Paget’s disease of bone is a chronic disorder characterized by abnormal bone remodeling, resulting in enlarged and weakened bones. This nursing diagnosis is crucial for healthcare providers to understand as it can lead to serious complications if left untreated, including bone deformities, fractures, and, in rare cases, bone cancer.
Causes (Related to)
Paget’s disease of bone can result from various factors that affect bone metabolism and remodeling. The following are common causes of Paget’s disease:
- Genetic factors: A family history of Paget’s disease increases the risk, suggesting a genetic component.
- Environmental triggers: Certain viral infections may play a role in activating the disease in genetically susceptible individuals.
- Age: Paget’s disease is more common in older adults, typically over 50 years of age.
- Gender: Men are slightly more likely to develop Paget’s disease than women.
- Ethnicity: People of Anglo-Saxon descent are more commonly affected.
Signs and Symptoms (As evidenced by)
Paget’s disease can manifest with a variety of signs and symptoms. In a physical assessment, a patient with Paget’s disease may present with one or more of the following:
Subjective: (Patient reports)
- Bone pain, particularly in the pelvis, spine, skull, or legs
- Joint pain, especially in areas adjacent to affected bones
- Headaches (if the skull is affected)
- Hearing loss (if the skull is affected)
- Warmth over affected areas of bone
Objective: (Nurse assesses)
- Visible bone deformities
- Bowing of limbs
- Enlargement of the skull
- Increased head size
- Fractures
- Limited range of motion in affected joints
- Neurological symptoms (if the spine is affected)
- Lab values
- Elevated serum alkaline phosphatase levels
- Imaging findings
- Abnormal bone structure on X-rays or bone scans
Expected Outcomes
The following are the common nursing care planning goals and expected outcomes for Paget’s disease:
- The patient will report reduced bone pain.
- The patient will demonstrate improved mobility and range of motion.
- The patient will maintain bone integrity without new fractures.
- The patient will show normal or stabilized serum alkaline phosphatase levels.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. The following section will cover subjective and objective data about Paget’s disease.
1. Conduct a comprehensive health history.
Gather information about family history, past medical history, and onset of symptoms. A family history of Paget’s disease or early onset of symptoms may indicate a genetic predisposition.
2. Assess pain levels and characteristics.
Use a standardized pain scale to evaluate pain’s intensity, location, and nature. Bone pain is a common symptom of Paget’s disease and can significantly impact quality of life.
3. Evaluate mobility and gait.
Assess the patient’s ability to move and walk. Paget’s disease can affect mobility due to bone deformities or pain.
4. Perform a neurological assessment.
Check for neurological deficits, especially if the spine or skull is affected. Paget’s disease can lead to nerve compression, causing neurological symptoms.
5. Measure vital signs.
Monitor blood pressure, heart rate, and temperature. Increased vascularity in affected bones can cause warmth in the overlying skin.
6. Assess for signs of complications.
Look for signs of fractures, arthritis, or hearing loss. These are common complications associated with Paget’s disease.
7. Review laboratory results.
Check serum alkaline phosphatase levels, which are typically elevated in Paget’s disease. This enzyme is a marker of bone turnover.
Nursing Interventions
Nursing interventions and care are essential for managing Paget’s disease. In the following section, you’ll learn about possible nursing interventions for a patient with Paget’s disease.
1. Administer medications as prescribed.
Medications are a cornerstone of Paget’s disease management. Common medications include:
- Bisphosphonates (e.g., alendronate, risedronate)
- Calcitonin
- Pain relievers (e.g., NSAIDs, acetaminophen)
2. Provide patient education.
Educate the patient about Paget’s disease, its progression, and management strategies. This includes information on:
- Disease process
- Importance of medication adherence
- Potential complications
- Lifestyle modifications
3. Implement pain management strategies.
Work with the patient to develop effective pain management techniques, which may include:
- Proper use of prescribed pain medications
- Application of heat or cold therapy
- Relaxation techniques
4. Promote safe mobility.
Assist the patient in maintaining mobility while reducing the risk of falls or fractures. This may involve:
- Teaching proper body mechanics
- Recommending assistive devices
- Suggesting home modifications for safety
5. Monitor for complications.
Regularly assess for signs of complications such as fractures, arthritis, or neurological changes. Early detection can lead to prompt intervention.
6. Encourage regular follow-up.
Stress the importance of regular medical check-ups and bone density scans to monitor disease progression and treatment effectiveness.
7. Provide nutritional counseling.
Advise on a diet rich in calcium and vitamin D to support bone health. This may include:
- Recommending calcium-rich foods
- Discussing vitamin D supplementation if necessary
8. Support psychosocial needs.
Offer emotional support and refer to support groups or counseling services if needed. Chronic conditions can have significant psychological impacts.
9. Collaborate with the healthcare team.
Work closely with physicians, physical therapists, and other healthcare providers to ensure comprehensive care.
10. Prepare for potential surgical interventions.
In some cases, surgery may be necessary to manage complications of Paget’s disease. Prepare the patient for potential procedures such as:
- Joint replacement
- Fracture repair
- Osteotomy (bone cutting) to correct deformities
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find examples of nursing care plans for Paget’s disease.
Nursing Care Plan 1: Chronic Pain
Nursing Diagnosis Statement:
Chronic Pain related to bone remodeling and deformities secondary to Paget’s disease as evidenced by patient reports of constant aching in affected bones, grimacing with movement, and a pain score of 7/10.
Related factors/causes:
- Increased osteoclastic activity leading to bone pain
- Bone deformities causing mechanical stress
- Potential microfractures in affected bones
Nursing Interventions and Rationales:
- Assess pain characteristics (location, intensity, quality, and aggravating/relieving factors) using a standardized pain scale every 4 hours and as needed.
Rationale: Regular pain assessment helps evaluate the effectiveness of pain management strategies and guides treatment adjustments. - Administer prescribed pain medications (e.g., NSAIDs, acetaminophen) as ordered and monitor for effectiveness and side effects.
Rationale: Pharmacological interventions can help manage pain and improve quality of life. Monitoring ensures optimal pain control and patient safety. - Teach and encourage non-pharmacological pain management techniques such as relaxation exercises, guided imagery, or heat/cold therapy application.
Rationale: Non-pharmacological methods can complement medication in pain management and give patients a sense of control over their condition. - Assist the patient in identifying and maintaining comfortable positions, using pillows or supportive devices.
Rationale: Proper positioning can alleviate pressure on affected bones and reduce pain. - Collaborate with the physical therapist to develop an appropriate exercise program that maintains mobility without exacerbating pain.
Rationale: Gentle exercises can help maintain joint flexibility and muscle strength without undue stress on affected bones.
Desired Outcomes:
- The patient will report a decrease in pain intensity from 7/10 to 3/10 or less within 1 week.
- The patient will demonstrate using at least two non-pharmacological pain management techniques by the end of the shift.
- The patient will verbalize understanding of pain management strategies and their importance in disease management by discharge.
Nursing Care Plan 2: Risk for Injury
Nursing Diagnosis Statement:
Risk for Injury related to weakened bone structure and increased risk of fractures secondary to Paget’s disease.
Related factors/causes:
- Altered bone metabolism leads to weakened bone structure
- Increased bone vascularity makes bones more prone to fractures
- Potential balance issues due to bone deformities
Nursing Interventions and Rationales:
- Conduct a thorough environmental safety assessment of the patient’s living space and recommend necessary modifications.
Rationale: Identifying and addressing potential hazards can significantly reduce the risk of falls and subsequent fractures. - Teach the patient about fall prevention strategies, including proper use of assistive devices, wearing appropriate footwear, and removing tripping hazards.
Rationale: Education empowers the patient to take an active role in preventing falls and injuries. - Assist the patient with mobilization, ensuring proper body mechanics and use of assistive devices as needed.
Rationale: Proper technique and support during movement can prevent undue stress on weakened bones and reduce the risk of falls. - Monitor and report any signs of potential fractures, such as sudden onset of pain, swelling, or deformity.
Rationale: Early detection of fractures allows for prompt treatment and prevention of further complications. - Collaborate with the dietitian to ensure adequate calcium and vitamin D intake to support bone health.
Rationale: Proper nutrition is crucial for maintaining bone strength and reducing fracture risk.
Desired Outcomes:
- The patient will remain free from falls and fractures during hospitalization and report no falls at home during follow-up visits.
- The patient will demonstrate proper use of assistive devices and fall prevention techniques by discharge.
- By the end of the education session, the patient will verbalize understanding of the importance of environmental safety and proper nutrition in preventing fractures.
Nursing Care Plan 3: Impaired Physical Mobility
Nursing Diagnosis Statement:
Impaired Physical Mobility related to bone pain and deformities secondary to Paget’s disease as evidenced by difficulty walking, decreased range of motion in affected joints, and reluctance to engage in physical activities.
Related factors/causes:
- Bone pain limits movement
- Joint stiffness due to altered bone structure
- Fear of falling or causing further damage to bones
Nursing Interventions and Rationales:
- Assess the patient’s current level of mobility, including gait, balance, and range of motion in affected joints.
Rationale: Baseline assessment helps develop an appropriate mobility plan and measure progress. - Collaborate with the physical therapist to develop and implement a personalized exercise program focusing on gentle stretching and strengthening exercises.
Rationale: Tailored exercises can improve flexibility, strength, and overall mobility while minimizing the risk of injury. - Encourage regular periods of rest between activities to prevent fatigue and exacerbation of pain.
Rationale: Balancing activity with rest helps manage pain and conserve energy, promoting overall mobility. - Teach and assist with proper body mechanics during transfers and activities of daily living.
Rationale: Proper techniques reduce stress on affected bones and joints, improving comfort and safety during movement. - Provide emotional support and encouragement to help overcome fear of movement.
Rationale: Psychological support can help patients overcome anxiety related to mobility and encourage participation in physical activities.
Desired Outcomes:
- The patient will demonstrate improved mobility as evidenced by increased participation in daily activities within one week.
- The patient will report decreased pain during movement, from 7/10 to 3/10 or less, within 2 weeks.
- The patient will verbalize confidence in using proper body mechanics during transfers and activities of daily living by discharge.
Nursing Care Plan 4: Deficient Knowledge
Nursing Diagnosis Statement:
Deficient Knowledge related to lack of information about Paget’s disease and its management as evidenced by the patient’s verbalization of uncertainty about the disease process and treatment options.
Related factors/causes:
- Lack of exposure to information about Paget’s disease
- Misinterpretation of available information
- Cognitive limitations due to age or educational background
Nursing Interventions and Rationales:
- Assess the patient’s current understanding of Paget’s disease, its progression, and management strategies.
Rationale: Identifying knowledge gaps helps tailor education to the patient’s specific needs. - Provide concise information about Paget’s disease, including its causes, symptoms, potential complications, and treatment options.
Rationale: Accurate information empowers the patient to make informed decisions about their care and actively participate in disease management. - Explain the bone remodeling process and how Paget’s disease affects it using visual aids, such as diagrams or models.
Rationale: Visual representations can enhance understanding, especially for complex physiological concepts. - Teach the importance of medication adherence, including proper administration techniques and potential side effects to watch for.
Rationale: Understanding the role of medications in managing Paget’s disease can improve treatment adherence and outcomes. - Provide written materials about Paget’s disease and encourage the patient to ask questions.
Rationale: Written information serves as a reference for the patient, and encouraging questions clarifies any misunderstandings.
Desired Outcomes:
- By the end of the education session, the patient will verbalize an accurate understanding of Paget’s disease, its progression, and management strategies.
- The patient will demonstrate proper medication administration technique before discharge.
- The patient will express confidence in managing their condition and knowing when to seek medical attention by the follow-up appointment.
Nursing Care Plan 5: Disturbed Body Image
Nursing Diagnosis Statement:
Disturbed Body Image related to visible bone deformities secondary to Paget’s disease as evidenced by the patient’s expressed dissatisfaction with appearance and reluctance to engage in social activities.
Related factors/causes:
- Visible bone enlargements, particularly in the skull or long bones
- Changes in gait or posture due to bone deformities
- Societal emphasis on physical appearance
Nursing Interventions and Rationales:
- Assess the patient’s perception of their body image and its impact on their daily life and relationships.
Rationale: Understanding the patient’s feelings about their appearance helps develop appropriate interventions to address body image concerns. - Provide emotional support and encourage expression of feelings related to body image changes.
Rationale: Emotional support can help the patient cope with the psychological impact of physical changes. - Teach adaptive strategies to minimize the appearance of deformities, such as clothing choices or hairstyles.
Rationale: Practical strategies can help patients feel more confident about their appearance in social situations. - Refer the patient to a support group for individuals with Paget’s disease or similar chronic conditions.
Rationale: Peer support can provide validation, coping strategies, and a sense of community. - Collaborate with an occupational therapist to address any functional limitations related to body changes.
Rationale: Occupational therapy can help the patient adapt to physical changes and maintain independence in daily activities.
Desired Outcomes:
- The patient will express improved acceptance of body image changes within 2 weeks.
- The patient will demonstrate the use of at least two adaptive strategies to manage appearance concerns by discharge.
- The patient will report increased participation in social activities at the follow-up appointment.
References
- Ralston, S. H., & Layfield, R. (2012). Pathogenesis of Paget disease of bone. Calcified Tissue International, 91(2), 97-113. https://link.springer.com/article/10.1007/s00223-012-9599-0
- Singer, F. R., Bone, H. G., Hosking, D. J., Lyles, K. W., Murad, M. H., Reid, I. R., & Siris, E. S. (2014). Paget’s disease of bone: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 99(12), 4408-4422. https://academic.oup.com/jcem/article/99/12/4408/2833929
