320 Exam 4 Study Guide PDF

lOMoARcPSD|23720181 320 Exam 4 Study Guide Adult Health Nursing (Grand Canyon University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Braulia Price ([email protected]) ...

lOMoARcPSD|23720181 320 Exam 4 Study Guide Adult Health Nursing (Grand Canyon University) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Ischemic Strokes Pathophysiology Signs and Symptoms Diagnostic Tests Thrombotic stroke: Injury to a blood Most patients with ischemic stroke do *We must rule out which type of stroke vessel wall and formation of a blood not have a decreased level of has occurred, and the likely cause of the clot (Most common) — likely to occur consciousness (LOC) in the first 24 stroke* during sleep hours, unless it is due to a brainstem - Rapidly undergo a noncontrast head stroke. CT or MRI. (Distinguishes between Manifestations of ischemic stroke may ischemic and hemorrhagic stroke) progress in the first 72 hours as - Determines type, size, location infarction and cerebral edema - CT angiography (CTA) provides increase. visualization of cerebral blood Embolic stroke: When an embolus vessels. It can be done after or at lodges in and occludes a cerebral The patient with an embolic stroke the same time as the noncontrast artery, resulting in infarction and often has severe manifestations that CT scan edema of the area supplied by the occur suddenly. - If stroke is suspected from emboli, involved vessel — Likely to occur cardiac tests should be run (EKG, during activity Neurologic manifestations do not cardiac labs, ECHO) significantly differ between ischemic - PT, aPTT, CBC, Electrolyte panel and hemorrhagic stroke. with blood glucose, Lipid profile, Renal and hepatic studies See table 1.1 Risk Factors Complications RN Interventions + Patient Teaching - Hypertension #1 - Permanent brain damage - Description of the current illness with - Heart disease - Permanent motor dysfunction attention to initial symptoms, especially - Diabetes - Death symptom onset and duration, nature - Smoking and alcohol (intermittent or continuous), and changes - Illicit drug use - History of having had similar symptoms - Obesity previously - Birth control pills - Current medications - Women who have migraines with - History of risk factors and other aura illnesses, such as hypertension - Rheumatoid arthritis, sickle cell - Family history of stroke, aneurysm, or disease, and blood clotting cardiovascular diseases. disorders, such as factor V Leiden - NIHSS stroke scale mutation. - Prevent aspiration and atelectasis. - Blacks, Hispanics, Asians and - See table 1.2 Native Americans - Male Medications and Treatments Unresponsive: ABCs!!! (O2 administration, artificial airway insertion, intubation, and mechanical ventilation may be needed) - Only use BP lowering meds if BP if above 220/120 and patient has not received tPA or fibrinolytic - tPA is given IV to reestablish blood flow through a blocked artery to prevent cell death in patients with the acute onset of ischemic stroke. tPA must be given within 3 to 4½ hours of the onset of signs of ischemic stroke. (Intraarterial must be given within 6 hours of onset) - Stent can be placed guided by neuroimaging into the part of the brain where the clot was formed Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Hemorrhagic Stroke Pathophysiology Signs and Symptoms Diagnostic Tests Hemorrhagic stroke: Bleeding into the *First signs: Severe headache with *We must rule out which type of stroke brain tissue itself or into the nausea and vomiting.* has occurred, and the likely cause* subarachnoid space or ventricles. - Weakness of one side (face, arm, - Rapidly undergo a noncontrast and leg) head CT or MRI. (Distinguishes - Slurred speech between ischemic and hemorrhagic Severe hemorrhage: hemiplegia, fixed stroke) and dilated pupils, abnormal body - Determines type, size, location posturing, and coma. See table 1.1 Risk Factors Complications RN Interventions + Patient Teaching Hypertension is the most common The prognosis of patients with - Description of the current illness with cause of intracerebral hemorrhage intracerebral hemorrhage is poor. The attention to initial symptoms, especially 30-day mortality rate is 40% to 80%. symptom onset and duration, nature Uncontrolled or undiagnosed Half of the deaths occur within the first (intermittent or continuous), and changes hypertension is the primary cause of 48 hours - History of having had similar symptoms stroke. previously - Current medications - History of risk factors and other illnesses, such as hypertension - Family history of stroke, aneurysm, or cardiovascular diseases. - NIHSS stroke scale - Prevent aspiration and atelectasis. - See table 1.2 Medications and Treatments Main drugs manage hypertension! Oral and IV agents may be used to maintain BP within a normal to high-normal range (SBP less than 160 mm Hg). Surgical therapy: - Immediate evacuation of aneurysm-induced hematomas or cerebellar hematomas larger than 3 cm - SAH: Insert a ventriculostomy for CSF — Reduces ICP - Clip aneurysm - Coiling: a hydrogel-coated platinum coil is inserted into the lumen of the aneurysm via interventional neuroradiology. Gives immediate protection against hemorrhage by reducing the blood pulsations within the aneurysm. Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 TABLE 1.1 — Clinical Manifestations of both Hemorrhagic and Ischemic Stroke (CVA) Motor deficits: 1. Mobility 2. Respiratory function 3. Swallowing and speech 4. Gag reflex 5. Self-care abilities 6. Loss of skilled voluntary movement (akinesia) 7. Impaired integration of movements 8. Changes in muscle tone 9. Altered reflexes. (Initial hyporeflexia progresses to hyperreflexia for most patients). 10. Arm and leg of the affected side may be weakened or paralyzed Right brain stroke characteristics: Impulsivity, impaired judgment, impaired concept of time, spatial-perceptual deficits, short attention span, left sided hemiplegia/neglect Left brain stroke characteristics: Impaired speech, language aphasia, slow performance (cautious), aware of deficits (causing depression and anxiety), impaired comprehension related to language and math Dysphasia/aphasia: Impaired ability to communicate. Receptive (Wernicke’s) vs Expressive (Broca’s). - Receptive – loss of comprehension - Expressive – loss of production of language - Global – total inability to communicate Dysarthria: Impaired muscular control of speech. Impairment may involve pronunciation, articulation, and phonation. Homonymous Hemianopsia: Blindness occurs in the same half of the visual fields of both eyes. The patient also has difficulty with spatial orientation, such as judging distances. (Tell patient to scan room) Agnosia: The inability to recognize an object by sight, touch, or hearing. Apraxia: The inability to carry out learned sequential movements on command. Bowel and bladder elimination problems: Frequency, urgency, and incontinence. Constipation associated with immobility, weak abdominal muscles, dehydration, and decreased response to the defecation reflex. (Scheduled toileting and clothes that are easily removed encourage independence). 1.2 Assessment and Interventions for a Cerebrovascular Accident (CVA) Assessment: Interventions: - Altered LOC - ABCs - Weakness, numbness, paralysis on side of the - Call code, call stroke team if in a stroke center body - Remove dentures - Speech disturbance - Take pulse ox reading (Keeps at or above 95 sat) - Visual disturbances - Ensure IV access - Severe headache - Remove clothing - HR ↑ or ↓ - Institute seizure precaution measures - Respiratory distress - Keep patient NPO - Unequal pupils - Calculate Is & Os - Hypertension - Facial drooping to affected side Health Promotion – modifiable risk factors - Difficulty swallowing - Reduce salt and sodium intake. - Seizures - Maintain a normal body weight. - Bladder or bowel incontinence - Follow a diet low in saturated fat and high in fruits and vegetables. - Vertigo - Limit alcohol use to moderate levels. - Nausea/vomiting - Maintain an SBP less than 140 mm Hg. Delegate to UAP: - Exercise 40 minutes 3 to 4 days per week. - Obtain vital signs and report these to RN. - Avoid cigarette smoking and tobacco products. - Measure and record urine output. - Maintain a normal blood glucose level and control diabetes. - Help with proper positioning and turning patient at - Follow the prescribed treatment plan for diagnosed cardiac problems. least every 2 hr. After the client is stabilized, treatment focuses on: ↓ the level of disability and - Perform passive and active ROM exercises. attaining optimal functioning Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Headaches Pathophysiology Signs and Symptoms Diagnostic Tests Headache is the most common type of Tension: Bilateral, band-like, base of - Neurologic examination pain that people have. skull, constant squeezing and - Inspection for local infection - Tension-type headache: Cycles for tightness, stiff neck shoulder tension, - Palpation of head for tenderness, many years, 30-70 min duration tenderness. More common in women bony swellings - Auscultation for bruits over major - Migraine headache: Periodic for Migraine: Unilateral (60%), often arteries, especially neck months/years, 4-72 hours. anterior, throbbing with synchronous Unknown cause (associated with pulse, aura, improves with sleep. - CBC (may show anemia, infection) seizures, ischemic stroke, asthma, Irritability, sweating, nausea, vomiting, - Electrolytes (may show depression, anxiety, MI, Raynaud’s, photophobia, phonophobia, more dehydration, other illnesses) and IBS) common in women - Urinalysis (may show infection, other medical diagnoses [e.g., - Cluster headache: Occur over 2-12 Cluster: Unilateral, radiating in eye, diabetes]) weeks. Can have months to years severe, bone crushing, nocturnal between attacks. Lasts 5 min to 3 (awakens person from sleep), facial Other: Angiography, EMG, EEG, MRA, hours. May be caused by flushing or pallor, unilateral lacrimation, MRI, LP dysfunction of hypothalamus ptosis, rhinitis, more common in men. CT scan, MRI, or MRA: Rule out Can occur up to 8x a day. aneurysm, tumor, or infection. A lumbar puncture (LP): Rule out other disorders that may cause similar symptoms. Risk Factors Complications RN Interventions + Patient Teaching Women: Migraine and tension Cluster: Alcohol is a dietary trigger, - Ask patient to keep headache diary headaches pains usually occurs within 1 hour - Avoid trigger foods (Table 58.4) Men: Cluster headaches - Take meds Seizures - Stress management Headaches can be debilitating - Regular exercise Medications and Treatments Tension: NSAIDs, acetaminophen, aspirin, combinations (caffeine), muscle relaxers (Antidepressants (Amitriptyline) and anti-seizure medications (Topiramate) may be used). Migraine: NSAIDs, aspirin, α-Adrenergic blockers, corticosteroids, combinations. For moderate to severe headaches, triptans are the first line of therapy (Sumatriptan). Do not give triptans to those with hx of stroke, HTN or hypercholesterol. Triptans can cause tremors and decreased respiratory rate. Can take 2 doses if the first dose doesn't work, is not preventative (take during aura), should be avoided during pregnancy (birth defects). - Topiramate (antiseizure drug): taken for migraine prevention. Common side effects include hypoglycemia, paresthesia, weight loss, and cognitive changes. Must be taken for 2 to 3 months to determine its effectiveness. - Botox and β-Blockers have been effective in migraine prevention. Cluster: Serotonin receptor agonists, α-Adrenergic blockers, O2 therapy via inhalation mask (High flow 100% O2, non rebreather mask, 6 to 8 L/min for 10 minutes) - Verapamil Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Seizures Pathophysiology Signs and Symptoms Diagnostic Tests Characterized by a group of abnormal Generalized onset: History and physical exam: neurons that seem to fire without a Tonic clonic: Body stiffens (tonic phase) for 10 to - Birth and developmental history 20 seconds and the extremities jerk (clonic clear cause. Any stimulus that causes phase) for another 30 to 40 seconds. Cyanosis, - Significant illnesses and injuries the neuron’s cell membrane to excessive salivation, tongue or cheek biting, and - Family history depolarize can cause this firing. incontinence may occur during the seizure. - Febrile seizures 0-6 months: Severe birth injury, Motor: Sudden increased tone in the extensor - Comprehensive neurologic muscles, stiff movements, most often occur in congenital defects involving the CNS, sleep and affect both sides of the body. Patient assessment infection, inborn errors of metabolism will fall if standing when the seizure occurs, Seizure history: 2-20 years: Birth injury, infection, head usually lasts less than 20 seconds, and the - Precipitating factors trauma, genetics patient usually stays aware. - Antecedent events 20-30 years: Structural lesions (trauma, Non-motor (absent): Brief staring spell that - Seizure description (including resembles daydreaming, often goes unnoticed, brain tumors, or vascular disease) lasts less than 10 seconds, usually onset, duration, frequency, 50+: stroke and metastatic brain tumors unresponsive when spoken to during the postictal state) Idiopathic generalized epilepsy (IGE): seizure. More common in children Diagnostic studies: unknowns cause Focal onset: Begins in 1 hemisphere of the brain - CBC, urinalysis, electrolytes, in a specific region of the cortex, as shown by the EEG. Causes sensory, motor, cognitive, or creatinine, fasting blood glucose Itcal: Observe and record. Note onset, duration, emotional manifestations based on the function - LP for CSF analysis body parts involved and autonomic signs - CT, MRI, MRA, MRS, SPECT, PET of the involved area of the brain. Patients are Postictal: Check vitals, LOC, pupil size and position, memory, soreness and speech. Assess conscious and alert. (automatisms: strange scan (Rules out structural lesions, for sleepiness. Maintain airway behavior, lip smacking, repetitive movements) and assess cerebral blood flow) - EEG (Only useful if showing abnormalities) Risk Factors Complications RN Interventions + Patient Teaching - Age Status epilepticus (SE): A state of - Ensure patent airway. - Genetics continuous seizure activity or a condition in - Protect from injury during seizure. Do not which seizures recur in rapid succession restrain. Pad side rails. - Metabolic problems: Acidosis, - Remove or loosen tight clothing. electrolyte imbalances, without return to consciousness between - Establish IV access. seizures. SE is defined as any seizure hypoglycemia, hypoxia, alcohol and - Stay with the patient until seizure has lasting longer than 5 minutes. passed. barbiturate withdrawal, dehydration, Refractory status epilepticus (RSE): - Anticipate giving phenobarbital, phenytoin and water intoxication. Continuous seizure activity despite (Dilantin), benzodiazepines (e.g., diazepam - Extracranial disorders: Systemic administration of first- and second-line [Valium], midazolam [Versed], lorazepam lupus erythematosus, diabetes, therapy. [Ativan]) to try to stop seizures. hypertension, sepsis, and heart, Subclinical seizures: Form of SE in which a - Suction as needed. lung, liver, or kidney diseases. sedated patient seizes but there are no - Assist ventilations if the patient does not external signs because of sedative use. breathe spontaneously after seizure. - Renal failure - Anticipate need for intubation if gag reflex is - Hypoglycemia Severe injury, and even death, can result absent. - Alcohol withdrawal from trauma suffered during a seizure. - Ensure medication adherence, do not stop Patients who lose consciousness during a abruptly, wean if going off medication seizure are at greatest risk. - Give IV dextrose of hypoglycemia Medications and Treatments Treatment of SE requires a rapid-acting IV antiseizure drug. The drugs most often used are lorazepam (Ativan) and diazepam (Valium) — Side effects of anti seizure meds include diplopia, drowsiness, ataxia, and mental slowness — Assess neuro status for drug related toxicity. Carbamazine — don't take grapefruit juice. - Surgical resection of that focal area - Vagal nerve stimulation (VNS): neuromodulation, used as an adjunct to drugs when an accessible focal point cannot be identified for surgical removal. - Responsive neurostimulation: continually monitors the EEG to detect abnormalities, then responds to seizure activity by delivering electrical stimulation to a precise location - A ketogenic diet: A special high-fat, low-carbohydrate diet that helps control seizures in some people. Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Alzheimer’s Disease Pathophysiology Signs and Symptoms Diagnostic Tests Characteristic findings of AD related to No definitive diagnostic test. changes in the brain’s structure and - History and physical assessment, function include (1) amyloid plaques, including psychological evaluation (2) neurofibrillary tangles, (3) loss of - Neuropsychological testing, connections between neurons, and (4) including Mini-Cog (Clock & 3 neuron death words) , Mini-Mental State Levels of alertness do not change Examination (Orientation, registration, naming, reading) - (Table 59.9)(Table 59.10) - Brain imaging tests: CT, MRI, MRS, PET - CBC - ECG - Serum glucose, creatinine, blood urea nitrogen - Serum levels of vitamins B1, B6, B12 - Thyroid function tests (Hypo) - Liver function tests - Screening for depression Risk Factors Complications RN Interventions + Patient Teaching - Greatest risk factor is age! (most - Repetitiveness See table Table 59.4, 59.13, 59.14 are 65+) - Delusions - Hallucinations - Maintain functional ability as long - Genetics/Family history (first as possible degree relative) - Agitation - Aggression - Be maintained in a safe - Diabetes environment with a minimum of - Altered sleep patterns - Head trauma (Football players, - Wandering injuries veterans with TBI of PTSD) - Hoarding - Resisting care - Have personal care needs met - Sundowning - Have dignity maintained - Retrogenesis - Don't ask patient “why” - Extremes in temperature or excessive - Use orientation, redirection and noise may lead to behavior changes Can be unpredictable and challenging reassurance. No restraints. Exhaust Often lead to placement of patients in all options before medication use institutional care settings Medications and Treatments Cholinesterase inhibitors - to slow progression of disease in mild to moderate stages (DR.G) - donepezil (Aricept) — take before bed, mild to mod and mod to severe - rivastigmine (Exelon): oral or transdermal patch — mild to mod - Galantamine (Razadyne) NMDA receptor antagonist - to slow progression of disease in moderate to severe stages: - memantine (Namenda), treat symptoms of moderate to severe AD (Momma G) Selective serotonin reuptake inhibitors include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and citalopram (Celexa). The antidepressant trazodone (Desyrel) may help with problems related to sleep. However, this agent may result in hypotension. Although antipsychotic drugs are approved for treating psychotic conditions (e.g., schizophrenia), they have been used for the management of behavioral problems (e.g., agitation, aggressive behavior) that occurs in patients with AD. Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Myasthenia Gravis Pathophysiology Signs and Symptoms Diagnostic Tests An autoimmune disease of the Key feature: Fluctuating weakness of - History and physical examination neuromuscular junction marked by skeletal muscles, These muscles - Anti-AChR antibodies are found in fluctuating weakness of certain skeletal include: the serum of 90% muscle groups. This weakness - Eyes and eyelids - EMG increases with muscle use. - Muscles involved in chewing, swallowing, - Fatigability with prolonged upward speaking, and breathing. - Muscles are generally strongest in the gaze (2–3 min) Autoimmune process in which morning and become exhausted with - Tensilon test: drug injection to see if antibodies attack ACh receptors continued activity. symptoms get better - Anti-AChR antibodies - More than 50% of patients have ptosis - In patients with a confirmed (drooping of the eyelids) in 1 or both eyes - Thymic hyperplasia or tumor and double vision. diagnosis of MG, a chest CT scan - MG does not progress beyond the ocular or x-ray may be done to evaluate muscles in about 20% of patients. the thymus. - Horse or fading voice - Muscles of the trunk and limbs are sometimes affected. (the proximal muscles of the neck, shoulder, and hip are more often affected than the distal muscles) - No other neural problems accompany MG. No sensory loss occurs, reflexes are normal, and muscle atrophy is rare. Risk Factors Complications RN Interventions + Patient Teaching MG can occur in anyone. Myasthenic crisis is an acute worsening - Teach about a balanced diet of muscle weakness triggered by - Scheduling doses of drugs to reach An estimated 60,000 people have MG respiratory infection, surgery, emotional peak action at mealtime may make in the United States. distress, pregnancy, exposure to certain eating easier. drugs, or beginning treatment with - Help the patient plan ADLs to avoid corticosteroids. The major complications of fatigue Women= Before 40 years old MG result from muscle weakness in areas Men= After 60 years old that affect swallowing and breathing. This results in aspiration, respiratory insufficiency, and respiratory tract infection. Medications and Treatments Medications: - Anticholinesterase agents: Pyridostigmine: the most successful drug in the long-term treatment of MG. - Corticosteroids - Immunosuppressive agents Other treatments: - Surgery (thymectomy) - Plasmapheresis IV immunoglobulin G (indicated for patients in myasthenic crisis or in preparation for surgery when corticosteroids must be avoided.) Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Multiple Sclerosis Pathophysiology Signs and Symptoms Diagnostic Tests A chronic, progressive, degenerative - Slow and gradual onset No definitive diagnostic test for MS disorder of the CNS characterized by - Rapid onset - History, manifestations, and disseminated demyelination of nerve - Remission and exacerbations results of certain diagnostic fibers of the brain and spinal cord. MS tests are important can affect people of any age. Symptoms will vary: - MRI of the brain and spinal cord - Usually between 20 and 50 years of - First symptom: blurred or double vision, may show plaques, inflammation, age, with symptoms first appearing red-green color distortion, or even atrophy, and tissue breakdown and at an average of 30 to 35 years. blindness in 1 eye destruction. - MS is marked by 3 processes: - Extremity weakness and poor - CSF analysis may show an chronic inflammation, coordination increase in immunoglobulin G and demyelination, and gliosis in the - Numbness and tingling the presence of oligoclonal banding CNS. - Speech impairments, hearing loss, tremors, and dizziness. To be diagnosed with MS, the patient - Cerebellar signs include nystagmus, must have (1) evidence of at least 2 ataxia, dysarthria, and dysphagia. - Severe, even disabling fatigue. inflammatory demyelinating lesions in (worsened by heat, humidity, at least 2 different locations within the deconditioning, and medication side CNS, (2) damage or an attack effects). occurring at different times (usually 1 - Spastic bladder (urgency/frequency) month or more apart), and (3) all other - Flaccid bladder (retention) possible diagnoses ruled out. - Sexual dysfunction Risk Factors Complications RN Interventions + Patient Teaching Genetics: Having a first-degree relative Exacerbations of MS are triggered by - No cure - supportive therapy with MS increases a person’s risk for infection (especially upper respiratory - Energy conservation developing the disease. and urinary tract infection), trauma, - Maintain adequate fluid intake 2000 immunization, delivery after pregnancy, ml/day Other risks: Infection, smoking, - Provide bowel and bladder training stress, and change in climate. Each physical injury, emotional stress, - Encourage activity independence person responds differently to these - Regulate temperatures on water excessive fatigue, pregnancy, and a triggers. heaters, baths, and heating pads poor state of health. - Home safety (rugs, cords, etc.) - Drug therapy Health Promotion - Promote independence! - Daily exercise improves functioning - Speech and physical therapy - Be aware of triggers - The patient should know: Treatment plan, drug side effects, how to identify and manage side effects, and drug interactions with over-the-counter (OTC) drugs. Medications and Treatments No cure, medication treatment is aimed towards symptom relief. First line of action drugs are immunomodulators: Glatiramer acetate (Copaxone)= immunomodulator: Treat flu-like symptoms with an NSAID or acetaminophen. Corticosteroids are most helpful to treat acute exacerbations Spasticity is treated mainly with muscle relaxants Tremors that become unmanageable with drugs are sometimes treated by thalamotomy or deep brain stimulation (DBS). Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Parkinson’s Disease Pathophysiology Signs and Symptoms Diagnostic Tests Parkinson’s disease (PD) is a chronic, - Slowness in the initiation and execution - History and physical examination progressive neurodegenerative of movement (bradykinesia) - TRAP (tremor, rigidity, akinesia, disorder - Increased muscle tone (rigidity) postural instability) May have genetic and - Tremor at rest (#1 sign) (tremor is - Positive response to described as “pill rolling” because the environmental factors antiparkinsonian drugs thumb and forefinger appear to move in Lack of DA (Neurotransmitter DA is a rotary fashion as if rolling a pill, coin, - MRI essential for normal functioning of or other small object.) - Rule out medication side effects of the extrapyramidal motor system, - Gait changes (shuffling gait). phenothiazines, reserpine, including control of posture, - Stooped posture benzodiazepines, haloperidol support, and voluntary motion. - Masked face (deadpan expression) Unusual clumps of protein called - Drooling of saliva Lewy bodies are found in the brains of patients with PD. It is not known Early signs: mild tremor, a slight limp, what causes Lewy bodies to form. decreased arm swing Late signs: Shuffling gait and appear unable to stop. Arms are flexed, and postural reflexes seem to be lost. Speech problems (hypokinetic dysarthria) that can affect communication and quality of life. Risk Factors Complications RN Interventions + Patient Teaching - Men Dyskinesias [spontaneous, involuntary Nutrition therapy: 6 small meals a day, plan - Genetics movements], weakness, neurologic problems ample time for eating, cut food into (e.g., dementia), and neuropsychiatric problems bite-sized pieces. Protein ingestion and - Exposure to well water, (e.g., depression, hallucinations, psychosis. pesticides, herbicides, industrial vitamin B6 can impair the absorption of Swallowing difficulty (dysphagia), malnutrition, levodopa. Limit protein intake!! chemicals, and wood pulp mills aspiration, iIncreasing weakness may lead to pneumonia, UTIs, and skin breakdown. - Promote exercise may increase risk for PD - Promote independence and self-care Orthostatic hypotension is common. Along with - Rural residence is considered a loss of postural reflexes, it can cause falls or - Encourage environmental changes to risk factor. improve safety (Move rugs, elevated - Exposure to carbon monoxide toilet seat, slip-on shoe, velcro) and manganese - Satin nightwear or satin sheets helpful in promoting sleep - Assess psychological well-being other injury. Medications and Treatments Levodopa with carbidopa (Sinemet) is the primary treatment for symptomatic patients. - Levodopa converted into DA - Carbidopa breaks down dopa-decarboxylase so that more levodopa can reach the brain After a few years of therapy, the effectiveness of Sinemet wears off. Therefore start therapy with a DA receptor agonist, a drug that directly stimulates DA receptors (pramipexole). Start with Pramipexole then move to levodopa/carbidopa Other options: Surgical therapy, Deep brain stimulation (DBS), Ablation surgery, Physical therapy, Occupational therapy, Dietitian consult for nutritional therapy Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Delirium Pathophysiology Signs and Symptoms Diagnostic Tests Delirium is a state of confusion that - Sudden onset, disorientation, or Confusion Assessment Method (CAM) develops over days to hours. clouded sensorium - Cause is unknown - Sleep disturbances - Health history and medication record. - May be due to impairment of - Ranging manifestations: - Labs: CBC, serum electrolytes, blood cerebral oxidative metabolism in hypoactivity and lethargy to urea nitrogen, creatinine levels, liver which the brain gets less oxygen hyperactivity, agitation, and and thyroid function tests - ECG and has problems using it. hallucinations. - Urinalysis - Stress, surgery, and sleep - Early: Inability to concentrate, - Oxygen saturation level. deprivation have been linked to disorganized thinking, irritability, - Drug and alcohol levels may be delirium. insomnia, loss of appetite, obtained. - Bacterial meningitis restlessness, and confusion. - Lumbar puncture (Encephalitis or - Late: Agitation, misperception, meningitis) misinterpretation, and - CSF is examined for glucose, protein, hallucinations. and bacteria. - X-ray, CT and MRI, are used only when head injury is known or suspected. Risk Factors Complications RN Interventions + Patient Teaching - Dementia is the leading risk Delirium is the most common surgical - Protect from harm factor for delirium complication among older adults. - If it is drug induced, medications are discontinued. - Dementia, dehydration - Keep in mind that delirium can also - Electrolyte imbalances, emotional accompany drug and alcohol withdrawal. stress - Depending on patient history, drug - Lung, liver, heart, kidney, brain screening may be performed. - Fluid and electrolyte imbalances and - Infection, intensive care unit nutritional deficiencies (e.g., thiamine) are - Rx drugs corrected if appropriate. - Injury, immobility - If the problem is related to environmental - Untreated pain, unfamiliar conditions (e.g., an overstimulating or environment understimulating environment), changes should be made. - Metabolic disorders - If delirium is secondary to chronic illness such as chronic kidney disease or heart failure, treatment focuses on these conditions. - Use reorientation and behavioral interventions in patients with delirium (Calm environment, reassurance, clocks and calendars) Medications and Treatments - Dexmedetomidine (Precedex), an α-adrenergic receptor agonist, has been used in ICU settings for sedation. - Haloperidol can be administered IV, IM, or orally and will produce sedation. - In addition to sedation, other side effects with antipsychotics include hypotension; extrapyramidal side effects, including tardive dyskinesia (involuntary muscle movements of the face, trunk, and arms) and athetosis (involuntary writhing movements of the limbs); muscle tone changes; and anticholinergic effects. - Carefully monitor older patients receiving antipsychotic agents. - Short-acting benzodiazepines (e.g., lorazepam [Ativan]) can be used to treat delirium associated with sedative and alcohol withdrawal or in conjunction with antipsychotics to reduce extrapyramidal side effects. However, these drugs may worsen delirium caused by other factors and must be used cautiously. Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Dementia Pathophysiology Signs and Symptoms Diagnostic Tests A disorder characterized by a decline - Manifestations associated with - History and physical from previous level of function in 1 or neurologic degeneration usually - Discuss with family (1) problems with more cognitive domains: complex occur gradually and progress over judgment; (2) reduced interest in attention, executive function, language, time. hobbies/activities; (3) repeating questions, stories, or statements; (4) learning and memory, - VaD may appear abruptly or trouble learning how to use a tool or perceptual-motor, and social cognition. progress in a stepwise pattern appliance; (5) forgetting the correct - Caused by treatable and month or year; (6) problems handling untreatable conditions. financial affairs; (7) difficulty - Most commonly neurodegenerative remembering appointments; and (8) disease than cannot be reversed consistent problems with thinking and/or memory. - Obtain medication history - Electrolyte panel, liver function tests, serum vitamin B12 level, complete blood count, and thyroid function tests. Specialized labs: Red blood cells folate in a patient with alcoholism or ionized serum calcium in a patient with multiple myeloma, are ordered based on history. - CT to rule out other diagnoses Risk Factors Complications RN Interventions + Patient Teaching Problems ultimately disrupt individual’s: Teach patient about preventing diseases - Work that can cause VaD such as hypertension, - Social responsibilities diabetes, smoking, hypercholesterolemia, - Family responsibilities and dysrhythmias - Always introduce yourself and refer to - Ability to perform ADLs client by their name - Speak slowly - Use short, simple words and phrases - Maintain 1 or 2 arms distance between you and the client - When client is: - Delusional: acknowledge client’s feeling and reinforce reality - Verbally aggressive: acknowledge client's feelings and change topics Delegation For Dementia and Alzheimer’s: Delegate to LPN/VN: - Monitor for behavioral changes that may indicate physiologic problems. - Check the environment for potential safety hazards. - Give enteral feedings to patients who are unable to swallow, if ordered. - Give ordered medications. Oversee UAP: - Help patients to use the toilet, commode, or bedpan at frequent intervals. - Provide personal hygiene, skin care, and oral care. - Help patients with eating. - Aid patients with daily activities. - Use bed alarms and surveillance to decrease risk for falls. Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Bell’s Palsy Pathophysiology Signs and Symptoms Diagnostic Tests Bell’s palsy is an acute peripheral facial - Bell’s phenomenon, an inability to No definitive diagnostic test exists. The paresis of unknown cause. as the most close the eyelid, with an upward diagnosis and prognosis are indicated common facial nerve disorder movement of the eyeball when by clinical examination and observing - Inflammation of cranial nerve 7 closure is attempted, is a inability to the typical pattern of onset. - Recover spontaneously within 3 smile, frown, or whistle weeks to 9 months - Unilateral loss of taste is common CT and MRI can eliminate other - Decreased muscle movement may reasons for facial drooping alter chewing ability - Pain behind the ear - Sudden onset Additional manifestations: - Numbness of the face, tongue, and ear - tinnitus - headache - hearing deficit Risk Factors Complications RN Interventions + Patient Teaching - History of recent viral illness - Psychological withdrawal - changes - Provide analgesics for pain in appearance - Protect face from sensitivities to - Malnutrition heat and cold - Dehydration - Teach way to prevent aspiration - Use eye protectant or eye shield - Mucous membrane trauma - Facial massage and facial - Corneal abrasions exercises - Muscle stretching - Frequent mouth care - Facial spasms - Avoid hot foods - Contractures Medications and Treatments Oral corticosteroid therapy to reduce inflammation and swelling should be started within 72 hours of onset. Some patients should receive an antiviral agent, such as acyclovir (Zovirax), in addition to the steroid therapy. Surgical decompression of the facial nerve is controversial but is considered in refractory cases. Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: OA Pathophysiology Signs and Symptoms Diagnostic Tests Chronic degenerative joint disease - Joint pain: Worsens with activity - No definitive study - Loss of cartilage and bone in and is relieved by rest - Take history and physical more than one joint - Crepitus - Severe OA may be seen on an - Knee is common - Pain of OA may be referred to the x-ray (Mostly those who are 65+) - Not inflammatory groin, buttock, or outside of the - Arthroscopy, ESR and CRP, and thigh or knee. synovial aspiration (for analysis) - Sitting down becomes hard, as - Synovial fluid is clear/yellow with does rising from a chair when the little to no sign of inflammation hips are lower than the knees. (Rules out RA). - Advanced: trouble sleeping, referred pain (groin, butt, outer thigh) - Deformities (Buchard’s (knuckles), Herberden’s (fingers, toes, thumb)) Risk Factors Complications RN Interventions + Patient Teaching Non-modifiable: More common in - Pain Non-drug interventions: Healthy diet, women due to decreased estrogen - Fractures encourage weight loss, reduce falling, - Aging (normal part of aging) by - Limited activity smoking cessations, protecting joints age 40 affected, more that half - Deformities (functional splint or brace if needed, no of those with OA are 65+ - Instability longer than a week). Modifiable: Obesity, skeletal deformities, chronic hemarthrosis, Balance rest and activity medications (corticosteroids), repeated joint trauma Drugs are supplements non-drug - Hip OA common in men therapies - Hand and knee OA common in women Home Management: Remove rugs, (table 64.1) supportive shoes, railing in shower and bathroom. Take analgesics or warm bath before sex to decrease joint stiffness. Medications and Treatments Heat/Cold therapies: Always alternate Meditation, yoga, Tai Chi, CAMs Table 64.3 Tylenol for mild to moderate pain NSAIDs, use misoprostol as protective agent for GI upset (Don’t use topical and oral NSAIDs at the same time) - Monitor BP, use regularly, report signs of bleeding, give with food, milk or antacids - Celexoib for those who can't take aspirin Topicals: Capsaicin cream — interferes with substance P from nerve ending (Do not use with heat source) - Voltaren gel — avoid sun/UV and no aspirin or NSAIDs Corticosteroid injections: Joint pain may feel worse immediately after injections (improvement lasts weeks to month) - 4 or more injections without relife the patient needs further interventions Flexeril: for muscle spasms Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: RA Pathophysiology Signs and Symptoms Diagnostic Tests Chronic, systemic, autoimmune Onset is subtle Positive rheumatoid factor (80% of all disease - Fatigue, anorexia, weight loss and adults with RA have this factor) Inflammation of connective tissue and morning stiffness - Autoantibodies are known as synovial joints - Joints= Pain, stiffness, swelling rheumatoid factor (RF) - Swollen PIP and MCP Unknown cause: Potentially a - Spindle shaped joints Diagnosis often made on history and combination of genetics and - Swan neck, boutonniere common in physical environmental triggers hand - Ulnar drift - Synovial fluid aspiration (cloudy - Tender, painful, swollen, warm to with straw colored fluid, fibren-flex, touch joints increased WBCs) - Affects many joints in the body - Increased ANA titer - Joint stiffness is increased after - Increased ESR and CRP periods of inactivity - Extraarticular manifestations: - X-rays are not diagnostics, but rheumatoid nodules (firm, can can be taken at baseline to non-tender, masses under the skin assess progression of disease common in finger and elbows *bony (only soft tissue swelling and prominences*) possible bone demineralization - Sjogren’s syndrome: effects present in early disease) lacrimal glands, give lubricating eye drops - Photosensitivity - Felty syndrome: enlarged spleen and low WBCs - Lymphoma - Fluction contracture (can't perform ADLs ) Risk Factors Complications RN Interventions + Patient Teaching - Genetic (HLA:human leukocyte - Loss of independence - Do not elevate knees with pillows at night antigen) and environmental triggers - Depression - No prevention for RA - Work with PT/OT and social work - Smoking - Fluction contractures - UAP: passive ROM, and patients self-care - Age (30-50) Inflammation and fibrosis of the joint capsule needs - Women (x3) and supporting structures may cause deformity - Alternate rest and activity and disability. - Alternate heat and cold Muscle atrophy and tendon destruction cause 1 - Low impact exercises joint surface to slip past the other (subluxation). - No bed rest — never necessary Metatarsal head dislocation and subluxation in - May needs daytime rest and 8-9 hours of the feet may cause pain and walking disability. sleep Ulnar drift (“zig-zag deformity”), swan neck, and - Help identify ways to make activities easier boutonnière deformities are common in the (sitting down while preparing a meal) hands. - Firm mattress or bed-board - Small flat pillow Medications and Treatments - Biofeedback and transcutaneous electrical nerve stimulation - First line and early treatment: Disease modifying antirheumatic drugs (DMARDs): Methotrexate — low toxicity rate and limited side-effects - Humira: TNF inhibitor — SubQ, TB test prior to drug therapy, chest x-ray, monitor for sides of infection (no live vaccines) — teach patient how to self administer - Corticosteroids for acute flare-ups - NSAIDs and salicylates are used to treat arthritis pain and inflammation. Aspirin may be used in doses of 3 to 4 g/day in 3 to 4 doses. Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Osteoporosis/Osteopenia (p. 1493) Pathophysiology Signs and Symptoms Diagnostic Tests Bone loss occurs because there is Early symptoms: Back pain and - Bone density test decreased bone density, increasing risk spontaneous fractures - Serum calcium for fracture. - Vertebral fractures - DEXA: evaluates changes in bone - Kyphosis (dowager’s hump) density over time and assesses if treatment is working - T Score: between 1 and -2.5 indicates osteopenia, -2.5 is osteoporosis - Frax tool: Calculates risk for fractures Risk Factors Complications RN Interventions + Patient Teaching - Women (decreased estrogen and - Fractures - Calcium intake: The recommended low calcium, women get regularly calcium intake is 1000 mg/day for screened) women ages 19 to 50 years and men - Old age (65+) ages 19 to 70 years and 1200 mg/day for women aged 51 years or older and - Low body weight men 71 years or older. - Whites and asians - High calcium foods: milk, yogurt, turnip - Sedentary lifestyle greens, cottage cheese, ice cream, - Alcohol sardines, and spinach - Family history - Low impact exercise (30 mins 3x per - In men: low testosterone week) - Corticosteroid use - Weight bearing exercise to increases strength,coordination and balance - Quit smoking and alcohol - Prevent immobility, ambulate often Medications and Treatments - Calcium supplementation and vitamin D supplementation (Especially elderly or post menopausal) - Bisphosphonates (Alendronate): Inhibit osteoclasts from reabsorbing bone. Treatment should continue for 5 years (p.1495) - Take with full glass of water (helps prevent gastritis) - 30 mins before food and other medications - Remain upright for 30 minutes after taking the medication - SE: Anorexia, weight loss, gastritis. Rare: Osteonecrosis — happens in the jaw. See dentist before treatment and annually during treatment - Selective Estrogen Receptor Modulator (Raloxifene): Leg cramps, hot flashes, blood clots - Only reduces risk for vertebral fractures — not hip Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Disease: Fracture Pathophysiology Signs and Symptoms Diagnostic Tests A disruption or break in the continuity of - Immediate localized pain - History and physical examination bone. Although traumatic injuries cause - Decreased function, and inability to - X-ray most fractures, some fractures are due bear weight or use the affected - CT scan, MRI to a disease process, such as cancer part. or osteoporosis (pathologic fracture). - The patient guards and protects the Open fracture: The skin is broken and extremity against movement. bone exposed, causing soft tissue - Obvious bone deformity may be DELEGATE TO UAP: injury. present. - Position casted extremity above Closed fracture: Skin is intact heart level as directed by RN. Complete fracture: The break goes - Apply ice to cast as directed by RN. completely through the bone - Maintain body position and integrity Incomplete fracture: Fracture occurs of traction (if trained in this partly across a bone shaft, but the bone procedure). is still intact - Help patients with passive and Displaced fracture: 2 ends of the active ROM exercises. broken bone are separated from each - Notify RN about patient reports of other and out of their normal positions pain, tingling, or decreased Nondisplaced fracture: The bone sensation in the affected extremity. fragments stay in alignment. Risk Factors Complications RN Interventions + Patient Teaching - Trauma Infection ALWAYS treat life threatening injuries first - Nutritional deficiencies Venous thromboembolism Healing process: - Osteoporosis Fat embolism syndrome 1. Fracture hematoma Rhabdomyolysis 2. Granulation tissue 3. Callus formation - Colle’s, humeral, hip, femoral 4. Ossification shaft, and tibia 5. Consolidation 6. Remodeling Patient needs nutrition therapy for proper healing: Adequate protein, vitamins B, C, and D, calcium, phosphorus, and magnesium. Assess traction for tingling or numbness, assess skin integrity and blood flow Medications and Treatments Traction: (p.1452) - Skeletal traction: Maintain traction always (continuously). Used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia with pins or wires and weights (5-45lbs) - Weights must be freely hanging, not touching the ground - Cannot remove traction without an order - Assess for signs of infection at pin sites - Eat 6 small meals (for skeletal traction or body jacket brace) — Gastric decompression with NG tube for superior mesenteric artery syndrome (cast syndrome) *cast is too tight* causing nausea, vomiting and pain - Body jacket brace is for vertebral fractures of thoracic or lumbar spine - Skin traction: Assess skin integrity q2-4 hours. Used for 24-72 hours until surgery or skeletal traction is possible. - Bucks traction: Type of skin traction, most commonly used for hip or femur - Casts: immobilization often used after closed reduction - External fixation and internal fixation - carisoprodol (Soma), cyclobenzaprine, or methocarbamol (Robaxin), may be given to manage pain associated with muscle spasms. - Give tetanus and diphtheria toxoid or tetanus immunoglobulin to the patient with an open fracture who has not been previously immunized or whose immunization is expired. - Bone-penetrating antibiotics, such as a cephalosporin (e.g., cefazolin), are used prophylactically before surgery. Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Facts: Sprain: An injury to the ligaments surrounding a joint. Sprains are usually caused by a wrenching or twisting motion. Most occur in the ankle, wrist, and knee joints. Strain: Excessive stretching of a muscle and its fascial sheath, often involving the tendon. Most strains occur in the large muscle groups, including the lower back, calf, and hamstrings - Cold therapy (cryotherapy) good immediately after injury (24-48hrs) apply no longer than 20-30 minutes at a time - Compression reduces edema and pain - Elevate 24-48 hours after injury, even during sleep, this prevents further edema. - Mild analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) may be used to manage patient discomfort. - After acute phase, use heat therapy Assessment findings with soft tissue injuries: - Bruising - ↓ Movement with limited function or inability to bear weight (lower extremity) - ↓ Pulse, coolness, capillary refill >2 sec - ↓ Sensation - Edema - Muscle spasms - Pain, tenderness - Pallor - Shortening or rotation of extremity Dislocation: The complete displacement or separation of the articular surfaces of the joint. Subluxation: A partial or incomplete displacement of the joint surface. - Dislocation is considered an orthopedic emergency (the longer a joint is dislocated, the greater the risk for necrosis) - Realign the joint with closed reduction Bursitis (inflammation of the bursa): Results from repeated or excessive trauma or friction, gout, RA, or infection. - If compartment syndrome is suspected, DO NOT elevate above heart level - Tell the patient not to scratch or place anything inside a cast because this may cause skin injury and infection. For itching, direct a hair dryer on a cool setting under the cast. Compartment syndrome: - A condition in which swelling causes increased pressure within a limited space (muscle compartment). Because the fascia surrounding the muscle has limited ability to stretch, continued swelling can cause pressure that compromises the function of blood vessels Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 and nerves in the compartment. Capillary perfusion is reduced below a level needed for tissue life. - Earliest signs= Pain unrelieved by drugs and out of proportion to the level of injury and paresthesia. - DO NT ELEVATE AND DO NOT APPLY COLD COMPRESS — worsens syndrome 6 P’s of compartment syndrome: 1. Pain out of proportion to the injury that is not managed by opioid analgesics, and pain on passive stretch of muscle in the compartment 2. Increasing Pressure in the compartment 3. Paresthesia (numbness and tingling) 4. Pallor, coolness, and loss of normal color of the extremity 5. Paralysis or loss of function 6. Pulselessness (decreased or absent peripheral pulses). To prevent VTE: anticoagulants, compression stockings, intermittent pneumatic compression devices, and ROM exercises. Fat embolism syndrome (FES:) Fat globules entering the circulatory system from fractures (usually from long bone, ribs, tibia, and pelvis OR total joint replacement, spinal fusion, liposuction, crush injuries, and bone marrow transplantation.) - EARLY RECOGNITION IS CRUCIAL - First signs: Chest pain, tachypnea, cyanosis, dyspnea, apprehension, tachycardia, and hypoxemia. - Changes in mental status due to hypoxemia are common. Petechiae on the neck, anterior chest wall, axilla, buccal membrane, and conjunctiva of the eye may help distinguish FES from other problems. - In a short time, skin color can change from pallor to cyanosis. The patient may become comatose. - Treatment includes fluid administration to prevent hypovolemic shock, correction of acidosis, and blood transfusions. Dobutamine and nitrous oxide may be given for hemodynamic support. Use of corticosteroids to prevent or treat FES is controversial. - The patient needs appropriate respiratory support, and O2 supplementation. Rhabdomyolysis: The breakdown of damaged skeletal muscle cells. This breakdown causes the release of myoglobin into the bloodstream. Myoglobin precipitates and causes obstruction in renal tubules. - This results in acute tubular necrosis and acute kidney injury (AKI). - Because of possible muscle damage, assess urine output. Common signs are dark reddish-brown urine and symptoms of AKI Colles Fracture: A fracture of the distal radius. The styloid process of the ulna may be involved as well. Occurs when the patient falls on an outstretched arm and hand. It is one of the most common types of fractures in adults. - Typically managed with closed reduction unless displaced, then external fixation Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Hip Fracture: Very common in older adults - Immediate surgery is the standard of care. - Initially the affected extremity may be immobilized with Buck’s traction (Fig. 62.9) if the patient’s physical condition needs stabilization before surgery can be done. - Buck’s traction can be used for 24 to 48 hours to relieve painful muscle spasms. - Post op: Assess the patient’s extremity for (1) color, (2) temperature, (3) capillary refill, (4) distal pulses, (5) edema, (6) sensation, (7) motor function, and (8) pain. - Pain in the affected extremity can be reduced by maintaining limb alignment with pillows between the patient’s knees when turning the patient to the non-operative side. - Teach the patient to avoid these activities until the soft tissue capsule around the hip has healed enough to stabilize the prosthesis (usually at least 6 weeks): - Putting on shoes and socks - Crossing the legs or feet while seated - Assuming the side-lying position incorrectly - Standing up or sitting down while the hip is flexed more than 90 degrees relative to the chair - Sitting on low seats, especially low toilet seats. - DO NOT have the patient sit on a soft pillow. This can cause internal rotation - Taking a tub bath and driving a car are not allowed for 4 to 6 weeks - To be discharged home, the patient must show proper use of crutches or a walker over a functional distance (about 150 ft). The patient must be able to transfer to and from a chair and bed and to go up and down stairs. Amputation: Removal of a body extremity by trauma or surgery - If amputation is planned or elective, as for the patient with PVD, carefully assess the patient’s general health. - Health promotion: Control of illnesses, such as PVD, diabetes, chronic osteomyelitis, and pressure injuries, can eliminate or delay the need for amputation. Teach patients with these problems to carefully examine their lower extremities daily for signs of infection or skin breakdown. Arthroplasty: The reconstruction or replacement of a joint to relieve pain, improve or maintain ROM, and correct deformity. Arthroplasty is most often done on patients with OA, RA, avascular necrosis, congenital deformities or dislocations, and other systemic problems. - Types of arthroplasty include surgical reshaping of the bones of the joints, replacement of part of a joint (hemiarthroplasty), and total joint replacement. Around 1 million Americans have knee and hip replacement surgery annually. Arthroplasty is also available for elbows, shoulders, fingers, wrists, ankles, and feet. - After surgery, emphasis is on pain management and PT. Gout: is a type of arthritis characterized by elevation of uric acid (hyperuricemia) and the deposit of uric acid crystals in 1 or more joints. - More common in men - Inflammation of the great toe (podagra) is the most common initial problem. Other affected joints may include wrists, knees, ankles, and the midfoot. - Diagnostic: serum uric acid is usually increased above 6 mg/dL - Allopurinol, colchicine, NSAIDs, corticosteroids Downloaded by Braulia Price ([email protected])  lOMoARcPSD|23720181 Systemic lupus erythematosus (SLE): A multisystem inflammatory autoimmune disease. - Affects the skin, joints, and serous membranes (pleura, pericardium). Renal, hematologic, and neurologic systems are also affected. SLE is marked by a chronic unpredictable course with alternating periods of remission and exacerbation. - General complaints, such as fever, weight loss, joint pain, and excessive fatigue, may precede worsened disease activity. - Arthritis occurs in many patients with SLE. Pain in multiple joints (polyarthralgia) with morning stiffness is often the first complaint. - May cause deformities (e.g., swan neck deformity of the fingers, ulnar deviation, subluxation with joint laxity). - Patients have increased risk for bone loss and fracture. Downloaded by Braulia Price ([email protected])