Week 5 content (2/10/25, RA, OA, Osteoporosis, Fractures, Gout etc)

Rheumatoid Arthritis

• Autoimmune disease.
• Chronic, progressive and systemic.
• Causes recurrent inflammation of diarthrotic, articulating surfaces in the joints.
• Marked by periods of remission.
• Pathophysiology: autoimmune disease that targets the synovial, causing inflammation, and over time, joint deformities and loss of function.

Recognizing Cues

• Joint manifestations include boutonniere and ulnar deviation.
• Early stage symptoms include generalized weakness, warm, tender, swollen, and painful joints.
• Late stage symptoms include joint stiffness, chronic pain and muscular atrophy.
• Exacerbation phase symptoms are fever, loss of appetite, fatigue and symmetrical joint deformity.

Diagnostics

• Lab tests include C-reactive protein, rheumatoid factor, CBC, erythrocyte sedimentation rate and anti-CCP antibodies.
• Imaging includes X-ray and MRI.

Pharmacotherapy

• NSAIDs
• Corticosteroids
• DMARDs such as methotrexate, etanercept and hydroxychloroquine.

Generate Solutions

• Promote exercise balanced with rest.
• Use assistive devises as necessary.
• Maintain proper body alignment.
• Apply moist heat before activity, cold after activity.
• Complementary/non-pharmacologic therapies.
• Balanced nutrition.

Surgical Management

• Arthrodesis is the fusion of two or more bones in a joint.
• Synovectomy is the removal of the synovial lining in a joint.

Goals of Patient Care

• Maintain the patient's joint mobility.
• Enable participation independently.
• Decrease related discomfort.
• Keep the process controlled with appropriate treatment.

Osteoarthritis

• Erosion of joint articular cartilage leads to overgrowth of bone.
• It is a chronic, painful condition with mild swelling.
• Affects hands and weight-bearing joints.

Joints Most Commonly Affected

• Neck
• Shoulders
• Hands
• Hips
• Knees
• Big toe/foot

Recognizing Cues

• Initial symptom is pain during joint movement.
• Causes stiffness
• Crepitus
• Decreased range of motion (ROM).
• Deformities associated with Heberden’s node in distal interphalangeal joints (DIP).
• Bouchard's nodes in proximal interphalangeal joints (PIP).

Analyzing Cues

• Risk factors include age of 55 and above, BMI, gender (women), genetics.
• Also related to weight/obesity
• History, physical exam, lab work such as CRP, ESR, rheumatoid factor, synovial fluid exam
• Also requires imaging with X-rays, MRI

Pharmacotherapy

• Medication manages control of related pain and inflammation.
• NSAIDs or acetaminophen
• Local injections
• Topical analgesics.

Collaborative Interventions

• Make changes to lifestyle and add physical therapy and exercise.
• Physical therapy and exercise should improve balance, increase ROM and build muscles.
• Focus on promoting rest and using heat and cold.
• Use assistive devices.

Surgical Management

• Arthroplasty (knee TKA or hip THA)
• Goal is to remove damage, relieve pain, and restore function of the joint.
• Complications are DVT (deep vein thrombosis), hip dislocation, infection, bleeding.

Post-operative Care

• VS monitoring
• Wound assessment
• Pain relief
• Infection prevention
• Promote early ambulation
• Neurovascular assessment
• Continuous passive motion

Post-operative Action

• Early mobilization using assistive devices and hip precautions.
• Wound care and drain care.
• Strict hip precautions apply.

Hip Precautions

• Do not bend hip above 90 degrees.
• Do not cross you legs when sitting.
• Do not bend body forward to pick up objects.
• Do not rotate leg when standing.

Post-operative Action

• Use abduction pillow to prevent legs moving inward
• Keep the knee in alignment with the hip.

Gout

• Inflammatory joint disorder resulting from deposition of uric acid crystals in joints.
• Caused by increased uric acid production and under-excretion of uric acid by the kidneys.
• Four stages: hyperuricemia, acute gout arthritis, intercritical gout, chronic tophaceous gout.
• Leads to uric acid build up, uric acid crystals form, inflammation and repeated attacks can damage joints

Analyzing Cues

• Assessment includes family history, excessive alcohol consumption, diet and medicines
• Assessment also includes looking at any other medical conditions.
• Serum uric acid levels must be checked by a physician.

Pharmacotherapy

• Colchicine
• NSAIDs
• Corticosteroids
• Allopurinol
• Probenecid

Collaborative Interventions

• Lifestyle: activity & rest, weight-loss, join protection, dietary restrictions, increase fluid intake.
• Heat/Cold Therapy
• Diet is low-purine, emphasizing limited shellfish and organ meats.

Treatment Goals

• Treat acute attacks.
• Prevent future attacks.
• Prevent complications

Osteoporosis Overview

• Chronic, progressive bone disease.
• Characterized by low bone mass, deterioration of bone tissue, bone resorption exceeding bone deposition, no early signs.
• Estimated to affect 54 million Americans with two million bone fractures annually.

Pathophysiology

• Bone remodeling is a continuous process where old bone (resorption) is removed by osteoclasts.
• New bone formation is completed by osteoblasts.
• After age 30, the bone density pace of osteoclasts outpaces osteoblasts.

Risk Factors

• Calcium and vitamin D deficiency, age, lifestyle, being Caucasian or Asian.
• Underweight or on medications that affect bone density.

Recognizing Cues

• Symptoms and Signs
• Loss of height
• Kyphosis (Dowager's hump)
• Low back pain
• Fragility-related fractures

Diagnostic Tests

• Dual-energy X-ray absorptiometry (DEXA scan) is the gold standard for diagnosing.
• Ultrasound, X-ray for fracture identification.
• Calcium, Vitamin D
• Alkaline phosphate

Pharmacotherapy

• Bisphosphonates like Fosamax
• Hormone replacement like calcitonin
• Calcium and vitamin D supplements

Surgical Intervention

• Vertebroplasty where bone cement is injected into fractured vertebra.
• Kyphoplasty using balloons to partially restore vertebral height and reinforce with cement.

Collaborative Care

• Assessing patient risk for risk factors and provide patient education.
• Teach safety to prevent injury and smoking cessation.
• Emphasis is encouraging weight-bearing exercises and adequate vitamin D.

Fractures

• Same pathophysiology as osteoporosis.
• Integrity has been altered.
• Most common in trauma, older adults.
• Direct injury, direct abuse.

Fracture Classifications

• Bone alignment
• Fracture line pattern
• Severity bone condition
• Location.

Types of Fractures Based on Bone Alignment

• Closed (Simple): Bone breaks but does not penetrate the skin.
• Open (Compound): Broken bone pierces through the skin, increasing the risk of infection.

Types of Fractures Based on Bone Line Pattern

• Transverse Fracture: Straight horizontal break across the bone.
• Oblique Fracture: Diagonal break across the bone.
• Spiral Fracture: Bone is twisted, causing a spiral-shaped break.
• Comminuted Fracture: Bone shatters into three or more fragments.
• Greenstick Fracture: Incomplete fracture where one side of the bone bends and the other breaks.

Types of Fractures Based on Severity and Bone Condition

• Complete Fracture: Bone is completely broken into two or more parts.
• Incomplete Fracture: Bone cracks but does not break all the way through.
• Stress Fracture: Repetitive force.
• Pathological Fracture: Bone is weakened by disease.

Examples of Fractures Bassed on Location

• Skull Fracture: Affect the bones of the skull.
• Spinal Fracture: Occurs in the vertebrae and can affect spinal cord function.
• Hip Fracture: Break in the femur near the hip joint, more common in older adults.
• Long Bone Fracture: Affects femur, tibia, humerus and the radius/ulna.

Recognizing Cues

• Pain, edema, deformity, muscle spasm, bruising, decline in ROM and crepitus.

Analyzing Cues: Complications

• Hemorrhage with hematoma formation and decreased H&H.
• Pain, paralysis, pallor, paresthesia. Compartment syndrome.
• Edema, warmth, pain, and cramping.
• Fat embolism syndrome can present as neurologic deterioration, respiratory distress, petechiae and tachypnea. Infection/Osteomyelitis can cause increased temperature, WBC.

Compartment Syndrome

• Increased pressure inside a muscle compartment with swelling and lack of stretch, resulting in reduced flow and nerve damage.
• Recognizing cues are pain, pressure paralysis, pallor and parethesia.
• Treatment requires fasciotomy to cut muscle and release the pressure. Without intervention amputation may be necessary.

Collaborative Management with Fat Embolism

• Careful immobilization of patient.
• Encourage deep breathing exercises.
• Administer O₂ therapy.
• Administer Volume expander

Fracture Diagnostics

• History and physical exam.
• X-ray, CT, MRI.
• CBC
• If surgery is indicated: Complete test of metabolic panel, coagulation, urinanalysis, EKG.

Fracture Management

• Immediate nursing care includes RICE:
• Rest: Keep limb stationary
• Ice: Reduces pain of inflammation (Intermittent application) for 24-48 hours.
• Compression: Reduces swelling immobilization
• Elevation: Reduces swelling

Treatments to Restore Function

• Reduction to correct bone alignment and restore anatomy.
• Immobilization to stabilize the bone until healing.
• Interventions to prevent secondary complications

Types of Fractures Treatments

• Closed reduction (non-surgical manual realignment of bone).
• Cast or splint.
• Traction.
• Open reduction = surgery, with internal fixation.

Cast or Splint

• Rigid immobilization, supports protect and is applied to a stable fracture after bone reduction.
• Splints can prevent compartment syndrome with less support or more adjustability for swelling.
• Splints stabilize initial injury before the swelling subsides.
• Splints allow healing with some movement.

Cast Care

• Perform neurovascular assessment.
• Expose.a newly applied cast to air circulation.
• Never allow the wet cast to rest directly on a flat or firm surface.
• Elevate the casted area with blow dryer and provide ice as necessary.

Traction

• Helps Straighten bones & maintains alignment with pressure.
• Slowly gently pulls the affected part and do not adjust tenson without an order.

Open Reduction and Internal Fixation

• Hardware is inserted into bone, with plates attached on the surface for alignment and support.

###External Fixation

• External fixation uses metal pins and screw that sets in bone to a bar.

Collaborative Treatment

• Physical therapy to encourage movement.
• Infection preventions to facilitate healing.
• Pain management with NSAIDS, opiods, muscle relaxants

Treatment Evaluation

• Adequate pain management, bone healing, normal neurovascular status, and restores function with no signs of infection.

This quiz covers rheumatoid arthritis and osteoarthritis, including autoimmune targets, symptoms during exacerbation, relevant lab findings, medication (methotrexate) considerations, nonpharmacological interventions, and surgical options like joint fusion. It also addresses osteoarthritis symptoms like reduced range of motion.