Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NUR 202 Week 2 > Connective Tissue Diseases > Flashcards

Connective Tissue Diseases Flashcards

* Osteoarthritis (OA) * Rheumatoid arthritis (RA) * Gouty arthritis (gout)

1
Q

Arthritis, or inflammation of the joints, has many etiologies

Most prevalent are -
* Osteoarthritis (OA)
* Rheumatoid arthritis (RA)
* Gout/gouty arthritis

A

Differential features of RA & OA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

RA

  • inflammatory, autoimmune, genetic component, younger onset; women to men 3:1
  • Inc RF factor, ESR, ANA
  • Meds: NSAIDs, methotrexate, corticosteroids, biologic response modifiers, other immunosuppressants
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

OA

  • degenerative, possibly genetic component; older age of onset, obesity; traumatic event; 55-60 y.o.; after 55 yrs women to men is 2:1
  • Normal to sl elevated ESR
  • Meds: Tylenol, analgesics, NSAIDs usually short-term & later in the dz process
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

OA is classified as idiopathic or secondary

A

Note, RA can lead to OA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

?

Caused from another dz process (DM, Paget’s, hemophilia, sickle cell, RA)

Probably prev trauma or infection; infection can cause joint sepsis

A

Secondary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

?

No known cause; seen more in the hips, knees, & spine
More in women than in men; people older than 65 yrs probably genetic link

A

idiopathic/primary

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Risk factors - primary OA

  • Middle-aged & older adults
  • Obesity
  • Repetitive joint injuries/trauma
  • Genetic component
  • Smoking
A

Age is the biggest risk factor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

OA - Pathophysiology

  • Articular cartilage degeneration & uneven surfaces
  • Thickening of subchondral bone
  • Osteophyte formation
  • Narrowing of joint space
  • Decline in synovial fluid protection
A
  • Central cartilage loss & peripheral growth of cartilage & bone causes uneven surfaces that have a grating sound (crepitus) upon movement
  • Dec in synovial fluid causes less lubrication & circulation of nutrients to the joint; these in turn cause pain, limited ROM & loss of function
  • Late in the dz process → 2° synovitis (inflammation) & joint effusions; bone cysts lead to bone deformations & atrophy of skeletal muscle (from guarding & not using) may be seen
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

S/S - OA

  • Localized pain & stiffness
  • Pain relieved w/rest, not systemic pain
  • Stiffness possible; atrophy of skeletal muscle that may effect ambulation
  • Crepitus - grating sensation w/movement
  • Asymmetrical - joint enlargement; monoarticular or polyarticular; usually r/t bony hypertrophy; not usually an inflammatory process
  • Possible mild swelling
  • not usually warm; may have joint effusions esp in knees from inc synovial fluid
A
  • Pain w/activity, improves w/rest
  • pain early on; pain dec w/rest & gets worse w/activity; late phase, pain can occur @ rest
  • Joint enlargement incl Heberden’s & Bouchard’s nodules
  • Possible “locking” or “giving way” of joints
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Bouchard’s & Heberden’s Nodes in OA

  • Heberden in the DIP joint (distal interphalangeal joints)
  • Bouchard in the PIP joints (proximal interphalangeal joints)
A
  • Can appear in both hands; may be red & painful
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Diagnostic testing (OA findings)

  • Arthroscopy for visualization of articular surfaces - degeneration
  • MRI
  • X-ray films - narrowing of joint space & osteophyte formation
A
  • Serological studies to look @ uric acid (gout), rheumatoid factor (RF), lyme titre, ESR for systemic sx’s [poss slightly elevated]
  • Synovial fluid for color & consistency; signs of infection; crystals
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Medications

  • Analgesic: acetaminophen - Tylenol
    > For mild to mod pain w/o inflammation - 1st choice
    > Monitor LFT’s @ beginning of therapy and q6-12 mos
    ! Not for persons w/liver dz or increased ETOH intake

! No greater than 3g max/day incl additive effects of Percocet & Darvocet, etc.

A

NSAIDs (nonselective):

  • Ibuprofen - Motrin
  • Naproxen - Naprosyn
  • Indomethacin - Indocin

COX-2 selective inhibitor: Celecoxib [Celebrex]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

NSAIDs

  • analgesic & anti-inflammatory; prevent prostaglandin formation
  • caution w/cardiac dz - inc fluid overload & BP
  • caution for GI bleeding - misoprostol (Cytotec) can be given w/NSAID; Cytotec produces prostaglandins for mucosal protection
  • Monitor renal & liver fxn tests
  • Avoid use w/other NSAIDs, steroids, anticoagulants, & ETOH - inc bleeding
A
  • Celecoxib is less of an issue w/dec GI prostaglandins
  • NSAIDs may actually disrupt articular cartilage metabolism
  • COX-2 inhibitors - not used as much r/t evidence of cardiovascular disorders like MI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Opioid analgesics
- codeine
- oxycodone - Percodan, Percocet
- Propoxyphene - Darvon, Darvocet [taken off market for cardiac arrhythmias]

Steroid injection - Kenalog, Depo-Medrol

Viscosupplementation
- Synvisc - Hylan G-F 20
- Orthovisc - Hyaluranon/hyaluronic acid

A

Opioids

  • Monitor for CNS & respiratory depression
  • s/e: nausea, constipation, dizziness
  • Monitor for renal/hepatic toxicity; safety precautions; drug dependence
  • Hyaluronan is a polysaccharide similar to synovial fluid & promotes independent articular production of synovial fluid for several mos
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Dietary supplements

?

This improves elasticity of cartilage; ! monitor for bleeding

A

condroitin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

SAM-e (5-adenosylmethionine)

Repairs cartilage by improving proteoglycans

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

?

Used to make & repair cartilage; s/e - inc blood glucose lvls & INR; diarrhea, HA

A

glucosamine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Topical Agents

  • Capsaicin - may produce a cutaneous burning sensation that resolves w/time
  • Icy Hot
  • Aspercreme
  • Lidocaine 5% patch [! can slow cardiac electrical activity]
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

For inflammation, should we treat with cold or heat?

A

Cold

20
Q

Non-Medication Interventions

  • Weight loss
  • Smoke cessation
  • Rest
  • Repositioning
  • Heat/cold
  • Protect joints from trauma/stress
A

! Heat inc circulation & dec muscle tension; can create edema

! Cold numbs nerve endings; also vasoconstricts

  • Protect & cover skin - thermo source not directly on skin; 20 min on/off & check skin following protocol
21
Q

Surgical Management

  • Joint debridement or abrasion
    > Abrasion chondroplasty performed w/arthroscopy stimulates growth
  • Cartilage transplant
    > w/graft or chondrocyte inj
  • Osteotomy - surgical incision in bone to redistribute the load-bearing surface of a joint
A
  • Arthrodesis - fusion of the bones of a joint usually of cervical & lumbar spine, finger, wrist, & ankle
  • Arthroplasty - joint replacement usually of the hip & knee but can be performed on shoulder, fingers, ankle, & elbow
    ! preserves ROM
22
Q

Varus deformity - knee osteotomy

  • Tibial osteotomy may delay knee replacement for 10 yrs
A

Arthrodesis

  • Joint fusion w/allograft, cadaver bone or hardware
    > bone graft in hardware [photo]
23
Q

Arthroplasty

  • Joint replacement w/hardware maintains ROM as compared to arthrodesis
A

Total knee replacement (TKR)

  • Gen anesthesia w/opiates or continuous femoral nerve block (CFNB) into the femoral or sciatic nerve
  • Less opiates req’d >surgery so faster rehab
  • Knee brace, CMS checks, plantar & dorsiflexion but no pain is normal

! systemic warning of infusion -
slurred speech, hypotension, dec resp, metallic taste, tinnitus

24
Q

Continuous passive motion (CPM) machine

  • Leg is placed slightly abducted
  • Pt’s leg is started at 0° of flexion & over a period of days inc the ° of flexion to the hcp’s orders; HOB no more than 15° off CPM to elevate HOB & eat
  • Can be very uncomfortable; there’s conflicting research on the efficacy on the use of CPM
A

Key Points - CPM

↣ Lining up the knee joint w/the joint in the CPM for flexion
↣ Making sure that the pt has the controller to stop the machine
↣ Shut off when the leg is in extension
↣ Check the skin for any reddened areas & instruct the pt to notify you if any discomfort noted
↣ Pre-medicate for pain; straight leg raises & isometrics to inc extremity muscle strength
↣ MD may order a knee brace for knee extension
↣ CryoPad, ConstaVac
↣ ! No hyperextension of knee - usually no pillow under the popliteal space - can contribute to contracture
↣ May lock the bottom of the bed so the knee will not flex

25
Q

OA of hip

e.g., hardware - hemiarthroplasty prosthesis

Anterior approach - more muscle damage but dec risk of dislocation

A

Posterior approach - less muscle damage but inc risk for dislocation & sciatic nerve injury

26
Q

Complications of TKR & THR

! Infection
! Blood vessel injury/blood loss/hypotension
! Nerve injury
! Fat embolism
! DVT/PE
! Dislocation or instability of joint
! Loosening of prosthesis
! Compartment syndrome

A
  • Prosthesis can be cemented or non-cemented
  • Non-cemented has a rough coat on the prosthesis so that the bone grows into the prosthetic
  • Cemented joints usually able to be PWB to FWB as tolerated
  • Non-cemented-PWB for a few wks until bone grows in
  • Start w/walker or crutches & advance to single cane 4-6 wks >surgery
  • Collaboration w/PT for early ambulation & leg exercises to strengthen muscles, improve balance, dec risk of clots
27
Q

Nursing Interventions

↣ No adduction beyond midline; abduction splint/wedge (hip)

↣ No flexion of hip beyond 90°

↣ No extreme external/internal rotation (hip)

↣ No lying on operated side (hip)

A

↣ Report acute pain, rotation, & extremity shortening

↣ Maintain drain(s)
- JP/Hemovac - make sure they’re compressed
- ConstaVac - able to autologously re-transfuse blood; empty q4h & prn

↣ Prevent thrombus formation - anticoag’s, dorsiflexion/plantar flexion
- Heels off bed - risk for decubitus
! prevent infection

↣ Regular pulmonary toilette

28
Q

↣ Do not put pillow under knee for TKR, keep knee @ 180°

↣ Weight-bearing activities as ordered w/inc activities as tol/assistive devices

↣ Pain control/PCA/CFNB
- check CMS q2-4 hrs - alt sensation, alt amb r/t nerve block

↣ CPM machine
- knee brace to help stabilize

↣ Prophylactic abx (for dental work hardware)

↣ Metal may activate metal detectors/MRI

A

↣ If getting into systemic circulation = restlessness, metallic taste, hypotension, bradycardia, dec resp, slurred speech

↣ Pillow placement less bulky

↣ Fracture bed pan vs regular pan

29
Q

↣ Observe dressing for drainage & reinforce/aseptic dressing change >1st MD change

↣ CMS checks (compared to unoperated extrem) - monitor for DVT, ! compartment synd

↣ Keep incision dry, no tub baths/shower seat
- no showers for about 3 days; then cover with Tegaderm
- shower seat d/t instability created from incision

↣ Rehab; PT/OT

A
  • Pt may be d/c’d home (usually about 4-5 days post-op) if can transfer independently to & from the bed, walk alone 150 ft on a flat surface, & safely negotiate stairs
  • If not, then may go to a SNF or rehab center
  • OT & PT will need to work w/pt to strengthen the muscles that had been severed during surgery
  • Pt unable to drive for until muscles heal & strength & stability return

! Hip dislocation - shortening of LE; inc pain; leg rotation adduction

30
Q

?

Chronic, inflammatory dz of connective tissue throughout the body

Systemic manifestations incl anorexia, wt loss, fatigue, muscle aching & stiffness, joint pain & stiffness

Is autoimmune & has a genetic component (allele of the MHC on the short arm of chromosome 6)

Inflamed synovial membrane & bone erosions

Periarticular osteopenia in hand or wrist joints is common

A

Rheumatoid Arthritis

31
Q
  • Usually dx’d @ a younger age & more prevalent among women
  • Subchondral cysts, inflamed synovial membrane, eroded cartilage
A

Pathophysiology

↣ Inflammation w/an unk etiology
- most likely autoimmune etiology

↣ Proliferation of the synovial membrane

↣ Erosion of articular cartilage & subchondral bone

↣ Can extend beyond joint into soft tissue
- can become systemic

32
Q

S/S - RA

  • Painful, stiff, red, warm, swollen joints
  • Bilateral & symmetrical
  • Mostly hands, knees, elbows, feet, wrist, ankle
  • Systemic involvement
  • Muscle atrophy
  • Joint fusion/dislocation
A
  • Inflammatory response (systemic sx’s) - low-grade fever, fatigue, weakness, anorexia, paresthesias
  • Mod to severe pain w/morning stiffness
  • Ulnar deviation
  • Systemic involvement - fatigue, anemia, wt loss, fever, vasculitis, SC nodules over bony prominences, bone erosions
33
Q

RA - late stage

  • Tenosynovitis (inflammation of the tendon sheath) on the wrist is common & carpal tunnel can result
  • Boutonniere deformity (of thumb)
  • Ulnar deviation (of metacarpophalangeal joints)
  • Swan-neck deformity (of fingers)
A
  • Nodules over extensor surfaces
  • Not painful in themselves but expose a person to integument issues if traumatized & skin breaks
  • Other systemic sx’s may incl osteoporosis, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung dz, Sjogren’s dz, renal dz
34
Q

Systemic complications

  • Vasculitis
  • Pulmonary - pleurisy, pneumonitis, diffuse interstitial fibrosis, Caplan’s syndrome
  • Cardiac - pericarditis, myocarditis
  • Eyes - iritis, scleritis
A

Sjogren’s syndrome
- dry eyes
- dry mouth (xerostomia)
- dry vagina

35
Q
  • Felty’s syndrome - hepatosplenomegaly, leukopenia
A
36
Q

Diagnostics

  • xray bone erosion in hand or wrist joints; narrowing joint space
  • (+) serum rheumatoid factor (RF) test
  • elevated ESR & C-reactive protein (CRP)

> indicators of inflammation

A
  • inc synovial fluid
  • inc WBC, cloudy, volume, rf
  • ice & rest for 24h; monitor for bleeding or synovial leakage
  • RF is an antibody to IgG
  • anti-CCP, cyclic citrullinated protein, antibodies are more specific for RA
  • Elevated WBC, anemia, thrombocytosis
  • Elevated ANA
37
Q

Medications

  • NSAIDs

DMARDs: disease-modifying anti-rheumatic drugs
- methotrexate (Rheumatrex)
- sulfasalazine (Azulfidine)
- penicillamine (Depen)
- azathioprine (Imuran)
- gold compounds
- hydroxychloroquine (Plaquenil)

A
  • NSAIDs + steroids + DMARDs for complete treatment
  • GI s/e’s controlled w/H2 blocker, PPI’s, or sucralfate
  • Steroid-induced osteoporosis counteracted w/calcium (1200-1500 mg/day) & vit D
  • Do not stop meds abruptly
  • Monitor for F&E balance, glucose lvls, HTN, dec healing, thinning skin, purpura
38
Q
  • Methotrexate + folic acid 1 mg/day dec toxicity
    > Inhibits DNA synthesis of inflammatory cells

s/e’s
> GI complaints, liver, bone marrow suppression
> incl pneumonitis, leukopenia, thrombocytopenia, anemia, n/d, stomatitis
- check kidney & liver function before & w/liver q4-8wks
- avoid sunlight

A

penicillamine (Azulfidine)
> GI upset, liver dysfunction, bone marrow suppression

39
Q

hydroxychloroquine (Plaquenil)
> suppresses formation of antigens responsible for hypersensitivity rxns

s/e’s
> HA, GI/visual disturbances, pruritus (esp palms, soles, scalp), impaired hearing
> Retinopathy can progress even after med d/c’d

! Monitor CBC & liver function

400-600 mg/daily for 5-10 days, gradually inc to optimum response

A

Maintenance in 4-12 wks - dec dose 50% then maintain @ 200-400 mg/day

40
Q

Tumor Necrosis Factor (TNF) blockers

leflunomide (Arava)
adalimumab (Humira)
infliximab (Remicade)
etanercept (Enbrel)

A

↣ Neutralize the biologic activity of TNF to dec immune responses

↣ BRMs (biologic response modifiers) are a branch of DMARDs - do not give to pt w/serious infection, TB, or MS
> Mantoux prior to starting drugs

↣ May take wks to mos to reach therapeutic effect so NSAIDs & steroids stay on board until that time

↣ All DMARDs are toxic to multiple body organs incl the liver, kidneys, GI, lungs, bone marrow, & eyes
> They suppress bone marrow & place pt @ risk for infection, anemia, & bleeding

41
Q

Tumor necrosis factor

A member of a super family of proteins, each w/157 amino acids, which induce necrosis (death) of tumor cells & possess a wide range of pro-inflammatory actions

A

TNF-alpha antagonists

s/e
! flu-like sx’s
! infections
! injection site irritation
! fatal pulmonary response

42
Q
  • Blocking the action of TNF has been shown to be beneficial in reducing the inflammation in inflammatory cases such as Crohn’s dz & RA
  • Remicade - infusion rxn = CP, tachy, dyspnea, light-headed, check CBC
A

Surgical treatment

  • Tendon transfer & osteotomy
    > Tendon transfers w/osteotomy & arthrodesis (fusions) are used commonly in the fingers to give them more function
  • Synovectomy - is removal of the synovia in the elbows, wrists, fingers, or knees b/c the dz process starts in the synovial membrane & destruction cont to other local tissues
  • Arthrodesis
  • Arthroplasty = joint replacement
43
Q

Other Interventions

  • Low impact exercises/wt loss/diet
  • yoga, walking, bike riding, tai chi all inc muscle tone to keep off wt
  • Heat & cold application
    > heat to inc circulation & elasticity of joint
    > cold to dec inflammation
  • Utilization of assistive devices
  • Steps for joint protection
A
  • 1st line of attack is through meds, PT w/poss assistive devices, exercise, wt loss; if interventions fail, then surgery may be considered
44
Q

Gouty arthritis

  • Overproduction or under-excretion of uric acid - collects in joints
  • S/S: acute pain, redness, edema in 1 joint last approx 1 wk
  • primary s/s may incl systemic findings like fever, malaise
  • Chronic collection in kidneys (calculi), soft tissues (tophi), & arteries (atherosclerosis)
  • purine crystals
A
  • Joints usually incl the great toe, fingers, wrist, ankle, knees
45
Q

Tophi

Collection of uric acid crystals in the soft tissue

A
46
Q

Diagnostics

  • Inc serum ESR
  • Inc serum uric acid
  • 24 hr urine
  • Joint aspirate positive for uric acid crystals
  • Painful, swollen joints
  • Tophi, renal stones w/chronic gout - check renal function
A

Serum > 8.5 mg/dL = abn

Urine >750 mg/24hr

Aspirate is definitive

47
Q

Treatment

  • Ice (to dec inflammation), bedrest
  • Increase fluid intake (2L H2O/day), weight reduction
  • Lower purine diet, avoid physical/emotional stress & alcohol (is dehydrating & will inc conc of uric acid crystals)
  • Medications - avoid aspirin & diuretics
A
  • Incr pH of urine w/alkaline ash foods - milk, citrus juices
  • Proper fitting shoes
  • Use of bed cradle (to keep sheets off skin)

! Foods high in purines -
> fish/seafood: anchovies, herring, mackerel
> meats: brains, organ meats, wild game
> veggies: asparagus, cauliflower, green peas, mushrooms, spinach
> grains: legumes, oatmeal, wheat bran, whole grains

NUR 202 Week 2 (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions