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Nurs 120- MCA I > Week 4: Pain, Musculoskeletal... > Flashcards

Week 4: Pain, Musculoskeletal... Flashcards

1
Q

Physiologic Process of Pain

Nociception
[4 steps]:

A
  1. Transduction
  2. Transmission
  3. Perception
  4. Modulation
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2
Q

Transduction involves the conversion of a noxious (tissue-damaging) stimulus into an ________________ called an __________________

A

Transduction involves the conversion of a noxious (tissue-damaging) stimulus into an electrical signal called an action potential

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3
Q

Transduction

*Noxious
Thermal
Mechanical
Chemical

A

Noxious stimuli can be

thermal (e.g., sunburn),
mechanical (e.g., surgical incision), or
chemical (e.g., toxic substances)

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4
Q

Transmission - Processing of pain through signal transmission to the __________

A

brain

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5
Q

What parts of the body are involved in the transmission process?

– Spinal cord
– Dorsal horn
– Thalamus and cortex

A

– Spinal cord
– Dorsal horn
– Thalamus and cortex

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6
Q

Modulation

  • _____________ pathways
  • Acts on _____________ of pain

What medications affect this phase of pain?
Tricyclic antidepressants
Serotonin norepinephrine reuptake inhibitors (SNRIs)

A
  • Descending pathways
  • Acts on transmission of pain

What medications affect this phase of pain?
Tricyclic antidepressants
Serotonin norepinephrine reuptake inhibitors (SNRIs)

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7
Q

Pain Classifications

  • Nociceptive
  • Neuropathic
  • Acute
  • Chronic

What differentiates each classification?

A
  • Nociceptive
  • Neuropathic
  • Acute
  • Chronic
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8
Q

Nociceptive Pain

Somatic

– ____________
* Skin, mucous membranes, SQ tissues
– Sharp, burning, prickly

– _________
* Bone, muscle, joint, connective tissue
– Aching, throbbing

– __________
* Internal organs, lining of body cavities

A

– Superficial
* Skin, mucous membranes, SQ tissues
– Sharp, burning, prickly

– Deep
* Bone, muscle, joint, connective tissue
– Aching, throbbing

– Visceral
* Internal organs, lining of body cavities

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9
Q

Acute & Chronic Pain

  • Acute
    – Pain resulting from an acute issue which resolves as __________ occurs
  • Examples: postoperative pain, labor pain, trauma, infection
  • Chronic
    – Pain usually lasting > ____ months
    – Often associated with ____________ and anxiety
A
  • Acute
    – Pain resulting from an acute issue which resolves as healing occurs
  • Examples: postoperative pain, labor pain, trauma, infection
  • Chronic
    – Pain usually lasting > 3 months
    – Often associated with depression and anxiety
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10
Q

Dimensions of Pain

  1. ____________
    – Perception of pain’s intensity, location, quality, and pattern
  2. _________
    – Emotional responses to pain
  3. ____________
    – Beliefs, attitudes, memories re: pain
  4. ___________
    – Observable actions to express pain
  5. ____________
    – age, gender, families, etc. influences pain
A
  1. Physiologic
    – Perception of pain’s intensity, location, quality, and pattern
  2. Affective
    – Emotional responses to pain
  3. Cognitive
    – Beliefs, attitudes, memories re: pain
  4. Behavioral
    – Observable actions to express pain
  5. Sociocultural
    – age, gender, families, etc. influences pain
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11
Q

____________ Pain

  • Central nerves
  • Peripheral nerves
  • Descriptors used:
    – Numbing
    – Burning, hot
    – Shooting
    – Stabbing
    – Sharp
    – Electric
A

Neuropathic

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12
Q

Pain Assessment [review]

Characteristics
– Pattern
* Break-through pain
– Location
– Intensity
– Quality
– Associated symptoms
– Management strategies
– Impact of pain
– Beliefs, expectations and goals

A

Characteristics
– Pattern
* Break-through pain
– Location
– Intensity
– Quality
– Associated symptoms
– Management strategies
– Impact of pain
– Beliefs, expectations and goals

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13
Q

Hospital Management of pain

  • Patient-controlled analgesia (PCA)
  • Patient-controlled epidural analgesia (PCEA)
  • Nerve blocks (regional)
A
  • Patient-controlled analgesia (PCA)
  • Patient-controlled epidural analgesia (PCEA)
  • Nerve blocks (regional)
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14
Q

Challenges to pain management

  • Tolerance
  • Dependence
  • Pseudoaddiction
  • Addiction
    – Physiologic
    – Psychological
  • Cognitive
  • Sociocultural
  • Monetary
A
  • Tolerance
  • Dependence
  • Pseudoaddiction
  • Addiction
    – Physiologic
    – Psychological
  • Cognitive
  • Sociocultural
  • Monetary
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15
Q

Gerontologic Concerns [pain]

  • Beliefs that pain is a normal aging process
  • Decreased report of pain
  • Chronic pain is prevalent
  • Pain is undertreated in elderly
  • Delayed metabolism of drugs in older adults
  • Impairments affecting pain assessment
A
  • Beliefs that pain is a normal aging process
  • Decreased report of pain
  • Chronic pain is prevalent
  • Pain is undertreated in elderly
  • Delayed metabolism of drugs in older adults
  • Impairments affecting pain assessment
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16
Q

________________ is the process by which we relay pain signals from the periphery to the spinal cord and then to the brain

A

Transmission is the process by which we relay pain signals from the periphery to the spinal cord and then to the brain

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17
Q

____________ occurs when pain is recognized, defined, and assigned meaning by the person experiencing the pain

A

Perception

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18
Q

___________ involves the activation of descending pathways that exert inhibitory or facilitatory effects on pain transmission

A

Modulation

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19
Q

____________ pain is caused by damage to somatic or visceral tissue.

A

Nociceptive

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20
Q

Nociceptive pain; Somatic pain often is further described as superficial or deep.

Superficial pain arises from skin, mucous membranes, and _______________ tissues. It is often described as sharp, burning, or prickly.

Deep pain is often described as aching or throbbing. It originates in ______ , joint, _________, skin, or connective tissue.

A

Superficial pain arises from skin, mucous membranes, and subcutaneous tissues. It is often described as sharp, burning, or prickly.

Deep pain is often described as aching or throbbing. It originates in bone, joint, muscle, skin, or connective tissue.

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21
Q

______________ pain is caused by damage to peripheral nerves or structures in the CNS.

A

Neuropathic

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22
Q

Nondrug Therapies for Pain

Physical Therapies
* Acupuncture
* Application of heat and cold
* Exercise
* Massage
* TENS

Cognitive Therapies
* Distraction
* Hypnosis
* Imagery
* Relaxation strategies
* Art therapy
* Imagery
* Meditation
* Music therapy
* Relaxation breathing

A

Physical Therapies
* Acupuncture
* Application of heat and cold
* Exercise
* Massage
* TENS

Cognitive Therapies
* Distraction
* Hypnosis
* Imagery
* Relaxation strategies
* Art therapy
* Imagery
* Meditation
* Music therapy
* Relaxation breathing

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23
Q

Pharmacologic: Routes of Pain Management

  • Oral
  • Sublingual
  • Intranasal
  • Rectal
  • Transdermal
  • Parenteral
    – IV, PCA
  • Intrathecal or epidural
  • Nerve blocks
A
  • Oral
  • Sublingual
  • Intranasal
  • Rectal
  • Transdermal
  • Parenteral
    – IV, PCA
  • Intrathecal or epidural
  • Nerve blocks
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24
Q

Patient-controlled analgesia (PCA) (demand analgesia) is a method that allows the patient to self-administer preset doses of an analgesic within a prescribed time period by activating an _________________. Routes of administration include IV and epidural

A

infusion pump

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25
Q

___________________ involve 1-time or continuous infusion of local anesthetics into an area to produce pain relief.

We also call these techniques regional anesthesia.

A

Nerve blocks

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26
Q

OSTEOPOROSIS

  • ____________ bone
  • Chronic, progressive metabolic bone disease characterized by
    – _____ bone mass
    – Structural deterioration
    – Increased bone ___________
A
  • Porous bone
  • Chronic, progressive metabolic bone disease characterized by
    – Low bone mass
    – Structural deterioration
    – Increased bone fragility
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27
Q

OSTEOPOROSIS

  • Over ____ million people in the United States
  • One in ___ women and 1 in 4 men over 50 will sustain an osteoporosis-related fracture.
  • Known as the “silent thief”
A
  • Over 54 million people in the United States
  • One in 2 women and 1 in 4 men over 50 will sustain an osteoporosis-related fracture.
  • Known as the “silent thief”
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28
Q

OSTEOPOROSIS: Why more common in women?

  • Lower _________ intake
  • Less ________ mass
  • Bone resorption begins earlier and accelerates after ____________ .
  • Pregnancy and _____________
  • Longevity .
A
  • Lower calcium intake
  • Less bone mass
  • Bone resorption begins earlier and accelerates after menopause.
  • Pregnancy and breastfeeding
  • Longevity .
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29
Q

OSTEOPOROSIS Preventive factors

  • Regular ________ -bearing exercise
  • Fluoride
  • Calcium
  • Vitamin ____
A
  • Regular weight-bearing exercise
  • Fluoride
  • Calcium
  • Vitamin D
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30
Q

OSTEOPOROSIS Risk Factors

  • Advancing age (>65 yr)
  • Female
  • Low body weight
  • White or Asian ethnicity
  • Current cigarette smoking
  • Nontraumatic fracture
  • Sedentary lifestyle
  • Postmenopausal
  • Family history
  • Diet low in calcium. Vitamin D deficiency
  • Excessive use of alcohol (>2 drinks/day)
  • Low testosterone in men
  • Specific diseases
  • Certain drugs
A
  • Advancing age (>65 yr)
  • Female
  • Low body weight
  • White or Asian ethnicity
  • Current cigarette smoking
  • Nontraumatic fracture
  • Sedentary lifestyle
  • Postmenopausal
  • Family history
  • Diet low in calcium. Vitamin D deficiency
  • Excessive use of alcohol (>2 drinks/day)
  • Low testosterone in men
  • Specific diseases
  • Certain drugs
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31
Q

Osteoporosis ETIOLOGY AND PATHOPHYSIOLOGY

  • Peak bone mass (by age 20) determined by heredity, nutrition, exercise, & hormone function
  • Bone loss after age ________ inevitable, rate of loss variable
  • Rapid bone loss for women at ___________

Remodeling
- Osteoblasts – deposit bone
- Osteoclasts – resorb bone

A
  • Peak bone mass (by age 20) determined by heredity, nutrition, exercise, & hormone function
  • Bone loss after age 35-40 inevitable, rate of loss variable
  • Rapid bone loss for women at menopause

Remodeling
- Osteoblasts – deposit bone
- Osteoclasts – resorb bone

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32
Q

In osteoporosis, bone resorption exceeds bone ____________

A

deposition

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33
Q
  • Osteoblasts – __________ bone
  • Osteoclasts – __________ bone
A
  • Osteoblasts – deposit bone
  • Osteoclasts – resorb bone
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34
Q

Osteoporosis SIGNS & SYMPTOMS

  • Occurs most commonly in spine, hips, and wrists
  • ______ pain
  • Spontaneous __________
  • Gradual loss of _________
  • Dowager’s hump (_________)
A
  • Occurs most commonly in spine, hips, and wrists
  • Back pain
  • Spontaneous fractures
  • Gradual loss of height
  • Dowager’s hump (kyphosis)
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35
Q

OSTEOPOROSIS Screening guidelines

  • Initial bone scan in women before age ____
  • Repeat in ___ years if normal
  • Earlier and more frequent if high risk
  • Men screened before age 70
  • By age 50 if high risk

.

A
  • Initial bone scan 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 high risk
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36
Q

Osteoporosis diagnostics

-History and physical exam
- X-ray and lab studies not diagnostic
- Bone mineral density (BMD)
- Quantitative ultrasound
- Dual-energy x-ray absorptiometry (DXA)

T-scores
- Standard deviation below average
-T-score _________ = normal bone density
- T-score between -2.5 and < -1 = osteopenia
- T-score _____ = Osteoporosis

Z-score compares with someone own age and ethnicity

A

-History and physical exam
- X-ray and lab studies not diagnostic
- Bone mineral density (BMD)
- Quantitative ultrasound
- Dual-energy x-ray absorptiometry (DXA)

T-scores
- Standard deviation below average
-T-score -1 to 1 = normal bone density
- T-score between -2.5 and < -1 = osteopenia
- T-score > -2.5 = Osteoporosis

Z-score compares with someone own age and ethnicity

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37
Q

Osteoporosis TREATMENT AND CARE

Prevention
- Proper _________
- Calcium supplements
- Exercise
- Prevention of __________
- Drug therapy

Treat if
- T-score lower than _____
- T-score between -1 and -2.5 with additional risk factors
- Prior history of hip or vertebral fracture

A

Prevention
- Proper nutrition
- Calcium supplements
- Exercise
- Prevention of fractures
- Drug therapy

Treat if
- T-score lower than -2.5
- T-score between -1 and -2.5 with additional risk factors
- Prior history of hip or vertebral fracture

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38
Q

Osteoporosis TREATMENT AND CARE Cont.

Adequate _________ intake
- 1000 mg/day premenopausal and postmenopausal taking estrogen
-1500 mg/day postmenopausal without estrogen

Supplemental calcium
- Must be taken in divided doses with food to enhance absorption

Vitamin D - necessary for calcium ____________________; bone formation
- Sunlight for 20 minutes adequate
- Supplemental (800-1000 IU/day)
– Postmenopausal
– Older adults
– Homebound/ Minimal sun exposure

Good sources of calcium
- Milk, Yogurt, Cottage cheese, Ice cream
- Turnip greens, Spinach
- Sardines

A

Adequate calcium intake
- 1000 mg/day premenopausal and postmenopausal taking estrogen
-1500 mg/day postmenopausal without estrogen

Supplemental calcium
- Must be taken in divided doses with food to enhance absorption

Vitamin D - necessary for calcium absorption/function; bone formation
- Sunlight for 20 minutes adequate
- Supplemental (800-1000 IU/day)
– Postmenopausal
– Older adults
– Homebound/ Minimal sun exposure

Good sources of calcium
- Milk, Yogurt, Cottage cheese, Ice cream
- Turnip greens, Spinach
- Sardines

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39
Q

Osteoporosis TREATMENT AND CARE Cont….

_______________________
- Build up and maintain bone mass
- Increase strength, coordination, balance
- Walking, hiking, weight training, stair climbing, tennis, dancing

-Quit ___________.
- Decrease ___________ intake.

-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

A

Weight-bearing exercise
- Build up and maintain bone mass
- Increase strength, coordination, balance
- Walking, hiking, weight training, stair climbing, tennis, dancing

-Quit smoking.
- Decrease alcohol intake.

-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

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40
Q

Osteoporosis PHARMACOLOGIC THERAPY

Bisphosphonates (Fosamax – alendronate)
- Inhibit bone resorption
- Side eff ects: anorexia, weight loss, gastritis
- Proper administration
- Take with full glass of water.
- Take 30 minutes before food or other meds.
- Remain upright for at least 30 minutes.

Calcitonin
- Inhibits bone resorption
- Give IM form at night to minimize side eff ects
- Alternate nostrils when using nasal form
- Must use calcium supplementation

Selective estrogen receptor modulators
- Raloxifene (Evista)
- Reduces bone resorption

Teriparatide (Forteo)
- Portion of parathyroid hormone
- First drug to stimulate new bone formation

Denosumab (Prolia)
- Monoclonal antibody for postmenopausal women
- Subcutaneous injection every 6 months

Management of patients receiving corticosteroids

A

Bisphosphonates (Fosamax – alendronate)
- Inhibit bone resorption
- Side eff ects: anorexia, weight loss, gastritis
- Proper administration
- Take with full glass of water.
- Take 30 minutes before food or other meds.
- Remain upright for at least 30 minutes.

Calcitonin
- Inhibits bone resorption
- Give IM form at night to minimize side eff ects
- Alternate nostrils when using nasal form
- Must use calcium supplementation

Selective estrogen receptor modulators
- Raloxifene (Evista)
- Reduces bone resorption

Teriparatide (Forteo)
- Portion of parathyroid hormone
- First drug to stimulate new bone formation

Denosumab (Prolia)
- Monoclonal antibody for postmenopausal women
- Subcutaneous injection every 6 months

Management of patients receiving corticosteroids

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41
Q

OSTEOMYELITIS - Severe __________ of bone, bone marrow, and surrounding ______ tissue

A

OSTEOMYELITIS - Severe infection of bone, bone marrow, and surrounding soft tissue

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42
Q

OSTEOMYELITIS - Most common microorganism is _____________________ , but can be
caused by variety of organisms.

A

Staphylococcus aureus

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43
Q

OSTEOMYELITIS

Indirect entry (hematogenous)
- Young boys, scrapes
- Blunt trauma
- Vascular insufficiency disorders
- GI & respiratory infections

Direct entry – via open wound

Foreign body presence

A

Indirect entry (hematogenous)
- Young boys, scrapes
- Blunt trauma
- Vascular insufficiency disorders
- GI & respiratory infections

Direct entry – via open wound

Foreign body presence

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44
Q

OSTEOMYELITIS - ETIOLOGY AND PATHOPHYSIOLOGY

  • _______________ grow →increase pressure in bone →ischemia and vascular compromise
  • Infection spreads through bone → leads to cortex revascularization and __________
A
  • Microorganisms grow →increase pressure in bone →ischemia and vascular compromise
  • Infection spreads through bone → leads to cortex revascularization and necrosis
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45
Q

SIGNS & SYMPTOMS - ACUTE OSTEOMYELITIS

  • Infection of _________ in duration

Local manifestations
- ______ unrelieved by rest; worsens with activity
- Swelling, tenderness, warmth
- Restricted movement

Systemic manifestations
- Fever, Night sweats, Chills
- Restlessness
- Nausea
- Malaise
- Drainage (late)

A
  • Infection of <1 month in duration

Local manifestations
- Pain unrelieved by rest; worsens with activity
- Swelling, tenderness, warmth
- Restricted movement

Systemic manifestations
- Fever, Night sweats, Chills
- Restlessness
- Nausea
- Malaise
- Drainage (late)

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46
Q

SIGNS & SYMPTOMS - CHRONIC OSTEOMYELITIS

  • Infection lasting longer _________ or failed to respond to initial course of antibiotic therapy
  • Continuous and persistent or process of exacerbations and remissions
  • Systemic signs are diminished
  • ________ signs of infection more common: Pain, swelling, warmth
  • Granulation tissue turns to scar tissue → avascular → ideal site for microorganisms to grow → away from antibiotic penetration
A
  • Infection lasting longer >1 month or failed to respond to initial course of antibiotic therapy
  • Continuous and persistent or process of exacerbations and remissions
  • Systemic signs are diminished
    -Local signs of infection more common: Pain, swelling, warmth
  • Granulation tissue turns to scar tissue → avascular → ideal site for microorganisms to grow → away from antibiotic penetration
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47
Q

OSTEOMYELITIS Diagnostics

  • Bone or soft tissue biopsy
  • Blood and/or wound cultures
  • WBC count (high)
  • Erythrocyte sedimentation rate (ESR)
  • X-rays
  • Bone scans
  • MRI/ CT scans
A
  • Bone or soft tissue biopsy
  • Blood and/or wound cultures
  • WBC count (high)
  • Erythrocyte sedimentation rate (ESR)
  • X-rays
  • Bone scans
  • MRI/ CT scans
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48
Q

TREATMENT of ACUTE OSTEOMYELITIS

  • Vigorous and prolonged _____________ therapy
  • Cultures or bone biopsy
  • Surgical debridement and decompression
  • Course of IV antibiotic therapy 4-6 weeks minimum may last 3-6 months
  • May be completed at home or in skilled nursing facility

Variety of antibiotics depending on microorganism; include penicillin, nafcillin (Nafcil), neomycin, vancomycin, cephalexin (Keflex), cefazolin (Ancef), cefoxitin (Mefoxin), gentamicin (Garamycin), and tobramycin (Nebcin)

A
  • Vigorous and prolonged IV antibiotic therapy
  • Cultures or bone biopsy
  • Surgical debridement and decompression
  • Course of IV antibiotic therapy 4-6 weeks minimum may last 3-6 months
  • May be completed at home or in skilled nursing facility

Variety of antibiotics depending on microorganism; include penicillin, nafcillin (Nafcil), neomycin, vancomycin, cephalexin (Keflex), cefazolin (Ancef), cefoxitin (Mefoxin), gentamicin (Garamycin), and tobramycin (Nebcin)

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49
Q

TREATMENT of CHRONIC OSTEOMYELITIS

  • _________ removal
  • Extended use of antibiotics
  • Antibiotic-impregnated polymethyl methacrylate bead chains
  • Intermittent or constant antibiotic irrigation of bone
  • Casts or braces
  • Negative-pressure wound therapy
  • Hyperbaric oxygen therapy
  • Removal of prosthetic devices
  • Muscle flaps, skin grating, bone grafts
  • Amputation
  • Oral fluoroquinolone (Cipro) for 6 to 8 weeks for chronic osteomyelitis
  • Monitor patient response to therapy with bone scans and ESR tests

Long-term and mostly rare complications
- Septicemia
- Septic arthritis
- Pathologic fractures
- Amyloidosis

A
  • Surgical removal
  • Extended use of antibiotics
  • Antibiotic-impregnated polymethyl methacrylate bead chains
  • Intermittent or constant antibiotic irrigation of bone
  • Casts or braces
  • Negative-pressure wound therapy
  • Hyperbaric oxygen therapy
  • Removal of prosthetic devices
  • Muscle flaps, skin grating, bone grafts
  • Amputation
  • Oral fluoroquinolone (Cipro) for 6 to 8 weeks for chronic osteomyelitis
  • Monitor patient response to therapy with bone scans and ESR tests

Long-term and mostly rare complications
- Septicemia
- Septic arthritis
- Pathologic fractures
- Amyloidosis

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50
Q

NURSING ASSESSMENT [OSTEOMYELITIS]

__________ Data
- IV drug and alcohol abuse, malaise
- Anorexia, weight loss, chills
- Weakness, paralysis, muscle spasms
- Local tenderness, increase in pain
- Irritability, withdrawal, dependency, anger

__________ Data
- Restlessness, high spiking temperature, night sweats
- Diaphoresis, erythema, warmth, edema
- Restricted movement, wound drainage, spontaneous fractures
- ↑ WBC, + cultures, ↑ ESR, presence of sequestrum and involucrum

A

Subjective Data
- IV drug and alcohol abuse, malaise
- Anorexia, weight loss, chills
- Weakness, paralysis, muscle spasms
- Local tenderness, increase in pain
- Irritability, withdrawal, dependency, anger

Objective Data
- Restlessness, high spiking temperature, night sweats
- Diaphoresis, erythema, warmth, edema
- Restricted movement, wound drainage, spontaneous fractures
- ↑ WBC, + cultures, ↑ ESR, presence of sequestrum and involucrum

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51
Q

OSTEOMYELITIS overall goals

  • Have satisfactory pain and fever control.
  • Do not experience any complications associated with osteomyelitis.
  • Cooperate with treatment plan.
  • Maintain a positive outlook on outcome of disease
A
  • Have satisfactory pain and fever control.
  • Do not experience any complications associated with osteomyelitis.
  • Cooperate with treatment plan.
  • Maintain a positive outlook on outcome of disease
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52
Q

Acute Intervention [OSTEOMYELITIS]

  • _____________ and careful handling of affected limb
  • Assess and treat ______
  • Dressing care
  • Proper positioning to prevent complications of immobility

Patient teaching re adverse and toxic reactions to __________ therapy
- Ototoxicity, nephrotoxicity, neurotoxicity
- Hives, diarrhea, bloody stools, throat and mouth sores
- Tendon rupture

  • Monitor peak and trough levels of abx
  • Lengthy antibiotic therapy can result in overgrowth of Candida albicans.
  • Patient and family are often frightened and discouraged.
  • Continued psychologic and emotional support
A
  • Immobilization and careful handling of affected limb
  • Assess and treat pain
  • Dressing care
  • Proper positioning to prevent complications of immobility

Patient teaching re adverse and toxic reactions to antibiotic therapy
- Ototoxicity, nephrotoxicity, neurotoxicity
- Hives, diarrhea, bloody stools, throat and mouth sores
- Tendon rupture

  • Monitor peak and trough levels of abx
  • Lengthy antibiotic therapy can result in overgrowth of Candida albicans.
  • Patient and family are often frightened and discouraged.
  • Continued psychologic and emotional support
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53
Q

OSTEOMYELITIS Ambulatory and Home Care

  • Patient teaching regarding antibiotic administration & management of venous access device
  • Wound care/dressing changes
  • Physical and psychologic support
A
  • Patient teaching regarding antibiotic administration & management of venous access device
  • Wound care/dressing changes
  • Physical and psychologic support
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54
Q

A _______ is an injury to the ligaments surrounding a joint.

A ________ is an excessive stretching of a muscle and its fascial sheath, often involving the tendon.

A

A sprain is an injury to the ligaments surrounding a joint.

A strain is an excessive stretching of a muscle and its fascial sheath, often involving the tendon.

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55
Q

Sprain VS Strain

A

A sprain is an injury to the ligaments and capsule of a joint in the body.

A strain is an injury to muscles or tendons

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56
Q

Dislocation is the complete displacement or separation of the articular surfaces of the ______

A

joint

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57
Q

Carpal tunnel syndrome (CTS) is caused by compression of the median nerve. It enters the ________ at the wrist through the narrow carpal tunnel

A

hand

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58
Q

The rotator cuff is made up of 4 muscles in the ___________ : the supraspinatus, infraspinatus, teres minor, and subscapularis muscles.

A

shoulder

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59
Q

Meniscus Injury
The menisci are crescent-shaped pieces of fibrocartilage in the _______ .

A

knee

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60
Q

Anterior Cruciate Ligament Injury

The most commonly injured ______ ligament is the anterior cruciate ligament (ACL).

A

knee

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61
Q

__________ are closed sacs that are lined with synovial membrane and contain a small amount of synovial fluid.

A

Bursae

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62
Q

___________ (inflammation of the bursa) results from repeated or excessive trauma or friction, gout, RA, or infection.

A

Bursitis

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63
Q

A __________ is a disruption or break in the continuity of bone.

A

fracture

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64
Q

_________ fracture - the skin is broken, and bone exposed, causing soft tissue injury; usually results from severe external forces.

__________ fracture - the skin is intact over the site.

A

open fracture - the skin is broken, and bone exposed, causing soft tissue injury; usually results from severe external forces.

closed fracture - the skin is intact over the site.

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65
Q

__________ fracture - the break goes completely through the bone

__________ fracture - occurs partly across a bone shaft, but the bone is still intact; often the result of bending or crushing forces applied to a bone.

A

Complete fracture - the break goes completely through the bone

incomplete fracture - occurs partly across a bone shaft, but the bone is still intact; often the result of bending or crushing forces applied to a bone.

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66
Q

__________ fracture - the 2 ends of the broken bone are separated from each other and out of their normal positions. Displaced fractures are often comminuted (more than 2fragments) or oblique

In a _____________ fracture, the bone fragments stay in alignment; usually transverse, spiral, or greenstick

A

displaced fracture - the 2 ends of the broken bone are separated from each other and out of their normal positions. Displaced fractures are often comminuted (more than 2fragments) or oblique

In a nondisplaced fracture, the bone fragments stay in alignment; usually transverse, spiral, or greenstick

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67
Q

Classification of fractures based on location

A
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68
Q

Complete fracture – Break completely through _______

A

bone

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69
Q

Incomplete fracture – Break partly through bone, but still ________

A

intact

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70
Q

Fracture Reduction:

*Closed reduction

  • Open reduction
    – Internal fixation (ORIF)
    *** Intramedullary rod (IM rodding)
A

*Closed reduction

  • Open reduction
    – Internal fixation (ORIF)
    *** Intramedullary rod (IM rodding)
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71
Q

Open reduction is the correction of bone alignment through ________ .

A

surgery

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72
Q

Traction is the application of a ________ force to an injured or diseased body part or extremity.

Traction is used to
(1) prevent or reduce pain and muscle spasm (e.g., whiplash, unrepaired hip fracture),
(2) immobilize a joint or part of the body,
(3) reduce a fracture or dislocation, and
(4) treat a pathologic joint condition (e.g., tumor, infection).

A

pulling

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73
Q

An external __________ is composed of metal pins and wires that are inserted into the bone and attached to external rods to stabilize the fracture while it heals

A

fixator

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74
Q

Bone Healing stages

  • Fracture hematoma
  • Granulation tissue
  • Callus formation
  • Ossification
  • Consolidation
  • Remodeling
A
  • Fracture hematoma
  • Granulation tissue
  • Callus formation
  • Ossification
  • Consolidation
  • Remodeling
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75
Q

Fracture Immobilization

Casts
– Short arm vs. long arm
– Body jacket
– Hip spica
***** Double vs. single
– Short leg vs. long leg
– Knee immobilizer

  • External fixation
  • Internal fixation
    – Pins, screws, plates, rods
A

Casts
– Short arm vs. long arm
– Body jacket
– Hip spica
***** Double vs. single
– Short leg vs. long leg
– Knee immobilizer

  • External fixation
  • Internal fixation
    – Pins, screws, plates, rods
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76
Q

Bone Healing Stages

A

(A) Bleeding at fractured ends of the bone with hematoma formation.

(B) Organization of hematoma into fibrous network.

(C) Invasion of osteoblasts, lengthening of collagen strands, and deposition of calcium.

(D) Callus formation: new bone is built up as osteoclasts destroy dead bone.

(E) Remodeling is accomplished as excess callus is resorbed and trabecular bone is laid down.

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77
Q

Fractures: Nursing Management

  • Assessment- neurovascular
  • Medications
    – Muscle relaxants
    – Tetanus
    – Antibiotics
    – Analgesics
  • Nutrition
  • Reinfusion drain
  • Drains
A
  • Assessment – neurovascular
  • Medications
    – Muscle relaxants
    – Tetanus
    – Antibiotics
    – Analgesics
  • Nutrition
  • Reinfusion drain
  • Drains
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78
Q

Weight-Bearing Ambulation Terminology

  • Non-weight-bearing (NWB)
  • Touch-down weight-bearing (TDWB)
  • Partial weight-bearing (PWB)
  • Weight-bearing as tolerated (WBAT)
  • Full weight-bearing (FWB)
A

(1) non–weight-bearing (no weight on the involved extremity),
(2) touch-down/toe-touch weight bearing (contact with floor for balance but no weight borne),
(3) partial–weight-bearing ambulation (25% to 50% of weight borne),
(4) weight bearing as tolerated (based on pain and tolerance), and
(5) full–weight-bearing ambulation (no limitations).

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79
Q

Assistive Devices

  • Cane
  • Walker
  • Crutch walking
    – Two-point gait
    – Four-point gait
    – Swing-to gait
    – Swing-through gait
A
  • Cane
  • Walker
  • Crutch walking
    – Two-point gait
    – Four-point gait
    – Swing-to gait
    – Swing-through gait
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80
Q

Complications of Musculoskeletal Trauma

  • ___________
    – Surgical debridement
  • ___________ syndrome
  • Venous thromboembolism
    – Pulmonary embolus
  • Fat embolism
  • Integumentary
A
  • Infection
    – Surgical debridement
  • Compartment syndrome
  • Venous thromboembolism
    – Pulmonary embolus
  • Fat embolism
  • Integumentary
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81
Q

Compartment Syndrome - Clinical Manifestations

  • Early recognition and treatment essential
  • May occur initially or may be delayed several days
  • ____________ can occur within 4 to 8 hours after onset.
  • Early recognition via regular ______________ assessments
    – Notify of pain unrelieved by drugs and out of proportion to injury
  • Assess urine output and kidney function.
A
  • Early recognition and treatment essential
  • May occur initially or may be delayed several days
  • Ischemia can occur within 4 to 8 hours after onset.
  • Early recognition via regular neurovascular assessments
    – Notify of pain unrelieved by drugs and out of proportion to injury
  • Assess urine output and kidney function.
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82
Q

Compartment syndrome is a condition in which swelling causes ____________________ within a limited space (muscle compartment).

A

increased pressure

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83
Q

A __________ fracture is a fracture of the distal radius.

A

Colles

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84
Q

Types of fractures

  • Colles’ fracture
  • Humeral shaft fracture
  • Pelvic fracture
  • Hip fracture
  • Femoral shaft fracture
  • Tibial fracture
  • Vertebral fracture
  • Facial fractures
    – Mandible
    – Maxilla
A
  • Colles’ fracture
  • Humeral shaft fracture
  • Pelvic fracture
  • Hip fracture
  • Femoral shaft fracture
  • Tibial fracture
  • Vertebral fracture
  • Facial fractures
    – Mandible
    – Maxilla
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85
Q

Facial Fractures

  • Mandible fractures
  • Maxilla fractures
  • Lefort I * Lefort II *Lefort III [types of facial surgeries]
  • Zygoma fractures
  • Frontal bone fractures
  • Temporal bone fractures

Facial fractures related to which CN?

A

4, 5, 6

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86
Q

What are some clinical manifestations from facial fractures?

Epistaxis
congestion
can they eat/see/hear?
Body image
pain
scarring
ADL
Infection prevention/ cleanliness

A

Epistaxis
congestion
can they eat/see/hear?
Body image
pain
scarring
ADL
Infection prevention/ cleanliness

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87
Q

Amputation

  • PVD
  • Diabetes
  • Atherosclerosis
  • Trauma
  • Injury
  • Prosthetics
    – Bandage
    – Elastic stocking
A
  • PVD
  • Diabetes
  • Atherosclerosis
  • Trauma
  • Injury
  • Prosthetics
    – Bandage
    – Elastic stocking
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88
Q

Amputation Care

  • Pain in missing limb [phantom pain]
    – Mirror therapy
    – Opioids
    – Adjuvants
  • Neuropathic
  • Prosthetics
    – Bandage
    – Elastic stocking
  • Flexion contractures
    – Hip flexion
    *** prone
A
  • Pain in missing limb [phantom pain]
    – Mirror therapy
    – Opioids
    – Adjuvants
  • Neuropathic
  • Prosthetics
    – Bandage
    – Elastic stocking
  • Flexion contractures
    – Hip flexion
    *** prone
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89
Q

Amputation Care

  • Pain in missing limb [phantom pain]
    – Mirror therapy
    – Opioids
    – Adjuvants
  • Neuropathic
  • Prosthetics
    – Bandage
    – Elastic stocking
  • Flexion contractures
    – Hip flexion
    *** prone
A
  • Pain in missing limb [phantom pain]
    – Mirror therapy
    – Opioids
    – Adjuvants
  • Neuropathic
  • Prosthetics
    – Bandage
    – Elastic stocking
  • Flexion contractures
    – Hip flexion
    *** prone
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90
Q

____________ helps prevent contracture (stiffening) of tendons and ligaments.

A

Movement

91
Q

Synovectomy (removal of ___________________)

A

synovial membrane

92
Q

An osteotomy involves removing a wedge or slice of ________ to restore alignment (joint and vertebral) and to shift weight bearing, thus relieving pain.

A

bone

93
Q

_______________ is the removal of debris, such as pieces of bone or cartilage (loose bodies) or osteophytes, from a joint using a fiberoptic arthroscope.

A

Debridement

94
Q

_______________ is the reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity.

A

Arthroplasty

95
Q

___________ is the surgical fusion of a joint.

A

Arthrodesis

96
Q

FIBROMYALGIA

Chronic central pain syndrome
- Widespread, non-articular musculoskeletal ________ & __________
- Multiple tender points

May also have
- Nonrestorative sleep
- Morning stiff ness
- Irritable bowel syndrome
- Anxiety

A

Chronic central pain syndrome
- Widespread, non-articular musculoskeletal pain and fatigue
- Multiple tender points

May also have
- Nonrestorative sleep
- Morning stiff ness
- Irritable bowel syndrome
- Anxiety

97
Q

-Fibromyalgia is a commonly diagnosed musculoskeletal disorder and a major cause of disability.

-Fibromyalgia and systemic exertion intolerance disease (SEID) (formerly called chronic fatigue syndrome) share many common features

-It affects an estimated __} of the general U.S. population.
-4 to 10 times more common in ___________

A

-Fibromyalgia is a commonly diagnosed musculoskeletal disorder and a major cause of disability.

-Fibromyalgia and systemic exertion intolerance disease (SEID) (formerly called chronic fatigue syndrome) share many common features

-It affects an estimated 2% of the general U.S. population.
-4 to 10 times more common in women than men.

98
Q

FIBROMYALGIA

  • Disorder involving abnormal central processing nociceptive pain input
  • Abnormal sensory processing in ______
A

CNS

99
Q

FIBROMYALGIA

Multiple physiologic abnormalities
- ↑ Levels of substance P in spinal fl uid
- Low blood flow to thalamus
- Dysfunction of hypothalamic-pituitary-adrenal (HPA) axis
- Low levels of serotonin and tryptophan
- Abnormalities in cytokine function

Genetics

Recent illness or trauma

A
100
Q

FIBROMYALGIA CLINICAL MANIFESTATIONS AND COMPLICATIONS

Widespread burning pain
Worsens and improves throughout day
Trouble determining if pain is in muscles, joints, or soft tissues
Head or facial pain
Can accompany temporomandibular joint (TMJ) dysfunction

A
101
Q

Fibromyalgia pain pattern

pain _____________________ throughout the day

A

worsens and improves

102
Q

Fibromyalgia if two criteria are met:

  • Pain is experienced in ____ of 18 tender points on palpation
  • History of widespread pain is noted for at least ___ months
    -Widespread pain is defined as pain that occurs on both sides of the body, and above and below the waist.

Fatigue, cognitive symptoms, somatic symptoms help establish diagnosis

A
  • Pain is experienced in 11 of 18 tender points on palpation
  • History of widespread pain is noted for at least 3 months
    -Widespread pain is defined as pain that occurs on both sides of the body, and above and below the waist.

Fatigue, cognitive symptoms, somatic symptoms help establish diagnosisFIBROMYALGIA
TREATMENT

103
Q

FIBROMYALGIA TREATMENT

  • Treatment of fibromyalgia is ______________ and requires a high level of patient motivation.
  • Teach the patient to be an active participant in the therapeutic regimen.
  • ______ can help the pain, aching, and tenderness.

-Supportive care
-Massage combined with ultrasound
-Application of alternating heat and cold packs
-PT (gentle stretching)
-Yoga/Tai Chi
-Low impact aerobic exercise

A

Symptomatic;
Rest

104
Q

Fibromylagia- medications

Drug therapy for chronic widespread pain
- Pregabalin (Lyrica)
- Duloxetine (Cymbalta)
- Milnacipin (Savella)

-Low-dose tricyclic antidepressants (TCAs), SSRIs, or benzodiazepines
-Muscle relaxants
-Nonopioid analgesics
-Zolpidem (Ambien)

A

Drug therapy for chronic widespread pain
- Pregabalin (Lyrica)
- Duloxetine (Cymbalta)
- Milnacipin (Savella)

-Low-dose tricyclic antidepressants (TCAs), SSRIs, or benzodiazepines
-Muscle relaxants
-Nonopioid analgesics
-Zolpidem (Ambien)

105
Q

RHEUMATOID ARTHRITIS (RA)

-Chronic, systemic autoimmune disease
-Inflammation of ____________ tissue in diarthrodial (synovial) _______
-Periods of remission and exacerbation
-Extraarticular manifestations

-Affects all ethnic groups
-Incidence ↑ with age, peaks between ages 30 and 50
-Estimated 1.5 million Americans
-______ times as many women as men

A

-Chronic, systemic autoimmune disease
-Inflammation of connective tissue in diarthrodial (synovial) joints
-Periods of remission and exacerbation
-Extraarticular manifestations

-Affects all ethnic groups
-Incidence ↑ with age, peaks between ages 30 and 50
-Estimated 1.5 million Americans
-Three times as many women as men

106
Q

RHEUMATOID ARTHRITIS (RA)

-____________ etiology - combo of genetics and environmental triggers

-Antigen triggers formation of abnormal _________________

-Autoantibodies develop against the abnormal IgG; The autoantibodies are known as __________________

-The exact cause of RA is unknown. However, it probably results from a combination of genetics and environmental triggers.

-Rheumatoid factor combines with IgG immune complexes → deposit on synovial membranes or cartilage in joints → activates complement → inflammatory response

-Neutrophils → proteolytic enzymes → damage cartilage and thicken synovial lining

A

-Autoimmune etiology - combo of genetics and environmental triggers

-Antigen triggers formation of abnormal immunoglobulin G (IgG)

-Autoantibodies develop against the abnormal IgG; Rheumatoid factor (RF); The autoantibodies are known as rheumatoid factor (RF).

-The exact cause of RA is unknown. However, it probably results from a combination of genetics and environmental triggers.

-Rheumatoid factor combines with IgG immune complexes → deposit on synovial membranes or cartilage in joints → activates complement → inflammatory response

-Neutrophils → proteolytic enzymes → damage cartilage and thicken synovial lining

107
Q

RHEUMATOID ARTHRITIS (RA)

-Other inflammatory cells include T helper (CD4) cells, which stimulate cell-mediated immune responses. Activated CD4 cells cause monocytes, macrophages, and synovial fibroblasts to secrete the proinflammatory cytokines interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor (TNF).

  • These cytokines drive the inflammatory response in RA.
    —Without adequate treatment
    -More than 60% may develop marked functional impairment within 20 years
    -Need of mobility aids
    -Loss of self-care ability
    -Need for joint reconstruction

By end-stage patients experience loss of independence, require daily care

A

-Other inflammatory cells include T helper (CD4) cells, which stimulate cell-mediated immune responses. Activated CD4 cells cause monocytes, macrophages, and synovial fibroblasts to secrete the proinflammatory cytokines interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor (TNF).

  • These cytokines drive the inflammatory response in RA.
    —Without adequate treatment
    -More than 60% may develop marked functional impairment within 20 years
    -Need of mobility aids
    -Loss of self-care ability
    -Need for joint reconstruction

By end-stage patients experience loss of independence, require daily care

108
Q

RHEUMATOID ARTHRITIS (RA)

-Genetic link
-Genetic predisposition is important in the development of RA.
– HLA-DR4 and HLA-DR1 antigens
– ____________ increases risk in patients genetically predisposed

A

-Genetic link
-Genetic predisposition is important in the development of RA.
– HLA-DR4 and HLA-DR1 antigens
– Smoking increases risk in patients genetically predisposed

109
Q

RHEUMATOID ARTHRITIS (RA) stages

Stage I
- __________
- X-ray: soft tissue swelling, possible osteoporosis, no joint destruction

Stage II
-____________ joint inflammation
- Gradual destruction in joint cartilage
- Narrowing joint space from loss of cartilage

Stage III
- Formation of synovial pannus
- X-ray: extensive cartilage loss, erosion at joint margins, possible deformity

Stage IV
- Inflammatory process subsides
- Loss of joint __________
- Formation of subcutaneous nodules

A

Stage I
- Synovitis
- X-ray: soft tissue swelling, possible osteoporosis, no joint destruction

Stage II
- Increased joint inflammation
- Gradual destruction in joint cartilage
- Narrowing joint space from loss of cartilage

Stage III
- Formation of synovial pannus
- X-ray: extensive cartilage loss, erosion at joint margins, possible deformity

Stage IV
- Inflammatory process subsides
- Loss of joint function
- Formation of subcutaneous nodules

110
Q

SIGNS & SYMPTOMS of RHEUMATOID ARTHRITIS (RA)

-Onset typically insidious
-Fatigue, anorexia, weight loss, generalized stiffness
-May report history of precipitating event
-Infection, stress, exertion, childbirth, surgery, emotional upset
-Specific joint involvement
-Pain, stiffness, limited motion, and signs of inflammation
-Symptoms occur symmetrically
-Often affects ________ joints
-Larger joints and cervical spine may be involved

A

-Onset typically insidious
-Fatigue, anorexia, weight loss, generalized stiffness
-May report history of precipitating event
-Infection, stress, exertion, childbirth, surgery, emotional upset
-Specific joint involvement
-Pain, stiffness, limited motion, and signs of inflammation
-Symptoms occur symmetrically
-Often affects small joints
-Larger joints and cervical spine may be involved

111
Q

More symptoms of RA

-Joint stiffness after ___________
-__________ stiffness 60 minutes to several hours or longer
-MCP and PIP joints typically swollen
-Fingers spindle shaped
-Joints tender, painful, warm to touch
-Pain ↑ with motion, intensity varies
-Tenosynovitis
-Deformity and disability
-Subluxation
-Walking disability
-Deformities in the hands

A

-Joint stiffness after inactivity
-Morning stiffness 60 minutes to several hours or longer
-MCP and PIP joints typically swollen
-Fingers spindle shaped
-Joints tender, painful, warm to touch
-Pain ↑ with motion, intensity varies
-Tenosynovitis
-Deformity and disability
-Subluxation
-Walking disability
-Deformities in the hands

112
Q

TYPICAL DEFORMITIES OF RHEUMATOID ARTHRITIS

A

A: Ulnar drift
B: Boutonnière deformity
C: Hallux valgus
D: Swan neck deformity

113
Q

RA SIGNS & SYMPTOMS (NON-JOINT) [review]

-Rheumatoid nodules
-Nodular myositis
-Sjögren’s syndrome
-Felty syndrome
-Flexion contractures
-Cataracts
-Depression

A

-Rheumatoid nodules
-Nodular myositis
-Sjögren’s syndrome
-Felty syndrome
-Flexion contractures
-Cataracts
-Depression

114
Q

RHEUMATOID ARTHRITIS (RA) diagnostics

-A diagnosis is often made based on history and __________ findings, but some laboratory tests are useful for confirmation and monitor disease progression
-Laboratory studies
-Rheumatoid factor (RF)
-ESR and C-reactive protein (CRP)
-Antinuclear antibody (ANA)
-Antibodies to citrullinated peptide (anti-CCP)
-Synovial fluid analysis
-X-rays of involved joints
-Bone scan

A

-A diagnosis is often made based on history and physical findings, but some laboratory tests are useful for confirmation and monitor disease progression
-Laboratory studies
-Rheumatoid factor (RF)
-ESR and C-reactive protein (CRP)
-Antinuclear antibody (ANA)
-Antibodies to citrullinated peptide (anti-CCP)
-Synovial fluid analysis
-X-rays of involved joints
-Bone scan

115
Q

INTERPROFESSIONAL CARE - RHEUMATOID ARTHRITIS (RA)

-Care of the patient with RA begins with a thorough program of education and drug therapy.

Patient teaching
- Drug therapy
- Disease process
- Home management strategies

–Physical therapy
–Occupational therapy
–Individualized treatment plan

A

-Care of the patient with RA begins with a thorough program of education and drug therapy.

Patient teaching
- Drug therapy
- Disease process
- Home management strategies

–Physical therapy
–Occupational therapy
–Individualized treatment plan

116
Q

RHEUMATOID ARTHRITIS (RA) drug therapy

Tumor necrosis factor (TNF) inhibitors
- Etanercept (Enbrel)- subcutaneous
-Infliximab (Remicade)- IV infusion
-Adalimumab (Humira)- subcutaneous
-Certolizumab (Cimzia)
-Golimumab (Simponi)

-Bind with TNF, inhibiting _____________

A

-Bind with TNF, inhibiting inflammation

117
Q

OTHER DRUG THERAPY [RA]

Corticosteroid therapy- Intraarticular injections; low-dose oral for limited time

NSAID and salicylates
- Antiinflammatory, analgesic, and antipyretic

Not commonly used
- Antibiotics (minocycline)
-Immunosuppressants (azathioprine [Imuran])
-Penicillamine (Cuprimine)
-Gold preparations (auranofin [Ridaura])

A

Corticosteroid therapy- Intraarticular injections; low-dose oral for limited time

NSAID and salicylates
- Antiinflammatory, analgesic, and antipyretic

Not commonly used
- Antibiotics (minocycline)
-Immunosuppressants (azathioprine [Imuran])
-Penicillamine (Cuprimine)
-Gold preparations (auranofin [Ridaura])

118
Q

NUTRITIONAL THERAPY for RA

-Balanced nutrition important
-Loss of appetite or inability to shop for and prepare food → weight loss
-Corticosteroid therapy → weight gain

A

-Balanced nutrition important
-Loss of appetite or inability to shop for and prepare food → weight loss
-Corticosteroid therapy → weight gain

119
Q

SURGICAL THERAPY [RA]

-Relieve severe pain
-Improve function
-Synovectomy
-Total joint replacement (arthroplasty) can be done for many different joints in the body.

A

-Relieve severe pain
-Improve function
-Synovectomy
-Total joint replacement (arthroplasty) can be done for many different joints in the body.

120
Q

RA NURSING ASSESSMENT

___________ Data
- Recent infections, presence of precipitating factors, pattern of remissions and exacerbations
-Use of aspirin, NSAIDs, corticosteroids, DMARDs
-Any joint surgery
-Family history
-Ability to participate in therapeutic regimen
-Impact on functional ability
-Anorexia, weight loss,Malaise
-Dry mucous membranes of mouth and pharynx
-Stiffness and joint swelling, muscle weakness, difficulty walking, fatigue
-Paresthesia of hands and feet
-Loss of sensation
-Symmetric joint pain and aching that ↑ with motion or stress on joint

A

Subjective

121
Q

RA NURSING ASSESSMENT

____________ Data
-Lymphadenopathy, fever
-Keratoconjunctivitis
-Rheumatoid nodules
-Skin ulcers
-Shiny, taut skin over joints
-Peripheral edema
-Raynaud’s phenomenon
-Distant heart sounds, murmurs
-Dysrhythmias
-Chronic bronchitis, tuberculosis
-Histoplasmosis, fibrosing alveolitis
-Splenomegaly (Felty syndrome)
-Symmetric joint involvement
-Swelling, erythema
-Heat, tenderness
-Deformities
-Joint enlargement
-Limitation of movement
- Muscle contractures; atrophy
-+ Rheumatoid factor
-↑ ESR
-↑ WBCs in synovial fluid

X-ray findings
-Joint space narrowing
-Bony erosion
- Deformity
-Osteoporosis

A

Objective

122
Q

RA PLANNING

Goals
-Satisfactory pain management
-Minimal loss of functional ability
-Participate in therapeutic regimen
-Maintain positive self-image
-Perform self-care

-Prevention not possible at this time
-Early treatment to prevent further joint damage
-Community education programs
- Symptom recognition to promote early diagnosis and treatment

A

-Satisfactory pain management
-Minimal loss of functional ability
-Participate in therapeutic regimen
-Maintain positive self-image
-Perform self-care

-Prevention not possible at this time
-Early treatment to prevent further joint damage
-Community education programs
- Symptom recognition to promote early diagnosis and treatment

123
Q

Primary goals in _____ management
-Decrease inflammation
-Manage pain
-Maintain joint function
-Prevent or correct joint deformity

A

RA

124
Q

RA TREATMENTS

Nondrug relief of pain
-Therapeutic heat and cold
-Rest
-Relaxation techniques
-Joint protection
-Biofeedback
-Transcutaneous electrical stimulation
-Hypnosis

Lightweight splints
-Removed at regular intervals
-Perform ROM exercises
-Reapply as prescribed

-Occupational therapist → additional self-help devices
-Plan care around morning stiffness
-To relieve joint stiffness and ↑ abilty to perform ADLs
-Sit or stand in warm shower
-Sit in tub with warm towels around shoulders
-Soak hands in warm water

A

Nondrug relief of pain
-Therapeutic heat and cold
-Rest
-Relaxation techniques
-Joint protection
-Biofeedback
-Transcutaneous electrical stimulation
-Hypnosis

Lightweight splints
-Removed at regular intervals
-Perform ROM exercises
-Reapply as prescribed

-Occupational therapist → additional self-help devices
-Plan care around morning stiffness
-To relieve joint stiffness and ↑ abilty to perform ADLs
-Sit or stand in warm shower
-Sit in tub with warm towels around shoulders
-Soak hands in warm water

125
Q

RA more treatments:

-Alternate rest periods with activity
-Avoid total bed rest
-8–10 hours of sleep + daytime rest
-Modify activities to avoid overexertion
-Firm mattress or bed board
-Encourage positions of extension
-Avoid flexion positions
-No pillows under knees
-Small, flat pillow under head and shoulders

-Modify tasks for less stress on joints
-Energy conservation
-Work simplification techniques
-Pacing and organizing
-Use of carts
-Joint protective devices
-Delegation
Occupational therapy
-Assistive devices

A

-Alternate rest periods with activity
-Avoid total bed rest
-8–10 hours of sleep + daytime rest
-Modify activities to avoid overexertion
-Firm mattress or bed board
-Encourage positions of extension
-Avoid flexion positions
-No pillows under knees
-Small, flat pillow under head and shoulders

-Modify tasks for less stress on joints
-Energy conservation
-Work simplification techniques
-Pacing and organizing
-Use of carts
-Joint protective devices
-Delegation
Occupational therapy
-Assistive devices

126
Q

Heat and cold for RA

Ice
- Especially beneficial during periods of disease exacerbation
- Application should not exceed 10–15 minutes at one time

Moist heat
-Heating pads, moist hot packs, paraffin baths, warm baths, or showers;
-Should not exceed 20 minutes at a time

A

Ice
- Especially beneficial during periods of disease exacerbation
- Application should not exceed 10–15 minutes at one time

Moist heat
-Heating pads, moist hot packs, paraffin baths, warm baths, or showers;
-Should not exceed 20 minutes at a time

127
Q

OSTEOARTHRITIS (OA)

-Slowly progressive noninflammatory disorder of the _____________ joints
-27 million Americans affected
- Numbers expected to increase as population ages
-Gradual loss of articular cartilage
-Formation of osteophytes
-Not normal part of aging process
-___________ destruction
-Begins between ages 20 and 30
- Symptoms do not manifest until after age 50–60
-After age 50, women > men

A

-Slowly progressive noninflammatory disorder of the synovial joints
-27 million Americans affected
- Numbers expected to increase as population ages
-Gradual loss of articular cartilage
-Formation of osteophytes
-Not normal part of aging process
-Cartilage destruction
-Begins between ages 20 and 30
- Symptoms do not manifest until after age 50–60
-After age 50, women > men

128
Q

OSTEOARTHRITIS PATHOPHYSIOLOGY

  • Caused by direct _________________ or instability
  • However, many persons with OA cannot identify a single cause.

Risk Factors
- Age
-Decreased estrogen at menopause
-Obesity
- Anterior cruciate ligament injury
-Frequent kneeling and stooping
-Regular exercise can help prevent

A
  • Caused by direct joint damage or instability
  • However, many persons with OA cannot identify a single cause.

Risk Factors
- Age
-Decreased estrogen at menopause
-Obesity
- Anterior cruciate ligament injury
-Frequent kneeling and stooping
-Regular exercise can help prevent

129
Q

OSTEOARTHRITIS PATHOPHYSIOLOGY

  • New joint tissue forms in response to _________________

Cartilage becomes:
- Dull, yellow, and granular
- Softer and less elastic
- Less able to resist wear with heavy use

  • Articular surfaces cracked and worn
  • Formation of osteophytes
A
  • New joint tissue forms in response to cartilage destruction

Cartilage becomes:
- Dull, yellow, and granular
- Softer and less elastic
- Less able to resist wear with heavy use

  • Articular surfaces cracked and worn
  • Formation of osteophytes
130
Q

OSTEOARTHRITIS

There is _______ in later disease when articular cartilage is lost and bony joint surfaces rub on each other

A

Pain

131
Q

OSTEOARTHRITIS SIGNS & SYMPTOMS

  • 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.

_______ pain
- Primary symptom ranging from mild discomfort to significant disability
- Pain worsens with joint use
- Early stages: rest relieves pain
- Later stages: pain with rest and trouble sleeping due to increased joint pain

As OA progresses, increasing pain can contribute significantly to disability and loss of function.

A
  • 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.

Joint pain
- Primary symptom ranging from mild discomfort to significant disability
- Pain worsens with joint use
- Early stages: rest relieves pain
- Later stages: pain with rest and trouble sleeping due to increased joint pain

As OA progresses, increasing pain can contribute significantly to disability and loss of function.

132
Q

OSTEOARTHRITIS SIGNS & SYMPTOMS cont.

-Pain may be referred to groin, buttock, or outside of thigh or knee
-Sitting down becomes difficult, also getting up from a chair when hips are lower than knees
-OA in intervertebral joints causes local pain and stiffness
-Joint stiffness occurs after periods of rest or unchanged position
-Early morning stiffness usually resolves within 30 minutes
-Overactivity → mild joint effusion, temporarily ↑ stiffness
-Crepitation - a grating sensation caused by loose cartilage particles in the joint cavity, can also cause stiffness.
-Asymmetrical - OA usually affects joints on one side of the body (asymmetrically).

A

-Pain may be referred to groin, buttock, or outside of thigh or knee
-Sitting down becomes difficult, also getting up from a chair when hips are lower than knees
-OA in intervertebral joints causes local pain and stiffness
-Joint stiffness occurs after periods of rest or unchanged position
-Early morning stiffness usually resolves within 30 minutes
-Overactivity → mild joint effusion, temporarily ↑ stiffness
-Crepitation - a grating sensation caused by loose cartilage particles in the joint cavity, can also cause stiffness.
-Asymmetrical - OA usually affects joints on one side of the body (asymmetrically).

133
Q

CLINICAL MANIFESTATIONS - DEFORMITY - OSTEOARTHRITIS

-Specific to involved joint

Nodes
- Red, swollen, and tender
- No significant loss of function
-Visible deformity

-Knee: bowleg, knock-kneedas a result of cartilage loss in one joint compartment
-Hip: one leg shorter as the joint space narrows.

A

-Specific to involved joint

Nodes
- Red, swollen, and tender
- No significant loss of function
-Visible deformity

-Knee: bowleg, knock-kneedas a result of cartilage loss in one joint compartment
-Hip: one leg shorter as the joint space narrows.

134
Q

OSTEOARTHRITIS Diagnostics

  • Bone scan, CT scan, MRI
  • Early joint changes
  • X-rays - Detect joint space narrowing, bony sclerosis, osteophyte formation
  • No specific lab abnormalities
  • Synovial fluid analysis
A
  • Bone scan, CT scan, MRI
  • Early joint changes
  • X-rays - Detect joint space narrowing, bony sclerosis, osteophyte formation
  • No specific lab abnormalities
  • Synovial fluid analysis
135
Q

OSTEOARTHRITIS INTERPROFESSIONAL CARE

-Managing _______ and inflammation
-Preventing disability
-Maintaining and improving joint function
-___________ interventions are the basis for OA management
-Drug therapy supplements nondrug treatment
-Balance rest and activity
-Rest during acute inflammation [functional positioning, Do not be immobilized > 1 week]
-Modify activities to ↓ joint stress
-Avoid prolonged standing, kneeling, squatting (knee OA)
-Assistive device as needed

A

-Managing pain and inflammation
-Preventing disability
-Maintaining and improving joint function
-Nondrug interventions are the basis for OA management
-Drug therapy supplements nondrug treatment
-Balance rest and activity
-Rest during acute inflammation [functional positioning, Do not be immobilized > 1 week]
-Modify activities to ↓ joint stress
-Avoid prolonged standing, kneeling, squatting (knee OA)
-Assistive device as needed

136
Q

OSTEOARTHRITIS

heat and cold therapy

  • Ice for acute ___________
  • Heat therapy for _____________
A
  • Ice for acute inflammation
  • Heat therapy for stiffness
137
Q

DRUG THERAPY - OSTEOARTHRITIS

Mild to moderate joint pain
- Acetaminophen (________ mg every 6 hours) – DRUG OF CHOICE FOR OLDER ADULTS
- Topical agent (e.g., capsaicin cream [Zostrix])
- OTC creams (BenGay, ArthriCare)
- Topical salicylates (e.g., Aspercreme)

Moderate to severe joint pain
-nonsteroidal antiinflammatory drug (NSAID) - Ibuprofen _____ mg 4x/day
-Misoprostol to decrease GI side effects
-Arthrotec (combination of misoprostol and NSAID)
-Diclofenac gel
- COX-2 inhibitor celecoxib (Celebrex) – USE WITH CAUTION CARDIAC DISEASE RISK
- Intraarticular corticosteroid injections

A

Mild to moderate joint pain
- Acetaminophen (1000 mg every 6 hours) – DRUG OF CHOICE FOR OLDER ADULTS
- Topical agent (e.g., capsaicin cream [Zostrix])
- OTC creams (BenGay, ArthriCare)
- Topical salicylates (e.g., Aspercreme)

Moderate to severe joint pain
-nonsteroidal antiinflammatory drug (NSAID) - Ibuprofen 200 mg 4x/day
-Misoprostol to decrease GI side effects
-Arthrotec (combination of misoprostol and NSAID)
-Diclofenac gel
- COX-2 inhibitor celecoxib (Celebrex) – USE WITH CAUTION CARDIAC DISEASE RISK
- Intraarticular corticosteroid injections

138
Q

SURGICAL THERAPY for Osteoarthritis

____________ surgery
- For patients with loss of function, unmanaged pain, and decreased independence
- Common for patients with knee OA
- May provide no additional benefit over PT and medical treatment

____________
- Total knee and hip replacements

A

Arthroscopic surgery
- For patients with loss of function, unmanaged pain, and decreased independence
- Common for patients with knee OA
- May provide no additional benefit over PT and medical treatment

Arthroplasty
- Total knee and hip replacements

139
Q

-ectomy

A

Excision or removal of

140
Q
  • -lysis
A

Destruction of

141
Q
  • -ostomy
  • -otomy
A

Creation of opening into

Cutting into or incision of

142
Q
  • -plasty
A

Repair or reconstruction of

143
Q
  • -orraphy
A

suture

144
Q
  • -oscopy
A

observing [with scope]

145
Q

Perioperative Phases

  • Preoperative phase
    – ________ to surgery
  • Intraoperative phase
    – __________ phase
  • Postoperative phase
    – PACU period and beyond
A
  • Preoperative phase
    – Prior to surgery
  • Intraoperative phase
    – Operative phase
  • Postoperative phase
    – PACU period and beyond
146
Q

____________ Assessment

  • Age
  • Allergies
  • Mental status
  • Ambulatory status
  • Type of surgery
  • Review family history, medical hx, medications (including herbals and OTC), surgical history
  • Alcohol, tobacco, and recreational substances
  • Social support system
  • Cultural or religious beliefs
  • Vital signs
  • Pain history
  • Complete physical assessment
A

Preoperative

147
Q

______________ Medications [operations]

  • Anticoagulants
  • Certain herbal remedies
  • Corticosteroids
  • Insulin
  • Diuretics
  • Hypoglycemics
  • Opioids and sedatives
  • Antihypertensives
A

Problematic

148
Q

Preoperative phase – Legal NPSG

  • __________ consent
  • __________ consent
  • Blood ____________ consent
  • _____ or Advance Directive
A
  • Informed consent
  • Surgical consent
  • Blood transfusion consent
  • DNR or Advance Directive
149
Q

Preoperative screening

  • Labs
  • EKG
  • Chest x-ray
  • Pregnancy test
  • Cardiac catheterization, stress test, echocardiogram
  • Type and cross match
  • NPO status
A
  • Labs
  • EKG
  • Chest x-ray
  • Pregnancy test
  • Cardiac catheterization, stress test, echocardiogram
  • Type and cross match
  • NPO status
150
Q

Preoperative teaching

  • Surgical preps
  • Medication regimen
  • Discuss indwelling catheters
  • NPO
  • Removal of jewelry, makeup, prostheses,
    contact lenses, dentures
  • Prevention of complications
    – Splinting incision (prn)
    – Coughing and deep breathing
  • Incentive spirometer
  • Ambulation
  • Explain TEDs and SCDs
A
  • Surgical preps
  • Medication regimen
  • Discuss indwelling catheters
  • NPO
  • Removal of jewelry, makeup, prostheses,
    contact lenses, dentures
  • Prevention of complications
    – Splinting incision (prn)
    – Coughing and deep breathing
  • Incentive spirometer
  • Ambulation
  • Explain TEDs and SCDs
151
Q

PACU stands for :

A

Post Anesthesia Care Unit.

152
Q

PACU phase
– Frequent monitoring
– Lack of visitation
– Pain management
– Dietary alterations
– Postoperative nausea/vomiting
– Elimination
– Ambulation restrictions

A

– Frequent monitoring
– Lack of visitation
– Pain management
– Dietary alterations
– Postoperative nausea/vomiting
– Elimination
– Ambulation restrictions

153
Q

Preoperative teaching * Outpatient surgery

– Ride home with responsible adult
– Post-operative instructions
– Explain new medications
– Expected discharge criteria
– Device teaching
* JP drain care
*Crutch teaching
* Foley care

A

– Ride home with responsible adult
– Post-operative instructions
– Explain new medications
– Expected discharge criteria
– Device teaching
* JP drain care
*Crutch teaching
* Foley care

154
Q

Common Preoperative Medications
* Benzodiazepines
* Antibiotics
* PPIs or H2-receptor blockades
* Beta-blockers
* Opioids
* Antiemetics
* Anticholinergics

A
  • Benzodiazepines
  • Antibiotics
  • PPIs or H2-receptor blockades
  • Beta-blockers
  • Opioids
  • Antiemetics
  • Anticholinergics
155
Q

Types of anesthesia

– Regional
* Spinal
* Epidural
* Nerve blocks

– General

– MAC (Monitored Anesthesia Care)

– Local anesthetics

– Conscious sedation

A

– Regional
* Spinal
* Epidural
* Nerve blocks

– General

– MAC (Monitored Anesthesia Care)

– Local anesthetics

– Conscious sedation

156
Q
  • Surgical Team
    – Circulating nurse
    – Scrub technician
    – Surgeons
    – Anesthesiologist (or CRNA)
A

– Circulating nurse
– Scrub technician
– Surgeons
– Anesthesiologist (or CRNA)

157
Q

An epidural block involves injection of a local anesthetic into the _________ space

A

epidural

158
Q

Surgical Time-Out

  • Before anesthesia induction, ask the patient to ___________________________
  • All surgical team members stop what they are doing just before the procedure starts to verify ______________________________
A
  • Before anesthesia induction, ask the patient to confirm name, birthdate, procedure, site, and consent.
  • All surgical team members stop what they are doing just before the procedure starts to verify patient identification, procedure, and surgical site.
159
Q

Operation- Complications

  • Malignant ______________
    – Results from general anesthesia
  • Inhalation agents
  • Succinylcholine

– Manifestations
* Body temperature
* Skeletal muscles

– Treat as emergency
* ___________ (dantrolene)
* Hospital protocol
* Look for signs in PACU too!

A
  • Malignant hyperthermia
    – Results from general anesthesia
  • Inhalation agents
  • Succinylcholine

– Manifestations
* Body temperature
* Skeletal muscles

– Treat as emergency
* Dantrium (dantrolene)
* Hospital protocol
* Look for signs in PACU too!

160
Q

Operation- Complications cont.

  • Retained foreign object
  • Estimated blood loss (EBL)
  • Infection
  • Intraoperative injuries
A
  • Retained foreign object
  • Estimated blood loss (EBL)
  • Infection
  • Intraoperative injuries
161
Q

Preventing respiratory complications post-operation

Proper patient positioning
* Lateral “recovery” position
* Once conscious – _________ position

A

Proper patient positioning
* Lateral “recovery” position
* Once conscious – supine position

162
Q

Postoperative phase

Nurses always use

A

SBAR

163
Q

The nurse is preparing to discharge a patient from the ambulatory surgery center following an inguinal hernia repair. The nurse delays the release of the patient upon discovering that the patient

a. Had IV morphine 45 minutes ago
b. Has an oxygen saturation of 92%
c. Has not voided since before surgery
d. Had one episode of vomiting 30 minutes ago

A

c. Has not voided since before surgery

164
Q

While in the PACU, the patient’s blood pressure drops from an admission pressure of 126/82 to 106/78 with a pulse change of 70 to 90. The nurse administers oxygen and then

a. Notifies the anesthesia care provider.
b. Increases the rate of the IV fluids.
c. Performs neurovascular checks on the lower extremities.
d. Uses a cardiac monitor to assess the patient’s heart rhythm.

A

b. Increases the rate of the IV fluids.

165
Q

During admission of the patient to the holding area or operating room before surgery, the perioperative nurse must

a. Prepare the skin by scrubbing the surgical site with an antimicrobial agent.
b. Ensure the patient’s identity with a formal identification process.
c. Verify the patient’s understanding of the risks of surgery.
d. Preform a peroperative assessment with a patient history and physical examination.

A

b. Ensure the patient’s identity with a formal identification process.

166
Q

A 68 year-old make scheduled for a herniorrhaphy at an ambulatory surgical center expresses concern that he will not have enough care at home and asks if he can stay in the hospital after the surgery. The best response by the nurse is

a. “Your health insurance will pay for inpatient care only if complications develop during surgery.”
b. “I’m sure you will be able to manage at home after surgery. It is a simple procedure.”
c. “Who is available to help you at home after the surgery?”
d. “We will teach you everything you need to know to be able to care for yourself after surgery.”

A

c. “Who is available to help you at home after the surgery?”

167
Q

A patient becomes restless and agitated in the postanesthesia care unit (PACU) as he begins to regain consciousness. The first action the nurse should take is to

a. Turn the patient to a lateral position
b. Orient the patient and tell him that the surgery is over
c. Check the patient’s oxygen saturation with pulse oximetry
d. Administer the ordered postoperative pain medication

A

c. Check the patient’s oxygen saturation with pulse oximetry

168
Q

A patient with a recent diagnosis of prostate cancer is scheduled for a radical prostatectomy.
Before signing the consent, the patient tells the nurse, “I am not sure if this surgery is safe.”
Which response by the nurse is the most appropriate?

A. “Tell me what you know about your surgery and the risks involved.”
B. “Any surgery has risks, but we will be here to take good care of you.”
C. “You seem anxious. After you sign the consent, I can give you a sedative.”
D. “You do not need to be concerned. Your surgeon has not had any complaints.”

A

A. “Tell me what you know about your surgery and the risks involved.”

169
Q

The nurse is admitting a patient to the same-day surgery unit and the patient informs the nurse they took kava last evening to sleep. Which nursing action would be most appropriate?

A. Tell the patient that using kava to help sleep is often helpful.
B. Inform the anesthesiologist of the patient’s recent use of kava.
C. Tell the patient that the kava should continue to help him relax before surgery.
D. Inform the patient about the dangers of taking herbal medicines without consulting his health care provider.

A

B. Inform the anesthesiologist of the patient’s recent use of kava.

Kava may prolong the effects of certain anesthetics. Thus, the anesthesiologist needs to be informed of recent ingestion of this herbal supplement. Patients should not take anything
before surgery without the health care provider’s knowledge.

170
Q

The perioperative nurse is supervising the surgical technologist before the arrival of the patient in the operating room for an exploratory laparotomy. Which action, if taken by the surgical technologist, would require the nurse to intervene?

The surgical technologist always holds hands away from the body and above the elbows.

The surgical technologist scrubs the fingers and hands first followed by the forearms and elbows.

After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves.

When wearing a sterile gown and gloves, the surgical technologist organizes the equipment on the sterile field.

A

After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves.

After a surgical hand scrub is completed, the surgical technologist should put on a sterile surgical gown and two pairs of gloves to prevent the transmission of microorganisms.

Surgical hand antisepsis is completed by scrubbing fingers and hands first followed by progression to forearms and elbows. The hands always should be held away from surgical attire and higher than the elbows to prevent contamination. After performing a surgical hand scrub and applying a sterile gown and two pairs of sterile gloves, the person may manipulate and organize all sterile items for use during the procedure.

171
Q

An older adult patient is having surgery. What risk areas will the nurse need to be especially aware of for this patient during surgery?

A) Sterility
B) Paralysis
C) Urine Output
D) Skin integrity

A

D) Skin integrity

Skin of older adults has lost elasticity and is at increased risk for injury from tape, electrodes, warming or cooling blankets, and dressings.

172
Q

The circulating nurse is preparing the patient for a surgical procedure. Prior to beginning, what National Patient Safety Goal (NPSG) requirement is enacted with a surgical time-out?

a. Prevention of infection

b. Improved staff communication

c. Identify patients at risk for suicide

d. Patient, surgical procedure, and site checked

A

d. Patient, surgical procedure, and site checked

During the surgical time-out, the Universal Protocol is used to verify the patient’s identity, surgical procedure, and site to prevent mistakes in surgery. Prevention of infection is to be done at all times. Improved staff communication relates to getting important test results to the right staff on time. Identifying patient’s safety risks for suicide usually is not vital before surgery and does not occur during the time out.

173
Q

The patient had surgery at an ambulatory surgery center. Which criteria support that this patient is ready for discharge (select all that apply)?

Vital signs baseline or stable

Minimal nausea and vomiting

Wants to go to the bathroom at home

Responsible adult taking patient home

Comfortable after IV opioid 15 minutes ago

A

Vital signs baseline or stable

Minimal nausea and vomiting

Responsible adult taking patient home

174
Q

The nurse is caring for a Native American patient 2 days after a thoracotomy for tumor resection. What would be the most appropriate action if the patient does not report any pain?

a. Contact the health care provider.

b. Identify possible reasons for denial of pain.

c. Administer the prescribed pain medication.

d. Assess the renal and liver function test results

A

b. Identify possible reasons for denial of pain.

Encourage older adults to report pain, especially those who are reluctant to discuss pain or deny pain when it is likely present, such as after surgery. Older patients may be hesitant to request pain medication, believe pain is an inevitable consequence of surgery, and may not understand how to use patient-controlled machines. Some cultures discourage the expression of pain. The nurse should encourage the use of analgesics, explaining to the patient that
untreated pain has a negative effect on recovery.

175
Q

Somatic VS visceral pain

■ Somatic either ____________ (skin, mucous membranes, or _____________ tissue) or ________ (bone, muscle, tendons, or joints) a deep aching or throbbing.

■ Visceral arises from __________ or body cavities (e.g., appendicitis or pancreatitis).

A

■ Somatic either superficial (skin, mucous membranes, or subcutaneous tissue) or deep (bone, muscle, tendons, or joints) a deep aching or throbbing.

■ Visceral arises from organs or body cavities (e.g., appendicitis or pancreatitis).

176
Q

*Neuropathic pain relates to ____________________________________

*○ Numbing, burning, shooting, stabbing, sharp, or electric.
*○ Responsive to opioids but often requires other medications.

A

*Neuropathic pain relates to peripheral or central nervous system

*○ Numbing, burning, shooting, stabbing, sharp, or electric.
*○ Responsive to opioids but often requires other medications.

177
Q

________ pain - *Sudden onset pain that has an identifiable cause, is of short duration, and has limited tissue damage and emotional responses

A

Acute

178
Q

Chronic pain *Pain that lasts longer than ____________ and is constant or recurring with mild to severe intensity.

A

three months

179
Q

Non pharmacologic management of pain

A
  • Heat, cold (need physician’s order), acupuncture or massage, exercise, herbs, distraction.
180
Q

Narcotic Overdose

*Signs and symptoms
decreased arousability, decreased __________________________

■ narcan or naloxone can reverse a narcotic overdose. Use small doses rather than giving the entire dose at once if this is necessary. Bag valve masks (Ambu Bag) or oxygen can be applied if you are concerned about oxygenation. Naloxone’s half life is shorter than that of most opiates, so patient’s respiratory rate should be monitored because it can drop again as soon as 20 minutes after naloxone administration.

A

*Signs and symptoms
decreased arousability, decreased respiratory rate (normal is 12 -20)

■ narcan or naloxone can reverse a narcotic overdose. Use small doses rather than giving the entire dose at once if this is necessary. Bag valve masks (Ambu Bag) or oxygen can be applied if you are concerned about oxygenation. Naloxone’s half life is shorter than that of most opiates, so patient’s respiratory rate should be monitored because it can drop again as soon as 20 minutes after naloxone administration.

181
Q

Equianalgesia

A patient takes morphine at home, but in the hospital the physician orders dilaudid. Equianalgesia tells you how much of the new medication you need to deliver an ____________ , allowing you to make substitutions for analgesic agents.

A

equal effect

182
Q

Compartment syndrome

Condition in which swelling causes ___________________ within limited space (muscle)🡪 ___________ the nerves and blood vessels in the compartment

  • usually involves ______ but can occur in any muscle group
A

Condition in which swelling causes increased pressure within limited space (muscle)🡪 squeezing the nerves and blood vessels in the compartment

  • usually involves leg but can occur in any muscle group
183
Q

Compartment syndrome causes

  • decreased compartment size resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia; also by excessive trauma (object crushing leg)
  • increased compartment contents r/t bleeding, inflammation, edema, or IV infiltration
  • edema→ ischemia→ contracture, disability, loss of function
A
  • decreased compartment ______ resulting from restrictive dressings, splints, casts, excessive traction, or premature closure of fascia; also by excessive trauma (object crushing leg)
  • increased compartment _________ r/t bleeding, inflammation, edema, or IV infiltration
  • __________ → ischemia→ contracture, disability, loss of function
184
Q

Compartment syndrome symptoms - 6 Ps

______ distal to the injury that is not relieved by opioid analgesics

________ & Poikilothermia: loss of normal color & temp of the extremity & inability to regulate body temp

__________: tingling, numbness early sign

________________ : diminished/absent peripheral pulses; late sign

_____________ or loss of function; late sign

A

Pain distal to the injury that is not relieved by opioid analgesics

Pallor & Poikilothermia: loss of normal color & temp of the extremity & inability to regulate body temp

Paresthesia: tingling, numbness early sign

Pulselessness: diminished/absent peripheral pulses; late sign

Paralysis or loss of function; late sign

185
Q

_________________

-slowly progressive noninflammatory disorder of diarthrodial (synovial) joints
-gradual loss of articular cartilage; formation of bony outgrowths (osteophytes) at joint
margins; cartilage destruction

A

OSTEOARTHRITIS

186
Q

___________________ (think OA, OVERUSE, OVERWEIGHT, OLDER AGE)

A

OSTEOARTHRITIS

187
Q

OSTEOARTHRITIS

There are no :

A

systemic systems
or inflammation (usually)

188
Q

Elevated BUN levels in older pts = at higher risk for _______ toxicity by NSAIDs (ex: naproxen)

A

renal

189
Q

RA

  • chronic, systemic _____________ disease; inflammation of connective tissue in synovial
    joints
  • remissions and exacerbation
  • incidence increases with age, peaks at 30-50.
  • More common in __________
A
  • chronic, systemic autoimmune disease; inflammation of connective tissue in synovial
    joints
  • remissions and exacerbation
  • incidence increases with age, peaks at 30-50.
  • More common in women
190
Q

What causes RA?

A

Combo of genetics and environmental triggers

191
Q

Pro-inflammatory ____________ drive the inflammatory response in RA

A

cytokines

192
Q

RA drug therapy

_________ (disease-modifying antirheumatic drugs) prescribed early to prevent joint degeneration that occurs as soon as the first year with RA; ↓ Permanent effects of RA;
start DMARD (such as Rheumatrex) ASAP

BRMS (__________ - response modifiers): slows progression, treats moderate/severe cases if
DMARDS not working; includes tumor necrosis factor inhibitors (TNF)

Other: corticosteroid therapy, NSAIDs and salicylates
nutritional: balance; often have loss of appetite or inability to shop/prepare food due to
reduced mobility/pain
__________ therapy: relieves severe pain, improves fx, total joint replacement (arthroplasty)

A

DMARDS (disease-modifying antirheumatic drugs) prescribed early to prevent joint degeneration that occurs as soon as the first year with RA; ↓ Permanent effects of RA;
start DMARD (such as Rheumatrex) ASAP

BRMS (biologic response modifiers): slows progression, treats moderate/severe cases if
DMARDS not working; includes tumor necrosis factor inhibitors (TNF)

Other: corticosteroid therapy, NSAIDs and salicylates
nutritional: balance; often have loss of appetite or inability to shop/prepare food due to
reduced mobility/pain
surgical therapy: relieves severe pain, improves fx, total joint replacement (arthroplasty)

193
Q

OSTEOMYELITIS - severe __________ of bone, bone marrow, and surrounding soft tissue
*most common microbe: _______________

A

OSTEOMYELITIS - severe INFECTION of bone, bone marrow, and surrounding soft tissue
*most common microbe: Staph. aureus.

194
Q

OSTEOMYELITIS Causes

  • _________ entry (hematogenous): common in young children (blunt trauma), vascular insufficiency (DM) disorders, GI/respiratory infections
  • _________ entry via open wound * foreign body presence
A
  • indirect entry (hematogenous): common in young children (blunt trauma), vascular insufficiency (DM) disorders, GI/respiratory infections
  • direct entry via open wound * foreign body presence
195
Q

OSTEOMYELITIS S/SX

For acute: infection of _________ ; local manifestations
1. pain unrelieved by rest; worsens with activity; swelling, tenderness, warmth, restricted movement
2. systemic: fever, night sweats, chills, restlessness, nausea, malaise, drainage (late sign)

For chronic: infection _________ or failed to respond to initial ABX therapy
3. continuous and persistent, or exacerbations and remissions
4. local signs more common: pain swelling warmth
5. granulation tissue turns to scar tissue
6. avascular is ideal site for microorgs since ABX do not work there

A

For acute: infection of < 1 month; local manifestations
1. pain unrelieved by rest; worsens with activity; swelling, tenderness, warmth, restricted movement
2. systemic: fever, night sweats, chills, restlessness, nausea, malaise, drainage (late sign)

For chronic: infection > 1 month or failed to respond to initial ABX therapy
3. continuous and persistent, or exacerbations and remissions
4. local signs more common: pain swelling warmth
5. granulation tissue turns to scar tissue
6. avascular is ideal site for microorgs since ABX do not work there

196
Q

OSTEOMYELITIS Treatment

For acute: vigorous and prolonged _______ ; get culture or bone biopsy before initiating
* Do not delay ABX treatment!
* Course of IV antibiotic therapy 4-6 weeks minimum; may last 3-6 months
* May be completed at home or in SNF
* Various ABX available; this is why culture is important. “-illin” and “-in”
* bed rest and immobilization to reduce pain

For chronic: _________________ may be necessary and extended use of ABX

A

For acute: vigorous and prolonged IV Abx; get culture or bone biopsy before initiating
* Do not delay ABX treatment!
* Course of IV antibiotic therapy 4-6 weeks minimum; may last 3-6 months
* May be completed at home or in SNF
* Various ABX available; this is why culture is important. “-illin” and “-in”
* bed rest and immobilization to reduce pain

For chronic: surgical removal may be necessary and extended use of ABX

197
Q

Which condition is called The “silent thief” ?

A

OSTEOPOROSIS

198
Q

OSTEOPOROSIS - * Chronic progressive ___________ ______ disease that worsens over time.

A

metabolic bone

199
Q

OSTEOPOROSIS

  • T-scores: (_________ SCORE = BAD)
  • Standard deviation below average🡪 the units are compared to someone who is healthy
    *-1 to 1 = normal bone density
    *-2.5 to -1 = Osteopenia
  • T-score lower than -2.5 = Osteoporosis
  • Z-score compares with someone else with same _______ and _____________
A
  • T-scores: (NEGATIVE SCORE = BAD)
  • Standard deviation below average🡪 the units are compared to someone who is healthy
    *-1 to 1 = normal bone density
    *-2.5 to -1 = Osteopenia
  • T-score lower than -2.5 = Osteoporosis
  • Z-score compares with someone else with same age and ethnicity
200
Q

OSTEOPOROSIS Pharmacologic therapy

  • _____________ (Fosamax-alendronate): inhibits bone resorption by inhibiting osteoclasts;
    take with water and on empty stomach; remain upright for ~30 min due to S/E of GI upset &
    esophagitis
  • ___________ : For post-menopausal osteoporosis. Inhibits bone resorption; must use calcium
    supplementation.
  • selective estrogen receptor modulators: Raloxifene (Evista); mimics effect of estrogen
  • teriparatide (Forteo): form of PTH; stimulates new bone formation (osteoblasts)
  • denosumab (Prolia): MAB for postmenopausal women; subQ injection q6 months
A
  • bisphosphonates (Fosamax-alendronate): inhibits bone resorption by inhibiting osteoclasts;
    take with water and on empty stomach; remain upright for ~30 min due to S/E of GI upset &
    esophagitis
  • calcitonin: For post-menopausal osteoporosis. Inhibits bone resorption; must use calcium
    supplementation.
  • selective estrogen receptor modulators: Raloxifene (Evista); mimics effect of estrogen
  • teriparatide (Forteo): form of PTH; stimulates new bone formation (osteoblasts)
  • denosumab (Prolia): MAB for postmenopausal women; subQ injection q6 months
201
Q

Gout - ● Type of __________ characterized by elevation of __________ crystals and deposits in 1+ joints

A

Gout - ● Type of arthritis characterized by elevation of uric acid crystals and deposits in 1+ joints

202
Q

Uric acid= major end product of __________ metabolism

A

purine

203
Q

Gout - More common in _____________ (3x), __________ big factor or other metabolic conditions

A

More common in men than women (3x), obesity big factor or other metabolic conditions

204
Q

Gout attack lasts _____ days then resolves; chronic gout if multiple joints involved

A

2-10

205
Q

Gout - Drug therapy: _________ and oral colchicine, corticosteroids last resort

A

NSAIDs and oral colchicine, corticosteroids last resort

206
Q

Lyme disease

  • Infection by spirochete Borrelia burgdorferi
  • Bite from infected ______ ________
  • Not transmitted person to person
  • Circular “bullseye” rash
  • Diagnosis based on manifestations (arthritis is second most common manifestation, flu like symptoms)
  • Treat active lesions with abx PO (ie: doxycycline and amoxicillin)
  • Educate on reducing exposure to ticks and hiking locations
A
  • Infection by spirochete Borrelia burgdorferi
  • Bite from infected deer tick
  • Not transmitted person to person
  • Circular “bullseye” rash
  • Diagnosis based on manifestations (arthritis is second most common manifestation, flu like symptoms)
  • Treat active lesions with abx PO (ie: doxycycline and amoxicillin)
  • Educate on reducing exposure to ticks and hiking locations
207
Q

Surgery

Same day admission (ambulatory) patient is ______________ after surgery.

A

released home

208
Q

___________ procedures - same day (e.g., colonoscopy, endoscopy). Usually don’t
require full anesthesia and possibly local or sedative instead.

A

Diagnostic

209
Q

Types of surgeries

○ Exploratory - looking for evidence of pathology suggested by patient’s symptoms

○ __________ - alleviates symptoms or cure condition

○ ___________ - removing moles that could become cancerous, for example

○ ______________ - for example, breast implants after mastectomy

○ __________ -does not cure (terminal disease), but provides relief of symptoms

A

○ Exploratory - looking for evidence of pathology suggested by patient’s symptoms

○ Curative alleviates symptoms or cure condition

○ Preventive removing moles that could become cancerous, for example

○ Reconstructive for example, breast implants after mastectomy

○ Palliative does not cure (terminal disease), but provides relief of symptoms

210
Q

Types of surgeries

○ Cosmetic face lifts, rhinoplasties, implants, etc. done to improve appearance

○ _________ surgery that is not physiologically necessary, but patient would like for it to occur (e.g., knee replacement even though patient can still ambulate)

○ ________ - emergent appendicitis would be considered emergent; emergent might involve a trauma victim who requires surgery to stop the bleeding

A

○ Elective surgery that is not physiologically necessary, but patient would like for it to occur (e.g., knee replacement even though patient can still ambulate)

○ Urgent - emergent appendicitis would be considered emergent; emergent might involve a trauma victim who requires surgery to stop the bleeding

211
Q

Systemic Lupus Erythematosus (SLE)

-_________ inflammatory autoimmune disease.
-Affects skin, joints, serous membranes. Renal, hematologic, and neurologic systems affected. Periods of remission and exacerbation.

A

-Multi-system inflammatory autoimmune disease.
-Affects skin, joints, serous membranes. Renal, hematologic, and neurologic systems affected. Periods of remission and exacerbation.

212
Q

Systemic Lupus Erythematosus (SLE) Manifestations

  • Severity is variable. No typical progression
  • Skin: _________________ on skin (butterfly rash, photosensitivity, discoid rash)
  • Joints: __________ and morning stiffness, may cause deformities
  • Respiratory/Cardiac: Tachypnea and cough, dysrhythmias
  • Renal: problems present within 5 yrs of diagnosis
  • Neuro: Generalized onset or focal onset seizures
  • Blood: Anemia, leukopenia, thrombocytopenia, coagulation disorders
  • Increased susceptibility to infection. Pneumonia most common
A
  • Severity is variable. No typical progression
  • Skin: Vascular lesions on skin (butterfly rash, photosensitivity, discoid rash)
  • Joints: Arthritis and morning stiffness, may cause deformities
  • Respiratory/Cardiac: Tachypnea and cough, dysrhythmias
  • Renal: problems present within 5 yrs of diagnosis
  • Neuro: Generalized onset or focal onset seizures
  • Blood: Anemia, leukopenia, thrombocytopenia, coagulation disorders
  • Increased susceptibility to infection. Pneumonia most common
213
Q

Scleroderma - _________ , degenerative, and inflammatory changes in skin, blood vessels, synovium, skeletal muscle, internal organs.

A

Fibrotic

214
Q

Systemic Lupus Erythematosus (SLE) Drug Therapy

  • ________
  • Antimalarial drugs (hydroxychloroquine)
  • Min possible dosing corticosteroid for shortest time
  • Immunosuppressive drugs for fatigue and skin/joint issues
  • Topical immunomodulators for skin issues
A
  • NSAIDs
  • Antimalarial drugs (hydroxychloroquine)
  • Min possible dosing corticosteroid for shortest time
  • Immunosuppressive drugs for fatigue and skin/joint issues
  • Topical immunomodulators for skin issues
215
Q

Scleroderma - Cause unknown

  • risk factors= environmental exposure to _______, _________, silica dust
  • Body makes too much _________
A

Scleroderma - Cause unknown

  • risk factors= environmental exposure to coal, plastics, silica dust
  • Body makes too much collagen
216
Q

Scleroderma Clinical Manifestations (CREST)

__________ - painful deposits of calcium in skin of fingers, forearms, pressure points

__________ phenonmenon- intermittent vasospasm of fingertips (blanching phase, blue cyanotic phase, then erythema)

Esophageal ___________ -hard to swallow due to scarring

___________ - tightening of skin on fingers and toes

___________ - red spots on hands, face, forearms, palms, lips from capillary dilation

A

Calcinosis- painful deposits of calcium in skin of fingers, forearms, pressure points

Raynoud’s phenonmenon- intermittent vasospasm of fingertips (blanching phase, blue cyanotic phase, then erythema)

Esophageal dysfunction-hard to swallow due to scarring

Sclerodactyly- tightening of skin on fingers and toes

Telangiectasia- red spots on hands, face, forearms, palms, lips from capillary dilation

217
Q

Paget’s Disease - Chronic __________ _______ disorder where excessive bone ____________ followed by replacement of normal bone marrow with vascular, fibrous connective tissue (chaotically organized).

Common areas: pelvis, long bones, spine, ribs, sternum, skull. New bone is larger and weaker. Men more affected.

A

Paget’s Disease - Chronic skeletal bone disorder where excessive bone resorption followed by replacement of normal bone marrow with vascular, fibrous connective tissue (chaotically organized).

Common areas: pelvis, long bones, spine, ribs, sternum, skull. New bone is larger and weaker. Men more affected.

218
Q

Paget’s Disease

  • _________ cause, might be viral or genetic
  • Affects _________ adults (like osteoporosis)
A
  • Unknown cause, might be viral or genetic
  • Affects older adults (like osteoporosis)
219
Q

Paget’s Disease Clinical Manifestations:
* Early signs: fatigue and _________ gait, pathologic fracture

A

waddling

220
Q

Paget’s Disease Diagnostics: _______ or serum chem shows high alkaline phosphatase
(means high bone turnover)

A

x-ray or serum chem shows high alkaline phosphatase
(means high bone turnover)

221
Q

Paget’s Disease Drug Therapy
* _________________ to slow bone resorption. If can’t tolerate this, then calcitonin
* Calcium and vit D
* Pain mgmt. via NSAIDs

A
  • Bisphosphonates to slow bone resorption. If can’t tolerate this, then calcitonin
  • Calcium and vit D
  • Pain mgmt. via NSAIDs
222
Q

Paget’s Disease Nursing Management
* Symptomatic and supportive care
* Physical therapy to build muscle
* Nutrition
* Assistive devices to prevent falls

A
  • Symptomatic and supportive care
  • Physical therapy to build muscle
  • Nutrition
  • Assistive devices to prevent falls
223
Q

Scleroderma
gnostics: blood tests usually normal, _________ tests

A

antibody

224
Q

_______ technician can be RN or specially trained technician. Stays in the field and assists by handing surgeon sponges, needles, scalpels, etc.

A

Scrub

Nurs 120- MCA I (19 decks)

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