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medsurg exam 4
musculoskeletal pt 2
| Question | Answer |
|---|---|
| rheumatoid arthritis is an | Autoimmune disease |
| rheumatoid arthritis results in | synovitis > swelling of joints > inflammatory exudate (pannus) forms > permanent damage of cartilage, bone, ligaments, and tendons > damage progresses, joints becomes painful, difficult to move |
| synovitis | inflammation tissue lines inside joints |
| classic signs and symptoms of rheumatoid arthritis | joint pain, swelling, warmth, erythema, lack of function |
| pattern of involvement for rheumatoid arthritis | 1st: small joints hands, wrists, feet 2nd: knees, shoulders, hips, elbows |
| rheumatoid arthritis has | bilateral involvement |
| course of rheumatoid arthritis | remissions and exacerbations since it is an AI disease |
| diagnosis of rheumatoid arthritis (becky said know) | Positive Rheumatoid factor (75%) ESR is significantly elevated RBC is decreased C reactive protein is positive Positive ANA (20-30%) X-ray changes |
| X-ray changes of rheumatoid arthritis | narrowing joint space, erosion of articular surface |
| Treatment/Medication goal for RA | Relieve pain, control inflammation, prevent bone erosion |
| for a pt with RA, teach | Balance rest & exercise Take meds regularly to maintain blood levels |
| medication treatment for RA (1st line) | Early, aggressive drug therapy with NSAIDS (first line of treatment) |
| Additional Medications for RA | COX-2 inhibitors DIMARDS-disease modifying anti-rheumatic Biologic Modifiers – new more effective therapy |
| COX-2 inhibitors | Inhibits enzyme involved in inflammation |
| DIMARDS-disease modifying anti-rheumatic | Prevent loss of fx ability, pain, joint tenderness |
| Biologic Modifiers – new more effective therapy | Inhibit adverse effects of cytokines |
| surgical treatment of RA | Arthroplasty |
| Arthroplasty | replace/repair joints hands to increase fx ability |
| OT/PT involvement with RA | work with the patient to provide assistive devices for ADL’s |
| Osteoarthritis/Degenerative Joint Disease (DJD) | Degeneration of bony plate, articular cartilage thins, formation bone spurs (osteophyte) |
| incidence of Osteoarthritis/Degenerative Joint Disease (DJD) increases with | age By age 65, 80% entire population shows radiographic evidence of this disease |
| Osteoarthritis/Degenerative Joint Disease (DJD) is known as | bone on bone |
| modifiable risk factors | Obesity increases risk up to 21% 10% weight loss can greatly impact disease |
| where is DJD seen | in the weight bearing joints especially the hips and knees |
| diagnosis/treatment of DJD | Primary signs and symptoms are pain, stiffness and functional impairment Use of Xrays |
| preventative measures that can slow DJD | exercise, loss of weight improve modifiable risk factors!! |
| Pharmacologic Management of DJD | symptom management and pain control |
| initial choice of med for DJD | Acetaminophen, NSAIDS, COX-2 inhibitors |
| OTC meds for DJD | glucosamine and chondroitin |
| patient teaching for DJD | Importance of weight loss Meds, SE Role of physical therapy to stabilize and maintain joints Importance exercise to maintain and restore function |
| cause of osteoporosis | Reduction bone density and change bone structure |
| risk factors for osteoporosis | Genetic = Caucasian or Asian Gender = female Age = post menopause Nutrition = low intake Ca, Vitamin D Lifestyle = Sedentary, caffeine, smoking Medications = corticosteroids |
| signs and symptoms of osteoporosis | Usually asymptomatic until fracture occurs |
| Monitoring of BMD (bone mineral density) can detect | bone loss |
| diagnostic studies of osteoporosis | Imaging Procedures Bone densitometry |
| Imaging Procedures | X-ray, CT, MRI |
| Bone densitometry | DEXA scan!! Measures BMD (Bone mineral density) hip, spine, arm |
| Gerontological Considerations for osteoporosis | Bone mass peaks at age 30 Muscles diminish size, tendons less elastic Joints, Ligaments |
| Bone mass peaks at age 30 | Bones more fragile Prone to fractures hip, wrist, vertebrae Women lose more bone mass than men |
| Muscles diminish size, tendons less elastic | Loss of strength, flexibility Stumbling, falls |
| Joints, Ligaments | Stiff, less flexibility Interferes ADL |
| The withdrawal of estrogen at menopause causes | accelerated bone resorption |
| More than ½ of all women over > 45 yrs show evidence of | osteopenia |
| Kyphosis (Dowager’s Hump) | Gradual vertebral collapse Progressive thinning of discs |
| Kyphosis (Dowager’s Hump) can be | asymptomatic |
| when do postural changes occur | post menopause |
| need to insure these things in your pts daily routine | Adequate Vitamin D and Calcium Vitamin D is necessary for calcium absorption and normal bone mineralization Elders = need to supplement |
| Elders Ca and Vit D supplements | 1500mg Ca and 400-2000 IU Vit. D daily |
| Hormone Replacement Therapy for Natural or surgical menopause | HRT with estrogen and progesterone has been the mainstay of treatment in the hope to retard bone loss and prevent fractures |
| HRT with estrogen and progesterone has demonstrated increased risk of | breast cancer, heart attack, stroke |
| Pharmacologic Therapy - Biphosphonates | increase bone density |
| back pain etiology | Herniated disc Spinal stenosis Unknown |
| radiculopathy | Swelling of joint capsule can impinge on nerve root and cause irritation |
| symptoms of radiculopathy | pain, tingling numbness (paresthesia) & muscle weakness along the distribution of nerve root |
| pain is dependent on | location |
| pain can be | acute or chronic (>3 mo without relief) |
| L4-L5 | pain in hip, lower posterior thigh, anterior let, dorsal surface of foot, great toe |
| L5-S1 | Pain in midgluteal, post thigh, calf to heal, planter surface of foot, 4th & 5th toes |
| C5-C6 | Pain in neck, shoulder, anterior arm, radial area of forearm, thumb |
| history for back pain | Onset of pain (activity) Location of pain (specific site, radiation of pain) Type and character of pain ( sharp, dull, burning) Aggravating factors Medical History (previous work injuries) Psychosocial stressors ( home or work) Check impact on ADL’s |
| Medical Management for acute lower back pain | If ESR is elevated, evaluate for malignancy or infection In older patients, initial x-ray useful to diagnose a compression fracture or tumor |
| 90 % of Acute LBP from mechanical causes will | resolve spontaneously within 6 weeks to 6 months |
| pt education | Spontaneous recovery is the rule Those who remain active despite acute pain have less future chronic pain - exercise has preventative power!! Rest for only 2-3 days or less Analgesics to permit activity Cortisone injections |
| Analgesics for back pain | Acetaminophen, NSAIDS, opioids |
| cortisone injections | decrease inflammation |
| Ligament Tears: Arthroscopy | direct visualization of joint, treatment of tears |
| Managing the Patient Undergoing Orthopedic Surgery | Total Hip Replacement Total Knee Replacement |
| when is total hip replacement indicated | Arthritis (degenerative joint disease, rheumatoid arthritis) Femoral neck fracture Failure previous reconstructive surgery - failed prosthesis, osteotomy Congenital hip disease |
| when is hip replacement indicated | Pain, disability Osteoarthritis Rheumatoid arthritis Trauma Congenital Deformity Fractures that cause avascular necrosis |
| types of hip replacement | anteriorly or posteriorly |
| Preparation of ortho surgery | prevent infection!! |
| prevent infection in | Urinary Tract Skin Asepsis Prophylactic Antibiotics |
| if pt has UTI before surgery | you have to postpone surgery until UTI is gone |
| Osteomyelitis can cause | the joint replacement to be removed |
| Osteomyelitis | infection in joint space |
| Total Hip Replacement is usually at | > 60 years of age |
| the style of replacement is related to | pt needs |
| Gerontological Considerations: Hip Replacement | Hospital stay may be complicated and prolonged with possible disability |
| Factors that influence recovery are | Preexisting medical problems Cognitive impairment Postoperative complications |
| Discharge pt education | Keep the wound area dry and clean. Look for any signs of complications Keep your affected leg in front of you, whether sitting or standing Use ice packs to decrease swelling Keep your leg elevated |
| Signs of complications (very important to teach) | Fever or chills Excessive drainage or bleeding from incision site |
| when can pts usually go home after hip surgery | day of surgery or one day post-op |
| you should also teach pts abt | daily exercise, use of assistive devices 3 months normal ADL Sexual Activity- patient in dependent position (on bottom ;P) Do not cross leg until approx 4 months Avoid low chairs to minimize hip flexion |
| how can pt prevent dislocation | Maintain hip in alignment Do not cross legs at the knee Do not flex at the hip |
| How to not flex at the hip | Keep in extension Limit flexion when sitting (90 degrees) When upright, turn using entire body, do not turn at waist Do not lean over to pick up things from the floor |
| Symptoms of hip replacement prosthesis dislocation | Increased pain, swelling at surgical site Sudden onset of acute groin pain in affected side Shortening of the leg Abnormal external or internal rotation Restricted ability or inability to move leg Reported "popping" sensation in hip |
| main Sx of hip replacement prosthesis dislocation | acute groin pain |
| post op complications of hip replacement | Deep Vein Thrombosis - ortho pts have higher risk of DVT |
| Interventions to prevent venous stasis | Pharmacologic = heparin Adequate fluid intake!!! Encourage foot exercises!!! - calf exercises Assist devices - SCD’s |
| people at risk for infection post op | elderly, obese, or poorly nourished and patients who have diabetes, rheumatoid arthritis, concurrent infections, or large hematomas |
| Total Hip Nursing Management | prevent infection prophylactic antibiotics remove foleys |
| prophylactic antibiotics | Placement of foreign body Begin prior to surgery |
| Total Knee replacement indications | Severe Pain Functional Disability: arthritis, hemophilia |
| hemophilia is an indication of knee replacement because | it can cause bleeds into joint |
| Total Knee Post Op | Compression bandage Ice to decrease swelling Exercise Plan Flexion of knee increases over time Assist with transfers Edema and Bleeding Neurovascular checks Active flexion of the foot |
| exercise plan is completed when | PT sees pt in recovery room |
| important to | Observe for any S&S of infection |
| Active flexion of the foot to prevent | Thromboembolism Peroneal nerve palsy Limited range of motion |
Created by:
leh195