What would the nurse assess a client with Paget's disease?

Affecting up to 10% of those over 80, Paget's disease is a metabolic bone disorder often found incidentally. A comprehensive nursing assessment is key to detecting symptoms, monitoring disease progression, and identifying complications in a client with Paget's disease.

Quick Summary

A nurse assesses for bone pain, skeletal deformities like skull enlargement or bowing limbs, and neurological symptoms such as hearing or vision changes. The assessment includes a physical examination, vital signs, and review of diagnostic tests to monitor disease activity and manage symptoms effectively.

Key Points

• Musculoskeletal Assessment: A nurse assesses for pain, warmth over affected bones, deformities like bowing limbs or skull enlargement, and observes for a characteristic waddling gait or kyphosis.

• Neurological Monitoring: Regular checks for nerve compression are vital, especially for hearing and vision loss, tinnitus, vertigo, or signs of spinal cord impingement.

• Cardiovascular Screening: For widespread disease, the nurse monitors for signs of high-output heart failure, including elevated pulse, blood pressure, peripheral edema, or dyspnea.

• Functional Evaluation: Assessment includes evaluating the patient's mobility, ability to perform daily activities, and identifying home safety hazards to prevent falls and fractures.

• Psychosocial Support: A nurse should assess the patient's emotional state, body image concerns, and coping mechanisms related to living with a chronic, progressive illness.

• Symptom Management: Pain assessment and management are ongoing priorities, differentiating between pain from active disease, arthritis, or fractures to guide interventions.

Paget's disease of bone is a chronic, progressive skeletal condition characterized by abnormal bone turnover. In this condition, excessive bone resorption (breakdown) is followed by disorganized and structurally unsound bone formation, leading to enlarged, dense, and fragile bone. A thorough nursing assessment is crucial for identifying symptomatic clients and monitoring those who are asymptomatic. This detailed guide covers the key areas a nurse must evaluate.

The Musculoskeletal Assessment

The musculoskeletal system is the primary area affected by Paget's disease, and a focused assessment is a high priority. The nurse should perform a systematic head-to-toe examination, paying close attention to the most commonly affected areas: the skull, spine, pelvis, and long bones of the legs.

Physical Examination for Deformities and Signs

• Inspect and palpate affected areas: Look for and feel for skeletal deformities such as a bowed appearance of the long bones (e.g., femur, tibia). The skull may appear enlarged, particularly in the frontal and occipital regions, a condition known as frontal bossing.
• Observe gait: Ask the patient to walk across the room. A characteristic waddling gait may be present due to bowing of the long bones, especially the femurs.
• Assess spinal curvature: Look for kyphosis (exaggerated thoracic curve), which can compromise chest expansion and lead to breathing difficulties (dyspnea).
• Check for warmth: Palpate the skin over affected bones. The area may feel abnormally warm due to increased blood flow from the hypervascularity of pagetic bone.

Pain Assessment

• Characterize the pain: Ask about the nature of the pain. Bone pain from Paget's is often described as deep, dull, and constant, and it may worsen with weight-bearing activities.
• Use a pain scale: Employ a standardized tool like the Numeric Rating Scale (NRS) or Visual Analog Scale (VAS) to quantify the patient's pain level. This helps in tracking pain severity and evaluating the effectiveness of interventions.
• Assess pain sources: Differentiate between pain caused directly by the active disease process, a secondary complication like osteoarthritis, or a fracture.

Neurological and Sensory Assessment

Enlarged or deformed bone can compress cranial nerves or the spinal cord, leading to significant neurological deficits. A thorough assessment is necessary to catch these complications early.

• Hearing and vision: Test hearing and vision acuity, as enlargement of the temporal or occipital bones can compress cranial nerves VIII (auditory) and II (optic). Patients may report tinnitus or vertigo.
• Cranial nerve assessment: Evaluate other cranial nerves by testing balance, swallowing, and other functions potentially impacted by skull enlargement.
• Spinal cord compression: Monitor for signs of spinal cord or nerve root compression, which may include paresthesias (tingling), muscle weakness, radiculopathy, or loss of bowel and bladder control.

Cardiovascular Assessment

Paget's disease involving a large portion of the skeleton can put a significant strain on the cardiovascular system. The increased vascularity of pagetic bone acts like an arteriovenous shunt, increasing blood flow demands.

• High-output heart failure: Assess for signs of high-output heart failure, which can occur in severe, widespread disease.
• Vital signs: Monitor apical pulse, blood pressure, and respiratory rate for abnormalities.
• Edema and neck vein distention: Look for peripheral edema and check for neck vein distention, which can indicate right-sided heart failure.

Psychosocial and Functional Assessment

Beyond the physical manifestations, the disease can have a profound impact on a patient's mental and emotional well-being. The nurse's role includes assessing these aspects to provide holistic care.

• Emotional status: Evaluate the patient's reaction to their changing body image and chronic illness. Provide psychological support and counseling.
• Activity tolerance: Assess the patient's ability to perform activities of daily living (ADLs). Encourage safe exercise to maintain function while preventing stress on affected bones.
• Safety assessment: Evaluate the home environment for safety hazards to prevent falls, which can lead to fractures in weakened bones. Discuss the use of mobility aids as needed.

Laboratory and Diagnostic Findings

While not performing the tests, the nurse plays a vital role in interpreting and monitoring results.

1. Elevated Alkaline Phosphatase (ALP): Note the patient's serum ALP levels. Elevated ALP is a key indicator of increased bone turnover and is a common finding in Paget's disease.
2. X-ray findings: Review x-ray reports, which typically show enlarged, deformed, and architecturally unsound bones.
3. Bone scans: Understand the results of radionuclide bone scans, which are highly sensitive for detecting affected bones throughout the body.
4. Medication regimen: Confirm patient compliance with prescribed bisphosphonates or calcitonin, and assess for side effects like gastrointestinal upset. Provide patient education on proper administration.

Complications of Paget's Disease: A Comparison

Assessment Area	Common in Paget's	Description and Nursing Focus
Fractures	Frequent and pathological	Can occur with minor trauma. Nurse assesses history of fractures, location, pain, and monitors for new or incomplete fractures.
Osteoarthritis	Yes, secondary to bone changes	Often affects joints near affected bones. Nurse distinguishes this pain from pagetic pain and manages with analgesics and physical therapy.
Nerve Compression	Common, especially in spine/skull	Caused by enlarged bone pressing on nerves. Nurse monitors for neurological changes (e.g., hearing loss, vision, weakness).
High-Output Heart Failure	Rare, but serious	Occurs with extensive skeletal involvement. Nurse monitors for symptoms like dyspnea, fatigue, and edema.
Osteosarcoma	Rare, but fatal	A malignant transformation of pagetic bone. Nurse watches for sudden, increasing pain or swelling in an affected area.

Conclusion

A comprehensive nursing assessment is foundational to the care of a client with Paget's disease. The nurse must not only focus on the obvious musculoskeletal changes but also be vigilant for subtle neurological, cardiovascular, and psychosocial complications. Ongoing monitoring, patient education, and a focus on safety are paramount to managing this chronic condition and improving the patient's quality of life. For additional resources and patient information, please visit the Bone Health and Osteoporosis Foundation.

Frequently Asked Questions

What is the most common symptom of Paget's disease that a nurse might assess?

The most common symptom is bone pain, which is often described as deep, dull, and constant. It is typically a key focus of the nurse's initial and ongoing assessment.

Why would a nurse check a patient's hearing and vision in relation to Paget's disease?

Enlargement of the bones in the skull can compress cranial nerves, which can lead to hearing loss (involving the auditory nerve) or vision changes (involving the optic nerve). This neurological check is an essential part of the assessment.

What might increased warmth over a bone indicate in a client with Paget's disease?

Increased warmth over a bone is a finding that can be assessed by palpation. It indicates increased vascularity, or blood flow, to the affected pagetic bone, a result of the rapid and disorganized bone remodeling process.

How does a nurse assess for potential fractures in a patient with Paget's disease?

The nurse assesses for a history of fractures and questions any new or worsening localized pain that might suggest a new break. Special attention is paid to weight-bearing bones like the femur and tibia, where fractures are common.

Can Paget's disease affect a person's gait, and how does a nurse assess this?

Yes, if the long bones of the legs are affected, they can bow, leading to an altered or waddling gait. The nurse assesses this by observing the patient walk across the room.

Why is fall prevention a nursing priority for clients with Paget's disease?

Fall prevention is a priority because the fragile, weakened bones associated with Paget's disease are more susceptible to fractures. The nurse assesses the home environment and discusses assistive devices with the patient to minimize risk.

What cardiovascular signs should a nurse assess for in a client with severe Paget's disease?

In severe, widespread disease, the nurse should assess for signs of high-output heart failure, including dyspnea (difficulty breathing), fatigue, peripheral edema, and neck vein distention, which result from the increased blood flow demands of the affected bones.