Case study Osteoarthritis

The nurse escorts Susan to an examination room and obtains the following information. Height 62" (157.48 cm) Weight 120 lbs (54.4 kg) (BMI 21.9) HR 84 BP 130/72 RR 16 T 98.8°F (37.1°C) Reports right knee pain 7 on scale of 1 to 10 Uses heat and cold applications to help relieve knee pain and stiffness. Which statement about the use of heat and cold for osteoarthritis pain by the client is of most concern to the nurse? "I place an empty pillowcase between my skin and the cold pack." "I use moist heat packs on my knee for about 15 minutes before I have to walk for a long distance." "I leave the cold packs on for about 10 minutes at a time when I have very deep pain in my knee." "I wrap the heating pad around my knee and use an extension cord so I can walk around the house."

"I wrap the heating pad around my knee and use an extension cord so I can walk around the house." The use of an extension cord creates a tripping hazard for the client. This statement should be addressed by the nurse.

Although she is groggy, Susan opens her eyes to the nurse's voice and is able to state her own name. Later that evening, Susan is able to sit on the side of the bed and perform range of motion exercises. Her pain is controlled with IV morphine. The next morning, another nurse is assigned to care for Susan for the 7 am to 7 pm shift. The nurse prepares to administer enoxaparin (Lovenox) to Susan. Susan's daughter, who remained at Susan's bedside throughout the night, asks the purpose of this medication. Which response is correct? "It dissolves any blood clots that may have occurred during the night." "It is an anti-platelet drug that keeps platelets from sticking together to prevent thrombosis." "It is a type of anticoagulant that is given to prevent venous blood clots." "It is a salicylate drug and will help with Susan's osteoarthritic pain."

"It is a type of anticoagulant that is given to prevent venous blood clots." Enoxaparin (Lovenox) is a low molecular weight heparin that works to prevent blood clots from forming by blocking the action of clotting factors X and II.

After the surgical procedure for the pulmonary embolism, Susan undergoes the same EKOS procedure for her right DVT. When the blood clots are cleared, she is started on enoxaparin (Lovenox) 1 mg/kg and warfarin (Coumadin) therapy. Susan asks the nurse why she is receiving two medications to prevent clots. How should the ICU nurse answer Susan's question? "Because you had two places with blood clots, you need two medications." "You will receive enoxaparin (Lovenox) injections and warfarin (Coumadin) pills until the target anticoagulation numbers are reached." "You will need both medications for 1 year. After 12 months, you will only take the pills." "While you are in the hospital, we will give you the injections. After you are home, you will only take the oral medication."

"You will receive enoxaparin (Lovenox) injections and warfarin (Coumadin) pills until the target anticoagulation numbers are reached." Enoxaparin (Lovenox) is provided at the same time a client is starting warfarin (Coumadin) therapy until the desired INR is reached. Once the INR is 2-3, the enoxaparin (Lovenox) may be stopped and the client will follow-up with the monthly coagulation labs with adjustments to warfarin (Coumadin) doses controlling anticoagulation.

The blood bank calls with the news that Ms. Weil's third unit of blood (PRBCs) is ready. Which task(s) are required before transfusing this unit of PRBCs? Hang unit of blood and have have the charge nurse verify the orders. Confirm the right client, the right blood type, and the right unit of blood with another RN. Have the nurse assistant take the client's vital signs, including temperature, prior to hanging the blood and after the transfusion is complete. Ensure that the consent is signed and current. Gather supplies, including new blood tubing, new normal saline to hang with the blood, and a pump if it is required by hospital policy.

-Confirm the right client, the right blood type, and the right unit of blood with another RN -Ensure that the consent is signed and current -Gather supplies, including new blood tubing, new normal saline to hang with the blood, and a pump if it is required by hospital policy

Expel the bubble from the syringe prior to injecting it into the client. Place a 1½ inch needle on the end of the syringe. Ensure that the bubble is nearest to the plunger end of the syringe. Inject the syringe into the subcutaneous tissue and aspirate prior to drug administration. Administer in the posteriolateral or anteriolateral abdomen.

-Ensure that the bubble is nearest to the plunger end of the syringe -Administer in the posteriolateral or anteriolateral abdomen

In order for Surgical Care Improvement Project (SCIP) guidelines to be met, Mrs. Weil should be given antibiotics postoperatively, with the last dose administered before the surgery end time the following day. (For example, if the surgery is completed Tuesday at noon, the client will receive antibiotics as scheduled, but not after noon on Wednesday.) The anesthesia report documents cefazolin (Ancef) 2 g given at 1900 and 0100 during the procedure. The surgery end time is 0230 on Wednesday. If the current order is cefazolin (Ancef) 2 grams every 6 hours for 24 hours, when will the last dose be given? 0230 on Thursday. 1900 on Wednesday. 0100 on Thursday. 0700 on Thursday.

0100 on Thursday. The last dose was 0100 on Wednesday . Cefazolin (Ancef) will be given q 6 hours for 24 hours (4 doses), which would be Wednesday at 0700, 1300, and 1900 and Thursday 0100, finishing before the 0230 surgical end time.

After four weeks in rehabilitation, Susan prepares to return home. She continues to take warfarin (Coumadin), but the naproxen (Aleve) for her osteoarthritis was discontinued because of possible drug-to-drug interaction with warfarin (Coumadin). She is prescribed acetaminophen 500 mg capsule every 6 hrs prn not to exceed 2000 mg in 24 hours.

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Susan visits her primary healthcare provider (HCP). The nurse reviews Susan's electronic health record and notes her history of hypertension, osteoporosis, and osteoarthritis and her current medication regimen. The nurse understands that which information is correct about osteoarthritis? An autoimmune disorder that typically affects the small joints in the hands and feet. Involves reduced bone mineral density that weakens the bone and increases the risk for fractures. A primary benign bone tumor characterized by overgrowth of both cartilage and bone near the end of the bone plate. A noninflammatory condition involving formation of new joint tissue in response to cartilage destruction.

A noninflammatory condition involving formation of new joint tissue in response to cartilage destruction. Osteoarthritis results from cartilage damage that initiates a metabolic response of the chondroyctes. It is a slowly progressive disorder of the diathrodial (synovial) joints.

As the nurse assistant obtains vital signs, the nurse reviews the post-operative prescriptions. Vital signs are P 90, BP 140/82, R 16, T 96.0°F (35.5°C), and 02 Sat 90%. Which post-operative prescription should the nurse implement first? Decrease IV to 75 mL/hour. Initiate clear liquid diet. Apply oxygen 2 L via nasal cannula. Use a Doppler to check left pedal pulse.

Apply oxygen 2 L via nasal cannula

Susan remains groggy from the morphine administered earlier, and she is unable to sign an informed consent. The surgeon explains the need for emergency surgery and its associated risks and complications to Susan's daughter, who agrees to sign the consent. Which ethical principle supports the decision to proceed with the emergency surgery when the client cannot give informed consent? Autonomy. Fidelity. Justice. Beneficence.

Beneficence. Beneficence refers to the act of taking positive action to help others. It includes client advocacy. In this case, the client needs a life-saving procedure and the healthcare team is acting on the client's behalf.

Which symptom should Mrs. Weil report immediately while taking a non-steroidal anti-inflammatory drug (NSAID)? Which symptom should Mrs. Weil report immediately while taking a non-steroidal anti-inflammatory drug (NSAID)? Black, tarry stools. Swelling in the extremities. Nausea. Constipation.

Black, tarry stools. NSAIDS can cause bleeding tendencies in addition to ulcer formation.

While the nurse is awaiting the return call from the physician, Susan complains of sudden shortness of breath and chest pain. What is the priority action? Call a code. Page the physician stat. Call for a Rapid Response Team. Call for a stat EKG.

Call for a Rapid Response Team. The client has symptoms of DVT; therefore, it is appropriate to activate the Rapid Response Team.

The nurse quickly completes the preoperative checklist and prepares Susan Weil for emergency surgery. Susan is transported to the operating room. Immediately prior to the procedure, the OR team performs a time out. Which are common components verified during an operating room time out? Select all that apply Client identity. Procedure to be done. Name of emergency contact. Surgical site. Allergies.

Client identity -Procedure to be done -Surgical site -Allergies

Morphine sulfate 4 mg IV push is administered to Susan for reported pain of 10 on a scale of 1-10. The nurse reviews the prescriptions and places Susan on bedrest and NPO status. Neurovascular checks every 30 minutes has been added to Susan's plan of care. Select all that apply The affected extremity should be assessed for which of the following when neurovascular checks are performed? Color. Temperature. Full range of motion. Sensation. Gait.

Color. A white or bluish color may indicate impaired circulation. Temperature. A cold temperature may indicate impaired circulation. Sensation. Pressure on the nerve from edema or compartment syndrome can cause changes in sensation.

After surgery, Susan is admitted to the surgical unit with a diagnosis of status post fasciotomy and repair of the right femoral neck with internal fixation. Susan Weil arrives from the OR with an IV of normal saline (NS) in her right forearm flowing at 100 mL per hour on blood transfusion tubing. She had an estimated blood loss of 750 mL during surgery, and she received two units of packed red blood cells (PRBCs) in the OR. She was given cefazolin (Ancef) 2 g at the start of the procedure and again 6 hours later. She has an indwelling urinary catheter, which has 500 mL of urine in the bag. A surgical dressing to her left hip is dry, clean, and intact. Upon arrival to the surgical unit, Susan is moaning with her eyes closed. Which action should the nurse take first? Determine the respiratory rate. Administer the prescribed analgesic. Record urinary output. Inform the client where the call bell is located.

Determine the respiratory rate. The effects of anesthesia are often potentiated in the elderly and can cause respiratory suppression.

Susan is scheduled for emergency surgery to relieve the compartment syndrome and repair the right hip fracture. What is the priority action in preparation for Susan's surgery? Insert an indwelling urinary catheter. Draw blood for type and cross match. Encourage the use of the incentive spirometer. Obtain a urine specimen.

Draw blood for type and cross match. The client is scheduled for surgery, and the type and cross match must be obtained prior to the surgical procedure.

The nurse performs neurovascular checks and notes pallor and absent pedal pulses to the right foot. These findings are reported to the emergency department physician immediately. The physician suspects that Susan may have compartment syndrome and notifies the orthopedic surgeon The nurse understands that which is a correct description of compartment syndrome? The formation of a blood clot deep within a vein on the affected extremity. A blockage of the main artery of the lung. Full thickness tissue loss with exposed muscle, tendon, or bone. Elevated pressure within a confined myofascial section compromises neurovascular function.

Elevated pressure within a confined myofascial section compromises neurovascular function. Tissue viability is compromised when compartment syndrome occurs. It can cause necrosis of the affected extremity and lead to death. It is a life-threatening condition.

The nurse understands that as the number of high-risk criteria increases, the client's risk for falls increases. The HCP completes a history and physical examination of Susan and prescribes hydrocodone (Hycodan), an oral prn narcotic, for Susan's knee pain, which also increases the risk for falls. Tuesday afternoon, Susan is going to dinner with friends and she falls off of a lower step to her apartment. She experiences severe hip pain. Susan's daughter calls 911 and Susan is taken to the hospital via ambulance. Susan tells the admitting nurse that she was in a hurry and lost her balance. "It is so painful," she states. X-ray confirms right subcapital hip fracture, and Susan is waiting for a bed on the medical-surgical unit and a scheduled hemiarthroplasty. Which clinical manifestation(s) of the affected extremity should the nurse practicing in the emergency department expect? Select all that apply ? External rotation. Shortening. Internal rotation. Muscle spasms. Hyper flexion.

External rotation. External rotation is rotation away from the center of the body and is a clinical manifestation of hip fracture. Shortening. Shortening of the affected extremity is a clinical manifestation of hip fracture. Muscle spasms. Muscle spasms caused by inflammation are a common clinical manifestation of hip fracture.

Susan is transferred to the ICU where she is treated with a heparin drip. She becomes very short of breath with activity, and she is kept on bedrest. She is eventually taken to surgery for placement of an Ekosonic endovascular system for catheter-directed thrombolysis (EKOS) of her left pulmonary embolism. The catheter is kept in place for 8 hours before removal by the acute care nurse practitioner (ACNP). After the catheter is removed, Susan calls the nurse with a complaint of feeling dizzy. The nurse finds that the client's vital signs are BP 82/56 and HR 62 bpm. When the nurse inspects the catheter site, the nurse observes a large area of blood on the sheets, and active bleeding coming from under the groin-site dressing.

Holding pressure over the site and calling for help. Applying continuous direct pressure to the site is the most immediate action to stop the bleeding.

Susan is transferred back to the surgical floor. The next morning, the nurse reviews Susan's morning laboratory data and her medication list. Which lab result requires immediate action by the nurse? Hemoglobin 10.9 gm/dL. Potassium 3.9 mEq/L. Calcium 9 mg. International normalized ratio (INR) 5.

International normalized ratio (INR) 5. Clients prescribed warfarin (Coumadin) require frequent monitoring of their blood levels. If the INR is outside the target range for anticoagulant therapy (usually 2.0 to 3.0 or 1.5 to 2.0 for Asian clients), then a high INR is indicative of bleeding while a low INR suggests the risk of a blood clot. People of Asian heritage have variation of the CYP2C19 gene that reduces the metabolism of warfarin (Coumadin), leading to an increased bleeding risk. They are more sensitive to anticoagulant therapy.

The nurse expects to see which manifestations of osteoarthritis in Mrs. Weil?

Joint pain. Pain typically worsens with joint use and may be relieved with rest in the early stages. In advanced osteoarthritis, pain may worsen, causing sleep disturbances and interfering with activities of daily living. Swollen nodes of the joints. Heberden's nodes, bony bumps on finger joints closest to the fingernails, or Bouchard's nodes, bony bumps on the middle joint of the finger, can form on the joints and cause visible disfigurement and tenderness. Asymmetrical involvement of the joints. Osteoarthritis typically affects joints asymmetrically and most commonly involves the joints of the fingers, thumb, hips, knees, feet, and cervical and lower lumbar vertebrae.

Which data places the client at highest risk for falls? Which data places the client at highest risk for falls? BMI of 21.9. Knee pain. Lives alone. Takes naproxen.

Knee pain. Musculoskeletal pain and decreased function associated with osteoarthritis heightens the risk for falls.

Susan continues with physical therapy treatments, and she is walking with the assistance of a rolling walker while supervised by a member of the healthcare team. Within 2 days, Susan's INR reaches a therapeutic level, and she experiences no further complications. Susan is transferred to a rehabilitation center for continuation of care. Susan works diligently to regain her strength during the rehabilitation process and she is anxious to get back home. Susan's daughter is worried about Susan's mobility because Susan is still using a walker. She asks the nurse how Susan will be able to cook meals for herself when she needs a walker to ambulate. Which member of the healthcare team is most appropriate to help the client learn how to cook while using a walker? Occupational therapist. Unlicensed assistive personnel (UAP). Physical therapist. Social worker.

OT

The nurse notifies the charge nurse of the red, warm, and edematous left leg and prepares to place a call to the surgeon. Which action should the nurse take before leaving the client's room to call the surgeon? Encourage range of motion of the left leg. Reapply the antiembolism stockings and SCDs bilaterally. Place the client on strict bedrest and elevate the left leg on a pillow. Place an ice pack on the affected area of the left leg.

Place the client on strict bedrest and elevate the left leg on a pillow. The client's symptoms are consistent with a deep vein thrombosis (DVT). Bedrest is the safest intervention to prevent the thrombus from breaking off and elevation may decrease the edema.

The nurse prepares to implement skin care after Susan returns to bed after her morning physical therapy. The nurse removes Susan's antiembolism stocking and sequential compression devices (SCDs) prior to examining the skin. Which finding is of most concern? Scant amount of blood on the surgical dressing. Red, warm, and edematous area of the left calf. A 1-cm localized brown patch on the right hand. Redness of the right heel that doesn't blanch when pressed.

Red, warm, and edematous area of the left calf. A red, warm, and edematous area of the calf is a possible indication of a life-threatening complication associated with orthopedic surgeries.

When the nurse is teaching Susan about medications for osteoporosis, which instruction is most important, knowing that Susan takes alendronate (Fosamax), a biphosphonate? Take this medication at bedtime. Remain upright (sitting or standing) for at least 30 minutes after taking this medication. Take this medication at the same time every day. Always take alendronate (Fosamax) with the mid-day meal to prevent stomach upset.

Remain upright (sitting or standing) for at least 30 minutes after taking this medication. Biphosphonates can cause erosion in the esophagus. Lying down or reclining after administration can allow regurgitation into the esophagus.

Susan is determined to be well enough to go back home to her apartment. She desires to live independently, but she is worried about falling again. Her daughter works full time but is available to visit Susan every morning and evening. Which resources are appropriate to promote safety and independence for the client? Select all that apply Which resources are appropriate to promote safety and independence for the client? Shower chair. Medical alert system. Home healthcare referral. Raised toilet seat. Admission to home hospice.

Shower chair. Medical alert system. Home healthcare referral. Raised toilet seat.

Fifteen minutes after the PRBCs are started, Susan reports headache and has tachypnea and chills. Her blood pressure is 88/52, and she has a temperature of 101.9°F (38.8°C). What is the priority intervention? Notify the physician of her probable post-operative infection. Stop the blood transfusion and hang a new normal saline infusion. Provide acetaminophen (Tylenol) by mouth and reassess in 15 minutes. Increase the rate of the blood infusion as the client's hemoglobin is low.

Stop the blood transfusion and hang a new normal saline infusion. Headache, tachypnea, chills, hypotension, and elevated temperature are signs and symptoms of a blood transfusion reaction.

The nurse prepares to obtain additional information about Susan's fall risk. Which additional information is associated with an increased risk for falls? Select all that apply Blood pressure remains at 130/72 between lying and sitting position. Throw rugs placed on hardwood floors in the home. Walks with short, shuffled steps. Uses the furniture to steady self. Advanced age.

Throw rugs placed on hardwood floors in the home. Throw rugs are a tripping hazard, and they should be removed from the home to decrease fall risk. Walks with short, shuffled steps. Shuffling steps indicate an abnormal gait pattern, and they increase the likelihood of tripping or falling. Uses the furniture to steady self. The use of furniture to steady oneself indicates a problem with balance and is a fall risk. Advanced age. The risk for falls increases over the age of 65.

The nurse and the charge nurse assess Susan for signs and symptoms of internal or external bleeding and none are noted. The HCP is notified of the INR level. Which new prescriptions and/or medication changes should the nurse anticipate next? Potassium and an increase in the warfarin (Coumadin) dose. Protamine sulfate and stopping warfarin (Coumadin). Vitamin K and holding the warfarin (Coumadin) dose today. Calcium and decreasing the warfarin (Coumadin) dose by 1 mg.

Vitamin K and holding the warfarin (Coumadin) dose today. This drug is the antidote for warfarin (Coumadin) overdose.