Care of Patients with Arthritis and Other Connective Tissue Diseases Flashcards
Rheumatic disease:
any disease or condition involving the musculoskeletal system
Arthritis:
inflammation of one or more joints
Osteoarthritis:
progressive disorder deterioration and loss of cartilage and bone in one or more joints
Articular cartilage (hyaline cartilage) contains:
water and a matrix of:
Proteoglycans
Collagen
Chondrocytes
The production of __________ which provides joint lubrication and nutrition, also declines because of _______ and ______ in the older adult
synovial fluid
decreased synthesis of hyaluronic acid and less body fluid
As cartilage and the bone beneath the cartilage begin to erode, the joint space
narrows and osteophytes (bone spurs) form
Eitology and Genetic Risk: Primary and Secondary
Primary OA: caused by aging and genetic factors
Secondary OA: results from joint injury and obesity
Incidence and Prevalence: Most people older than 60 years have
joint changes that can be seen on x ray examination
Assessment:
History: joint stiffness, joint swelling, control of pain, loss of mobility or difficulty w/ ADLs
Physical assessment/clinical manifestations
Psychosocial assessment: continuous pain from arthritis may develop depression or anxiety
Lab assessment: ESR and hsCRP might be elevated
Imaging: MRI/CT
Physical assessment/clinical manifestations: OA
Crepitus might be felt or heard (popping)
The presence of inflammation in patients with OA indicates a secondary synovitis
Heberden’s nodes: bony nodules at the distal interphalangeal joints
Bouchard’s nodes: bony nodules at proximal interphalangeal joints
Joint effusions (excess fluid)
Atrophy
Loss of function
Immobility
Severe pain
Managing chronic pain: Expected outcome
The patient w/ OA is expected to have pain control that is acceptable to the patient (3 on a 0-10 scale)
Interventions for OA
Combinations of therapies
No drug cab influence course of OA
Recommend regular acetaminophen as the primary drug
Topical drug application may help with temporary relief
Positioning and heat/cold applications
No food that causes or cures arthritis
Glucosamine does what and
Chondroitin plays a role in what?
may decrease inflammation
may play a role in strengthening cartilage
Most common surgical procedure performed for older adults with OA and other conditions including RA, trauma, congenital anomalies, and osteonecrosis =
total joint arthroplasty TJA also known as total joint replacement TJR
Osteonecrosis:
bony necrosis secondary to lack of blood flow, usually from trauma or chronic steroid therapy
Contradictions for TJA are
active infection anywhere in the body, advanced osteoporosis, and rapidly progressive inflammation
Total Hip Arthroplasty:
The first time a patient receives any total joint arthroplasty, it is referred to as primary arthroplasty
If the implant loosens, revision arthroplasty is performed
Most common in people of 60 and older
Preoperative care: Drugs that increase the risks for clotting and bleeding are
NSAIDs Vit C and E Hormone replacement therapy (HRT) Oral contraceptive drugs MUST BE DISCONTINUED A WEEK BEFORE SURGERY
Operative Procedures: For lower extremity surgery the anesthesiologist or nurse anesthetist places the patient
under general or neuraxial (epidural/spinal) anesthesia
Postoperative care: complications
Venous thromboembolism (VTE) Infection Anemia Neurovascular compromise MAJOR complication = Hip Subluxation (partial dislocation) or total dislocation
Interventions for Dislocation:
Position correctly
Hip= keep leg slightly abducted, prevent hip flexion beyond 90 degrees
Assess for acute pain, rotation, and extremity shortening
Report physician immediately
Interventions for Infection:
Aseptic technique for wound care & draining
Wash hands
Monitor temp
Culture drainage fluid if change
Report excessive inflammation or drainage to physician
Interventions for VTE:
Wear stockings per policy Teach leg exercises Encourage fluid intake Look for redness, swelling, pain Observe for changes in mental status Adm anticoagulant as prescribed Do not massage legs Do not flex knees for prolonged time
Interventions for hypotension, bleeding, and infection
Take vital signs at every 4 hr for 1st 24 hr, then 8-12 hr after
Observe for bleeding
Report excessive low BP to physician
Teach the patient to perform what kind of exercises by pushing the heels into the bed and achieve what by straightening the legs and pushing the back of the knees into the bed?
Gluteal exercises
Achieve quadriceps-setting exercises
An older patient may not have a fever with infection but instead may experience
an altered mental state
The total amount of drainage is usually
less than 50 mL/8hr
Managing pain:
Includes extended release epidural morphine (EREM) or patient controlled analgesia (PCA)
-Patients may receive additional analgesic drugs for chronic arthritic pain in other joints
Promoting self management: Traditional surgery vs minimally invasive THA
Traditional: length of stay is typically 2-3 days
-Acute rehab takes 1-2 wk or longer, takes 6 wk or longer for full complete recovery
THA: discharged on the second postoperative day or the day of surgery (23 hr stay)
Expected life for a Total Knee Arthroplasty (TKA)
20 years or more
Preoperative care for TKA: PT & OT provide info about
transfers, ambulation, post-op exercises, and ADL assistance
One of the most recent advances in post-op pain management for lower extremity total joint arthroplasty is
peripheral nerve blockade (PNB)
In the procedure of PNB, the anesthesiologist does what
Injects the femoral or sciatic nerve w/ local anesthetic; the patient may receive continuous infusion of the anesthetic by portable pump
Other joint arthroplasties:
Total shoulder arthroplasty (TSA)
Total elbow arthroplasty (TEA)
Any joint of the hand or foot can be replaced, often for patients w/ RA
Any bone of the wrist can be replaced, plus radius and ulna
Because shoulder joint is complex and has many articulations (joint surfaces), what is a major potential complication?
subluxation or complete dislocation
What is ab alternative to TSA:
Hemiarthroplasty (replacement of part of the joint), typically the humeral component
As for other total joint arthroplasty, perform frequent what for how many hours?
Neurovascular assessments at least every 4-8 hr
The pannus is:
vascular granulation tissue composed of inflammatory cells; it erodes articular cartilage and eventually destroys bone
If blood vessel involvement (vasculitis) occurs,
the organ supplied by that vessel can be affected, leading to eventual failure of the organ or system in late disease
Assessment - Early disease manifestations of RA:
Inflammation, generalized weakness, and fatigue.
Anorexia and a weight loss of 2-3 lbs usually occur
May report migrating symptoms known as migratory arthritis
Presence of only one hot, swollen, painful joint = infected – refer to health care provider immediately
Assessment -Late disease manifestations of RA:
frequent morning stiffness (gel phenomenon)
Synovitis and effusions (joint swelling w/ fluid, especially the knees)
Muscle atrophy
Decreased ROM
Joint deformity
Baker’s cyst (enlarged popliteal bursae behind the knee
moderate - severe weight loss, fever, extreme fatigue = exacerbations (flare-ups)
Subcutaneous nodules: usually on ulnar surface of arm, on fingers, and Achilles tendon
Assess for ischemic skin lesions that appear
in groups of small, brownish spots, most commonly around the nail bed (periungual lesions)
Monitor number of lesions, note location each day, and report vascular changes to the health care provider
Peripheral neuropathy associated w/ decreased circulation can cause
foot drop and paresthesias (burning and tingling sensations) = usually in older adults
Respiratory complication may manifest as
pleurisy, pneumonitis, diffuse interstitial fibrosis, and pulmonary hypertension
Several syndromes are seen in patient w/ advanced RA, the most common is
Sjogren’s syndrome
Sjogren’s syndrome includes a triad of:
Dry eyes Dry mouth (xerostomia) Dry vagina (in some cases)
Less common syndromes are:
Felty’s syndrome: characterized by RA, hepatosplenomegaly (enlarged liver and spleen), and leukopenia
Caplan’s syndrome: characterized by the presence of rheumatoid nodules in the lungs
Lab Assessment for RA:
Rheumatoid factor - RF: Presence of unusual antibodies of IgG & M
Antinuclear antibody (ANA): test measures the titer of a group of antibodies that destroy nuclei of cells and cause tissue death in patients w/ autoimmune disease
ESR
hsCRP
Serum complement proteins
Albumin levels: 3.5-5.0
Interventions of RA:
- Synovectomy: to remove inflamed synovium may be needed for joints like the knee or elbow
- Disease-modifying antirheumatic drugs (DMARDs): slow the progression of the disease
- Strict birth control
- Leflunomide (Arava)
What are one of the newest DMARDs:
biological response modifiers (BRMs), biologics
- Etanercept (Enbrel)
- Infliximab (Remicade)
- Adalimumab (Humira)
- Anakinra (Kineret)
- Abatacept (Orencia)
Other drugs: Glucocorticoids
Steroids
-Usually Prednisone: may be given in high does for short duration (pulse therapy) or as a low chronic dose
Chronic steroid therapy can result in numerous complications:
Diabetes mellitus Infection Fluid and electrolyte imbalances Hypertension Osteoporosis Glaucoma
Nonpharmacologic interventions for RA:
Apply ice packs
Heated paraffin (Wax) dips
Hot packs
Plasma exchange: plasmapheresis
Alternative medicine:
- Cold water fish or fish oil capsules containing omega-3 fatty acids
- Gamma-linolenic acid (GLA) omega-6 fatty acid
Older white women are most likely to experience
GI bleeding as a result of taking NSAIDs - reason is unknown
Principles of energy conservation:
Pacing activities
Allowing rest periods
Setting priorities
Obtaining assistance when needed
