Concepts of Mobility and Immunity in NURS 1250/1610

Rheumatoid Arthritis (RA)

• It is an autoimmune, chronic, progressive, and systemic disease.
• Recurrent inflammation occurs in the diarthrodial joints, specifically the articulating surfaces, and it involves periods of remission and exacerbation.

Diarthrodial Joints

• These are freely movable, such as the shoulder and have a joint capsule, synovial membrane, cartilage, and ligaments.
• They are affected in rheumatoid arthritis

RA Joint Cues/Manifestations

• Boutonniere and swan neck deformities can present
• Ulnar deviation and nodules can present

Early Stage RA Cues

• Generalized weakness can present
• The joints are warm, tender, swollen, and painful.
• Mild to moderate pain presents

Late Stage RA Cues

• Joint stiffness and chronic pain can present
• Muscular atrophy can present

Lab Diagnostics for RA

• Measure C-reactive protein, rheumatoid factor, and perform a complete blood count (CBC).
• The erythrocyte sedimentation rate and anti-cyclic citrullinated peptide (anti-CCP) antibodies can be measured - a positive anti-cyclic citrullinated peptide test result can indicate RA

Imaging Diagnostics for RA

• An X-Ray and MRI can be done for diagnosis

RA Pharmacotherapy

• Medications include NSAIDs, corticosteroids like Methotrexate, and DMARDs such as Etanercept and Hydroxychloroquine.

Nursing Actions/Solutions for RA

• Promote exercise balanced with rest and use assistive devices as necessary.
• Maintain proper body alignment.
• Apply moist heat before activity and cold after activity; encourage complementary/nonpharmacologic therapies and balanced nutrition.

Surgical Management of RA

• Arthrodesis, fusion of two or more bones in a joint, can be performed
• Synovectomy: removal of the synovial lining in a joint, can be performed

Goals of Patient Care in RA

• Maintain joint mobility, reduce pain, and enable the patient to participate independently in ADLs and control the disease with interventions.

Rheumatoid Arthritis Exacerbation Cues

• Fever, loss of appetite (anorexia), fatigue, and symmetrical joint deformity indicates the condition worsening

Boutonniere Deformity

• Finger deformity involves flexion at the PIP joint.

Ulnar Deviation

• Fingers bend towards the ulnar side of the hand.

Swan Neck Deformity

• Hyperextension of the PIP joint and flexion of the DIP is present

Nodules

• Firm lumps under the skin are associated with arthritis.

DMARDs

• They are disease-modifying antirheumatic drugs used for arthritis treatment.

NSAIDs

• They are non-steroidal anti-inflammatory drugs used for pain relief.

Corticosteroids

• They are anti-inflammatory medications used in severe arthritis.

Methotrexate

• Common DMARD is used in rheumatoid arthritis treatment.

Etanercept

• It is a biologic DMARD that inhibits tumor necrosis factor.

Hydroxychloroquine

• It is an antimalarial drug used for rheumatoid arthritis management.

Arthrodesis

• Surgical fusion of two or more bones in a joint.

Synovectomy

• Surgical removal of the synovial membrane.

Osteoarthritis

• It is a degenerative joint disease causing articular cartilage erosion, affecting hands and weight-bearing joints.

Joints Affected by Osteoarthritis

• Neck, shoulders, back, hips, hands, fingers, knees, and big toes/foot.

Osteoarthritis Cues

• Pain with joint movement is the initial symptom, along with stiffness, crepitus, and decreased range of motion (ROM).

Osteoarthritis Deformities

• Heberden's and Bouchard's nodes can present.

Osteoarthritis Risk Factors

• Over the age of 55 and high BMI.
• Repetitive stress, gender (women), weight (obesity), work-related (poor posture), and genetic influences all contribute to risk

Lab Diagnostics for Osteoarthritis

• Measure C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).
• The rheumatoid factor will be negative, and synovial fluid can be tested.

Imaging Diagnostics for Osteoarthritis

• An X-Ray and MRI can be done.

Pharmacotherapy for Osteoarthritis

• Goal is reduction of pain and inflammation
• Acetaminophen, NSAIDs (including aspirin), and topical medications such as capsaicin cream or prescription diclofenac (Pennsaid) are used.
• If OTC drugs don't succeed, sodium hyaluronate injections into the joint could be an option

Nursing Interventions for Osteoarthritis

• Lifestyle adjustments and physical therapy/exercise are key, as well as improving balance and ROM.

• Build muscle, decrease fall risk, and promote rest.

• Apply heat and cold, and provide assistive devices.

Surgical Intervention for Osteoarthritis

• Arthroplasty (knee (TKA) or hip (THA)) aims to remove damage, relieve pain, and restore joint function.

Goals of Osteoarthritis Treatment

• Aim to maintain joint mobility and muscle strength and achieve satisfactory pain management, preventing complications.

Goals of Patient Care in Osteoarthritis

• Maintain joint mobility and muscle strength
• Ensure satisfactory pain management and prevent complications.

Arthroplasty Potential Complications

• Deep vein thrombosis (DVT) can result
• Hip dislocation, joint infection, and bleeding can result

Hip Precautions Post-Op

• Avoid adduction and hyperflexion.

Neurovascular Assessment Post-Op

• Assess for pain, pulselessness, pallor, paresthesia, and paralysis.

Crepitus

• Grating sound or sensation in joints during movement.

Heberden's Node

• Bony growths on the distal joints of fingers.

Bouchard's Node

• Bony growths on the proximal joints of fingers.

CRP

• C-reactive protein indicating inflammation in the body.

ESR

• Erythrocyte sedimentation rate, a blood test for inflammation.

Gout

• An inflammatory joint disorder results from deposition of uric acid crystals in joints

Gout Cause

• The cause is increased uric acid production and under excretion of uric acid by the kidneys

Gout Stage 1

• Asymptomatic hyperuricemia, involves elevated serum urate, no acute attack, and uric acid builds.

Gout Stage 2

• Acute gouty arthritis with acute/rapid onset (6–24 hours).
• Intense pain, usually monoarticular, hot, red, swollen, tender to palpation, and self-limiting; uric acid crystals form.

Gout Stage 3

• Intercritical gout represents the period between acute gout attacks.
• Another attack usually occurs within 6 months to 2 years after the 1st attack, radiographic changes may occur, and inflammation presents.

Gout Stage 4

• Chronic gout is polyarticular with no pain-free intercritical periods.
• Visible tophi can present
• Repeated attacks can damage joints.

Uric Acid Value Indicating Gout

• It is anything over 7

Uric Acid Normal Levels

• Normal range is 2-7.

Hyperuricemia (Stage 1)

• Indicates elevated uric acid levels in the blood and is known as the silent stage.

Hyperuricemia Symptoms

• It is Asymptomatic and a Silent Stage

Acute Gouty Arthritis (Stage 2)

• Sudden, severe pain due to uric acid crystal deposition causes flare ups

Symptoms of Acute Gouty Arthritis

• Warmth, swelling, redness, and pain predominantly in the big toe present
• Flare ups last 3–10 days.

Intercritical Gout (Stage 3)

• It is the asymptomatic phase between gout attacks, the symptoms disappearing for a couple of months to a couple of years.

Cues of Intercritical Gout

• It feels like it's gone while crystals may still be building.

Chronic Tophaceous Gout (Stage 4)

• Long-term gout with deposits of uric acid crystals, and permanent joint damage.

Gout Risk Factors

• Family history, excessive alcohol consumption, diet, medicines, and medical conditions.

Gout Diagnostics

• History and physical examination, serum uric acid levels, 24-hour urine, and synovial fluid aspiration.

Pharmacotherapy for Gout

• Colchicine, NSAIDs, corticosteroids, allopurinol, and probenecid.

Nursing Collaborative Actions for Gout

• Promote activity and rest balance, dietary restrictions, increased fluid intake, heat/cold therapy, joint protection, and weight loss.

Food to Eat More of When Diagnosed with Gout

• Fruits, veggies, whole grains, low-fat dairy, legumes, and nuts are healthy choices

Foods to Eat Less Of When Diagnosed with Gout

• Shellfish and alcohol should be restricted

Goals of Gout Treatment

• Treatment of acute attacks, prevention of future attacks, and prevention of complications.

Probenecid

• Inhibits reabsorption of uric acid in the proximal convoluted tubule and inhibits secretion of penicillin, it can precipitate uric acid calculi and increases excretion of uric acid.

Colchicine

• Is given with meals as an anti gout medication - If diarrhea develops, stop the drug during a gout flare up
• Blocks the immune system from triggering inflammatory response to build up of crystals

Allopurinol

• Treats gout and kidney stones, also for long term gout treatment.
• Prevents kidney stones and prevents the buildup of uric acid

Osteoporosis

• A chronic, progressive bone disease characterized by low bone mass and deterioration of bone tissue
• Bone resorption (osteoclast) exceeds bone deposition (osteoblast).
• "Silent disease" with no signs or symptoms, affecting an estimated 54 million Americans; approximately 2 million bone fractures each year.

Osteoclasts

• Bone-destroying cells breakdown bone matrix for remodeling and the release of calcium.

Osteoblasts

• Bone building cells.

Osteoporosis Pathophysiology

• Increased rate of resorption by osteoclasts and a decreased rate of bone formation by osteoblasts, resulting in a net decrease in bone density.
• After age 30, the pace of osteoclasts outpaces osteoblasts (rate of bone resorption exceeds rate of bone formation).

Osteoporosis Risk Factors

• Low Calcium & vitamin D intake
• Age: (after 30 lower testosterone and estrogen) presents the highest risk
• Lifestyle: smoking, regular alcohol use, sedentary, and immobile habits presents risk
• Caucasian or Asian female
• Inherited
• Underweight: BMI <19, thin, small frame, anorexia, and medications (corticosteroids)

Osteoporosis Signs and Symptoms (Cues)

• A loss of height of 1 inch or more height is concerning, as well as kyphosis (Dowager's hump) and low back pain
• Fractures can present

Dual-energy X-ray Absorptiometry (DEXA) Scan

• It is a quick, painless, and noninvasive test that uses low levels of X-rays to measure BMD at various sites in the body, including the hip and spine.
• The scan is the considered the gold standard for diagnosing osteoporosis and predicting fracture risk.

Osteoporosis Diagnostic Studies

• Dual-energy X-ray absorptiometry (DEXA) scan, ultrasound and X-ray, calcium, vitamin D, and alkaline phosphate.

Osteoporosis Pharmacotherapy

• Bisphosphonates like Alendronate (Fosamax), hormonal Agents, calcium & Vitamin D

Bisphosphonates

• Alendronate (Fosamax) inhibits bone reabsorption by suppressing osteoclasts and must be taken on an empty stomach every week.
• It’s considered FIRST LINE and the preferred treatment of osteoporosis as it is only taken once a week, increasing patient compliance.

Hormonal Agents

• Calcitonin produces modest increases in bone mass because it slows the rate at which osteoclasts absorb bone.

Calcium & Vit D (in osteoporosis)

• Supplementation can help osteoporosis.
• The calcium RDA is 1000 - 1200 mg
• And the Vit D RDA is 600 - 700 iu

Kyphoplasty

• Minimally invasive procedure to treat spinal compression fractures caused by osteoporosis.
• A balloon is inserted into the fractured vertebra, and the area is restored to its height, followed by injecting for stabilization

Collaborative Actions in Osteoporosis

• Assess and educate on reducing risk Factors related to smoking and lifestyle
• Implement weight-bearing exercises like swimming, and increase calcium and vit D intake.
• Educate about prevention.

Prevention of Injury in Osteoporosis

• Enable fall prevention, teach adequate calcium and vitamin D intake, implement smoking cessation, and decrease alcohol & caffeine consumption.

Ways to Prevent Osteoporosis

• Encourage weight-bearing exercises for at least 30 minutes a day and consume foods rich in calcium & vitamin D.

Kyphosis

• Abnormal curvature of the spine, also the Dowager's hump or hunchback

Fasciotomy

• A surgical procedure to relieve compartment syndrome.

Neurovascular Compromise/Compartment Syndrome

• Caused by increased pressure in muscle compartments leading to damage, creating pain, pressure, paralysis, pallor, and paresthesia

Closed Fracture

• The bone breaks but does not penetrate the skin.

Open Fracture

• The broken bone pierces through the skin, increasing the risk of infection.

Complete Fracture

• Bone completely broken into two or more parts.

Incomplete Fracture-

• The bone cracks but does not break all the way through.

Stress Fracture

• A small crack in the bone caused by repetitive force or overuse, common in athletes.

Pathological Fracture

• Occurs in a bone weakened by disease (e.g., osteoporosis, cancer).

Arthroplasty

• Knee (TKA) or hip (THA) aims to remove damage, relieve pain, and restore function of the joint

Fractures

• Same pathophysiology as osteoporosis.
• The integrity of the bone or joint has been altered
• Most common in trauma and in older adults

Direct Injury Causes Fractures

• Trauma and abuse

Pathologic Causes of Fractures

• Neoplasms, malnutrition, medication, and osteoporosis.

Fractures are Classified Based on Their Characteristics

• Bone alignment, fracture line pattern, severity and bone condition, and location

Transverse Fracture

• A straight horizontal break across the bone.

Oblique Fracture

• A diagonal break across the bone

Spiral Fracture

• The bone is twisted, causing a spiral-shaped break.

Comminuted Fracture

• The bone shatters into three or more fragments.

Greenstick Fracture

• An incomplete fracture where one side of the bone bends and the other side breaks, commonly seen in children.

Skull Fracture

• Involves the bones of the skull.

Spinal Fracture

• Occurs in the vertebrae and may affect spinal cord function.

Hip Fracture

• A break in the femur near the hip joint, common in older adults.

Long Bone Fracture

• Includes fractures of the femur, tibia, humerus, and radius/ulna.

Fractures Cues

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

Fractures Complications

• Hemorrhage and DVTs
• Neurovascular compromise/compartment syndrome

Compartment Syndrome

• Occurs with too much pressure build up inside of a muscle compartment. Causes: A compartment contains a group of muscles, blood vessels, and nerves surrounded by a tough layer of tissue called fascia, which doesn't stretch. When there's swelling (from an injury, like a fracture, or a tight cast), the fascia traps the swelling inside, causing blood flow to be cut off to the muscles and tissues, damaging the nerves and muscles if the pressure isn't relieved.

How Compartment Syndrome Looks/Feels

• Severe pain that doesn't go away, even with medication, a tight or swollen limb, and numbness or tingling.
• The limb might look pale or feel cool because blood isn't circulating properly, pain when passively extending fingers, pain, and pressure presents

Compartment Syndrome Untreated

• Potentially may cause permanent damage, loss of function, or even amputation

Collaborative Management of Compartment Syndrome

• A fasciotomy - fascia is cut to relieve pressure.
• It can be managed via rest, pain reliever, and ice/cold pack

Comlications of Compartment Syndrome

• Infection/osteomyelitis, increased temperature, and increased WBC.
• May cause fat embolism syndrome, neurologic deterioration, respiratory distress, petechiae, and tachypnea

Fat Embolism (Syndrome)

• A rare but serious condition that occurs when fat globules are released into the bloodstream, typically after fractures of long bones (like the femur).
• Fat particles can travel to the lungs, brain, and other organs, causing respiratory distress, neurological symptoms, and petechial rashes and usually occurs within 24-72 hours of the injury.

Fat Embolism Symptoms

• Hypoxemia (low oxygen levels) and dyspnea (difficulty breathing).
• Altered mental status (confusion, agitation).
• Petechial rash (small red or purple spots on the skin)

Fat Embolism Risk Factors

• Breaking a long bone (usually femur), and surgical procedures
• Occurs most frequently in young adults, and males.

Nursing Actions: Fat Embolism

• Careful immobilization of patient
• Encourage deep breathing exercises
• Administer 02 therapy and volume expander.

Fractures: Diagnostics

• History and physical exam is important
• X-ray, CT, MRI, and CBC

Fracture Additional Diagnostics if Surgery is Indicated

• Complete metabolic panel, Coags, Urinalysis (UA), and EKG

Fracture Immediate Nursing Actions

• Rest, keep limb stationary, ice, compress, and elevation.

Fracture Treatment Goals

• Reduction: anatomic bone realignment
• Fixation: immobilization of bone until healing occurs
• Prevent secondary complications

T Score indicating Osteoporosis

• -2.8 indicates the condition

Closed Reduction

• Nonsurgical, manual realignment of bone using a cast or splint, or through traction

Open Reduction

• Surgery with internal or external fixation

Cast

• A rigid device used to immobilize, support, and protect fractured bones & surrounding tissue, it is applied to a stable fracture after it has been reduced.

Splint

• Less support and is easily adjusted to accommodate swelling & prevent compartment syndrome.
• It is often used to stabilize fresh injuries before the swelling has subsided as well after the reparative phase of healing to allow some movement of the joint.

Cast Care/Nursing Actions

• Perform neurovascular assessment
• Expose a newly applied cast to air circulation.
• Never permit the wet cast to rest directly on a flat or firm surface, elevate the casted extremity.
• May use blow dryer on low, COOL setting for itching.
• Observe all edges and check for integrity of the cast/Apply ice for first 24-36 hours.

Traction

• Straightens bones & maintains alignment with pressure, slowly/ gently pulls fracture or dislocated body part, and do not change tenson without order.

Open Reduction and Internal Fixation

• During reduction the bone is correctly aligned
• Hardware is inserted into the bone to hold the bone in place and plates are attached on the outer surface

External Fixation

• Used to set bone fractures in which a cast would not allow proper alignment of the fracture.
• Metal pins and screws are placed into the bone above and below the fracture, and then attached to a metal bar outside of the skin.
• This is often performed if damage to the soft tissue prevents internal fixation.

Collaborative Actions Post-Op Fractures

• Provide physical therapy in addition to infection prevention and pain management/pharmacotherapy.

Infection Prevention Post-Op Fractures

• Sterile dressing changes, antibiotics, and pin care

Pain Management/Pharmacotherapy Fracture Post-Op

• NSAIDs, opioid analgesics, muscle relaxants, steroids, and non-pharmacologic treatments

Fracture Treatment Evaluation

• Assess and ensure pain is adequately controlled while healing occurs via bones realignment, and the remodeling of bones.
• Neurovascular status should be intact, and there should be no signs of infection with function restored.

Laminectomy

• Surgical removal of a lamina, or posterior portion, of a vertebra

Isometric Exercises

• Involves muscle contraction without shortening where there is no movement or a min. shortening of muscle fibers. *EX - contracting quadriceps/gluteal muscles.