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Med Surge 1 > Exam #2 > Flashcards

Exam #2 Flashcards

1
Q

musculoskeletal system anatomy

A
  • muscle

- connective tissue: bones, cartilage, ligaments, tendons, fascia

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2
Q

Bone Functions

A
  • support
  • protection
  • voluntary movement
  • blood cell production
  • mineral storage
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3
Q

types of bones

A
  • cortical: compact and dense

- cancellous: spongy

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4
Q

three types of bone cells

A
  • osteoblasts: build bone
  • osteocytes: mature bone cells;
  • osteoclasts: break down bone
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5
Q

Gross Bone Structure

A
  • epiphysis: top of bone
  • diaphysis: middle long bone
  • metaphysis: the curved part of the bone between the epiphysis and diaphysis
  • epiphyseal plate:
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6
Q

Gross Bone Structure

A
  • epiphysis: top of bone
  • diaphysis: middle long bone
  • metaphysis: the curved part of the bone between the epiphysis and diaphysis
  • epiphyseal plate: The epiphyseal plate (or epiphysial plate, physis, or growth plate) is a hyaline cartilage plate in the metaphysis at each end of a long bone. The plate is found in children and adolescents; in adults, who have stopped growing, the plate is replaced by an epiphyseal line.
  • periosteum: membrane that covers the outer surface of all bones
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7
Q

Bone Types

A
  • long bone: femur, humerus, tibia
  • short bone: carpals tarsals
  • flat bone: ribs, skull, scapula, sternum
  • irregular bone: sacrum, mandible, ear ossicles
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8
Q

Joints

A
  • articulation where two bones are in proximity to each other
  • classified by the degree of movement
    TYPES OF JOINTS
    1) hinge joint - elbow, knee
    2) ball and socket - shoulder, hip
    3) pivot (rotary) - radioulnar joint
    4) condyloid
    5) saddle
    6) gliding
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9
Q

Joints

A
  • articulation where two bones are in proximity to each other
  • classified by the degree of movement
    TYPES OF JOINTS
    1) hinge joint - elbow, knee
    2) ball and socket - shoulder, hip
    3) pivot (rotary) - radioulnar joint
    4) condyloid - wrist joint between radial and carpals
    5) saddle - carpometacarpal joint of thumb
    6) gliding - between tarsal bones
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10
Q

Joints

A
  • articulation where two bones are in proximity to each other
  • classified by the degree of movement
    TYPES OF JOINTS
    1) hinge joint - elbow, knee
    2) ball and socket - shoulder, hip
    3) pivot (rotary) - radioulnar joint
    4) condyloid - wrist joint between radial and carpals
    5) saddle - carpometacarpal joint of thumb
    6) gliding - between carpal bones
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11
Q

cartilage

A
  1. hyaline: bronchi, trachea
  2. elastic: ear, epiglottis, larynx
  3. fibrous: shock absorber, verterae, pelvis, knee, shoulder
    * functions: support, articulation, protection, growth
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12
Q

cartilage

A
  1. hyaline: bronchi, trachea
  2. elastic: ear, epiglottis, larynx
  3. fibrous: shock absorber, verterae, pelvis, knee, shoulder
    - functions: support, articulation, protection, growth
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13
Q

muscles

A
  • cardiac: striated, involuntary
  • smooth: nonstriated, involuntary
  • Skeletal: striated, voluntary (requires a nerve impulse to contract)
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14
Q

Tendons

A
  • attach muscle to bone
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15
Q

ligaments

A
  • attach bone to bone
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16
Q

fascia

A
  • layers of connective tissue

- provide strength to muscle

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17
Q

bursae

A
  • sacs of connective tissue lined with synovial membrane containing synovial fluid
  • bursitis: inflammation of bursae
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18
Q

Gerontologic considerations

A
  • decreased bone density = osteopenia (first) and osteoporosis (progressed)
  • decreased muscle mass and strength
  • decreased flexibility
  • functional problems: balance issues, functional status (get patients to do as much for themselves as they can)
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19
Q

Gerontologic Age Groups

A
  • 65-74: young old
  • 75-84: middle old
  • 84-100: old old (fastest growing population in US)
  • 100+: elite old
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20
Q

Gerontologic considerations

A
  • decreased bone density = osteopenia (first) and osteoporosis (progressed)
  • decreased muscle mass and strength
  • decreased flexibility
  • functional problems: balance issues, functional status (get patients to do as much for themselves as they can, prominant indicator of outcome)
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21
Q

muskuloskeletal assessment subjective

A
  • past health history: TB, polio, diabetes, parathyroid problems, hemophillia, rickets, bacterial infections
  • medications: bad for bones = steroids, antiseizure meds, phenothiazines, diuretics; good for bones = vit d, calcium, Hormone replacement therapy
  • nutrition: vit c & d, calcium, protein, obesity
  • occupation: extremes can lead to MSK problems
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22
Q

musckuloskeletal assessment objective

A
  • inspeciton
  • palpation: cephalopedally (head to toe), warm hands
  • range of motion: goniometer, active vs. passive
  • muscle strength
  • measurement: limb length, muscle mass
  • scoliosis: can cause lung and heart problems
  • straight leg raising test: tests for disc herniation, supine leg lift assess for pain
  • gait: get up and go test
  • assistive devices: safety, proper use
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23
Q

common musculoskeletal abnormalities

A
  • Rheumatoid arthritis
  • genu varum: bow legged
  • Genu valgum: knock knees
  • torticolis
  • osteoarthritis
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24
Q

muskuloskeletal diagnostic studies

A
  • Xray: most common
  • diskogram: cray with contrast
  • CT scan: injected with contrast - assess iodine and seafood allergies
  • myelogram: disc herniation, spinal stenosis - injection into spine, common side effect is headache
  • MRI: views soft tissue
  • Bone mineral density: determines osteopenia or osteoporosis
  • bone scan: osteomueltis, cancer; radioisotope attaches to abnormal tissue and bone
  • arthrocentesis: joint aspiration - apsirate to see if infected or inflamed
  • EMG: painful muscle test, needle put into muscle to wartch for electric impulses
  • duplex venous doppler: US looking for DVT
  • SSEP: similar to EMG but uses electrodes instead of needles
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25
Q

arthroscopy

A
  • examines interior of joint cavity
  • anesthesia
  • needle inserted and cleans up area and repairs tissue
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26
Q

lab tests for musckuloskeletal system

A
  • alkaline phosphatase: produced by osteoblasts, needed for mineralization; osteoporosis, osteomualgia, paget’s
  • serum calcium
  • serum phosphorus: related to calcium: kidney diesase
  • Rheumatoid factor
  • erythrocyte sedimentation rate: indicated inflamamation; RA, osteomyelitis
  • ANA: can destroy nucleous of cell; positive in 95% of patients w lupus or scleroderma
  • uric acid: gout
  • C-reactive protein: diagnoses inflammation dieases, infection, presents in serum 24 hours after tissue damage
  • cratine kinase: muscle damage = inceased CK
  • serium potassium: increased muscle trauma, when cells are destroyed they release k+, dysrhythmias
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27
Q

contusion

A
  • bruise
  • soft tissue injury from blunt force
  • overlying skin intact, becomes black and blue from localized hemorrhage
  • usually only painful if palpated
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28
Q

hematoma

A
  • more concerning than contusion
  • blood collecting from torn blood vessel
  • pain occurs as blod accumualtes and places pressure on nerves
  • pain occurs without palpation
  • may burst or become infected
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29
Q

strain

A
  • tendon
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30
Q

sprain

A
  • ligament
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31
Q

RICE

A

rest, ice, compress, elevate

  • analgesia as necessary
  • after 24-48 hours, warm moist heat
  • strains: change ergonomics, splints, heal in 3-6 weeks
  • sprains: may need surgery if the ligament is torn
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32
Q

subluxation/dislocation

A
  • dislocation is an emergency
  • joint capsule and ligaments can be damaged
  • S/S: shortened affected limb, loss of function, swelling, pain, deformity
  • complications: joint fx, neurovascular damage, avascular necrosis
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33
Q

Fractures

A
  • disruption of break in continuity of structure of bone
  • majority of fractures from traumatic injuries
  • some fractures secondary to disease process: cancer or osteoporosis
  • open vs closed
  • complete vs incomplete
  • displaced: two ends separated from one another VS nondisplaced: periosteum is intact and bone is aligned
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34
Q

signs and symptoms of fracture

A
  • S/S:
  • swelling: can occlude circulation and damage nerves (compartment syndrome)
  • deformity: can lead to union and functional problems if not corrected
  • muscle spasm: can displace a nondisplaced fracture or prevent it from reducing on its own
  • crepitation: can increase change for nonunion if bone ends are allowed to move about freely
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35
Q

healing process of bone

A

1) fracture hematoma
2) granulation tissue
3) callus formation
4) ossification
5) consolidation
6) remodeling

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36
Q

factors influencing healing

A
  • displacement and site of fracture
  • blood supply to area (can cause compartment syndrome)
  • immobilization
  • internal fixation devices
  • infection of poor nutrition
  • age
  • smoking (constricts vessels)
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37
Q

complications of fracture healing

A
  • delayed union (longer than expected to heal)
  • nonunion (no callus forms)
  • malunion (no realligning correctly)
  • angulation (?)
  • pseudoarthrosis (nonunion at fracture site, can develop false joint)
  • refracture
  • myositis ossificans (calcium in muscle tissue after blunt trauma)
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38
Q

goals of treatment for fracture

A
  • anatomic realignment (reduction)
  • immobilization
  • restoration of normal or near normal function
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39
Q

closed reduction

A
  • nonsurgical, manual realignment of bone fragments
  • traction and countertraction applied
  • under local or general anesthesia
  • immobilization afterwords until it heals
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40
Q

open reduction

A
  • incision required
  • internal fixation
  • risk for infection
  • early ROM of joint to prevent adhesions
  • facilitates early ambulation
  • ORIF = open reduction internal fixation
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41
Q

traction

A
  • prevent or decrease pain and muscle spasm
  • immobilize joint or part of body
  • reduce fracture or dislocation
  • treat a pathologic joint condition
  • pulling force to attain realignment - countertraction pulls in opposite direction
  • two most common types of traction: skin and skeletal
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42
Q

skin traction

A
  • used for short term treatment until skeletal traction is ok (48-72 hours)
  • tape, boots, splints applied directly to skin
  • traction weights 5-10lbs
  • skin assessment and prevention of breakdown imperative
  • assess skin (6Ps) every 4 hours
  • buck’s traction is an example (boot)
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43
Q

skeletal traction

A
  • long term pull to maintain alignment
  • pin or wire inserted into bone
  • weight 5-45lbs
  • risk for infection
  • complications of immobility
  • maintain counter-traction, eelvate end of bed
  • maintain continous traction
  • keep weights off floor
  • inspect skin and pin sites carefully
  • pin clean site every shift to prevent infection
  • maintain ROM of inaffected joints
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44
Q

casts

A
  • Arms: sugar tong splint, short arm, long arm
  • slings: pad axillary area, be careful of neck, encourage movement of fingers
  • long leg, short leg, jones dressing
  • Hip spica: used for femoral fracture in peds, dont move using the support bar, can put pt prone, use fracture bedpan
  • body jacket for vert immobilization: risk for cast syndrome, listen to bowel sounds, may need NG
  • cast syndrome: compression of superior mesenteric artery against duodenum
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45
Q

cast care interventions

A
  • do not cover a drying cast
  • handle a wet cast with palms only, can support cast with pillows when wet
  • elevate at or above heart level
  • pad or petal rough cast edges
  • do not scratch skin with any objects
  • can use cool air form hair drying for itching
  • apply ice for first 24-36 hours
  • do not get cast wet
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46
Q

prevention of musckuloskeletal problems in older adults

A
  • use ramps
  • eliminate scatter rugs
  • treat pain and discomfort from osteoarthritis
  • use walker or cain
  • proper nutrition, avoid obesity which adds extra stress to bones
  • use shoes with good support
  • gradually initiate and decrease activities
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47
Q

6Ps

A
  • parasthesia, pain, pressure, pallor, paralysis, pulselessness
  • asses with muskuloskeletal injuries
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48
Q

use of crutches

A
  • never bear weight on axillary, bear weight in hands
  • elbows at 15 degree angle
  • canes held in opposite hand of involved extremity. cane and weak leg go together
  • flat ground: involved limb and device first, followed by uninvolved limb
  • stairs: good leg first going up, bad leg first going down
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49
Q

fracture complications

A
  • direct: infection, inadequate bone union, avascular necrosis (bone death from lack of blood supply)
  • indirect: compartment syndrome, VTE, rhabdo (can damage kidneys), fat embolism, shock
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50
Q

bone infection

A
  • high incidence with open fracture or soft tissue injury
  • need aggressive debridgement
  • antibiotic beads
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51
Q

VTE

A
  • venous thromboembolism
  • esp after a hip fracture, total knee
  • prevention - anticoags, SCDs, rom to unaffecte joints
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52
Q

compartment syndrome

A
  • pressure that compromises neurovascular function
  • causes: restrictive dressings, edema
  • S/S: early = pain, unrelieved by drugs and out of proportion; late = no pulses, paralysis, dark brown urine
  • tx: quick recognition, do NOT elevate, NO ice, loosen dressing, fasciotomy (opens muscle and relieves pressure)
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53
Q

Fat embolism syndrome

A
  • main contibuting factor to death with people with fractures
  • far globules transported to lungs cause a hemorrhagic interstitial pneumonitis
  • risk with long bone, ribs, tibia, pelvis fx
  • S/S: chest pain, tachypnea, dyspnea, change in mental status, hypoxia, petechiae on neck, chest, axilla, eyes, sense of impending doom
  • tx: early recognition, reposition as little as possible, oxygen
  • immobilize to drecrease risk of disloding fat embolism
  • within 24-48 hours of broken bone
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54
Q

facial fractures

A
  • maintain patent airway, provide adequate ventilation
  • assume that they have a cervical injury
  • always have suction available
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55
Q

jaw fractures

A
  • position pt on the side with head slightly elevated
  • wire cutter at bedside
  • tach tray always available
  • NG tube for decompression
  • oral hygeine is important
  • protein suppliments
  • liquid diets
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56
Q

Pelvic Fracture

A
  • can be life-threatening
  • s/s: bruising on abdomen, pelvis instability, swelling, tenderness
  • tx: bed rest, may need traction, hip spica cast, ORIF, only turn when ordered by HCP
  • complications: paralytic ileus, internal bleeding, fat embolism, other GI problems
  • rule out internal bleeding first
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57
Q

hip fracture

A
  • 30% die within 1 year of injury
  • s/s: external rotation, spasm, shortening of affected leg, severe pain
  • complications: nonunion, avascular necrosis, dislocation, arthritis, DVT
  • tx: surgery, may temp use buck’s traction
  • can shorten the leg and impair mobility
58
Q

femoral shaft fracture

A
  • can have lots of blood loss, risk of fat embolism

- tx: ORIF with traction after, hip spica cast

59
Q

tibia fracture

A
  • risk of compartment syndrome

- neurovascular assessment q 2 hours x 48 hours

60
Q

stable vertebral fracture

A
  • fracture with no spinal cord injury
  • logroll, orthotic devices, ard vervial collar
  • vertebroplasty (inject cement)
  • kyphoplasty (balloon and then cement)
61
Q

joint procedures

A
  • synovectomy: removal of synovial membrane
  • osteotomy: remove a wedge of bone
  • debridement: removal of degenerative debris
  • arthroplasty: reconstruction or replacement of a joint
62
Q

knee arthoplasty

A
  • reason: unremitting pain and instability r/t severe destructive deterioriation of the knee joint
  • may replace all or part of the knee joint
  • post op: will be in extension while abulating for 4 weeks, exercises on 1st day progressing to gentle ROM until 90 degree flexion, CPM, full weight bearing before discharge
63
Q

total hip arthroplasty

A
  • pillow abductor splint between knees esp when turning, avoid extreme hip flexion, dont turn on affected side, OOB on first post op day, in hispital for 3-4 days
  • posterior and anterior (bettwe outcomes) approach
  • home care instructions: cant drive or take tub bath for 4-6 weeks; knees must be kept apart; dont cross legs; dont twist to reach behind; quadriceps and hip muscle exercises; high risk for thromboembolism; no high-impact exercises/sports
64
Q

teaching for amputation

A
  • sterile technique for dressing changes
  • immedaite prosthesis vs delayed
  • dont sit in chair > 1 hr
  • lie on abdomen 3-4 times a day to keep hip in extension
  • residual limb bandaging
65
Q

osteomyelitis

A
  • severe infection of bone, bone marrow, and surrounding soft tissue
  • most common microorganism is STAPHYLOCOCCUS AUREUS but can be caused by many organisms
  • etiology: indirect entry - hematogenous, young boys, blunt trauam, DM, GI and respiratory infections; direct entry - via open wound, foreign body presence
  • patho: microorganisms frow in area of slow cirrculation –> increase pressure in bone –> ischemia and vascular compromise
  • infection spreads through bone –> cortex devascularization and necrosis
  • dead bone separates from living bone forming sequestra
  • sequestra is surrounded by pus and is very hard for antibiotics and WBCs to get
  • must be removed surgically or will turn into chronic infection
66
Q

clinical manifestations of acute osteomyelitis

A
  • infection of 10 days after symptoms appear
67
Q

clinical manifestations of chronic osteomyelitis

A
  • infection losting longer than >1 month or has failed to respond to initial course of antibiotic therapy
  • continuous and persistent or process of exacerbations and remissions (flair ups)
  • may result in amputation
  • systemic signs diminished
  • local signs of infection more common (pain, swelling, warmth)
  • granulation tissue turns to scar tissue –> avascular –> ideal sire for microorganisms to grow –> impenetrable by antibiotics
68
Q

collaborate care, acute osteomyelitis

A
  • vigorous and prolonged IV antibiotic therapy (4 weeks to 6 months)
  • cultures or bone biopsy prior to
  • surgical debridement and decompression if antibiotic therapy delayed
69
Q

collaborate care, chronic osteomyelitis

A
  • surgical removal of dead bone (amputate)
  • extended use of antibiotics
  • antibiotic impregnated beads
  • intermittent or constant irrigation with antibiotics
  • wound VAC
  • hyperbaric oxygen
  • removal of prosthetic devices
70
Q

osteomyelitis interventions

A
  • absorbent dressings using sterile technique
  • bed rest
  • immobilization, NSAIDS
  • no exercise or heat application
  • observe for antibitoic side effects: hearing problems, jaundice, photosensitivity, achilles tendon rupture
  • follow up: monitor patient response to therapy with bone scans and ESR
  • rare complications: septicemia, septic arthritis, pathologic fractures, amyloidosis
71
Q

osteoporosis risk factors

A 
Alcohol use
Corticosteroid use
Calcium low
Estrogen low
Smoking
Sedentary lifestyle
- heredity, sex, race, early menopause, poor nutrition, sedentary lifestyle, thinness, smoking, alcohol, low testosterone, endocrine diseases, - drug related causes: glucocorticosteroids, anticonvulsants, some antacids, diuretics, thyroid meds
72
Q

osteoporosis

A
  • 44 million people have it in US
  • 1/2 women and 1/4 men over 50 will sustain an osteoporosis-related fracture
  • known as the “silent thief”
  • porous bone
  • chronic, progressive metabolic bone disease characterized by low bone mass, structural deterioration, increased bone fragility
73
Q

etiology and patho of osteoporosis

A
  • remodeling: osteoblasts deposit bone, osteoclasts resorb bone
  • bone resorption exceeds bone deposition
74
Q

clinical manifestations of osteoporosis

A
  • occurs most commonly in spine, hips, and wrists
  • back pain
  • spontaneous fractures
  • gradual loss of height
  • dowager’s hump (kyphosis)
75
Q

osteoporosis prevention

A
  • regular weight-bearing exercise
  • fluoride
  • calcium and vitamin d
  • stop smoking
  • decrease alcohol intake
  • nutrition - foods high in calcium (milk, cheese, yogurt, seafood)
76
Q

screening guidelines for osteoporosis

A
  • intial bone scane in women before age 65
  • repeat in 15 years if normal
  • earlier and more frequent if high risk
  • men screened before age 70, by age 50 if iat high risk (history of prostate cancer)
77
Q

osteoporosis collaborate care

A
  • treatment of existing disease
  • prevent further loss with supplements and meds
  • keep ambulatory
  • gait aid to prevent falls/fractures
  • brace for vertebral fracture
  • vertebroplasty and kyphoplasty to treat osteoporotic vertebral fracture
78
Q

drug therapy for osteoporosis

A
  • bisphophonates: inhibit bone resportion
  • side effects: anorexia, weight loss, gastritis
  • proper administration: take with full glass of water, take 30 minutes before food or other meds, remain upright for 30 minutes

*calcitonin: inhibits bone resportion, give IM form at night to minimize side effects, alternate nostrils when using nasal form, must use calcium supplementation

79
Q

low back pain

A
  • very common
  • causes: strain, instability, osteoarthritis, Degenerative Disk Disease, disk herniation
  • straight leg raising test: test for disk herniation (usually in low back) - supine lift leg 60 degrees assess for pain
80
Q

low back pain treatment

A
  • analgesics, muscle relaxants, massage, heat and cold
  • avoid prolonged bed rest
  • ## stop smoking
81
Q

nursing care for back pain

A
  • proper body mechanics
  • no twisting
  • sleep with head up and knees flexed and no pillows under upper back
  • dont life above level of elbows
  • avoid prolonged sitting or standing
  • exercise to strengthen back and abs
  • may sometimes use a corset-like brace to provide support
82
Q

Intervertebral disk disease

A
  • progressive degeneration: normal process of aging that can lead to herniated disks
  • most common sites of slipped disks: l4-5, l5-s1, c5-6, c6-7 (low lumbar and neck area)
  • s/s: low back pain, radiuclar pain to buttox and below the knee, for cervical disk have radicular pain to arms/hands, static nerve
83
Q

diagnosis and treatment of back pain

A
  • straight leg test is usually positive
  • xrya, myelogram, MRI, CT
  • conservative treatment first
  • may need laminectomy, diskectomy, or spinal fusion
84
Q

spinal fusion

A
  • must maintain proper alignment until healing has occured
  • oullows under thights when supine, between legs when side laying
  • IV opioids for 24-48 hours, muscle relaxants
  • watch for CSF leak
  • movement and sensation should be unchanged after surgery, check every 2-4 for 48 hours
  • clarify if they need brace or corset
  • check donor site, usually more painful
  • avoid sitting or standing for prolonged times
  • no twisting movement of the spine
  • firm mattress or bed board
85
Q

NSAIDS

A
  • block production of prostaglandins by inhibiting cox1 and cox2
  • ibuprofen, naproxen, indomethacin, diclofenac, celecoxib
  • side effects: GI irritation, bleeding, renal problems, cardiac problems
  • nursing care: give with food, watch for bleeding s/s, don’t combine with aspirin
86
Q

salicylates

A
  • inhibit synthesis of prostaglandins
  • aspirin most common
  • side effects: GI irritation, bleeding, tinnitus, worsening of asthma
  • nursing care: give with good, watch for bleeding, don’t combine with NSAIDS
87
Q

acetaminophen

A
  • tylenol
  • analgesic and antipyretic, not an antiinflammatory
  • side effects: live toxicity
  • nursing care: primary tx for OA and mild pain, limit to 4 grams/day, DO NOT take if alcoholic or have liver disease
88
Q

topical analgesics

A
  • block pain by locally interfering with substance P thus interrupting pain signals to the brain
  • capsaicin cream, voltaren gel
  • side effects: skin irritation
  • nursing care: dont use creams with a heating pad, avoid oral NSAIDs
89
Q

corticosteroids (intraarticular injections)

A
  • inhibit synthesis and/or release of mediators of inflammation
  • methylprednisolone, triamcinolone
  • side effects: local osteoporosis, tendon rupture, skin changes, local infection
    nursing care: HCP should use strict sterile technique, often makes the pt feel worse for 24-48 hours, can last for weeks to months
90
Q

corticosteroids (systemic)

A
  • inhibit synthesis and/or release of mediators of inflammation
  • solu-cortef, solu-medrol, dexamethasone, prednisone
  • side effects: cushing syndrome, HTN, psychosis, diabetes, acne, menstrual problems, hirsutism, immunosupression, bruising
  • nursing care: tape dose and use shrot term when possible, watch for side effects closely, nt for osteoarthritis
91
Q

hyaluronic acid (HA)

A
  • lubricates, maintains normal joint cushioning
  • orthovisc, synvisc, hyalgen
  • side effects: not many, pain, redness, rare to have an allergy
  • nursing care: typically given as 3 weekly injections directly into joint space, may give pain relief up to 6 months
92
Q

antimalarials

A
  • unknown acton, but may supress formation of antigens
  • plaquenil
  • side effects: retinopathy, ototoxicity, low BP, ecg changes
  • nursing care: have pt immediately report vision changes and hearing changes, may take up to 6 months to take full effect
93
Q

diease modifyin antirheumatic drugs (DMARDs)

A
  • rapid, antiinflammatory effect, inhbiits DNA, blocks immunce cell over production
  • methotrexate, sulfasalazine, arava
  • used aggresively for RA to prevent irreversible join changes
  • side effects: hepatotoxicity, bone marrow dpression, teratogenic
  • nursing care: monitor CBC, hepatic, and renal function
94
Q

biologic/targeted therapy

A
  • slows disease progression in RA
95
Q

immunosupressants

A
  • inhibit DNA, RNA, and protein synthesis
  • imuran, cytoxan, cellcept
  • side effects: n/v, rash, anorexia, teratogenic, hemorrhagic cystistis with cytoxan, infection
  • nursing care: avoid live vaccines, watch for bleeding, infection
  • may take up to 3 months to work
96
Q

disease modifying osteoarthritis drugs (DMOADs)

A
  • slow progression or support joint healing

- still under investigation

97
Q

arthritis

A
  • number one chronic complaint and cause of disability in the US
  • rheumatic disease incolving bone, muscle and joints
  • 2 common types: osteoarthritis, Rheumatoid arthritis, gout
98
Q

osteoarthritis

A
  • involves formation of new joint tissue in response to cartilage destruction
  • not a normal part of aging
  • lose flexibility
  • bone on bone, decreased cartilage
  • risk factors: age, menopause, genetics, obesity, overuse, trauma
99
Q

OA signs and symptoms

A
  • no systemic symptoms
  • joint pain ranging from mild discomfort to significant disability; pain worse with joint use;
  • early morning stiffness resolving within 30 minutes, stiffness worse with rest or static positions
  • over activity may cause mild joint effusion, stiffness
  • crepitus
  • deformities: heberdens nodes, bouchards nodes, knee joint misalignment, leg length discrepancy
100
Q

OA diagnosis and treatment

A
  • xrays, mri, ct scan, bone scan
  • labs: will be normal, synovial fluid will be clear yellow with little/no sign of inflammation
  • tx: aimed at symptom reduction - exercise, prevent joint stress, coping/managing pain, control weight, assure patient that OA is localized disease and severe deforming arthritis is not the usual course
  • rest/joint protection: balance rest and activity, rest and splint with acute inflammation, use assistive devices
  • heat/cold
  • drugs: tylenol q 6 hours, topicals, nsaids for more severe pain, intraarticular corticosteroids
101
Q

Rheumatoid arthritis

A
  • more common in women than men
  • characterized by gradual onset and remissions and exacerbations of inflammation within the joint
  • fingers, wrists, knees, spine
  • chronic inflamm that can cause severe joint deformities and loss of function over time
  • thought to be an autoimmune disease
102
Q

RA risk factors

A
  • women
  • predisposing gene
  • exposure to an infection
  • advanced age
  • smoking over a period of years
103
Q

RA S/S

A
  • malaise/fatigue
  • symmetirical pattern of joint inflamm
  • pain, stiffness, swelling
  • gelling, joints stiff after rest
  • elevated sedimentation rate
  • presence of serum rheumatoid factor
  • elevated WBC in synovial fluid of inflamed joint
  • erosion of bone
  • pain more prevealanet
  • more debilitaiton than with OA
104
Q

RA goals of care

A
  • can avoid permanent joint damage if diagnosis and tx start early
  • educate: exercise and mobility, individual PT/OT, independence with ADLs
105
Q

RA diagnosis

A
  • labs: RF, ESR, CRP, ANA titers, anti-cpa
  • synovial fluid is straw colored with fibrin flecks and high WBC count
  • ## bone scan can diagnose, not xrays
106
Q

RA complications

A
  • joint destruction
  • cataracts, vision loss
  • ulcerated nodules
  • hoarseness
  • cardipulmonary effects
  • carpal tunnel syndrome
107
Q

RA Nursing care

A
  • prevention is not possible
  • refer to arthritis foundation
  • help make easy drug regimen
  • plan around morning stiffness
  • alternate scheduled rest periods with activity
  • encourage positions of extension, not flexion
  • no pillows under the knees an use only a small pillow under the head and shoulders
  • heat cold and exercise
108
Q

gerontologic considerations

A
  • OA is most common type of arthritis in elderly, but consider other types
  • lab values may be affected by aging
  • be careful with NSAIDs and corticosteroids
109
Q

gouty arthritis

A
  • disease in which acute attacks of arthrits pain occur as a result of elevated levels of serum uric acid
  • joint inflamm caused by sodium urate crystals in joint
  • most commonly affected joint is great toe
  • affected joint becomes hot, reddened, tender
  • most common in middle aged men
  • risk factors: obesity, HTN, diuretic use, excessive alcohol use, genetics, AA; diet high in purine wont cause gout but can trigger an attack
110
Q

S/S of goutry arthritis

A
  • may occur in 1-3 joints
  • joints may be cyanotic, tender
  • onset usually at night with sudden swelling and excruciating pain
  • may have low grade fever
  • tophi
111
Q

diagnosis and treatment of gouty arthritis

A
    • uric acid >6, may need 24 hour uric acid levels, joint aspiration
  • if colchicine works, then diagnostic
  • tx: colchine, NSAIDs, prevent future attacks with alloprinol
  • ## avoid alcohol and high purine foods
112
Q

nursing care for gouty arthritis

A
  • nutrtion: weight control, limit alchol, limit foods with purine
  • nursing: careful jandling to avoid causing pain, bed rest with joint immobilization, elevation doesnt help = pain is due to crystals
113
Q

Lyme Disease

A
  • spriochetal infection caused by borrelia burgdorferi (transmitted by bite of deer tick), no person-to-person transmission
  • minics MS, mono, meningitis
  • S/S: erythema migran appearing 2-30 days after exposure
  • actue viral like symptoms
114
Q

lyme disease diagnosis and treatment

A
  • dx: E lesion , hx of exposure, CBC/ESR are noral
  • tx: oral antibiotics, doxycycline can be given to prevent infection within 3 days after tick bite
  • prevention: DEET, remove attached ticks with tweezers and pull out, wash with soap and water
115
Q

septic arthritis

A
  • infectious or bacterial arthritis with invasion of the joint cavity with microorganisms (staph aurus)
  • usually affects large joints; severe pain, swelling, erythema; fever and chills
  • diagnosis by joint aspiration
  • tx: antibiotics, may take 2-8 weeks, getnle ROM, local hot compression
116
Q

spondyloarthropathies

A
  • group of interrelated multisystem inflammatory disorders that affect the spine, peripheral joints, and peri-articular structures
  • all are negative for RF
  • HLA-B27 antigen is strongl assocaited with these
  • most common is ankylosing spondylitis, psoriatic arthritis, reactive arthritis
117
Q

ankylosing spondylitis

A
  • primarily affects the SI joints, disc spaces, costovertebral joints
  • men are 3-5 times more likely,
118
Q

S/S anylosing spondylitis

A
  • symmetric sacrolitis
  • low back pain, and stiffness with limitation of motion worse during the night and in the morn but improvs with mild activity
  • chest pain, sternal costal cartilage tenderness
  • fixed kyphosis
  • can have heart and lung complications
119
Q

diagnosis and treatment of ankylosing spondylitis

A
  • xray, Ct scan, mri
  • elevated ESR, mild anemia, HLA-B27
  • tx: cant prevent, heat, NSAIDS, asa, local corticosteroids, exercise once pain and stiffness are better, postural control, hydrotherapy, surgery for severe deformities
120
Q

nursing care of ankylosing spondylitis

A
  • baseline ROM
  • stop smoking
  • proper positioning at rest
  • firm mattress
  • sleep in bac with flat pillow
  • avoid heavy lifting, prolonged exercise
121
Q

psoriatic arthritis

A
  • inflammatory skin disorder with red, scaly patches
  • 4 forms: small joints of hands/feet, asymmetric extremely joints, symmetric polyarthritis, arthrisits of SI joings and spine
  • looks a lot like RA
  • elevated ESR, mild anemia, elevated uric acid
  • tx: splinting, PT, NSAIDs, DMARDs
  • psoriasis of skin, plaques of skin
122
Q

reactive arthritis (reiter’s syndrome)

A
  • more common in young men
  • includes conjuntctiviti, muscotaneous lesions
  • caused by GU or GI infections (chylmidia)
  • disease develops within 1-2 weeks after infection
  • asymmetric involvement of large joints of lower extremeties and toes
  • tx: doxycycline, OT
  • most pts recover within 2-16 weeks
123
Q

systemic lupus erythematosus

A
  • SLE
  • multisystem inflammatory autoimune disease n which circulating immune complexes are deposited in organs causing inflammation
  • can be genetic, hormonoal (worses with onset of menarche), sun exposure, sunburns, infection; drugs: procainamide, hydralazine, antiseizure
  • affects skin, joints, serious membranes, renal, hematologic, neurologic systems
  • usually occurs in women of child-bearing age
124
Q

S/S systemic lupus erythematosus

A
  • renal: lupus nephritis in 50%
  • nervous system: neuropsychiatric symptoms, seizures, anxiety, psychosis, headaches
  • hematologic: antibidoies against blood cells
  • infection: increase susceptibility, major cause of death esp pneumonia
  • dx: no specific test to diagnos, ANA positive
  • tx: manage the active phase of the disease while preventing complications of tx that cause long term tissue damage
125
Q

SLE medications

A
  • NSAIDs
  • hydroxychloroquine for fatigue and skin/joint problems
  • need regular eye exams
  • limit corticosteroid use except when severe
  • immunosupressants
  • anticoagulants for blood clots
126
Q

SLE nursing care

A
  • prevention is not possible
  • disease is unpredictable, even with regimented meds
  • many psychosocial issues to deal with
  • avoid sun
127
Q

systemic sclerosis

A
  • fibrotic, degenerative and inflamm changes in skin, blood vessels, synovium, skeletal muscle and internal organs
  • 2 types: limited cutaneous disease, diiffuse cutanous
  • more common in AA
128
Q

systemic sclerosis patho and etio

A
  • cause is unknown, think autoimmune
  • risk factors include occupational exposure to coal, plastics, silica dust
  • collagen is overproduced
129
Q

systemic sclerosis: CREST

A
  • calcium deposits
  • raynaud’s syndrome
  • esophageal dysfunction
  • sclerodactly - tightening of skin
  • telangiectasia - red spots on hands, forearm, palms
130
Q

systemic sclerodis: diagnosis treatment

A
  • dx: labs - SCL-70 or anticentromere antibody
  • xray to show calcification
  • tx: PT, OT, no drugs are affective
131
Q

systemic sclerosis nursing care

A
  • prevention is not possible
  • no finger stick blood tests
  • good oral hygeine, job modifications
132
Q

polymyositis and dermatomyositis

A
  • diffues, idiopathic, inflamm myopathies of striated muscle that produce bilateral weaknes
  • common in women 45-65
  • etio/patho: associated with humoral immunity
  • dx: MRI, EMG, muscle bipsy, CK elevated, myoglobin elevated, ESR elevated in active disease
133
Q

S/S polymyositis and dermatomyositis

A
  • weight loss, fatigue, weakness
  • unable to move muscles against resistenace or gravity
  • demal: classic violet colored cyanotic or erythematous symmetric rash with eema around eyelids
  • joint redness, pain, inflamm
  • weka pharyngeal muscles
  • interstitial lung disease
134
Q

treatment and nursing care polymyositis and dermatomyositis

A
  • high dose corticosteroids, if that doesnt work use immunosupressants
  • IV immunoglobin for dermatomyositis
  • PT, massage
  • daily ROM
135
Q

sjorgren’s syndrome

A
  • comomon autoimmune disease that targets moisture producing glands causing xerostomia and keratoconjuncitivits sicca
  • affects mainly women (90%0 > age 40
  • s/s: tearing, gritty sensation in the eyes, burining, blurry vision
  • risk of non-hodgkin’s lymphoma
  • dx: eye exam, salivary gland tests
  • tx: symptomatic, artifical tears, increased fluids with meals, good dental hygeine
136
Q

soft tissue rheumatic syndromes

A
  • myofacial pain syndrome
  • fibromyalgia syndrome
  • chronic fatigue syndrome
  • need multidisciplinary approach
137
Q

myofacial pain syndrome

A
  • chronic muscle pain typically in chest, neck, shoulders, hips, low back
  • results from muscle trauma or chornic strained muscles
  • deep, aching, burning stinging, stiffness pain
  • simialr to fybromyalgia
  • dx: palpation of trigger pints with hardness and muscle twitch
  • tx: PT, lidocaine, acupuncture
138
Q

fibromyalgia syndrome

A
  • chornic, widespread, nonarticular musculoskeletal pain and fatiuge with multiple tender pints, nonrestorative sleep, morning stiffness, IBS, anxiety
  • major cause of disability
  • patho: recent viral illness or trauma may trigger
  • dx: must have pain at 11 tender points and hx of widespread pain for at least 3 months
  • S/S: widespread burning pain that worsesn and improves thorughout teh day, 11 tender pints, difficiuly concencentrating depression, IBS, diff swallowing, diffi menstruating
139
Q

tx and nursing care fibromylagia

A
  • rest
  • motivated pt
  • low dose flexeril, SSRIs at high dose
  • manage with NSAIDs
  • antianxiety meds
  • neurontin, lyrica, cymbalta
  • nursing care: massage, heat and cold, yoga, limit sugar, caffeine, alcohol, relaxation strategies
140
Q

chornic fatigue syndrome

A
  • debillitating fatigue an immune problems
  • recover is more common if disease has acute onset
  • may be triggered by flu like illness
  • dx: need to rule out other disorders
  • nursing care: take all complaints seriously, NSAIDs, exercise, well-balanced diet

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