bone cancer. This complication occurs in up to 1% of people with Paget’s disease of bone.

Diagnosis of Paget’s disease

The diagnosis of Paget’s disease may be confirmed by a thorough clinical evaluation, detailed patient history, and several specialized tests such as x-rays, blood tests, and urine tests.

  • X-rays – usually done to diagnose Paget’s disease. Bones may appear larger, denser, and also have a deformed shape
  • Blood tests – may reveal elevated levels of the alkaline phosphatase enzyme
  • Bone scan – may reveal the severity of abnormalities in the bones
  • Urine tests – such as pyrilinks and osteomark to assist in the diagnosis

Treatment for Paget’s disease

There is still no cure for Paget’s disease or a way to reverse its effects on the bones. Treatment focuses on the relief of symptoms and the prevention of future complications. There are 4 main methods of treatment namely: non-pharmacological therapy, pharmacological therapy with the use of bisphosphonates or calcitonins, pain management with the use of analgesics, and surgical intervention.

  • Non-pharmacological Therapy. Physical therapy for the improvement of muscle strength and pain relief in some types of pain.
  • Pharmacological Treatment. The medications used in the management of Paget’s disease include:
    • Biphosphonates – suppress or reduce the resorption of bone by osteoclasts. Currently, there are 6 approved bisphosphonates for the treatment of Paget’s disease. Prior to the start of the therapy, patients undergo a regimen of calcium and vitamin D every day for two weeks. This is for the reduction of risk of low blood calcium after infusions. This drug is not indicated for those with low blood calcium or those with vitamin D deficiency and those with compromised renal function. Calcium supplements need to be taken with bisphosphonates to reduce the risk of hypocalcemia.
    • Calcitonins. Salmon calcitonins have shown to reduce elevated indices of bone turnover by 50%, decrease symptoms of bone pain, reduce inflammation over bones, improve neurological complications, and promote healing of lytic lesions. Calcitonins are used mostly by patients who cannot tolerate bisphosphonates.
  • Pain Management. Pain due to Paget’s disease may be the result of bone deformity, arthritic, or neurological complications. Acetaminophen, NSAIDs, and cox-2 inhibitors are used for the management of pain associated with Paget’s disease.
  • Surgery. Surgical procedures used to treat fractures, malalignment, or arthritis in patients with Paget’s disease.
    • Internal fixation. This is used to treat fractures in the bone affected by the disease. In internal fixation, bone fragments are first repositioned into their normal alignment, then immobilized through the use of screws, wires, pins, or metal plates attached to the outside of the bone.
    • Osteotomy. This can help relieve pain and restore alignment to weight-bearing joints especially the hip and knee. The procedure involves the removal of a wedge of bone near the damaged joint in order to shift weight to a healthier, more stable part of the joint.
    • Total joint replacement. In this procedure, parts of a damaged or arthritic joint are removed and replaced with a metal, ceramic, or plastic device called a prosthesis. The prosthesis is designed to replicate the movement of a healthy joint.

Nursing Care Plans for Paget’s Disease

Nursing Care Plan 1

Nursing Diagnosis: Pain related to joint inflammation secondary to Paget’s disease, as evidenced by pain score of 10 out of 10, guarding sign on the affected fingers, restlessness, and irritability

Desired Outcome: The patient will report a pain score of 0 out of 10.

InterventionRationale
Assess the patient’s vital signs. Ask the patient to rate the pain from 0 to 10, and describe the pain he/she is experiencing.To create a baseline set of observations for the patient. The 10-point pain scale is a globally recognized pain rating tool that is both accurate and effective.
Administer analgesics/ pain medications as prescribed. Administer other prescribed medications for Paget’s disease.To provide pain relief to the patient.  Acetaminophen, NSAIDs, and cox-2 inhibitors are used for the management of pain associated with Paget’s disease.  
Ask the patient to re-rate his/her pain 30 minutes to an hour after administering the analgesic.To assess the effectiveness of treatment.
Provide more analgesics at recommended/prescribed intervals.To promote pain relief and patient comfort without the risk of overdose.
Reposition the patient in his/her comfortable/preferred position. Encourage pursed lip breathing and deep breathing exercises.To promote optimal patient comfort and reduce anxiety/ restlessness.
Refer the patient to a pain specialist as required.To enable to patient to receive more information and specialized care in pain management if needed.

Nursing Care Plan 2

Nursing Diagnosis: Activity intolerance related to joint inflammation and pain secondary to Paget’s disease, as evidenced by pain score of 8 to 10 out of 10, fatigue, disinterest in ADLs due to pain, verbalization of tiredness and generalized weakness

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

InterventionRationale
Assess the patient’s activities of daily living, as well as actual and perceived limitations to physical activity. Ask for any form of exercise that he/she used to do or wants to try.To create a baseline of activity levels and mental status related to acute pain, fatigue and activity intolerance.
Encourage progressive activity through self-care and exercise as tolerated. Explain the need to reduce sedentary activities such as watching television and using social media in long periods. Alternate periods of physical activity with 60-90 minutes of undisturbed rest.To gradually increase the patient’s tolerance to physical activity. To prevent triggering of acute pain by allowing the patient to pace activity versus rest.
Administer analgesics as prescribed  prior to exercise/ physical activity. Teach deep breathing exercises and relaxation techniques. Provide adequate ventilation in the room.To provide pain relief before an exercise session. To allow the patient to relax while at rest and to facilitate effective stress management. To allow enough oxygenation in the room.
Refer the patient to physiotherapy / occupational therapy team as required.To provide a more specialized care for the patient in terms of helping him/ her build confidence in increasing daily physical activity.

Nursing Care Plan 3

Nursing Diagnosis: Deficient Knowledge related new diagnosis of Paget’s disease, as evidenced by patient’s verbalization of “I want to know more how to manage my illness.”

Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of his/her acute pain and its management.

InterventionsRationales
Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g., denial of diagnosis or poor lifestyle habits).To address the patient’s cognition and mental status towards disease management and to help the patient overcome blocks to learning.
Explain what his/her pain management program entails (e.g., medications, relaxation techniques, diet, and related physiotherapy or exercises). Avoid using medical jargons and explain in layman’s terms.To provide information on his/her pain management program for Paget’s disease.
Inform the patient the details about the prescribed medications (e.g., drug class, use, benefits, side effects, and risks) to treat acute pain. Ask the patient to repeat or demonstrate the self-administration details to you.To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.
Educate the patient about non-pharmacological methods for acute pain such as imagery, distraction techniques, recommended exercises, and relaxation techniques.To reduce stress and to promote optimal pain relief without too much dependence on pharmacological means.
If the patient is for surgery, explain the surgical procedure related to osteoarthritis to the patient and caregiver.The doctor may recommend surgery to resolve unbearable joint pain due to Paget’s disease.

Other possible nursing diagnoses:

  • Risk for Fracture
  • Fatigue
  • Disturbed Sensory Perception

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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