Week 4: Pain, Musculoskeletal... Flashcards by Sasha K.

Physiologic Process of Pain

Nociception
[4 steps]:

Transduction
Transmission
Perception
Modulation

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

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

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Transduction

*Noxious
Thermal
Mechanical
Chemical

Noxious stimuli can be

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

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Transmission - Processing of pain through signal transmission to the __________

brain

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

– Spinal cord
– Dorsal horn
– Thalamus and cortex

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Modulation

_____________ pathways
Acts on _____________ of pain

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

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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Pain Classifications

Nociceptive
Neuropathic
Acute
Chronic

What differentiates each classification?

Nociceptive
Neuropathic
Acute
Chronic

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Nociceptive Pain

Somatic

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

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

– __________
* Internal organs, lining of body cavities

– 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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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

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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Dimensions of Pain

____________
– Perception of pain’s intensity, location, quality, and pattern
_________
– Emotional responses to pain
____________
– Beliefs, attitudes, memories re: pain
___________
– Observable actions to express pain
____________
– age, gender, families, etc. influences pain

Physiologic
– Perception of pain’s intensity, location, quality, and pattern
Affective
– Emotional responses to pain
Cognitive
– Beliefs, attitudes, memories re: pain
Behavioral
– Observable actions to express pain
Sociocultural
– age, gender, families, etc. influences pain

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____________ Pain

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

Neuropathic

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Pain Assessment [review]

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

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Hospital Management of pain

Patient-controlled analgesia (PCA)
Patient-controlled epidural analgesia (PCEA)
Nerve blocks (regional)

Patient-controlled analgesia (PCA)
Patient-controlled epidural analgesia (PCEA)
Nerve blocks (regional)

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Challenges to pain management

Tolerance
Dependence
Pseudoaddiction
Addiction
– Physiologic
– Psychological
Cognitive
Sociocultural
Monetary

Tolerance
Dependence
Pseudoaddiction
Addiction
– Physiologic
– Psychological
Cognitive
Sociocultural
Monetary

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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

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

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

Perception

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

Modulation

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

Nociceptive

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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.

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

Neuropathic

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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

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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Pharmacologic: Routes of Pain Management

Oral
Sublingual
Intranasal
Rectal
Transdermal
Parenteral
– IV, PCA
Intrathecal or epidural
Nerve blocks

Oral
Sublingual
Intranasal
Rectal
Transdermal
Parenteral
– IV, PCA
Intrathecal or epidural
Nerve blocks

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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

infusion pump

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

We also call these techniques regional anesthesia.

Nerve blocks

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OSTEOPOROSIS

____________ bone
Chronic, progressive metabolic bone disease characterized by
– _____ bone mass
– Structural deterioration
– Increased bone ___________

Porous bone
Chronic, progressive metabolic bone disease characterized by
– Low bone mass
– Structural deterioration
– Increased bone fragility

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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”

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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OSTEOPOROSIS: Why more common in women?

Lower _________ intake
Less ________ mass
Bone resorption begins earlier and accelerates after ____________ .
Pregnancy and _____________
Longevity .

Lower calcium intake
Less bone mass
Bone resorption begins earlier and accelerates after menopause.
Pregnancy and breastfeeding
Longevity .

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OSTEOPOROSIS Preventive factors

Regular ________ -bearing exercise
Fluoride
Calcium
Vitamin ____

Regular weight-bearing exercise
Fluoride
Calcium
Vitamin D

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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

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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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

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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In osteoporosis, bone resorption exceeds bone ____________

deposition

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Osteoblasts – __________ bone
Osteoclasts – __________ bone

Osteoblasts – deposit bone
Osteoclasts – resorb bone

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Osteoporosis SIGNS & SYMPTOMS

Occurs most commonly in spine, hips, and wrists
______ pain
Spontaneous __________
Gradual loss of _________
Dowager’s hump (_________)

Occurs most commonly in spine, hips, and wrists
Back pain
Spontaneous fractures
Gradual loss of height
Dowager’s hump (kyphosis)

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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

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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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

-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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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

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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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

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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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

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.

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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

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

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

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

Staphylococcus aureus

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OSTEOMYELITIS

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

Direct entry – via open wound

Foreign body presence

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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OSTEOMYELITIS - ETIOLOGY AND PATHOPHYSIOLOGY

_______________ grow →increase pressure in bone →ischemia and vascular compromise
Infection spreads through bone → leads to cortex revascularization and __________

Microorganisms grow →increase pressure in bone →ischemia and vascular compromise
Infection spreads through bone → leads to cortex revascularization and necrosis

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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)

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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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

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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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

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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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)

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

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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

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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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

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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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

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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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

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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OSTEOMYELITIS Ambulatory and Home Care

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

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

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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 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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Sprain VS Strain

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

joint

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

hand

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

shoulder

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

knee

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Anterior Cruciate Ligament Injury

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

knee

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

Bursae

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

Bursitis

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

fracture

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_________ 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.

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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__________ 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.

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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__________ 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

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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Classification of fractures based on location

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Complete fracture – Break completely through _______

bone

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Incomplete fracture – Break partly through bone, but still ________

intact

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Fracture Reduction:

*Closed reduction

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

*Closed reduction

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

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Open reduction is the correction of bone alignment through ________ .

surgery

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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).

pulling

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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

fixator

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Bone Healing stages

Fracture hematoma
Granulation tissue
Callus formation
Ossification
Consolidation
Remodeling

Fracture hematoma
Granulation tissue
Callus formation
Ossification
Consolidation
Remodeling

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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

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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Bone Healing Stages

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

(B) Organization of hematoma into fibrous network.

(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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Fractures: Nursing Management

Assessment- neurovascular
Medications
– Muscle relaxants
– Tetanus
– Antibiotics
– Analgesics
Nutrition
Reinfusion drain
Drains

Assessment – neurovascular
Medications
– Muscle relaxants
– Tetanus
– Antibiotics
– Analgesics
Nutrition
Reinfusion drain
Drains

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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)

(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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Assistive Devices

Cane
Walker
Crutch walking
– Two-point gait
– Four-point gait
– Swing-to gait
– Swing-through gait

Cane
Walker
Crutch walking
– Two-point gait
– Four-point gait
– Swing-to gait
– Swing-through gait

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Complications of Musculoskeletal Trauma

___________
– Surgical debridement
___________ syndrome
Venous thromboembolism
– Pulmonary embolus
Fat embolism
Integumentary

Infection
– Surgical debridement
Compartment syndrome
Venous thromboembolism
– Pulmonary embolus
Fat embolism
Integumentary

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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.

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

increased pressure

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A __________ fracture is a fracture of the distal radius.

Colles

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Types of fractures

Colles’ fracture
Humeral shaft fracture
Pelvic fracture
Hip fracture
Femoral shaft fracture
Tibial fracture
Vertebral fracture
Facial fractures
– Mandible
– Maxilla

Colles’ fracture
Humeral shaft fracture
Pelvic fracture
Hip fracture
Femoral shaft fracture
Tibial fracture
Vertebral fracture
Facial fractures
– Mandible
– Maxilla

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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?

4, 5, 6

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What are some clinical manifestations from facial fractures?

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

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Amputation

PVD
Diabetes
Atherosclerosis
Trauma
Injury
Prosthetics
– Bandage
– Elastic stocking

PVD
Diabetes
Atherosclerosis
Trauma
Injury
Prosthetics
– Bandage
– Elastic stocking

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Amputation Care

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

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

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Amputation Care

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

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

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

Movement

Synovectomy (removal of ___________________)

synovial membrane

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

bone

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

Debridement

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

Arthroplasty

___________ is the surgical fusion of a joint.

Arthrodesis

FIBROMYALGIA

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

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

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

-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 ___________

-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.

FIBROMYALGIA

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

CNS

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

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

Fibromyalgia pain pattern

pain _____________________ throughout the day

worsens and improves

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

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

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

Symptomatic;
Rest

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)

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)

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

-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

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

-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

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

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

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

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

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

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

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

-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

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

-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

TYPICAL DEFORMITIES OF RHEUMATOID ARTHRITIS

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

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

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

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 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

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

-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

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 _____________

-Bind with TNF, inhibiting inflammation

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])

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])

NUTRITIONAL THERAPY for RA

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

SURGICAL THERAPY [RA]

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

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

Subjective

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

Objective

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

-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

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

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

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

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

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

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

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

-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

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

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

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

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

OSTEOARTHRITIS

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

Pain

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.

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.

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).

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.

-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.

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

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

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

-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

OSTEOARTHRITIS

heat and cold therapy

Ice for acute ___________
Heat therapy for _____________

Ice for acute inflammation
Heat therapy for stiffness

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

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

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

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

-ectomy

Excision or removal of

-lysis

Destruction of

-ostomy
-otomy

Creation of opening into

Cutting into or incision of

-plasty

Repair or reconstruction of

-orraphy

suture

-oscopy

observing [with scope]

Perioperative Phases

Preoperative phase
– ________ to surgery
Intraoperative phase
– __________ phase
Postoperative phase
– PACU period and beyond

Preoperative phase
– Prior to surgery
Intraoperative phase
– Operative phase
Postoperative phase
– PACU period and beyond

____________ 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

Preoperative

______________ Medications [operations]

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

Problematic

Preoperative phase – Legal NPSG

__________ consent
__________ consent
Blood ____________ consent
_____ or Advance Directive

Informed consent
Surgical consent
Blood transfusion consent
DNR or Advance Directive

Preoperative screening

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

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

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

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

PACU stands for :

Post Anesthesia Care Unit.

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

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

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

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

Benzodiazepines
Antibiotics
PPIs or H2-receptor blockades
Beta-blockers
Opioids
Antiemetics
Anticholinergics

Types of anesthesia

– Regional
* Spinal
* Epidural
* Nerve blocks

– General

– MAC (Monitored Anesthesia Care)

– Local anesthetics

– Conscious sedation

– Regional
* Spinal
* Epidural
* Nerve blocks

– General

– MAC (Monitored Anesthesia Care)

– Local anesthetics

– Conscious sedation

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

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

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

epidural

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 ______________________________

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.

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!

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!

Operation- Complications cont.

Retained foreign object
Estimated blood loss (EBL)
Infection
Intraoperative injuries

Retained foreign object
Estimated blood loss (EBL)
Infection
Intraoperative injuries

Preventing respiratory complications post-operation

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

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

Postoperative phase

Nurses always use

SBAR

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

c. Has not voided since before surgery

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.

b. Increases the rate of the IV fluids.

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.

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

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.”

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

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

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

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

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.

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.

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.

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.

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

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.

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

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.

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

Vital signs baseline or stable

Minimal nausea and vomiting

Responsible adult taking patient home

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

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.

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).

■ 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).

*Neuropathic pain relates to ____________________________________

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

*Neuropathic pain relates to peripheral or central nervous system

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

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

Acute

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

three months

Non pharmacologic management of pain

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

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.

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

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.

equal effect

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

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

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

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

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

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

_________________

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

OSTEOARTHRITIS

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

OSTEOARTHRITIS

There are no :

systemic systems
or inflammation (usually)

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

renal

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

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

What causes RA?

Combo of genetics and environmental triggers

Pro-inflammatory ____________ drive the inflammatory response in RA

cytokines

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)

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)

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

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

OSTEOMYELITIS Causes

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

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

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

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

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

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

Which condition is called The “silent thief” ?

OSTEOPOROSIS

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

metabolic bone

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 _____________

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

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

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

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

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

Uric acid= major end product of __________ metabolism

purine

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

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

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

2-10

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

NSAIDs and oral colchicine, corticosteroids last resort

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

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

Surgery

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

released home

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

Diagnostic

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

○ 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

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

○ 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

Systemic Lupus Erythematosus (SLE)

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

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

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

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

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

Fibrotic

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

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

Scleroderma - Cause unknown

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

Scleroderma - Cause unknown

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

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

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

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.

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.

Paget’s Disease

_________ cause, might be viral or genetic
Affects _________ adults (like osteoporosis)

Unknown cause, might be viral or genetic
Affects older adults (like osteoporosis)

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

waddling

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

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

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

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

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

Symptomatic and supportive care
Physical therapy to build muscle
Nutrition
Assistive devices to prevent falls

Scleroderma
gnostics: blood tests usually normal, _________ tests

antibody

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

Scrub

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Week 4: Pain, Musculoskeletal... Flashcards

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