TEST 2 MOD 7 WINKS

Question 1

RA joint deformities

Answer 1

Rheumatoid arthritis

A, Early pathologic change is rheumatoid synovitis.
Synovium becomes inflamed. Lymphocytes and plasma cells increase greatly.

B, Over time, articular cartilage destruction occurs, and vascular granulation tissue
grows across the cartilage surface (pannus) from the edges of the joint.
Joint surface shows loss of cartilage beneath the extending pannus, most marked
at joint margins.
C, Inflammatory pannus causes focal destruction of bone.
Osteolytic destruction of bone occurs at joint edges, causing erosions seen on x-rays.
This phase is associated with joint deformity.

Question 2

OA assessment findings, treatments, complications, joint deformities, medications

Answer 2

Osteoarthritis: Degeneration of articular cartilage over time caused by wear and tear
Early disease
Synovitis may occur when phagocytic cells (WBCs) attempt to rid the joint of small pieces of cartilage torn from the joint surface.
Results in pain and stiffness early in the disease process.
Osteoarthritis (OA) is a slowly progressive noninflammatory disorder of the
diarthrodial (synovial) joints.

A is not a normal part of the aging process, but aging is one risk factor for disease
development.
Later disease
Pain is primarily due to loss of articular cartilage and bony joint surfaces rubbing against each other.

Osteophytes form around the periphery of the joint by irregular overgrowths of bone.
With time, thickening of subarticular bone (cysts) occurs, caused by constant friction of the
2 bone surfaces.
Osteophytes form around the periphery of the joint by irregular overgrowths of bone. (bumpy bone)

Joint pain (early)
Diminishes after rest
Intensifies after activity

Joint pain (advanced)
Pain occurs with slight motion or even at rest

Morning stiffness for less that 30 minutes or less
OA usually affects joints on 1 side of the body (asymmetrically) rather than in pairs.

Fatigue, fever, and organ involvement are not present in OA.

This is an important distinction between OA and inflammatory joint disorders, such
as rheumatoid arthritis.
Symptoms are aggravated by temperature change and humidity

Crepitus

Joint enlargement
Heberden’s Nodes
On the Distal Interphalangeal Joints (DIP joints)
Bouchard’s Nodes
On the Proximal Interphalangeal Joints (PIP joints)

Indicative of osteophyte formation
Often red, swollen, and tender
Although they usually do not cause significant loss of function,
the visible deformity may bother the patient.
Knee
Joint misalignment common due to cartilage loss
Hip
One leg may become shorter from a loss of joint space

For example, the patient becomes bowlegged (varus deformity) in response (knees bent out)
to medial joint arthritis.
Lateral joint arthritis causes a knock-kneed appearance (valgus deformity). (knees bent in)

Bone Scan, CT scan, MRI
To detect early joint changes
X-rays
Progressive OA results in joint space narrowing, bony sclerosis, and osteophyte formationX-ray changes do not always reflect the degree of pain the patient has.
Despite strong x-ray evidence of disease, the patient may be relatively
free of symptoms. Another patient may have severe pain with only slight
x-ray changes.
Joint rest: Avoid immobilization for more than 1 week because of the risk for joint
stiffness with inactivity.

Question 3

Closed

Answer 3

Skin over the fractured area remains intact

types and treatments

Question 4

simple

Answer 4

Skin over the fractured area remains intact

types and treatments

Question 5

Open

Answer 5

Bone is exposed to air through a break in the skin The skin is broken and bone exposed, causing soft tissue injury. increase infection risk

types and treatments

Question 6

Compound

Answer 6

Bone is exposed to air through a break in the skin The skin is broken and bone exposed, causing soft tissue injury. increase infection risk

types and treatments

Question 7

Complete

Answer 7

Bone completely separated by a break into two parts A fracture is complete if the break goes completely through the bone.

types and treatments

Question 8

Incomplete

Answer 8

Partial break in the boneAn incomplete fracture occurs partly across a bone shaft,
but the bone is still intact.
An incomplete fracture is often the result of bending or crushing
forces applied to a bone.

types and treatments

Question 9

Displaced

Answer 9

The 2 ends of the broken bone are separated from each other and out of their normal positions

types and treatments

Question 10

Nondisplaced

Answer 10

The bone fragments stay in alignment

types and treatments

Question 11

Fracture nursing care

Answer 11

Patient’s dietary requirements must include
Ample protein (1 g/kg of body weight)
Vitamins (B, C, D)
Calcium
Phosphorus
Magnesium
Adequate fluid intake
2000 to 3000 mL/day
High-fiber diet with fruits and vegetables

Constipation can be prevented by
Increased activity
High fluid intake (>2500 mL/day)
Diet high in bulk and roughage
Warm fluids, stool softeners, laxatives, or suppositories may be necessary.

Prevent constipation by increasing patient activity.
Maintain high fluid intake (more than 2500 mL/day unless contraindicated
by the patient’s health status) and a diet high in bulk and roughage
(fresh fruits and vegetables). If these measures are not effective in continuing
the patient’s normal bowel elimination pattern, give stool softeners, laxatives, or
suppositories. Maintain a regular time for elimination to promote bowel regularity.

Renal stones can develop from bone demineralization due to reduced mobility.
Hypercalcemia from demineralization causes a rise in urine pH and stone formation
from calcium precipitation. Unless contraindicated, maintain a fluid intake of 2500
mL/day to decrease the risk for stone formation.

Rapid deconditioning of cardiopulmonary system
Result of prolonged bed rest
Results in
Orthostatic hypotension
Decreased lung capacity

Reinforce physical therapist’s instructions.
Nurse may need to assist patient with lower extremity dysfunction.
Usually start mobility training when able to sit in bed, dangle feet over side

Question 12

neurovascular assessments

Answer 12

Peripheral Vascular Assessment

Color
Temperature
Capillary refill
Peripheral pulses
Edema

Peripheral Neurologic Assessment

Sensation
Motor function
Pain

Question 13

treatments (surgical

Answer 13

Open reduction

Correction of bone alignment through surgical incision

Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails

The main risks of open reduction are infection, complications associated
with anesthesia, and effects of preexisting medical conditions (e.g., diabetes).
However, open reduction internal fixation (ORIF) facilitates early ambulation,
thus decreasing the risk for complications related to prolonged immobility.

Traction, casting, splints, or orthoses (braces) may be used after reduction
to maintain alignment and immobilize the injured part until healing occurs.

External Fixation
Metallic device
Composed of metal pins inserted into bone and attached to external rods
External device holds fracture fragments in place similar to a surgically implanted internal device.
Infection control is critical.
Infection signaled by
Exudate
Erythema
Tenderness
Pain
Instruct patient and family on meticulous site care.

Question 14

traction

Answer 14

Closed Reduction

Nonsurgical, manual realignment of bone fragments to previous anatomic position

Traction and countertraction manually applied to bone fragments to restore position, length, and alignment

Closed reduction is usually done while the patient is under local or
general anesthesia.

Traction, casting, splints, or orthoses (braces) may be used after reduction
to maintain alignment and immobilize the injured part until healing occurs.

Description
The exertion of a pulling force applied in two directions to reduce and immobilize a fracture
Force exerted on distal bone fragment to align it with the proximal fragment
Countertraction (opposite direction) is usually supplied by the patient’s own body weight or weights in the opposite direction
Provides proper bone alignment and reduces muscle spasms
Two most common types
Skin
Skeletal
Traction must be maintained continuously.
Keep the weights off the floor and moving freely through the pulleys.

Do not interrupt weights applied

Skin should be inspected AT LEAST every 8 hours for inflammation and irritation

Monitor color, motion, and sensation of the affected extremity

Monitor the insertion sites for redness, swelling, or drainage

Provide insertion site care as prescribed

Question 15

casting

Answer 15

Provide immobilization of bone and joints after a fracture or injury

Cast materials are natural, synthetic acrylic, fiberglass-free, latex-free polymer, or a hybrid of materials.
A cast generally immobilizes the joints above and below a fracture.
This restricts tendon and ligament movement, thus assisting with joint stabilization
while the fracture heals.

The 2 most common cast materials are natural (plaster of Paris) and fiberglass.
Fiberglass casts are most often because they are lighter, relatively waterproof, and
longer wearing than plaster of Paris.

Keep cast and extremity elevated
Handle a wet cast with the palms of the hand until dry
Examine the skin and cast for pressure areas
Monitor the extremity for circulatory impairment and signs of infection

Explain the importance of elevating the extremity above heart level to promote
venous return and applying ice to control or prevent edema during the initial phase.

Tell the patient not to scratch or place anything inside the cast because this may
cause skin injury and infection.
For itching, direct a hair dryer on a cool setting under the cast.

Question 16

fixation devices

Question 17

Fracture complications (risk factors, assessment, treatment, nursing care)

Answer 17

Fracture healing may
Not occur in the expected time
Delayed union
Not occur at all
Nonunion

Healing time of fractures increases with age and smoking

Overall goals of fracture treatment
Anatomic realignment of bone fragments
Immobilization to maintain realignment
Restoration of normal or near-normal function of injured parts

Majority heal without complication.
If death occurs, usually result of
Damage to underlying organs and vascular structures
Complications of fracture or immobility

Infection
Treatment is costly in terms of
Extended nursing and medical care
Time for treatment
Loss of patient income
Osteomyelitis may become chronic.
Osteomyelitis is inflammation or swelling that occurs in the bone. It can result from an infection somewhere else in the body that has spread to the bone, or it can start in the bone — often as a result of an injury. Osteomyelitis is more common in younger children (five and under) but can happen at any age.

There are 38 muscle compartments in the upper and lower extremities

Contains nerves and blood vessels

Fascia surrounding the muscle has a limited ability to stretch, so increased pressure leads to compression of nerves and blood vessels

Veins of the lower extremities and pelvis are at great risk for clot (thrombus)
formation after a fracture, especially a hip fracture. VTE may also occur after total
hip or total knee replacement surgery.

The patient should dorsiflex and plantar flex the ankle of an affected lower extremity
against resistance and perform ROM exercises on the unaffected leg.
For upper extremity injuries, have the patient flex and extend the wrist if not
immobilized by a cast or splint and perform ROM exercises on the unaffected arm.

Instruct patient to
Wear antiembolism stockings, SCDs
Encourage ambulation if permitted
ROM exercises

Fat Embolism
Presence of systemic fat globules from fracture that are distributed into tissues and organs after a traumatic skeletal injury
Contributory factor in many deaths associated with fracture
Sx start w/ dyspnea/hypoxia Clinical course of fat embolus may be rapid and acute.
Most patients manifest symptoms 24 to 48 hours after injury.

Patient frequently expresses a feeling of impending disaster or mental status changes.
In a short time, skin color changes from pallor to cyanosis.
Petechiae on the neck, chest, axilla, conjunctiva may help distinguish FES from other problems
Prevention: Careful immobilization and handling of long bone fractures
Treatment:
Oxygen and ventilatory support
Fluid resuscitation
Replacement of blood loss

Question 18

Fall prevention

Question 19

Postoperative care of patient undergoing amputation

Answer 19

*Normal postop care PLUS
Observe and prevent contractures
Flexion contractures of the hip and knee are common with LE amputations
Prosthetic fitting
Immediate or delayed
Use of compression bandages

Prevention and detection of complications are important after surgery.
Carefully monitor the patient’s vital signs.
Assess dressings for hemorrhage.
Use sterile technique during dressing changes to reduce the risk for wound infection.

To prevent flexion contractures, have patients avoid sitting in a chair for more than
1 hour with hips flexed or having pillows under the surgical extremity.
Unless contraindicated, patients should lie on their abdomen for 30 minutes 3 or
4 times each day and position the hip in extension while prone.

Question 20

ambulation with cane

Answer 20

23-30 degree bend in elbow

handle at greater trochanter

cane 4 inches from foot

use on opposite side of affected leg

when injured leg goes forward, the cane goes forward

when teaching 1st time, use gait belt, stand on weak side,

Question 21

ambulation with crutches

Answer 21

set to your height, two fingers between armpit and top of crutch , hands set at hip height

elbows slightly bent and crutches out to either side

So once you have the crutches correctly adjusted, you need to know how much you are allowed to put on your injured side. There is non-weight bearing, toe touch weight bearing, partial weight bearing, and weight bearing as tolerated.

The first one is non-weight bearing. Without shrugging your shoulders, shift all your weight to your good leg, and then bring both crutches forward in front of you. Then shift your weight onto the crutches, and swing your good leg forward. The crutches go where your injured leg would go. Continue this movement.

Then next one is a toe touch weight bearing. You can put about 20% of your body weight on your injured leg, or imagine you are putting your foot on eggshells, and you don’t want to crush them. The crutches go where your injured leg goes. Bring your crutches and your injured leg forward putting most of your weight on the crutches and step through with the good leg. Continue this movement.

Now you have partial weight bearing or maybe even weight bearing as tolerated. So now you can go down to one crutch. Begin in a standing upright position holding a crutch on the opposite side of your injured leg. The crutch goes where your injured leg goes. Bring your crutch and your injured leg forward and step through with the good leg. Continue this movement. Try not to lean on the crutch. It is just there for a little bit of support to get you closer to walking without anything.

Question 22

ambulation with walker

Answer 22

lift walker, put all four point on ground, weak leg first an put all weight on walker when moving strong leg forward

Question 23

skin traction is used to help diminish

Answer 23

muscle spasms in injured extremity

Question 24

describe skin traction

Answer 24

Skin traction
Used for short-term treatment until skeletal traction or surgery is possible
Tape, boots, or splints applied directly to skin to maintain alignment, assist in reduction, and help diminish muscle spasms in injured extremity
Traction weights 5 to 10 pounds

Question 25

When would you use bucks traction

Answer 25

MID shaft femur fracture, ortho surgeon can’t immediately perform procedure and pt needs relief from muscle spasms and femur pain

Question 26

Skeletal Traction

Answer 26

Provides a long-term pull that keeps injured bones and joints aligned
Physician inserts pin or wire into bone, either partially or completely, to align and immobilize injured body part.
Skeletal traction weight range: 5 to 45 pounds
The major complications of skeletal traction are infection at the pin insertion
site and the effects of prolonged immobility.

Often used for patients with unstable, displaced fractures for whom the
risk of an operation is too great given their medical comorbidities
(i.e., recent myocardial infarction)

Question 27

What is a fascia

Answer 27

thin fibrous lining that separates compartments in body cavity

Question 28

compartment syndrome (6 P’s)

Answer 28

Compartment syndrome is usually associated with fractures (especially
of long bones), extensive soft tissue damage, and crush injury.

Within 4 to 6 hours after the onset of compartment syndrome, neuromuscular damage is irreversible

Pain: distal to injury that is not relieved by opioid analgesics and pain on
passive stretch of muscle traveling through compartment
Pressure: ↑ in compartment
Pallor: coolness and loss of normal color of extremity
Paresthesia: numbness and tingling
Paralysis: loss of function
Pulselessness: diminished/absent peripheral pulses

Prompt, accurate diagnosis
Extremity should not be elevated above heart level.
Elevation may raise venous pressure and slow arterial perfusion.
Application of cold compresses may result in vasoconstriction and may exacerbate compartment syndrome.
May be necessary to remove or loosen bandage or bivalve cast

Treatment: Fasciotomy
An incision through the skin and subcutaneous tissue into the fascia of the affected compartment
Relieves pressure and restores circulation
Treatment: Amputation

Complications of Compartment Syndrome
Infection
Persistent motor weakness
Contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.)
Myoglobinuric renal failure (Rhabdo)

Question 29

RA assessment findings

Answer 29

Lab studies
CBCPeople with RA often have an abnormal CBC, with anemia decreased red blood cells or hemoglobin (anemia).6,7
Elevated sedimentation rate (ESR)increased=general indicators of active inflammation.
Rheumatoid factor (RF)
Antinuclear antibody (ANA)increased=indicator of autoimmune reaction.
C-reactive protein (CRP)increased=general indicators of active inflammation.
X-ray of involved jointsX-rays alone are not diagnostic of RA. They may show only soft tissue swelling and
possible bone demineralization in early disease. A narrowed joint space, articular
cartilage destruction, erosion, subluxation, and deformity are seen in later disease.
Poor alignment and fusion may be seen in advanced disease.

Synovial fluid analysisSynovial fluid analysis in early disease often shows slightly cloudy, straw-colored
fluid with many fibrin flecks. The enzyme MMP-3 is increased in the synovial fluid.
It may be a marker of progressive joint damage. The WBC count of synovial fluid
is increased. Tissue biopsy can confirm inflammatory changes in the synovial
membrane.

Question 30

Rheumatoid arthritis complications

Answer 30

Systemic Manifestations may occur
Rheumatoid nodules
Subcutaneous nodules on bony areas exposed to pressureRheumatoid nodules appear under the skin as firm, nontender masses.
They are often found on bony areas exposed to pressure, such as the fingers and elbows.

Sjogren’s syndrome
Decreased lacrimal and salivary gland secretion
Dry mouth, dry/itchy eyes, photosensitivitySjögren’s syndrome can occur by itself or with other arthritic disorders, such as RA
and SLE. The inflammation of RA can damage the tear-producing (lacrimal) glands,
making the eyes feel dry and gritty. Affected patients may have photosensitivity.

Felty syndrome
Enlarged spleen, low WBC count
Increased risk of infection and lymphomaFelty syndrome is rare but can occur in those with long-standing RA.
It is characterized by an enlarged spleen and low white blood cell (WBC) count.
Patients with Felty syndrome are at increased risk for infection and lymphoma.

Question 31

Rheumatoid arthritis meds

Answer 31

Disease-modifying antirheumatic drugs (DMARDs)
Cornerstone of RA treatment
Slows disease progression
Examples: Methotrexate and hydroxychloroquine (Plaquenil)
Risk of toxicity and some not safe in pregnancy

Biologic/Targeted therapy
Slows disease progression for patients who haven’t responded to DMARDs by inhibiting inflammation.
Examples: etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira)

Corticosteroids
To treat exacerbations
Oral or intraarticular injections
Do not affect disease progression
Complications include osteoporosis and avascular necrosis.
NSAIDs and salicylates
For pain and inflammation
Aspirin may be used in dosages of 3 to 4 g/day in 3 to 4 doses.
NSAIDs have anti-inflammatory and analgesic effects.
Corticosteroids have many side effects:
Side effects
Cushing’s syndrome
GI irritation
Osteoporosis
HTN
Psychosis
Hyperglycemia
Risk of infection

Corticosteroids, NSAIDs, and Aspirin: Give w/ food

Question 32

Include the following instructions when teaching the patient with arthritis how to
protect small joints:

Answer 32

1. Maintain joint in neutral position to minimize deformity.
   * Press water from a sponge instead of wringing.
2. Use strongest joint available for any task.
   * When rising from chair, push with palms rather than fingers.
   * Carry laundry basket in both arms rather than with fingers.
3. Distribute weight over many joints instead of stressing a few.
   * Slide objects instead of lifting them.
   * Hold packages close to body for support.
4. Change positions often.
   * Do not hold book or grip steering wheel for long periods without resting.
   * Avoid grasping pencil or cutting vegetables with knife for extended periods.
5. Avoid repetitious movements.
   * Do not knit or sew for long periods.
   * Rest between rooms when vacuuming.
   * Use faucets and doorknobs that are pushed rather than turned.
6. Modify chores to avoid stress on joints.
   * Avoid heavy lifting.
   * Sit on stool instead of standing during meal preparation

Question 33

Arthroplasty

Answer 33

Surgical reconstruction or replacement of diseased joints
To relieve pain, improve or maintain ROM, and correct deformity
Joints replaced include elbow, shoulder, phalangeal joints of the fingers, wrist, hip, knee, ankle, and foot

Complications
Infection (esp. w/ joint replacements)
Prevention
Self-contained OR suites
Operating rooms w/ laminar flow
Prophylactic antibiotics
Venous thromboembolism of LE
Prevention
Prophylactic medications (heparin, enoxaparin, warfarin)
SCDs (sequential compression devices)

Nursing Management
Normal postoperative care plus
Neurovascular assessment
Pain management
Activity advanced as soon as possible
Joint arthroplasty
3-5 day hospital stay
Physical therapy
Preparation of home environment
Patient teaching (complications)