Musculoskeletal (OA, RA, SLE)

Question 1

4 major parts of a joint

Answer 1

subchondral bone plate

articular cartilage

synovium

joint capsule

Question 2

synovial or diarthrodial joint is any joint that allows __________.

Answer 2

movement

Question 3

three phases of bone healing

Answer 3

• inflammatory
• reparative
• remodeling

Question 4

inflammatory phase of bone healing

Answer 4

hematoma forms at fx site
provides stability
aseptic inflammation occurs

duration
1-3 days for hematoma
3 days - 2 weeks for early repair

Question 5

reparative phase of bone healing

Answer 5

• fibrous cartilage → formation of granular tissue containing blood vessels, fibroblasts, osteoblasts
• formation of callus → when granular tissue has matured
• ossification → space in bone is bridged and fx ends are united; callus replaced by trabecular bone

duration → 6 weeks

Question 6

remodeling phase of bone healing

Answer 6

bone consolidation with final remodeling

healing complete

Question 7

osteoarthritis (oa)

Answer 7

degeneration of joints cause by aging and stresses
most common cause of disability in US
obesity and aging are ↑ oa in U.S.

Question 8

commonly affected joints of oa

Answer 8

cervical spine
lumbosacral spine
hip
knee
hand 
first metatarsal phalangeal joint (big toe)

Question 9

spared joints of oa

Answer 9

wrist
elbow
ankle

Question 10

etiology of oa

Answer 10

stresses applied to joints (weight bearing)
degeneration of cartilage (begins in articular cartilage)
chronic disease

Question 11

osteophytes

Answer 11

• small bony projections that develop along the rim of bone adjacent to cartilage loss
• important hallmark of OA

Question 12

sxs of oa

Answer 12

• deep aching joint pain, esp. after exercise, relieved with rest
• joint pain during cold weather
• stiffness in the morning
• crepitus of joint during motion
• joint swelling
• altered gait
• limited range of motion (thickening of synovial fluid)

Question 13

OA physical exam

Answer 13

joint
deformity
tenderness
↓ ROM

fingers often involved
distal interphalangeal joint (DIP) - Herbeden’s nodes
proximal (PIP) - Bouchard’s nodes

both caused by osteophytes

Question 14

dietary supplement for oa

both also naturally occur in the body

Answer 14

glucosamine sulfate - maintains cartilage health

chondroitin sulfate - might slow cartilage breakdown

Question 15

s/s of DDD in lumbar spine

Answer 15

• pain in low back that radiates down back of leg (sciatica)
• pain in buttocks or thighs
• pain that worsens when sitting, bending, lifting, or twisting
• pain that’s minimized when walking, changing positions or lying down
• numbness, tingling, or weakness in the legs
• foot drop

Question 16

s/s of DDD in cervical spine

Answer 16

• chronic neck pain that can radiate to the shoulders and down arms
• numbness or tingling in the arm or hand
• weakness of the arm or hand

Question 17

rheumatoid arthritis

Answer 17

type III hypersensitivity

systemic, autoimmune disease of the synovium

Question 18

RA etiology & risk factors

Answer 18

not fully understood
environmental and genetic factors

40s-60s
women (2.5x higher risk than men)
tends to show up after pregnancy
tobacco use

Question 19

RA patho

Answer 19

autoimmune attack against the synovial tissue
Immune cells activated
-lymphocytes
-macrophages
-produce rheumatoid factor (RF) → auto-antibody against IgG
-formation of immune complexes & activates complement

measure RF in serum and that’s how RA’s diagnosed

Question 20

progression of RA

Answer 20

• cartilage is destroyed by osteoclasts
• pannus develops → type of scar tissue that’s vascularized so it’s able to get nutrients but also contains inflammatory cells
• pannus very destructive
• causes: bone erosion, bone cysts, fissure development

Question 21

RA clinical manifestations

Answer 21

• early → vague sxs of fatigue, malaise, wt loss, generalized stiffness
• joint manifestations → symmetrical (different from OA); pain, stiffness, motion limitation; inflammation: heat, swelling, tenderness

advanced disease → deformity & disability; joint subluxation

RA nodes feel spongy, soft
OA hard bc it’s bone
Swan neck deformity - common; joint has lost structure so it bends down (tip of finger)

Question 22

RA can also be systemic

Answer 22

important to assess other systems

rheumatoid nodules - occur in about 25% of RA pts

• immune-mediated granulomas
• develop around inflamed joints & lungs
• subcut and firm, sometimes painful

Question 23

systemic lupus erythematous (SLE)

Answer 23

type III hypersensitivity
autoimmune inflammatory disease
   -multiple organ systems
   -acute flare-ups
   -unpredictable

attacks body’s dna

two forms

• discoid - targets skin
• systemic - internal organs

Question 24

SLE predisposing factors

Answer 24

genetic factors
female
20-40
blacks
sun exposure/uv rays
allergy to abx
prolonged exposure to estrogen
tobacco use

Question 25

SLE patho

Answer 25

- beta lymphocytes are hyperactive & produce autoantibodies (antinuclear antibody) - activated against DNA - formation of immune complexes - can impact all major organ systems - inflammatory response destroys tissue - kidneys often affected

Question 26

SLE manifestations (early?)

Answer 26

``` extreme fatigue photosensitivity (butterfly rash) fever wt changes unusual hair loss edema raynaud's phenomenon - capillary constriction in distal extremities, often triggered by cold ```

Question 27

SLE manifestations

Answer 27

CNS: HA, dizziness, seizures, stroke Lungs: pleuritis, pleural effusions heart: myocarditis & endocarditis kidneys: nephritis (50% develop kidney damage) blood vessels: vasculitis blood: anemia, leukopenia, thrombocytopenia, blood clots joints: arthritis

Question 28

SLE flares

Answer 28

warning sign: fatigue, pain, HA prevention → recognize warning signs and avoid triggers triggers: sunlight exposure, infection, abruptly stopping a med (steroids), stress (try to manage)

Question 29

Sjogren syndrome (seen in RA & SLE)

Answer 29

autoimmune destruction of any moisture producing gland enlarged glands with decreased functioning lacrimal: ↓tearing, burning, itchy dry eye salivary: dry reddened deeply fissured tongue; loses its papilla; ↑ risk for candida infections

Question 30

methotrexate

Answer 30

classification: antineoplastic (folic-acid antimetabolite) DMARD (disease modifying anti-rheumatic drug) moa: immunosuppressive administered weekly via PO or SQ/IV route

Question 31

methotrexate SEs

Answer 31

GI: N/V, anorexia, liver toxicity bone marrow suppression shortened life expectancy Pt teaching: watch for signs of infection; expect GI effects

Question 32

methotrexate nursing implications

Answer 32

11 black box warnings folic acid supplementation is necessary NO ETOH Teratogenic Contact HCP if s/s of infection develop

Question 33

hydroxychloroquine

Answer 33

DMARD antimalarial, antirheumatic MOA: unknown, antiinflammatory properties slows progression of RA when used with another DMARD SE: retinopathy (rare)