Mobility Disorders in the Older Adults

a. "Avoid extending your left hip behind you when you sit." d. "Avoid twisting your body when moving or performing ADLs." e. "Stand on your right leg and pivot into the chair when getting out of bed."

A client had a left anterior total hip arthroplasty 2 days ago. Which precautions will the nurse teach the client to prevent surgical complications? (Select all that apply.) a. "Avoid extending your left hip behind you when you sit." b. "Do not flex your hips more than 90 degrees when toileting." c. "You may cross your legs to be more comfortable in a chair." d. "Avoid twisting your body when moving or performing ADLs." e. "Stand on your right leg and pivot into the chair when getting out of bed."

B. Use an ice pack for the first 24 hours to decrease tissue swelling C. Move the nights of the right hand frequently to promote blood flow D. Report coolness or discoloration of your right hand to your doctor E. Don't place any device under the cast to scratch the skin if it itches

A client has a synthetic cast placed for a right wrist fracture in the ED. Which priority health teaching is important for the nurse to provide for this client before returning home? (SATA) A. Keep your right arm below the level of your heart as often as possible B. Use an ice pack for the first 24 hours to decrease tissue swelling C. Move the nights of the right hand frequently to promote blood flow D. Report coolness or discoloration of your right hand to your doctor E. Don't place any device under the cast to scratch the skin if it itches

B. Perform a neurovascular assessment

A client who has a plaster leg splint report a painful pressure sensation under the plastic wrap that is holding the splint in place. What is the nurse's best initial reaction? A. Remove the splint to reduce skin pressure B. Perform a neurovascular assessment C. Report the client's concern to the health provider D. Inspect the skin under the elastic bandage

A. Take medication in the morning before eating. C. Drink a full glass of water with each tablet. E. Avoid lying down after taking this medication

A client who has osteoporosis has a new prescription for alendronate (Fosamax). Which of the following instructions should the nurse provide for the client? (SATA) A. Take medication in the morning before eating. B. Chew tablets to increase bioavailability. C. Drink a full glass of water with each tablet. D. Take Fosamax with an antacid if heartburn occurs. E. Avoid lying down after taking this medication

B. Buck's traction

A nurse in the emergency department is planning care for a client who has a right hip fracture. Which of the following immobilization devices should the nurse anticipate in the plan of care? A. Skeletal traction B. Buck's traction C. Halo traction D. Gardner-Wells traction

a. Check continuous passive motion device settings b. Palpate dorsal pedal pulses d. Elevate heels off the bed

A nurse is admitting a client to the orthopedic unit following a total knee arthroplasty. Which of the following actions by the nurse are appropriate? (SATA) a. Check continuous passive motion device settings b. Palpate dorsal pedal pulses c. Place a pillow behind the knee d. Elevate heels off the bed e. Apply heat therapy to incision

b. Loss in height of 2 in c. BMI of 18 d. Kyphotic curve at upper thoracic spine e. History of lactose intolerance

A nurse is admitting an adult who has suspected osteoporosis. Which of the following findings are risk factors for osteoporosis? (SATA) a. History of consuming one glass of wine daily b. Loss in height of 2 in c. BMI of 18 d. Kyphotic curve at upper thoracic spine e. History of lactose intolerance

A. Intense pain when the client's left foot is passively moved C. Hard, swollen muscle in the client's left leg D. Burning and tinging of the client's left foot E. Client report of minimal pain relief following a second dose of opioid medication

A nurse is assessing a client who had an external fixation device applied 2 hours ago for a fracture of the left tibia and fibula. Which of the following findings is a manifestations of compartment syndrome? (SATA) A. Intense pain when the client's left foot is passively moved B. Capillary refill of 3 seconds on the client's left toes C. Hard, swollen muscle in the client's left leg D. Burning and tinging of the client's left foot E. Client report of minimal pain relief following a second dose of opioid medication

A. Altered mental status

A nurse is assessing a client who has a casted compound fracture of the femur. Which of the following findings is a manifestations of a fat embolus? A. Altered mental status B. Reduced bowel sounds C. Swelling of toes distal to injury D. Pain with passive movement of the foot distal to the injury

A. Heberden's nodes D. Enlarged joint size E. Limp when walking

A nurse is assessing a client who has osteoarthritis of the knees and fingers. Which of the following manifestations should the nurse expect to find? (SATA) A. Heberden's nodes B. Swelling of all joints C. Small body frame D. Enlarged joint size E. Limp when walking

b. Pain when bearing weight c. Joint crepitus d. Swelling of the affected joint e. Limited joint motion

A nurse is assessing a client who is scheduled to undergo a right knee arthroplasty. The nurse should expect which of the following findings? (SATA) a. Skin reddened over the joint b. Pain when bearing weight c. Joint crepitus d. Swelling of the affected joint e. Limited joint motion

A. Skin test for allergy to the medication

A nurse is caring for a client who has a new prescription for calcitonin-salmon for osteoporosis. Which of the following tests should the nurse tell the client to expect before beginning this medication? A. Skin test for allergy to the medication B. ECG to rule out cardiac dysrhythmias C. Mantoux test to rule out exposure to tuberculosis D. Liver function tests to assess risk for medication toxicity

B. Erythrocyte sedimentation rate (ESR) D. Antinuclear antibody (ANA) titer E. WBC count

A nurse is caring for a client who has rheumatoid arthritis. Which of the following laboratory tests are used to diagnose this disease? (Select all that apply.) A. Urinalysis B. Erythrocyte sedimentation rate (ESR) C. BUN D. Antinuclear antibody (ANA) titer E. WBC count

B. Semi-Fowler's with a pillow under the knees

A nurse is caring for a client who injured her lower back during a fall and describes sharp pain in her back and down her left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease her pain? A. Prone without use of pillows B. Semi-Fowler's with a pillow under the knees C. High-Fowler's with the knees flat on the bed D. Supine with the head flat

B. Calcium carbonate (Tums)

A nurse is caring for a young adult client whose serum calcium is 8.8 mg/dL. Which of the following meds should the nurse anticipate administering to this client? A. Calcitonin-salmon (Miacalcin) B. Calcium carbonate (Tums) C. Zoledronic (Reclast) D. Ibandronate (Bonivia)

B. Inspect your incision daily for indications of infection C. Apply ice packs to the area for the first 24 hours E. Perform isometric exercises

A nurse is completing a preoperative teaching for a client who is to undergo an arthroscopy to repair a shoulder injury. Which of the following statements should the nurse include? (SATA) A. Avoid damage or moisture to the cast on your arm B. Inspect your incision daily for indications of infection C. Apply ice packs to the area for the first 24 hours D. Keep your arm in a dependent position E. Perform isometric exercises

a. Encourage complete autologous blood donation d. Use an abductor pillow when turning the client e. Perform isometric exercises

A nurse is completing a preoperative teaching plan for a client who is scheduled to have a total hip arthroplasty. Which of the following should the nurse include in the teaching plan? (SATA) a. Encourage complete autologous blood donation b. Sit in a low reclining chair c. Instruct the client to roll onto the operative hip d. Use an abductor pillow when turning the client e. Perform isometric exercises

A. Antibiotic therapy should continue for 3 months

A nurse is completing discharge teaching to a client who had wound debridement for osteomyelitis. Which of the following information should the nurse include? A. Antibiotic therapy should continue for 3 months B. Relief of pain indicates the infection is eradicated C. Airborne precautions are used during wound care D. Expect paresthesia distal to the wound

B. The hip and spine are the usual areas the device scans D. Bone pain can indicate need for a scan E. Females should have a baseline scan during their 40s

A nurse is education clients at a health fair about dual-energy x-ray absorptiometry (DXA) scans. Which of the following information should the nurse include? (SATA) A. The test requires the use of contrast material B. The hip and spine are the usual areas the device scans C. The scan detects arthritis D. Bone pain can indicate need for a scan E. Females should have a baseline scan during their 40s

A. Muscle atrophy B. Slowed movement D. Arthritis E. Widened gait

A nurse is performing a musculoskeletal assessment on an older adults living independently. What normal physiologic changes of aging does the nurse expect? (SATA) A. Muscle atrophy B. Slowed movement C. Scoliosis D. Arthritis E. Widened gait

a. A 40yr old client who takes prednisone for 4 months c. A 45yr old client who takes phenytoin for seizures d. A 65yr old client who has a sedentary lifestyle e. A 70yr old client who has smoked for 50 years

A nurse is performing health screenings of clients at a health fair. Which of the following clients are at risk for osteoporosis? (Select all that apply) a. A 40yr old client who takes prednisone for 4 months b. A 30yr old client who jogs 3 miles daily c. A 45yr old client who takes phenytoin for seizures d. A 65yr old client who has a sedentary lifestyle e. A 70yr old client who has smoked for 50 years

A. Assess color and temperature of the extremity C. Place pillows under the extremity D. Administer analgesic medication E. Assess pulse and sensation in the foot

A nurse is planning care for a client who is postoperative following an arthroscopy of the knee. Which of the following actions should the nurse take? (SATA) A. Assess color and temperature of the extremity B. Apply warm compresses to incision sites C. Place pillows under the extremity D. Administer analgesic medication E. Assess pulse and sensation in the foot

A. Assess for bruising C. Determine whether the client takes a muscle relaxant D. Instruct the client to flex muscles during needle insertion

A nurse is planning care for a client who will undergo an electromyography (EMG). Which of the following actions should the nurse include? (SATA) A. Assess for bruising B. Administer aspirin prior to the procedure C. Determine whether the client takes a muscle relaxant D. Instruct the client to flex muscles during needle insertion E. Expect swelling, redness, and tenderness at the insertion sites

a. Clean the incision daily with soap and water c. Sit in a straight-backed armchair e. Use a raised toilet seat

A nurse is planning discharge teaching for a client who had a total hip arthroplasty. Which of the following should the nurse include in the teaching? (SATA) a. Clean the incision daily with soap and water b. Turn the toes inward when sitting or lying c. Sit in a straight-backed armchair d. Bend at the waist when putting on socks e. Use a raised toilet seat

a. Remove throw rugs in walkways b. Use prescribed assistive devices c. Remove clutter from the environment e. Maintain lighting of doorway areas

A nurse is planning discharge teaching on home safety for an older adult client who has osteoporosis. Which of the following information should the nurse include in the teaching? (Select all that apply) a. Remove throw rugs in walkways b. Use prescribed assistive devices c. Remove clutter from the environment d. Wear soft-bottomed shoes e. Maintain lighting of doorway areas

b. Place the client in a supine position

A nurse is providing care for a client who had a vertebroplasty of the thoracic spine. Which of the following actions should the nurse take? a. Apply heat to the puncture site b. Place the client in a supine position c. Turn client every 1 hr d. Ambulate the client within the first hour post-procedure

b. kale

A nurse is providing dietary teaching about calcium-rich foods to a client to has osteoporosis. Which of the following foods should the nurse include in the instructions? a. white bread b. kale c. apples d. brown rice

B. Put on gloves before applying the cream to other parts of the body

A nurse is providing information about capsaicin cream to a client who reports continuous knee pain from OA. Which of the following information should the nurse include in the discussion? A. continuous pain relief is provided B. Put on gloves before applying the cream to other parts of the body C. Leave cream on the hands for 10 minutes following application D. apply the medication every 2 hours during the day

A. "You may experience morning stiffness when you get out bed."

A nurse is providing information to a client newly diagnosed with rheumatoid arthritis (RA). Which of the following statements by the nurse is appropriate? A. "You may experience morning stiffness when you get out bed." B. "You may experience abdominal pain." C. "You may experience weight gain." D. "You may experience low blood sugar."

A. Apply heat to joints to alleviate pain C. Reduce the amount of exercise done on days with increased pain E. Active ROM is more effective than passive

A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (Select all that apply) A. Apply heat to joints to alleviate pain B. Ice inflamed joints for 30 minutes following activity C. Reduce the amount of exercise done on days with increased pain D. Prop the knees with a pillow in bed E. Active ROM is more effective than passive

D. Alternate nostrils each time calcitonin-salmon is inhaled.

A nurse is providing instruction to a client who has a prescription for calcitonin-salmon (Miacalcin) for postmenopausal osteoporosis. Which of the following should the nurse teach the client regarding self-administration of this medication? A. Swallow tablets on an empty stomach with plenty of water. B. Watch for skin rash and redness when applying calcitonin-salmon topically. C. Mix the liquid medication with juice and take it after meals. D. Alternate nostrils each time calcitonin-salmon is inhaled.

A. Engage in regular exercise including walking. D. Create a smoking cessation plan. E. Wear low-heeled shoes.

A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain? (Select all that apply) A. Engage in regular exercise including walking. B. Sit for up to 10 hr each day to rest the back. C. Maintain weight within 25% of ideal body weight. D. Create a smoking cessation plan. E. Wear low-heeled shoes.

A. Hot flashes C. Swelling or redness in calf D. Shortness of breath

A nurse is providing teaching to a client who is taking raloxifene to prevent postmenopausal osteoporosis. The nurse should advise the client that which of the following are adverse effects of the medication? (SATA) A. Hot flashes B. Lump in breast C. Swelling or redness in calf D. Shortness of breath E. Difficulty swallowing

d. Bronchitis 2 weeks ago

A nurse is reviewing the health record of a client who is to undergo total joint arthroplasty. The nurse should recognize which of the following findings as a contraindication to this procedure? a. Age 78 years b. History of cancer c. Previous joint replacement d. Bronchitis 2 weeks ago

A. I will clean the pins more often if drainage from the pins increases B. I will use a separate cotton swab for each pin C. I will report loosening of the pins to my doctor E. I will report increased redness at the pin sites

A nurse is teaching a client how to manage an external fixation device upon discharge. Which of the following statements by the client indicates understanding? (SATA) A. I will clean the pins more often if drainage from the pins increases B. I will use a separate cotton swab for each pin C. I will report loosening of the pins to my doctor D. I will more my leg by lifting the device in the middle E. I will report increased redness at the pin sites

D. You will have to urinate just before the procedure

A nurse is teaching a client who is going to have a bone scan. Which of the following statements should the nurse include? A. You will receive an injection of a radioactive isotope when the scanning procedure begins B. You will be inside a tube-like structure during the procedure C. You will need to take radioactive precautions with your urine for 24 hours after the procedure D. You will have to urinate just before the procedure

C. Increase the amount and distance of walking

A nurse notes that an older person's thigh muscles are atrophied; however, the muscles of the upper arms are tight and have definition. Which recommendation should the nurse make to this person to improve muscle function? A. Eliminate smoking and alcoholic beverages B. Increase the amount of housework done each day C. Increase the amount and distance of walking D. Decrease the intake of protein at meals

A. Recent influenza B. Decreased range of motion E. Pain at rest

A nurse working in an outpatient clinic is assessing a client who has rheumatoid arthritis (RA). The client reports increased joint tenderness and swelling. Which of the following findings should the nurse expected? (SATA) A. Recent influenza B. Decreased range of motion C. Hypersalivation D. Increased blood pressure E. Pain at rest

a. "I'll keep an abduction pillow in place at all times."

A nursing assistant (NA) is assigned to care for a client who had a cemented total knee arthroplasty. Which statement by the NA indicates a need for further teaching and supervision by the nurse? a. "I'll keep an abduction pillow in place at all times." b. "I'll tell the client not to place a pillow under the surgical knee." c. "I'll apply ice packs to decrease swelling in the knee as ordered." d. "I'll check to make sure the client's leg is not rotated."

A. Maintain a normal body weight

An older person with osteoarthritis asks what can be done to prevent further development of the disorder. Which response should the nurse make? A. Maintain a normal body weight B. Increase the intake of calcium and vitamin D (good, but better for osteoporosis) C. Limit weight lifting and walking exercises D. Avoid beverages containing alcohol and caffeine (good, but better for osteoporosis)

A. Change in cartilage

An older person is observed walking slowly down the street. Which age-related change should the nurse consider as most likely contributing to this person's ability? A. Change in cartilage B. Poor nutrition C. Fatigue D. Lack of balance

B. Do you take anything to protect your stomach?

An older person reports taking an NSAID medication several times a day to help with pain caused by rheumatoid arthritis. Which response should the nurse make after learning this information? A. Have you considered using acetaminophen instead? (WRONG: not drug of choice for RA! Its for OA!) B. Do you take anything to protect your stomach? C. They are the treatment of choice for your health problem D. Increase the dose if the medication becomes less effective

B. Allopurinol (it is better than probenecid and sulfinpyrazone b/c it is given at all levels of renal function. Colchicine is used less often cause of renal/liver/and bone problems)

An older person with a low glomerular filtration rate is experiencing gout. Which medication should the nurse anticipate being prescribed for this person? A. Colchicine B. Allopurinol C. Sulfinpyrazone D. Probenecid

A. Remain upright for 30 minutes after taking

An older person with osteoporosis is prescribed alendronate. Which information should the nurse emphasize when teaching about this medication? A. Remain upright for 30 minutes after taking B. Take 30 minutes after consuming a full meal C. Remain upright for 60 minutes after taking (WRONG: because 60min only with ibandronate) D. Take first thing in the morning with breakfast

T-score is at or more than -2.5

Bone Testing · Testing is performed every 2 years in patients 65 years old and older & who are: § -estrogen deficient § -have vertebral abnormalities § -receive long-term steroid therapy-Have primary hyperparathyroidism § -are being monitored while on osteoporosis drug therapy. · BMD testing should be done on any woman with a fracture Diagnostics for Osteopenia and Osteoporosis · Bone Mass Density (BMD) testing is the basis of the diagnosis of osteoporosis, and results in a T-score. · T-score represents the number of standard deviations above or below the average BMD for young, health adults. · Osteopenia is dx when T-score is between -1 and above -2.5 · Osteoporosis is dx when ______________________________________ · Can be dx as regional or generalized ( involves many structures) & is divided into primary and secondary osteoporosis.

T-score is between -1 and above -2.5

Bone Testing · Testing is performed every 2 years in patients 65 years old and older & who are: § -estrogen deficient § -have vertebral abnormalities § -receive long-term steroid therapy-Have primary hyperparathyroidism § -are being monitored while on osteoporosis drug therapy. · BMD testing should be done on any woman with a fracture Diagnostics for Osteopenia and Osteoporosis · Bone Mass Density (BMD) testing is the basis of the diagnosis of osteoporosis, and results in a T-score. · T-score represents the number of standard deviations above or below the average BMD for young, health adults. · Osteopenia is dx when _____________________________ · Osteoporosis is dx when T-score is at or more than -2.5 · Can be dx as regional or generalized ( involves many structures) & is divided into primary and secondary osteoporosis.

Osteopenia

Bones · Bone is a dynamic tissue, it is constantly undergoing changes (bone remodeling). · _________________ (low bone mass) occurs when osteoclastic (bone absorption) is greater than osteoblastic (bone building) activity; resulting in decreased bone mineral density (BMD). · Bone Mass Density (BMD) determines bone strength (it peaks between 25 & 30 years of age). · After peak bone years, resorption exceeds bone-building, resulting in decreased bone density. · Bone Mass Density (BMD) decreases faster in postmenopausal women as serum estrogen levels diminish. · Estrogen helps prevent bone loss (not build bones). · Spongy (trabecular or cancellous) bone is lost first, then compact bone (cortical). · Resulting in fragile bone tissue that is at r/f fracture.

neutral position, no hyperflexion, no internal/external rotation, no pillows under replaced knee, no knee gatches, and no hyperextended knees · Place one pillow under the lower calf and foot to cause a slight extension of the knee joint and to prevent flexion contractions. The knee can rest flat on the bed.

Care and Treatment of Osteoarthritis (OA) · Total Knee Arthroplasty or Total Knee Replacement: POST- OP care of Total Knee Arthroplasty or Total Knee Replacement: § Continuous passive motion (CPM) may be used post-op (may prevent scar tissue). It keeps the prostatic knee in motion · CPM may be applied in PACU · PT or Tech will preset the machine for appropriate Range of motion · Ensure machine is well padded · Check cycle and ROM settings every 8 hours · Ensure joint is being moved properly · If patient is confused, place controls out of the patient's reach · Assess patient's response to machine · Turn of the machine when patient is eating in bed. When not in use do not store the machine on the floor § May swell more than hip surgery: cryotherapy, Ice packs or ice machine to surgical site. § Maintain knee in ______________________________________________________________________________________ § If the patient has a continuous femoral nerve blockade (CFNB), perform neurovascular assessment q2-4h · Be sure patients can perform dorsiflexion and plantar flexion on affected foot without pain in lower leg. · Monitor for s/s that indicate absorption of anesthetic into system:metallic taste, tinnitus, nervousness, slurred speech, bradycardia, hypotension, decreased respirations, seizures § Manage pain to provide comfort, increase participation in therapy, and improve mobility: analgesics, ice or cold therapy to incision § Administer anticoagulants, SCDs, foot pumps, or anti-embolism stockings as ordered to prevent VTE and DVT § Monitor neurovascular status q2-4h, assess for bleeding/hypovolemia, assess level of flexibility and mobility § Complications: VTE, infection, anemia, neurovascular compromise

continuous femoral nerve blockade (CFNB), perform neurovascular assessment q2-4h · Be sure patients can perform dorsiflexion and plantar flexion on affected foot without pain in lower leg. · Monitor for s/s that indicate absorption of anesthetic into system:metallic taste, tinnitus, nervousness, slurred speech, bradycardia, hypotension, decreased respirations, seizures

Care and Treatment of Osteoarthritis (OA) · Total Knee Arthroplasty or Total Knee Replacement: POST- OP care of Total Knee Arthroplasty or Total Knee Replacement: § Continuous passive motion (CPM) may be used post-op (may prevent scar tissue). It keeps the prostatic knee in motion · CPM may be applied in PACU · PT or Tech will preset the machine for appropriate Range of motion · Ensure machine is well padded · Check cycle and ROM settings every 8 hours · Ensure joint is being moved properly · If patient is confused, place controls out of the patient's reach · Assess patient's response to machine · Turn of the machine when patient is eating in bed. When not in use do not store the machine on the floor § May swell more than hip surgery: cryotherapy, Ice packs or ice machine to surgical site. § Maintain knee in neutral position, no hyperflexion, no internal/external rotation, no pillows under replaced knee, no knee gatches, and no hyperextended knees · Place one pillow under the lower calf and foot to cause a slight extension of the knee joint and to prevent flexion contractions. The knee can rest flat on the bed. § If the patient has a ___________________________, _____________________________________________________________ - - § Manage pain to provide comfort, increase participation in therapy, and improve mobility: analgesics, ice or cold therapy to incision § Administer anticoagulants, SCDs, foot pumps, or anti-embolism stockings as ordered to prevent VTE and DVT § Monitor neurovascular status q2-4h, assess for bleeding/hypovolemia, assess level of flexibility and mobility § Complications: VTE, infection, anemia, neurovascular compromise

Continuous passive motion (CPM)

Care and Treatment of Osteoarthritis (OA) · Total Knee Arthroplasty or Total Knee Replacement: POST- OP care of Total Knee Arthroplasty or Total Knee Replacement: § __________________________________________ may be used post-op (may prevent scar tissue). It keeps the prostatic knee in motion · CPM may be applied in PACU · PT or Tech will preset the machine for appropriate Range of motion · Ensure machine is well padded · Check cycle and ROM settings every 8 hours · Ensure joint is being moved properly · If patient is confused, place controls out of the patient's reach · Assess patient's response to machine · Turn of the machine when patient is eating in bed. When not in use do not store the machine on the floor § May swell more than hip surgery: cryotherapy, Ice packs or ice machine to surgical site. § Maintain knee in neutral position, no hyperflexion, no internal/external rotation, no pillows under replaced knee, no knee gatches, and no hyperextended knees · Place one pillow under the lower calf and foot to cause a slight extension of the knee joint and to prevent flexion contractions. The knee can rest flat on the bed. § If the patient has a continuous femoral nerve blockade (CFNB), perform neurovascular assessment q2-4h · Be sure patients can perform dorsiflexion and plantar flexion on affected foot without pain in lower leg. · Monitor for s/s that indicate absorption of anesthetic into system:metallic taste, tinnitus, nervousness, slurred speech, bradycardia, hypotension, decreased respirations, seizures § Manage pain to provide comfort, increase participation in therapy, and improve mobility: analgesics, ice or cold therapy to incision § Administer anticoagulants, SCDs, foot pumps, or anti-embolism stockings as ordered to prevent VTE and DVT § Monitor neurovascular status q2-4h, assess for bleeding/hypovolemia, assess level of flexibility and mobility § Complications: VTE, infection, anemia, neurovascular compromise

take a shower with special antiseptic soap 1-3 nights before and the morning of surgery. They will wear clean nightwear and sleep on clean linens the night before. (SAME FOR HIP REPLACEMENT!)

Care and Treatment of Osteoarthritis (OA) · Total Knee Arthroplasty or Total Knee Replacement: § Often younger than hip replacement pts. § Used when pain mgt. is no longer effective or mobility is limited. § PRE-OP care of Total Knee Arthroplasty or Total Knee Replacement: · Verbal or written preop instructions: activity protocols after surgery · PT and OT provide info on transfers, ambulation, post-op exercises, and ADL assistance · Practice walking with walker/crutches pre-op to prepare for post-op · Teach about possible need for assistive devices: elevated toilet seat, safety rails, dressing devices (shoehorn) · They NEED to ___________________________________________________________ · If medications aren't contraindicated before surgery (antiHTN, GERD/heart drugs), take with SMALL amount of water to prevent n/v and aspiration · Pre-op antibiotics to prevent infection

the break has multiple fracture lines and the bone is in multiple pieces

Care of Patients with Musculoskeletal Trauma · Classification of Fractures: § Complete Fracture: the break is across the entire width of the bone and bone is divided into two sections. § Incomplete Fracture: the fracture is only through part of the bone and does not divide the bone into 2 portions § Closed Fracture: The fracture does not break the skin § Open (compound) Fracture: the fracture causes a break in the skin and external wound § Simple Fracture: fracture on has one fracture line § Comminuted Fracture: _________________________________________________________________________________ § Displaced Fracture: the bone fragments are not in alignment § Non-displaced Fracture: bone fragments remain in alignment § Pathologic (spontaneous) Fracture: this fracture occurs after minimal trauma to a bone that has been weakened by a disease § Fatigue (stress) Fracture: a fracture that results from excessive strain and stress, commonly seen in professional athletes. § Compression Fracture: these fractures are produced by a loading force applied to the long axis of a cancellous bone, and commonly occur in vertebrae of older adults with osteoporosis § Spiral Fracture: this fracture occurs from twisting motion (common with abuse) § Oblique Fracture: this fracture occurs at an oblique angle across the bone § Impacted Fracture: this fracture occurs when the bone is wedged inside the opposite fractured bone § Greenstick Fracture: this fracture occurs on one side but does not go completely through the bone (common in children)

this fracture occurs after minimal trauma to a bone that has been weakened by a disease

Care of Patients with Musculoskeletal Trauma · Classification of Fractures: § Complete Fracture: the break is across the entire width of the bone and bone is divided into two sections. § Incomplete Fracture: the fracture is only through part of the bone and does not divide the bone into 2 portions § Closed Fracture: The fracture does not break the skin § Open (compound) Fracture: the fracture causes a break in the skin and external wound § Simple Fracture: fracture on has one fracture line § Comminuted Fracture: the break has multiple fracture lines and the bone is in multiple pieces § Displaced Fracture: the bone fragments are not in alignment § Non-displaced Fracture: bone fragments remain in alignment § Pathologic (spontaneous) Fracture: ____________________________________________________________ § Fatigue (stress) Fracture: a fracture that results from excessive strain and stress, commonly seen in professional athletes. § Compression Fracture: these fractures are produced by a loading force applied to the long axis of a cancellous bone, and commonly occur in vertebrae of older adults with osteoporosis § Spiral Fracture: this fracture occurs from twisting motion (common with abuse) § Oblique Fracture: this fracture occurs at an oblique angle across the bone § Impacted Fracture: this fracture occurs when the bone is wedged inside the opposite fractured bone § Greenstick Fracture: this fracture occurs on one side but does not go completely through the bone (common in children)

these fractures are produced by a loading force applied to the long axis of a cancellous bone, and commonly occur in vertebrae of older adults with osteoporosis

Care of Patients with Musculoskeletal Trauma · Classification of Fractures: § Complete Fracture: the break is across the entire width of the bone and bone is divided into two sections. § Incomplete Fracture: the fracture is only through part of the bone and does not divide the bone into 2 portions § Closed Fracture: The fracture does not break the skin § Open (compound) Fracture: the fracture causes a break in the skin and external wound § Simple Fracture: fracture on has one fracture line § Comminuted Fracture: the break has multiple fracture lines and the bone is in multiple pieces § Displaced Fracture: the bone fragments are not in alignment § Non-displaced Fracture: bone fragments remain in alignment § Pathologic (spontaneous) Fracture: this fracture occurs after minimal trauma to a bone that has been weakened by a disease § Fatigue (stress) Fracture: a fracture that results from excessive strain and stress, commonly seen in professional athletes. § Compression Fracture: _____________________________________________________________________________________ § Spiral Fracture: this fracture occurs from twisting motion (common with abuse) § Oblique Fracture: this fracture occurs at an oblique angle across the bone § Impacted Fracture: this fracture occurs when the bone is wedged inside the opposite fractured bone § Greenstick Fracture: this fracture occurs on one side but does not go completely through the bone (common in children)

weakness, fatigue, nausea, constipation, kidney stones

Drugs for Osteoporosis · Vitamin D: increases absorption of calcium for remineralization of bone § S/S of toxicity: _____________________________

this fracture occurs when the bone is wedged inside the opposite fractured bone

Care of Patients with Musculoskeletal Trauma · Classification of Fractures: § Complete Fracture: the break is across the entire width of the bone and bone is divided into two sections. § Incomplete Fracture: the fracture is only through part of the bone and does not divide the bone into 2 portions § Closed Fracture: The fracture does not break the skin § Open (compound) Fracture: the fracture causes a break in the skin and external wound § Simple Fracture: fracture on has one fracture line § Comminuted Fracture: the break has multiple fracture lines and the bone is in multiple pieces § Displaced Fracture: the bone fragments are not in alignment § Non-displaced Fracture: bone fragments remain in alignment § Pathologic (spontaneous) Fracture: this fracture occurs after minimal trauma to a bone that has been weakened by a disease § Fatigue (stress) Fracture: a fracture that results from excessive strain and stress, commonly seen in professional athletes. § Compression Fracture: these fractures are produced by a loading force applied to the long axis of a cancellous bone, and commonly occur in vertebrae of older adults with osteoporosis § Spiral Fracture: this fracture occurs from twisting motion (common with abuse) § Oblique Fracture: this fracture occurs at an oblique angle across the bone § Impacted Fracture: ________________________________________________________________ § Greenstick Fracture: this fracture occurs on one side but does not go completely through the bone (common in children)

· 1. abnormalities of the autonomic nervous system (changes in color, temperature, and sensitivity, excessive sweating, edema) · ----->Goes from warm, red, and swollen to cool, clammy, and blue · 2. Motor symptoms (paresis, muscle spasms, loss of function) · 3. Sensory perception symptoms (burning pain that becomes intractable or unrelenting)

Complications of Fractures: Chronic Complications · Avascular Necrosis, delayed bone healing, and chronic regional pain syndrome · Complex regional pain syndrome (CRPS), or reflex sympathetic dystrophy (RDS),is a poorly understood dysfunction of the central and peripheral nervous systems that leads to chronic severe pain § Often results from fractures or traumatic injury § Common in feet and hands § Triad symptoms: 1 2 3 § Treatment: · pain relief with oral analgesics, antiepileptics, antidepressants, steroids, and bisphosonates; sometimes nerve blocks (phentolamine) · use of ROM to promote independence · collab with PT; avoid taking BP or starting IVs on affected side · peripheral or spinal cord neurostimulation · sympathectomy: removal of a sympathetic nerve branch

Avascular necrosis

Complications of Fractures: Chronic Complications · Avascular Necrosis, delayed bone healing, and chronic regional pain syndrome · ______________________________ occurs when blood supply to the bone is disrupted, causing decreased perfusion and death of the bone § Common complication of hip fractures, rheumatoid arthritis, and sickle cell § Surgical repair can cause necrosis when hardware interferes with circulation § Long-term prednisone and radiation therapy increases risk of necrosis · Delayed union is a fracture that has not healing within 6 months of injury. Some never achieve union or completely heal (nonunion) § Common with tibial fractures, fractures that need casting or traction, and pathologic fractures § Older people are at risk due to poor bone health § This typically causes chronic pain and impaired mobility § Treatment: electrical bone stimulation, bone grafting, bone banking

§ Edema, hard, swollen palpable muscle § Pink tissue- early § Paresthesia, Numbness and tingling - early § Pallor of tissue, nails cyanotic- late § Tissue is pale, nailbeds cyanotic- late § Paralysis, Paresis- late § Loss of pulses- late § NEUROVASCULAR DAMAGE AND TISSUE NECROSIS CAN OCCUR IN 4-6 HOURS

Complications of Fractures: Compartment Syndrome · Hypovolemic Shock: blood loss, vasodilation · Compartment Syndrome: this is a serious, life-threatening complication of fractures that occurs when pressure within a muscle compartment (area covered with fascia) compromises circulation resulting in an ischemia-edema cycle. The injury/trauma causing the problem is above the compartment involved § Can result in tissue necrosis § Neuromuscular damage occurs within 4-6 hours § Most commonly occurs with musculoskeletal issues in lower leg or forearm § ischemia-edema cycle: capillaries in the muscle dilate, raising capillary and venous pressure. Capillaries become more permeable due to histamine, plasma leaks into interstitial space, and edema occurs. Edema increases pressure on nerve endings causing severe pain. Perfusion to the area is reduced, resulting in ischemia · Causes of Compartment Syndrome: can be external (tight, bulky dressings) or internal (blood/fluid accumulation from fracture) · Signs/symptoms (5 Ps) of Compartment Syndrome: pain, paralysis, paresthesia, pallor, pulseless) § PAIN unrelieved by elevation or medication. Intense pain with movement - - - - - - - - · Complications of Compartment Syndrome: infection, persistent motor weakness, contracture, myoglobinuric renal failure, amputation · Compartment Syndrome Treatment § Surgical Fasciotomy to relieve pressure § Sterile packing and dressing is done after fasciotomy daily until closure occurs (4-5 days) § Wound Vac may be used to decrease edema and contain blood from the site § Skin grafts may be used to try to close the incision § Assess neurovascular status frequently and notify provider if compartment syndrome is suspected (provider will cut a cast on one side, or bivalve) § Loosen constricting bandages or tape

§ decreased SaO2, Dyspnea, Tachypnea (early findings), crackles § Confusion, mental status changes, lethargy, agitation, decreased LOC (early finding after pulmonary findings) § Headache § Chest pain § Headache § Tachycardia § Cutaneous petechiae - (differentiates from PE) are nonpalpable, red-brown, macular, measles-like rash over the neck, upper arms, or chest (usually last sign to develop) § Retinal hemorrhage (not common), mild thrombocytopenia § Labs: increased ESR and lipids; decreased PaO2, calcium, RBCs, platelets

Complications of Fractures: Fat Embolism · Fat Embolism Syndrome (FES) is a serious complication of fractures where fat globules are released from the yellow bone marrow into the bloodstream within 12-48 hours after injury/surgery/illness § Globules clog vessels supplying vital organs (commonly lungs) and impair perfusion § Usually results from fractures or fracture repair · Risk factors for Fat Embolism Syndrome (FES) § Young men ages 20-40 and older adults ages 70-80 are at greatest risk § Patients with hip and pelvis fracture · Signs/symptoms of Fat Embolism Syndrome (FES) - - - - - - - - · Treatment for Fat Embolism Syndrome (FES) § Bedrest § Gentle Handling § Oxygen for respiratory compromise § Hydration, possible vasopressors for fluid replacement § Possible steroid therapy for cerebral edema § Fracture immobilization, minimal manipulation during turning § Pain and anxiety control

Long course (3mth) IV and oral antibiotics

Complications of Fractures: Osteomyelitis · Osteomyelitis: infection in bone usually due to bacteria (MRSA), virus, or fungi, that commonly occurs with open fractures or surgical repair of fractures § Risk with open fractures & decrease skin integrity, or surgical repair of fracture § For patients that have Osteomyelitis, the risk of hospital acquired infection is great · Signs/symptoms of Osteomyelitis: § Bone Pain constant, pulsating, localized, worse with movement § Erythema and edema at site of infection § Leukocytosis, sediment · Diagnostics: bone scan, MRI, cultures · Treatment for Osteomyelitis: § ___________________________________________________ § Surgical debridement, possible bone removal with bone graft § Hyperbaric oxygen treatments to promote healing § Surgically implanted antibiotic beds in bone § Amputation if unsuccessful antibiotic treatment § Nursing actions: administer antibiotics, analgesics, conduct neurovascular assessment, dressing changes

Bedrest, oxygen, possible mechanical ventilation, anticoagulants, thrombolytics, possible surgery (pulmonary embolectomy, vena cava umbrella

Complications of Fractures: Venous Thromboembolism · Venous Thromboembolism (VTE) includes both DVT and PE and is the most common complication of lower-extremity surgery/trauma. It is also the most fatal complication of musculoskeletal surgery. · Risk factors for Venous Thromboembolism (VTE) in patients with fractures : § Cancer, chemotherapy, surgical procedure longer than 30 min, smoking, obesity, heart disease, prolonged immobility, oral contraceptives or hormones, history of VTE complications, older adults (hip fractures) · Nursing Implications for Venous Thromboembolism (VTE) § Prevention of Venous Thromboembolism (VTE): early leg exercises/mobility, antiembolic stockings, SCDs, anticoagulants, fluids, monitoring for VTE § Monitor for signs and symptoms of Venous Thromboembolism (VTE) · Confusion, mental status changes (early finding) · Chest pain · Dyspnea, tachypnea, crackles, decreased SaO2 · Headache · Tachycardia · Reddened, swollen calf § Notify provider if suspected DVT or PE § Treatment of DVT/PE: _____________________________________________________________

"pop", pain, internal/external rotation of leg, shortened leg

Complications of Total Joint Arthroplasty: § Dislocation: _______________________________________________ · Prevent by positioning correctly · Posterior approach: keep legs slightly abducted and prevent hip flexion beyond 90 degrees · Anterior Approach: prevent hip hyperextension · Assess for pain, rotation, and extremity shortening · Perform neurovascular assessments q4h for 24h · report dislocation immediately § Infection: fever, redness, swelling, purulent drainage · Use aseptic technique for wound care/drains · Wash hands thoroughly when caring for patient · Culture drainage fluid if it changes in color/odor · Monitor temperature, report excess inflammation or drainage § Venous thromboembolism: swelling, redness, pain in calf · *OLDER ADULTS and OBESE patients are at high VTE risk · Have patient wear elastic stockings or SCDs · Teach leg exercises: plantar flexion, dorsiflexion, circumduction · Encourage fluid intake · Signs of DVT: redness, swelling, pain · Monitor for mental status changes, SOB, = PE · Administer anticoagulants as prescribed · DO NOT massage legs or flex knees for prolonged time § Hypotension, bleeding: · Take vitals q4h for 24h, observe for bleeding, report low BP or bleeding

decreased cartilage, little/no space between bones which causes bone spurs (joint narrowing and boney sclerosis), joint effusions especially in knees, nodes especially in hands. X-ray is preferred because it is less expensive and invasive and is best for diagnosis

Diagnosis of Osteoarthritis (OA) · based on history and physical examination: jobs, hobbies, is it worse in AM and get better throughout day, · Normal/slightly elevated ESR or WBC · X-rays may be performed routinely to determine structural joint changes: ___________________________________________________________ · MRI or CT may be used in vertebral or knee involvement (more expensive and invasive)

Rheumatoid factor (RF)

Diagnostics for Rheumatoid Arthritis (RA): · Antinuclear antibody (ANA): Commonly found in the blood of people who have lupus; ANAs (abnormal antibodies directed against the cells' nuclei) can also suggest the presence of polymyositis, scleroderma, Sjogren's syndrome, mixed connective tissue disease or rheumatoid arthritis. Tests to detect specific subsets of these antibodies can be used to confirm the diagnosis of a particular disease or form of arthritis. · _____________________________________: Designed to detect and measure the level of an antibody that acts against the blood component gamma globulin, this test is often positive in people with rheumatoid arthritis. This is the ONLY TEST that is specific to rheumatoid arthritis § Positive RF titer: greater than/equal to 1:320 BUT greater than 1:80 is more specific to RA · Erythrocyte sedimentation rate (ESR or "sed rate"): this test measures how fast red blood cells cling together, fall and settle (like sediment) in the bottom of a glass tube over the course of an hour. There are many conditions that can cause an elevated ESR, including an infection or anemia. The higher the sed rate (above 15-20), the greater the amount of inflammation. § 20-40 = mild inflammation, 40-70 = moderate inflammation, 70-150 = severe inflammation · C-reactive protein (CRP): blood test measures body-wide inflammation. It measures a substance made by liver that increases in the presence of inflammation (normal <1.0) · Anti-CCP antibodies: detects antibodies to cyclic citrullinated peptide; it is often positive in those with RA, even years before manifestations develop. · CBC: low H/H/RBC, increased WBC, increased platelets (thrombocytosis) · X-ray: symmetrical, soft-tissue swelling, loss of articular cartilage · CT: cervical involvement · Arthrocentesis: aspirating synovial fluid to assess for inflammatory cells (monitor for bleeding or leakage of synovial fluid; apply ice/rest joint for 24 hours)

Antinuclear antibody (ANA)

Diagnostics for Rheumatoid Arthritis (RA): · _____________________________________: Commonly found in the blood of people who have lupus; ____________ (abnormal antibodies directed against the cells' nuclei) can also suggest the presence of polymyositis, scleroderma, Sjogren's syndrome, mixed connective tissue disease or rheumatoid arthritis. Tests to detect specific subsets of these antibodies can be used to confirm the diagnosis of a particular disease or form of arthritis. · Rheumatoid factor (RF): Designed to detect and measure the level of an antibody that acts against the blood component gamma globulin, this test is often positive in people with rheumatoid arthritis. This is the ONLY TEST that is specific to rheumatoid arthritis § Positive RF titer: greater than/equal to 1:320 BUT greater than 1:80 is more specific to RA · Erythrocyte sedimentation rate (ESR or "sed rate"): this test measures how fast red blood cells cling together, fall and settle (like sediment) in the bottom of a glass tube over the course of an hour. There are many conditions that can cause an elevated ESR, including an infection or anemia. The higher the sed rate (above 15-20), the greater the amount of inflammation. § 20-40 = mild inflammation, 40-70 = moderate inflammation, 70-150 = severe inflammation · C-reactive protein (CRP): blood test measures body-wide inflammation. It measures a substance made by liver that increases in the presence of inflammation (normal <1.0) · Anti-CCP antibodies: detects antibodies to cyclic citrullinated peptide; it is often positive in those with RA, even years before manifestations develop. · CBC: low H/H/RBC, increased WBC, increased platelets (thrombocytosis) · X-ray: symmetrical, soft-tissue swelling, loss of articular cartilage · CT: cervical involvement · Arthrocentesis: aspirating synovial fluid to assess for inflammatory cells (monitor for bleeding or leakage of synovial fluid; apply ice/rest joint for 24 hours)

§ Give with food in divided doses with 6-8 oz of water § Take 1/3 of daily dose at bedtime because no activity to build bone occurs while sleeping § Take with 6-8oz of water to help dissolve it § Take at least 1hr apart from steroids and 4hr apart from thyroid hormone

Drugs for Osteoporosis Drugs for Osteoporosis · Calcium: supplements calcium consumed in food products to promote bone health § Side effects: · Hypercalcemia: high then low BP, tachycardia, weakness, hypotonia, constipation, n/v, ABD pain, lethargy, confusion, deposits under skin, cardiac dysrhythmia, urinary stones, calcium greater than 10.5 § Contraindications: hypercalcemia, renal stones, digoxin toxicity, Vfib § Interactions: glucocorticoids, thyroid hormone, thiazides, spinach, rhubarb, beets, digoxin § Antidote: furosemide, plicamycin -How to take calcium: - - - - § Assess temperature before giving IV § Assess for urinary stones before giving calcium, and encourage fluids to prevent renal stones § Monitor calcium level: 9.0-10.5

1 Take drug on empty stomach first thing in the morning with a full glass of water and remain upright for 30 min after taking to prevent esophagitis, esophageal ulcers, and gastric ulcers 2 Take drug 30 minutes before food, drink, other drugs; 2 hr before calcium 3 If a dose is skipped, wait until the next day 30 minutes before breakfast to take the dose. Do NOT take two tablets in one day

Drugs for Osteoporosis · Bisphosphonates: these drugs slow bone resorption. § Alendronate, ibandronate, pamidronate, risedronate, zoledronic acid § Side Effects: esophagitis, esophageal ulceration, GI disturbance, muscle pain, visual disturbances, osteonecrosis of the jaw, kidney toxicity (IV) § Contraindications: dysphagia, GERD, esophageal stricture, kidney impairment, hypocalcemia, allergy to aspirin (causes bronchospasm) § It is taken for 3 years, then CEXA scan is performed. If bone density is improved or maintained, it is discontinued for 3 years until the next scan, which results direct if it needs to be restarted. How to take: 1___________________ 2_____________________ 3___________________________ § Perform weight-bearing exercises each day § Eat adequate calcium (diary) and vitamin D (eggs); but don't take calcium supp. § If chest discomfort (esophageal irritation) occurs, stop drug and call doctor § Have a dental exam before starting drug therapy due to jaw osteonecrosis (with long-term therapy), especially with poor dental hygiene; or long-bone fracture § IV: monitor for hypercalcemia

dental exam before starting drug therapy due to jaw osteonecrosis (with long-term therapy), especially with poor dental hygiene; or long-bone fracture

Drugs for Osteoporosis · Bisphosphonates: these drugs slow bone resorption. § Alendronate, ibandronate, pamidronate, risedronate, zoledronic acid § Side Effects: esophagitis, esophageal ulceration, GI disturbance, muscle pain, visual disturbances, osteonecrosis of the jaw, kidney toxicity (IV) § Contraindications: dysphagia, GERD, esophageal stricture, kidney impairment, hypocalcemia, allergy to aspirin (causes bronchospasm) § It is taken for 3 years, then CEXA scan is performed. If bone density is improved or maintained, it is discontinued for 3 years until the next scan, which results direct if it needs to be restarted. § Take drug on empty stomach first thing in the morning with a full glass of water and remain upright for 30 min after taking to prevent esophagitis, esophageal ulcers, and gastric ulcers § Take drug 30 minutes before food, drink, other drugs; 2 hr before calcium § Perform weight-bearing exercises each day § Eat adequate calcium (diary) and vitamin D (eggs); but don't take calcium supp. § If a dose is skipped, wait until the next day 30 minutes before breakfast to take the dose. Do NOT take two tablets in one day § If chest discomfort (esophageal irritation) occurs, stop drug and call doctor § Have a __________________________________________________ § IV: monitor for hypercalcemia

sub Q (rotate sites), IM, or intranasally (best for osteoporosis; use different nares each day)

Drugs for Osteoporosis · Calcitonin (salmon): decreases bone resorption by inhibiting osteoclast activity. It can only be given subQ § Side Effects: nausea, nasal dryness and irritation (with nasal route) § Contraindications: allergy to fish protein § Interactions: lithium § Calcitonin salmon is given ____________________________________ § Monitor for HYPOCALCEMIA (Trousseau's and Chvostek's) § Eat adequate calcium (diary) and vitamin D (eggs)

high then low BP, tachycardia, weakness, hypotonia, constipation, n/v, ABD pain, lethargy, confusion, deposits under skin, cardiac dysrhythmia, urinary stones, calcium greater than 10.5

Drugs for Osteoporosis · Calcium: supplements calcium consumed in food products to promote bone health § Side effects: · Hypercalcemia: _______________________________________ § Contraindications: hypercalcemia, renal stones, digoxin toxicity, Vfib § Interactions: glucocorticoids, thyroid hormone, thiazides, spinach, rhubarb, beets, digoxin § Antidote: furosemide, plicamycin § Give with food in divided doses with 6-8 oz of water § Take 1/3 of daily dose at bedtime because no activity to build bone occurs while sleeping § Take with 6-8oz of water to help dissolve it § Assess temperature before giving IV § Take at least 1hr apart from steroids and 4hr apart from thyroid hormone § Assess for urinary stones before giving calcium, and encourage fluids to prevent renal stones § Monitor calcium level: 9.0-10.5

VTE (report calf pain, tenderness); discontinue 72 hours prior to prolonged bed rest. Perform weight-bearing exercises regularly

Drugs for Osteoporosis · Estrogen Agonist/Antagonists: mimic estrogen in some parts of the body, but block its effect elsewhere. Increases bone mineral density, reduces bone resorption and reduces incidence of osteoporotic vertebral fractures. § Raloxifene (Evista) § Side Effects: VTE (DVT, PE, Clotting, possible stroke), liver impairment, hot flashes § Contraindications: history of thromboembolism. § Have a bone scan every 12-18 months § Eat adequate calcium (diary) and vitamin D (eggs) § Can increase risk of _______________________________________________ § Report acute migraine, insomnia, UTI, vaginal burning § Monitor liver function tests

back pain, cholesterol, UTI, & muscle pain.

Drugs for Osteoporosis · Monoclonal antibodies (Prolia, Xgeva): Used when other Rx are not effective. Binds to a protein essential for osteoclast. Decreases bone loss and increases bone mass & strength. ADMINISTERED SUBQ § Denosumab § Contraindication: hypocalcemia § Side effects: __________________________________ § Can result in low CA levels § Have dental exam prior to taking (osteonecrosis of jaw)

Only give subQ. It is only given for 2 years, then bisphosphonates are started

Drugs for Osteoporosis · Teriparatide: a parathyroid hormone that stimulates osteoblasts to increase new bone formation, stimulate calcium absorption, and increase bone mass. § Contraindications: hypercalcemia, bone cancer, radiation, Paget's disease § Side effects: nausea, back pain, arthralgia, leg cramps, orthostatic hypotension § ___________________________________________

Immobilize the extremity by splinting (include joints above and below the site), bandages, casts, traction. Recheck pulse after splinting

Emergency Care of an Extremity Fracture · ABCs: airway, breathing, circulation (especially with shock/unconsciousness) · Ask client about cause of injury to determine possibility of internal injuries · Remove clothing to inspect area while supporting area above/below injury. Do not remove shoes because this can cause further injury · Remove jewelry on the affected extremity due to swelling · Apply direct pressure if bleeding, proximal artery nearest fracture · Keep warm & flat (supine or on side if vomiting) with airway open to prevent shock · Neurovascular assessment including temperature, color, sensation, movement, cap refill, pulse and compare to unaffected limbs (at least q1h) · ___________________________________________________________ · Cover open wounds with a dressing (sterile dressing if available) · Manage pain (adults over 50 need cardiac monitoring): morphine sulfate, opioids, ice/heat, electrical stimulation

Reduce the number of repetitions when inflammation is severe and you have more pain

Exercises for Patients with Osteoarthritis and Rheumatoid Arthritis · Follow exercise instructions prescribed to you. There are no universal exercises; yours have been tailer to your needs · Do exercises on both good and bad days. Consistency is important · Respect pain. ________________________________________________________ · Use active rather than active-assist or passive exercise when possible · Do not substitute normal activities or household tasks for the prescribed exercises · Avoid resistive exercises when joints are severely inflamed

meperidine (Demerol) for pain relieve due to risk of seizures

Fracture of the Hip Surgical Repair of Hip Fracture · Internal repair using screws · Partial hip replacement · Total hip replacement · Do not use _______________________________________________ · After surgical repair, older adults can be confused or delirious due to anesthesia. They can try to climb out of bed, which increases fall risk and self-injury. Some stay awake all night and sleep in the day · *Fall prevention · *patients with hemiarthroplasty are at risk for hip dislocation or subluxation. Prevent hip adduction and rotation to keep operative leg in alignment. Pillows or devices can be used for confused/restless patients. If straps are used, ensure they are not too tight and monitor skin integrity (neurovascular assessments) · Often patient begins ambulating the day after surgery to prevent complications (pressure sores, VTE, atelectasis) · Be sure patient's heels are off the bed at all times. Inspect heels and bony prominences for pressure injury and turn every 1-2 hours.

pin care needs to be performed (one swab for each pin. Move from closest area to skin upwards) and clothing may need to be altered. If activity is restricted, perform deep breathing and leg exercises to prevent complications from immobilization (pneumonia, thrombus)

Fracture of the Hip · External Fixation is a system in which pins or wires are inserted through the skin and affected bone and then connected to a rigid external frame. After fixation is removed, the patient may be in a cast, boot, or splint until healing is complete or have internal fixation § Advantages: minimal blood loss, early ambulation/exercise of body part, pain relief, maintains alignment in closed fractures that will not maintain position in cast and stabilizes comminuted fractures that require bone grafting § Disadvantages: pin site infection, overwhelming appearance to client, noncompliance issues § Nursing Implications for External Fixation · Elevate extremity, and monitor neurovascular status and skin integrity · Monitor for complications: fat/pulmonary embolism. May have to apply anti-embolism stockings and SCDs to prevent DVT · IV Ketorolac is often given to reduce pain and inflammation after surgery · Patients who receive a nerve block may feel no pain for 18-24hr after surgery, so ensure they have pain management after this time · Use nonpharmacy measures for pain relief: imagery, distraction, music · Monitor pin sites for inflammation and infection (redness, drainage, color, odor) and perform pin care every 8-12 hours. In first 48-72 hours, clear fluid drainage or weeping is expected · Be sensitive to disturbed body image, teach about alterations to clothing that may be needed · Circular fixation devices often require turning the four-sided nuts up to 4 times a day. These are often in place for up to a year. · Teach patients that _____________________________________________

greater than 6.5 mg/dL

Gout · Diagnosis of Gout: § Serum uric acid (SUA) level = ___________________________ § BUN/creatinine § Arthrocentesis (aspirate of joint): shows urate crystals in synovial fluid § Chronic gout may also develop renal calculi, oliguria.

Colchicine

Gout · Treatment of Gout - Acute Gout § ______________________ (IV/PO) (requires adequate renal function) § NSAIDS (usually for 2-7 days; contraindicated with renal/cardiac/hepatic disease) § Possible steroid injection into joint (if gout is affecting one joint) § Oral steroids (if gout attack is affecting multiple joints)

§ Inability to move/weight bear immediately after a fall § Severe pain in hip or groin; or pain behind the knee on affected side; sometimes patients only have lower back pain or no pain (but cannot stand without pain) § Inability to put weight on leg of injured side. § SHORTER LEG on the side of injured hip with the foot TURNED OUT § Turning outward of leg on side of injured hip.

Fracture of the Hip · Hip Fracture is the most common injury in older adults. It has a high mortality rate due to complications related to surgery, depression, and prolonged immobility. Because older adults with hip fractures are unable to live independently, many die within the first year. § Intracapsular hip fracture: within the joint § Extracapsular hip fracture: outside of the joint capsule § In the area of the femoral neck, disruption of blood supply is a concern, and can lead to ischemia or avascular necrosis or the femoral head. · Older Adults Risk Factors for Hip Fracture § OSTEOPOROSIS IS A BIG RISK FACTOR. It weakens the upper femur, which causes it to break (fragility fracture) and the older person to fall § Sensory changes, less visual acuity and hearing, changes in gait/balance/strength, joint stiffness § Diseases like osteoporosis, foot disorders, bony metastases, cardiac problems § Drugs: diuretics, antihypertensives, antidepressants, sedatives, opioids, alcohol (fall risk) § Use of 3 or more drugs drastically increases fall risk § Throw rugs, loose carpeting, floor clutter, inadequate lighting, uneven walking surfaces or steps, and pets · Signs and Symptoms of a Fractured hip: - - - - - · May have bed rest to allow natural healing if the patient is so debilitated that surgery cannot be done · Buck's traction maybe applied before surgery · Open reduction and internal fixation (ORIF) is treatment choice of fractured hip.

drainage/BLEEDING. The cast may have a window cut in it for monitoring incisions. Elastic wrap is used to keep the window block cover in place

Fracture of the Hip · Open reduction and internal fixation (ORIF): a surgical management of fractures that uses open reduction, which allows the surgeon to directly view the fracture. Internal fixation uses metal pins, rods, screws, plates, prostheses to immobilize the fracture during healing. § May have cast, boot, or splint after procedure § After the bone achieves unions, the metal hardware may be removed. § Preoperative care Open reduction and internal fixation (ORIF): · Teach the patient and family what to expect during and after surgery. · Teach about general/epidural anesthesia · Informed consent · Allergies § Open reduction and internal fixation (ORIF) Nursing Implications · Perform neurovascular assessment · Monitor for complications (fat/pulmonary embolism) and skin integrity (ensure heels are off bed and inspect bony prominences), prevent dislocation of hip · May have to apply anti-embolism stockings and SCDs to prevent DVT · Observe the cast/dressing for ______________________________________________ · Monitor pain: IV Ketorolac is often given to reduce pain and inflammation after surgery, other meds: NSAIDS, analgesics, antispasmodics; position for comfort with ice on surgical site · Monitor for infection: get vitals, observe for fever, tachycardia, drainage, redness, odor, WBCs, ESR, give aseptic wound care · Patients who receive a nerve block may feel no pain for 18-24hr after surgery, so ensure they have pain management after this time · Use nonpharmacy measures for pain relief: imagery, distraction, music · Increase mobility as ordered. Monitor for orthostatic hypotension, turn and reposition q2h, get out of bed from unaffected side, position for comfort · Support nutrition: encourage calories, calcium supplements, small/frequent meals with snacks, monitor for constipation

§ Diseases/conditions: DM, Hyperthyroidism, hyperparathyroidism, Cushing's syndrome, growth hormone deficiency, metabolic acidosis, female hypogonadism, Paget's disease, osteogenesis imperfecta, RN, prolonged immobilization, Bone CA, Cirrhosis, HIV/AIDS, chronic airway limitation. § Drugs (chronic use): Corticosteroids, Anti-epileptic drugs (phenytoin), Barbiturates, ethanol/alcohol, drugs that induce hypogonadism, high levels of thyroid hormone, cytotoxic agents, immunosuppressants, loop diuretics, aluminum-based antacids.

Generalized Osteoporosis: osteoporosis that involves many structures in their skeleton and is further divided into primary and secondary osteoporosis · Primary Osteoporosis is caused by a combination of genetic and environmental factors; is more common, occurring in postmenopausal women and men in 70s-80s. § Testosterone builds bone. Men in this age range have lower testosterone levels and a decreased ability to absorb calcium. § Risk factors: older age, parental history, low-trauma fracture after age 50, low body weight, thin build, estrogen/androgen deficiency, smoking, high alcohol intake, lack of exercise or prolonged immobility, lactation · Secondary Osteoporosis may result from other medical conditions (hyperparathyroidism), long-term drug therapy (steroids) or prolonged immobility (spinal injury). § Treatment of secondary is directed toward the cause of the osteoporosis if possible. -Diseases:_______________________________________________ -Drugs:___________________________________________________

1. Excessive caffeine can result in Calcium loss in the urine. 2. Low CA and vitamin D intake in the diet or from malabsorption 3. High phosphorus intake (results in CA loss). (large number of carbonated beverages, over 40 ounces). 4. Protein deficiency. (excessive protein can increase calcium loss in urine, Atkins diet) 5. Excessive alcohol and tobacco use. 6. Lack of sunlight in homebound/institutionalized patients (check their vitamin D)

Generalized Osteoporosis: osteoporosis that involves many structures in their skeleton and is further divided into primary and secondary osteoporosis · Primary Osteoporosis is caused by a combination of genetic and environmental factors; is more common, occurring in postmenopausal women and men in 70s-80s. § Testosterone builds bone. Men in this age range have lower testosterone levels and a decreased ability to absorb calcium. § Risk factors: older age, parental history, low-trauma fracture after age 50, low body weight, thin build, estrogen/androgen deficiency, smoking, high alcohol intake, lack of exercise or prolonged immobility, lactation · Secondary Osteoporosis may result from other medical conditions (hyperparathyroidism), long-term drug therapy (steroids) or prolonged immobility (spinal injury). § Treatment of secondary is directed toward the cause of the osteoporosis if possible. § Diseases/conditions: DM, Hyperthyroidism, hyperparathyroidism, Cushing's syndrome, growth hormone deficiency, metabolic acidosis, female hypogonadism, Paget's disease, osteogenesis imperfecta, RN, prolonged immobilization, Bone CA, Cirrhosis, HIV/AIDS, chronic airway limitation. § Drugs (chronic use): Corticosteroids, Anti-epileptic drugs (phenytoin), Barbiturates, ethanol/alcohol, drugs that induce hypogonadism, high levels of thyroid hormone, cytotoxic agents, immunosuppressants, loop diuretics, aluminum-based antacids. · Dietary causes of osteoporosis: 1 2 3 4 5 6

Pegloticase

Gout Refractory Gout: § ___________________: IV dose Q2 weeks · Converts uric acid to allantoin · May cause anaphylaxis

§ Allopurinol ·1 Takes drug for life ·2 Take after a meal with a full glass of water ·3 Adequate fluid intake to promote kidney filtration, hydration ·4 DO NOT take aspirin(deactivates meds to treat)

Gout · Treatment of Gout -Chronic Gout -_____ 1. ----> 2. ----> 3. ----> 4. ----> -_Febuxostat § Drugs are used to block xanthine into uric acid § Probenecid § Increases secretion of renal dysfunction § Take after meals with a full glass of water § 64 oz of water is great to reduce renal insufficiency (3L/day) § Avoid Aspirin (deactivates meds to treat)

· Organ meats · Shellfish · Oily fish with bones (sardines) · Excessive alcohol (ETOH) · Fad diets/ASA/diuretics should be avoided

Gout Treatment and Management: 1 NonPharm: rest joint during attack, cold/heat therapy, 2 All patients with gout should eat a low purine diet § AVOID: - - - - -

· At home: walk on toes around house or stand on one foot at a time for as long as possible to help decrease risk for falling by improving balance · Exercise routinely with activities you like (can find a partner to enjoy them with) · Healthy eating habits and ideal weight management

Healthy Aging Tips for Non-Pharm Musculoskeletal Improvement 1 2 3

local or systemic antibiotic therapy for 6 to 8 weeks. After infection resolves, treatment is similar to that of osteoarthritis, eventually leading up to joint replacement.

Infectious Arthritis · Any infectious agent can invade joint spaces and cause pain, inflammation, and tissue destruction. · Staph A destroys tissue rapidly. · Viruses do not cause irreversible damage. · Treatment is done with ______________________________________________________________________

have diabetes, monitor glucose because taking Glucosamine for a long time can increase glucose *Glucosamine adverse effects: rash, GI disturbance, diarrhea, drowsiness, headache

Nursing Care and Treatment of Osteoarthritis (OA) · Complementary therapies: § Topical capsaicin (OTC) is made from hot peppers and is safe. It works by blocking pain neurotransmitters. Burning is expected for a short time after application; patients should be instructed to wash hands immediately after applying to prevent burning of eyes or other body parts (apply 3-4x/day) · If application site is the hands, leave on for 30 minutes (don't touch anything else), and then wash hands § Glucosamine & chondroitin are the most effective non-Rx supplements taken for pain and function. Supporting evidence is not consistent. Natural products in/around bone cartilage for maintenance and repair. · Chondroitin may strengthen cartilage. · Glucosamine may decrease inflammation. · Tell the doctor if you plan on taking Glucosamine · Do not take Glucosamine if you have HTN, are pregnant, or are breastfeeding · Monitor for bleeding if you take Chondroitin with Glucosamine or Chondroitin alone if you are on anticoagulants · If you______________________________________ · Glucosamine adverse effects: __________________________________ · Take the recommended dosage based on weight · Read drug labels to ensure you do not take too much Glucosamine, and assess for drugs that contain Glucosamine

HTN, are pregnant, or are breastfeeding

Nursing Care and Treatment of Osteoarthritis (OA) · Complementary therapies: § Topical capsaicin (OTC) is made from hot peppers and is safe. It works by blocking pain neurotransmitters. Burning is expected for a short time after application; patients should be instructed to wash hands immediately after applying to prevent burning of eyes or other body parts (apply 3-4x/day) · If application site is the hands, leave on for 30 minutes (don't touch anything else), and then wash hands § Glucosamine & chondroitin are the most effective non-Rx supplements taken for pain and function. Supporting evidence is not consistent. Natural products in/around bone cartilage for maintenance and repair. · Chondroitin may strengthen cartilage. · Glucosamine may decrease inflammation. · Tell the doctor if you plan on taking Glucosamine · Do not take Glucosamine if you have ____________________________________________ · Monitor for bleeding if you take Chondroitin with Glucosamine or Chondroitin alone if you are on anticoagulants · If you have diabetes, monitor glucose because taking Glucosamine for a long time can increase glucose · Glucosamine adverse effects: rash, GI disturbance, diarrhea, drowsiness, headache · Take the recommended dosage based on weight · Read drug labels to ensure you do not take too much Glucosamine, and assess for drugs that contain Glucosamine

turn doorknobs clockwise. Turn in counterclockwise to avoid twisting arm and causing ulnar deviation

Nursing Care and Treatment of Osteoarthritis (OA) · Teaching for Home Care and Self-Care Management: § Patients may have difficulty going up/down stairs, so making arrangements to live on the first floor is best. Avoid stairs with hip/knee pain § Kitchen counters may need to be lowered or seat/rails may need to be placed in showers § For total hip arthroplasty, get an elevated toilet seat § Remove throw rugs to prevent falls § Use large joints instead of small ones. Place purse strap over shoulder instead of hand/wrist. Use functional splints of wrists, fingers, or thumbs § Do not ___________________________________________________ § Use two hands to hold objects. Rest periods with repetitive joint movement (typing, sewing, playing instruments) § Sit in chairs with high, straight backs § When getting out of bed, use entire palm of hand (not fingers) to push up § Do not bed at waist. Bend at the knees with back straight § Use long-handled devices and assistive devices to protect joints (Velcro closures, built-up utensils, dressing aids, walkers, canes, crutches) § Do not use pillows in bed except one for head support § Avoid twisting and wringing of hands

aerobic exercise, SLOW MOVING, LOW IMPACT (walking, biking, swimming, aerobic dance, yoga, tai chi). § The ideal time for exercise is immediately after application of heat

Nursing Care and Treatment of Osteoarthritis (OA) · WEIGHT CONTROL: weight loss for obese patients to decrease pain and slow joint degeneration. Collab with dietician for meal planning · Balance rest/exercise; collab with PT to plan a program for muscle-strengthening exercises to support joints. Get adequate sleep at night and frequent/short rest periods during day (avoid long rest periods) § Stretch muscles for 10 min/day; use active ROM, isometric exercises, isotonic exercises, resistance exercises/2x/week, aerobic exercises (walking/swimming) · Promote mobility: therapeutic exercise, promotion of ADLs and ambulation, use _________________________________________________ - · joint positioning: resting in a functional position. When in supine, use a small pillow under the head/neck but AVOID the use of other pillows to prop joints in a flexed position (large pillows under the knees can result in flexion contractures) · Wear supportive shoes; foot insoles can help relive pressure on joints · Heat/cold alternating: § HEAT: hot showers, baths, hot packs/compresses, moist heat (make sure that heat sources is not too heavy or hot that it causes burns). The temperature should be just above body temperature · Collab with PT for special heat treatments like paraffin dips, diathermy, and ultrasonography. 15-20 minute application is usually sufficient to reduce pain, spams, and stiffness § COLD: cold acks or gels to promote comfort, numb nerve endings, and decrease inflammation. Use ice packs that are not too heavy. DO NOT place directly on skin (wrap them in a towel) and USE FOR MAX 20 MINUTES at a time.

AVOID the use of other pillows to prop joints in a flexed position (large pillows under the knees can result in flexion contractures)

Nursing Care and Treatment of Osteoarthritis (OA) · WEIGHT CONTROL: weight loss for obese patients to decrease pain and slow joint degeneration. Collab with dietician for meal planning · Balance rest/exercise; collab with PT to plan a program for muscle-strengthening exercises to support joints. Get adequate sleep at night and frequent/short rest periods during day (avoid long rest periods) § Stretch muscles for 10 min/day; use active ROM, isometric exercises, isotonic exercises, resistance exercises/2x/week, aerobic exercises (walking/swimming) · Promote mobility: therapeutic exercise, promotion of ADLs and ambulation, use aerobic exercise, SLOW MOVING, LOW IMPACT (walking, biking, swimming, aerobic dance, yoga, tai chi). § The ideal time for exercise is immediately after application of heat · joint positioning: resting in a functional position. When in supine, use a small pillow under the head/neck but AVOID _________________________________________________________________ · Wear supportive shoes; foot insoles can help relive pressure on joints · Heat/cold alternating: § HEAT: hot showers, baths, hot packs/compresses, moist heat (make sure that heat sources is not too heavy or hot that it causes burns). The temperature should be just above body temperature · Collab with PT for special heat treatments like paraffin dips, diathermy, and ultrasonography. 15-20 minute application is usually sufficient to reduce pain, spams, and stiffness § COLD: cold acks or gels to promote comfort, numb nerve endings, and decrease inflammation. Use ice packs that are not too heavy. DO NOT place directly on skin (wrap them in a towel) and USE FOR MAX 20 MINUTES at a time.

Hyaluronic acid (HA)

Nursing Care and Treatment of Osteoarthritis (OA) · manage pain at a level of or less than 3 out of 10. · Acetaminophen is the primary choice because OA is not a primarily anti-inflammatory disorder. § Standard dose: 400mg/day. DO NOT TAKE MORE THAN 3000mg/day DUE TO LIVER DAMAGE § Increased risk for liver damage with alcohol use § Older adults have a high risk for liver damage due to age-related slowed excretion of drug metabolites. They need to read labels thoroughly § Liver enzymes need to be monitored; caution with use of Percocet (contains acetaminophen) · Topicals: 5% lidocaine patches (Lidoderm), biofreeze § Use for 12 ours, up to 3 patches may be used on joint at one time. § Skin irritation can occur. § *contraindicated in patients taking class I antidysrhythmics · NSAIDS (short-term use) can be used when Acetaminophen does not relive discomfort § Celecoxib (Cox2 inhibitor); (also naproxen, ibuprofen) § Before starting, obtain CBC, LFT, and kidney tests § Do not take with HTN, kidney disease, or cardio disease (because all Cox2 inhibitors are thought to cause cardio disease and kidney problems) § Monitor for GI effects, bleeding, and acute kidney failure (BUN, creatinine) § REPORT: dark, tarry stools, SOB, edema, dyspepsia, hematemesis, changes in urinary output · Joint injections with corticosteroids (up to 4x year). · __________________________________- is an alternative injection for osteoarthritis that replaces the body's natural hyaluronic acid by acting as a synthetic joint fluid replacement § Least likely to help those who are obese, over 65, have severe OA, or have previous knee injections · Muscle relaxants: cyclobenzaprine § Use with caution in older adults because they can cause acute confusion. DO NOT DRIVE OR OPERATE HEAVY MACHINERY · Weak opioids: tramadol

Acetaminophen *DO NOT TAKE MORE THAN 3000mg/day DUE TO LIVER DAMAGE *Liver enzymes need to be monitored; caution with use of Percocet (contains acetaminophen)

Nursing Care and Treatment of Osteoarthritis (OA) · manage pain at a level of or less than 3 out of 10. · _______________________ is the primary choice because Osteoarthritis (OA) is not a primarily anti-inflammatory disorder. § Standard dose: 400mg/day. DO NOT TAKE MORE THAN 3000mg/day DUE TO LIVER DAMAGE § Increased risk for liver damage with alcohol use § Older adults have a high risk for liver damage due to age-related slowed excretion of drug metabolites. They need to read labels thoroughly § Liver enzymes need to be monitored; caution with use of Percocet (contains acetaminophen) · Topicals: 5% lidocaine patches (Lidoderm), biofreeze § Use for 12 ours, up to 3 patches may be used on joint at one time. § Skin irritation can occur. § *contraindicated in patients taking class I antidysrhythmics · NSAIDS (short-term use) can be used when Acetaminophen does not relive discomfort § Celecoxib (Cox2 inhibitor); (also naproxen, ibuprofen) § Before starting, obtain CBC, LFT, and kidney tests § Do not take with HTN, kidney disease, or cardio disease (because all Cox2 inhibitors are thought to cause cardio disease and kidney problems) § Monitor for GI effects, bleeding, and acute kidney failure (BUN, creatinine) § REPORT: dark, tarry stools, SOB, edema, dyspepsia, hematemesis, changes in urinary output · Joint injections with corticosteroids (up to 4x year). · Hyaluronic acid (HA) is an alternative injection for osteoarthritis that replaces the body's natural hyaluronic acid by acting as a synthetic joint fluid replacement § Least likely to help those who are obese, over 65, have severe OA, or have previous knee injections · Muscle relaxants: cyclobenzaprine § Use with caution in older adults because they can cause acute confusion. DO NOT DRIVE OR OPERATE HEAVY MACHINERY · Weak opioids: tramadol

OA as a result of aging and genetic factors. § Joints most commonly affected: § weight bearing joints (hips & knees), vertebral column and hands. Most likely r/t mechanical stresses

Osteoarthritis (OA) · Osteoarthritis (OA) (degenerative joint disease (DJD): Progressive deterioration & loss of articular cartilage & bone in one or more joints. The most common form of arthritis, a major cause of disability. · Primary Osteoarthritis (OA): _______________________________________________________ · Secondary Osteoarthritis (OA): OA as a result of obesity & joint injury (car wrecks) § Trauma, joint disease, and excessive use result in joint injury. Metabolic diseases (DM) and blood disorders (Sickle cell, hemophilia) can also result in joint degeneration.

obesity

Osteoarthritis (OA) · Osteoarthritis (OA) (degenerative joint disease (DJD): Progressive deterioration & loss of articular cartilage & bone in one or more joints. The most common form of arthritis, a major cause of disability. · Primary Osteoarthritis (OA): OA as a result of aging and genetic factors. § Joints most commonly affected: § weight bearing joints (hips & knees), vertebral column and hands. Most likely r/t mechanical stresses · Secondary Osteoarthritis (OA): OA as a result of obesity & joint injury (car wrecks) § Trauma, joint disease, and excessive use result in joint injury. Metabolic diseases (DM) and blood disorders (Sickle cell, hemophilia) can also result in joint degeneration. · Preventing Osteoarthritis (OA): § Maintain proper nutrition to prevent ___________________ § Take care to avoid injuries, especially those that can occur from sports. Avoid repetitive strain on joints (jogging, contact sports, risky activities) § Take adequate work breaks to rest joints in jobs where repetitive motion is common. Wear well-fitted shoes with support to prevent falls § Stay active and maintain healthy lifestyle; good body mechanics, labor-saving devices

Osteomalacia

Osteoporosis · Osteoporosis: Chronic metabolic disease caused by bone loss, which causes decreased density/strength and fragile bone tissue, increasing risk of fracture. First sign often is a fracture. § Spine, hip & wrist are most often at risk, but any bone can fracture. § Lack of calcium, estrogen, or testosterone are common causes. Calcium levels are low (phosphate, PTH, and phosphatase are normal) § 3 factors most likely to contribute to osteoporosis in older adult: failure to reach peak bone mass in early adulthood, increased bone resorption, and decreased bone formation § _______________________________ is a loss of bone related to lack of vitamin D (needed for calcium absorption). Bones get soft (no calcification), and fractures and leg bowing are common. Calcium and phosphorus are low; PTH and alkaline phosphatase is high § Osteopenia (low bone mass) occurs when osteoclastic (bone absorption) is greater than osteoblastic (bone building) activity; resulting in decreased bone mineral density (BMD). · Cancellous (spongy) bone is lost first, followed by loss of cortical (compact) bone, resulting in thing, fragile, bone tissue with risk of fracture · Risk Factors: family history, thin/lean body build, females (primary), males (secondary), low calcium/vitamin D intake, limited protein intake, smoking, alcohol, excess caffeine, malabsorption disorders, physical inactivity, immobility, older adults, musculoskeletal disorders, stress, long term use of steroids/PPIs/thyroid hormones/aluminum-antacids

Chronic metabolic disease caused by bone loss, which causes decreased density/strength and fragile bone tissue, increasing risk of fracture. First sign often is a fracture.

Osteoporosis · Osteoporosis: ____________________________________________________________________ § Spine, hip & wrist are most often at risk, but any bone can fracture. § Lack of calcium, estrogen, or testosterone are common causes. Calcium levels are low (phosphate, PTH, and phosphatase are normal) § 3 factors most likely to contribute to osteoporosis in older adult: failure to reach peak bone mass in early adulthood, increased bone resorption, and decreased bone formation § Osteomalacia is a loss of bone related to lack of vitamin D (needed for calcium absorption). Bones get soft (no calcification), and fractures and leg bowing are common. Calcium and phosphorus are low; PTH and alkaline phosphatase is high § Osteopenia (low bone mass) occurs when osteoclastic (bone absorption) is greater than osteoblastic (bone building) activity; resulting in decreased bone mineral density (BMD). · Cancellous (spongy) bone is lost first, followed by loss of cortical (compact) bone, resulting in thing, fragile, bone tissue with risk of fracture · Risk Factors: family history, thin/lean body build, females (primary), males (secondary), low calcium/vitamin D intake, limited protein intake, smoking, alcohol, excess caffeine, malabsorption disorders, physical inactivity, immobility, older adults, musculoskeletal disorders, stress, long term use of steroids/PPIs/thyroid hormones/aluminum-antacids

bone density in your youth, especially for young women because they begin to lose bone after 30

Prevention of Osteoporosis · Build __________________________________ · CA & Vit D. intake: milk, dairy, dark green leafy vegetables, eggs, fish, cereal, orange juice, red/white beans, figs · Sunlight (with sunscreen) · Weight bearing exercises: walking, lifting weights · Smoking cessation, avoiding alcohol · Weight loss

focuses on pain and inflammation management & slowing progression. Similar treatment to RA, using DMARDS, Biologic response modifiers

Psoriatic Arthritis · Psoriatic Arthritis: a chronic skin condition characterized by a scaly, itchy rash, usually on the elbows, knees, and scalp. Joints are also inflamed. It is autoimmune · Some patients with psoriasis can be affected with psoriatic arthritis (PsA). · Joint pain associated with psoriasis is often associated with stiffness, especially in the AM. It is often one large joint, but it may be multiple joints · Neck and back/spine pain are common, but forms of the disease can cause small joint arthritis or sacroiliac joints of the spine. · Most often ages 30-50 years old. · Genetic & environmental factors, infectious agents & immune system dysfunction may be cause. · Most pt's don't experience destructive & deforming arthritis affecting more than 3 joints, but if they do, they experience a major impact on life. · Treatment ___________________________________________________

regional epidural/spinal blocks (good for older adults), morphine, PCA, acetaminophen. Often they do not need IV analgesics after the first day

Surgical Management of Osteoarthritis (OA): Total Joint Arthroplasty (total joint replacement) § Use an abduction pillow or splint. Keep the leg in a neutral rotation § Keep heels off the bed (pressure ulcers) § Promote mobility: Assist with movement, move slowly. Often they get out of bed the night of surgery · Caution for orthostatic hypotension in the older adult. · Put a gait belt on them and stand on the same side of the bed as the affected let. Remind them to stand on the unaffected leg and pivot to the chair with guidance · To avoid injury, do not lift the patient! · Use raised toilet seats and reclining chairs to prevent flexing hips beyond 90 degrees (posterior). · Avoid twisting the body or crossing legs · Collaborate with PT on weight-bearing instructions. Most older adults use walkers, but younger adults often use crutches · Extensive physical therapy is needed. Discharge can be to home or rehab, but if to home, home care is needed for 4-6 weeks. § Manage pain: ____________________________________________________________________________ § Ice therapy: max of 20 minutes on, monitor skin integrity, document education § Monitor surgical site, vitals, H/H q4h for 24hr, observe for infection (altered mental state in elderly, drainage, odor, possible fever) § Neurovascular assessment q2-4h: color, temp, distal pulses, cap refill, movement, sensation; compare operative leg to unaffected leg § Prevent VTE: SCDs, antiembolism stockings, anticoagulant therapy for 10 days after surgery (warfarin, LMWH), early ambulation · Monitor PT/INR · Plantar flexion and dorsiflexion (heel pumping) · Circumduction (circles) of the feet · gluteal and quadriceps muscle setting: push heels into bed and achieve quad sets by straightening the legs and pushing the backs of knees into bed · straight-leg raises (SLRs) § Promote self management: supply assistive devices to help with ADLs · Use extended handles on shoehorns and dressing sticks for reaching to prevent bending, stooping, and flexing hips beyond 90 degrees · Use grab bars, raised toilet seats, walkers, shower chairs · Often takes 6 weeks or more for complete recovery § *maintain correct positioning at all times. When patient returns from PACU, place them in a supine position with head slightly elevated. Do not turn on operative side § Posterior approach: keep legs slightly abducted with abduction pillow between legs to prevent adduction beyond the midline of the body · prevent hip flexion beyond 90 degrees · Some hospitals have straps to help restless patients or those with delirium/dementia. But one or two pillows is often enough to remind them do keep legs abducted § Anterior Approach: do not need abduction; prevent hip hyperextension and external rotation of the leg

a single limb/bone.

Regional Osteoporosis · Regional Osteoporosis, an example of secondary disease, occurs when a limb is immobilized related to an injury, fracture, or paralysis. § Occurs to ________________________________ § Example when a limb is immobilized r/t a injury for longer than 8 to 12 weeks. § Bone loss also occurs when people spend prolonged time in gravity-free zones (astronauts)

asbestos or silica

Rheumatoid Arthritis (RA) · Rheumatoid Arthritis (RA): CHRONIC, PROGRESSIVE, SYSTEMIC,INFLAMMATORY, AUTOIMMUNE disease affecting ANY synovial joints (and other tissues). Unlike OA, you assess the whole body because this condition affects theENTIRE BODY and has REMISSIONS/EXACERBATIONS · Risk Factors for Rheumatoid Arthritis (RA): § Gender (Women > men). § Age (can occur at any age, but commonly begins between the ages of 40 and 60). § Family history, Genetics, Viral exposure (Epstein-Barr Virus), Stress § Smoking (particularly with a genetic predisposition for developing the disease). also associated with greater disease severity. § Environmental exposures (_______________________________________________) Emergency workers exposed to dust from the collapse of the World Trade Center are at higher risk of autoimmune diseases such as rheumatoid arthritis. § Obesity, Older Age

keep legs slightly abducted with abduction pillow between legs to prevent adduction beyond the midline of the body · prevent hip flexion beyond 90 degrees · Some hospitals have straps to help restless patients or those with delirium/dementia. But one or two pillows is often enough to remind them do keep legs abducted

Surgical Management of Osteoarthritis (OA): Total Joint Arthroplasty (total joint replacement) § Use an abduction pillow or splint. Keep the leg in a neutral rotation § Keep heels off the bed (pressure ulcers) § Promote mobility: Assist with movement, move slowly. Often they get out of bed the night of surgery · Caution for orthostatic hypotension in the older adult. · Put a gait belt on them and stand on the same side of the bed as the affected let. Remind them to stand on the unaffected leg and pivot to the chair with guidance · To avoid injury, do not lift the patient! · Use raised toilet seats and reclining chairs to prevent flexing hips beyond 90 degrees (posterior). · Avoid twisting the body or crossing legs · Collaborate with PT on weight-bearing instructions. Most older adults use walkers, but younger adults often use crutches · Extensive physical therapy is needed. Discharge can be to home or rehab, but if to home, home care is needed for 4-6 weeks. § Manage pain: regional epidural/spinal blocks (good for older adults), morphine, PCA, acetaminophen. Often they do not need IV analgesics after the first day § Ice therapy: max of 20 minutes on, monitor skin integrity, document education § Monitor surgical site, vitals, H/H q4h for 24hr, observe for infection (altered mental state in elderly, drainage, odor, possible fever) § Neurovascular assessment q2-4h: color, temp, distal pulses, cap refill, movement, sensation; compare operative leg to unaffected leg § Prevent VTE: SCDs, antiembolism stockings, anticoagulant therapy for 10 days after surgery (warfarin, LMWH), early ambulation · Monitor PT/INR · Plantar flexion and dorsiflexion (heel pumping) · Circumduction (circles) of the feet · gluteal and quadriceps muscle setting: push heels into bed and achieve quad sets by straightening the legs and pushing the backs of knees into bed · straight-leg raises (SLRs) § Promote self management: supply assistive devices to help with ADLs · Use extended handles on shoehorns and dressing sticks for reaching to prevent bending, stooping, and flexing hips beyond 90 degrees · Use grab bars, raised toilet seats, walkers, shower chairs · Often takes 6 weeks or more for complete recovery § *maintain correct positioning at all times. When patient returns from PACU, place them in a SUPINE POSITION with HEAD SLIGHTLY ELEVATED. Do not turn on operative side!!!!! § Posterior approach: ________________________________________________________________________________ - - - - § Anterior Approach: do not need abduction; prevent hip hyperextension and external rotation of the leg

do not need abduction; prevent hip hyperextension and external rotation of the leg

Surgical Management of Osteoarthritis (OA): Total Joint Arthroplasty (total joint replacement) § Use an abduction pillow or splint. Keep the leg in a neutral rotation § Keep heels off the bed (pressure ulcers) § Promote mobility: Assist with movement, move slowly. Often they get out of bed the night of surgery · Caution for orthostatic hypotension in the older adult. · Put a gait belt on them and stand on the same side of the bed as the affected let. Remind them to stand on the unaffected leg and pivot to the chair with guidance · To avoid injury, do not lift the patient! · Use raised toilet seats and reclining chairs to prevent flexing hips beyond 90 degrees (posterior). · Avoid twisting the body or crossing legs · Collaborate with PT on weight-bearing instructions. Most older adults use walkers, but younger adults often use crutches · Extensive physical therapy is needed. Discharge can be to home or rehab, but if to home, home care is needed for 4-6 weeks. § Manage pain: regional epidural/spinal blocks (good for older adults), morphine, PCA, acetaminophen. Often they do not need IV analgesics after the first day § Ice therapy: max of 20 minutes on, monitor skin integrity, document education § Monitor surgical site, vitals, H/H q4h for 24hr, observe for infection (altered mental state in elderly, drainage, odor, possible fever) § Neurovascular assessment q2-4h: color, temp, distal pulses, cap refill, movement, sensation; compare operative leg to unaffected leg § Prevent VTE: SCDs, antiembolism stockings, anticoagulant therapy for 10 days after surgery (warfarin, LMWH), early ambulation · Monitor PT/INR · Plantar flexion and dorsiflexion (heel pumping) · Circumduction (circles) of the feet · gluteal and quadriceps muscle setting: push heels into bed and achieve quad sets by straightening the legs and pushing the backs of knees into bed · straight-leg raises (SLRs) § Promote self management: supply assistive devices to help with ADLs · Use extended handles on shoehorns and dressing sticks for reaching to prevent bending, stooping, and flexing hips beyond 90 degrees · Use grab bars, raised toilet seats, walkers, shower chairs · Often takes 6 weeks or more for complete recovery § *maintain correct positioning at all times. When patient returns from PACU, place them in a supine position with head slightly elevated. Do not turn on operative side § Posterior approach: keep legs slightly abducted with abduction pillow between legs to prevent adduction beyond the midline of the body · prevent hip flexion beyond 90 degrees · Some hospitals have straps to help restless patients or those with delirium/dementia. But one or two pillows is often enough to remind them do keep legs abducted § Anterior Approach: _______________________________________________________________________

SCDs, antiembolism stockings, anticoagulant therapy for 10 days after surgery (warfarin, LMWH), early ambulation · Monitor PT/INR · Plantar flexion and dorsiflexion (heel pumping) · Circumduction (circles) of the feet · gluteal and quadriceps muscle setting: push heels into bed and achieve quad sets by straightening the legs and pushing the backs of knees into bed · straight-leg raises (SLRs)

Surgical Management of Osteoarthritis (OA): Total Joint Arthroplasty (total joint replacement) § Use an abduction pillow or splint. Keep the leg in a neutral rotation § Keep heels off the bed (pressure ulcers) § Promote mobility: Assist with movement, move slowly. Often they get out of bed the night of surgery · Caution for orthostatic hypotension in the older adult. · Put a gait belt on them and stand on the same side of the bed as the affected let. Remind them to stand on the unaffected leg and pivot to the chair with guidance · To avoid injury, do not lift the patient! · Use raised toilet seats and reclining chairs to prevent flexing hips beyond 90 degrees (posterior). · Avoid twisting the body or crossing legs · Collaborate with PT on weight-bearing instructions. Most older adults use walkers, but younger adults often use crutches · Extensive physical therapy is needed. Discharge can be to home or rehab, but if to home, home care is needed for 4-6 weeks. § Manage pain: regional epidural/spinal blocks (good for older adults), morphine, PCA, acetaminophen. Often they do not need IV analgesics after the first day § Ice therapy: max of 20 minutes on, monitor skin integrity, document education § Monitor surgical site, vitals, H/H q4h for 24hr, observe for infection (altered mental state in elderly, drainage, odor, possible fever) § Neurovascular assessment q2-4h: color, temp, distal pulses, cap refill, movement, sensation; compare operative leg to unaffected leg § Prevent VTE: ____________________________________________________________________ - - - - § Promote self management: supply assistive devices to help with ADLs · Use extended handles on shoehorns and dressing sticks for reaching to prevent bending, stooping, and flexing hips beyond 90 degrees · Use grab bars, raised toilet seats, walkers, shower chairs · Often takes 6 weeks or more for complete recovery § *maintain correct positioning at all times. When patient returns from PACU, place them in a supine position with head slightly elevated. Do not turn on operative side § Posterior approach: keep legs slightly abducted with abduction pillow between legs to prevent adduction beyond the midline of the body · prevent hip flexion beyond 90 degrees · Some hospitals have straps to help restless patients or those with delirium/dementia. But one or two pillows is often enough to remind them do keep legs abducted § Anterior Approach: do not need abduction; prevent hip hyperextension and external rotation of the leg

Dual-energy x-ray absorptiometry scan (DEXA) · Women over 40 should have baseline scan taken, to compare with later bone changes. · Patient's height is taken before exam · They can leave clothes on, but should remove jewelry or metal

Screening and Treatment for Osteoporosis · Screening/Diagnosis of Osteoporosis: § ESR, alkaline phosphatase, vitamin D, calcium, H/H to rule out other causes § Serum calcium and vitamin D measured yearly for all women and men over 50 § ______________________________________: is the best tool to dx osteoporosis; a scan that estimates the density of bone mass and presence of osteoporosis using two beans of radiation (no contrast solution). It is not recommended for pregnant or lactating clients. The client can stay dressed by should remove metal objects. After the scan, follow up with provider for results. · Women over 40 should have baseline scan taken, to compare with later bone changes. · Patient's height is taken before exam · They can leave clothes on, but should remove jewelry or metal § Osteoporosis is dx when T-score is at or more than -2.5 on BMD § CT-based absorptiometry, or quantitative computed tomography to measure bone density and strength of vertebral spine and hip § MRI and MRS to provide info on bone density without exposure to radiation. Areas of osteoporosis show decreased perfusion § Vertebral imaging for: · All women older than 70 and men older than 80 if BMD score is less than or equal to 1.0 · Women aged 65-95 and men 70-79 id BMD is less than or equal to 1.5 · Postmenopausal women and men age 50 and up with risk factors

§ Heberden's nodes: bony nodules at the distal interphalangeal joints (tip of finger) § Bouchard's nodes: bony nodules at the proximal interphalangeal joints (knuckles, joints closer to palm)

Signs and Symptoms of Osteoarthritis (OA): NO SYSTEMIC SYMPTOMS, fever, malaise, fatigue · History/Risks: older women (60+), occupation that causes repetitive movement (construction, labor, plumbers, carpet layers who have stooped posture), falls/trauma, weight history (obesity), sports, family history of arthritis, previous medical conditions that may cause joint problems/injuries, metabolic disorders (diabetes, sickle cell) § Typical pt is a middle-aged or older woman reporting chronic joint pain & stiffness. · Most commonly affects weight-bearing joints in your hands, knees, hips and spine · Symptoms often develop slowly over years, and is ASYMMETRICAL · Pain & Tenderness: assess pain on scale of 0-10 § Pain IMPROVES WITH REST, WORSE WITH ACTIVITY (later in disease, pain stays at rest) § Tenderness to palpation or with ROM § Pain may occur with minor movement/motion or at rest later in the disease. § Vertebral/radiating pain affected by cervical/lumbar compression of nerves · STIFFNESS/LOSS OF FLEXIBILITY/PAIN especially in the morning that lasts less than 30min · CREPITUS (popping/cracking/crunching/grinding) felt/heard during ROM · Bone spurs (May feel like hard lumps). · JOINT MAY BE ENLARGED/INFLAMED/WARM (BONY HYPERTROPHY) & may feel hard to palpation (synovitis). It can result in bone malalignment, DEFORMITY, and ankylosis · JOINT EFFUSIONS (excess joint fluid) is common when knees are inflamed. · NODES: common on hands; they appear red, hot, painful (discomfort on palpation) § Heberden's nodes: ____________________________________ § Bouchard's nodes: __________________________________________________________ § OA is NOT typically a bilateral/symmetric disease, but these nodes typically appear bilaterally. Usually it is worse in one hand than the other § Often in women, and with familial history · *observe for any ATROPHY OF MUSCLE because OA discourages movement of painful joints, which can cause contractions, muscle atrophy, and further pain. § Loss of function or decreased mobility can result, especially walking with hip/knee pain (results in limping) · OA can affect the SPINE, resulting in radiating pain, stiffness, and muscle spasms in extremities · Psychosocial: impaired QOL, sexual function, depression, anxiety, impaired body image

IMPROVES WITH REST, WORSE WITH ACTIVITY (later in disease, pain stays at rest)

Signs and Symptoms of Osteoarthritis (OA): NO SYSTEMIC SYMPTOMS, fever, malaise, fatigue · History/Risks: older women (60+), occupation that causes repetitive movement (construction, labor, plumbers, carpet layers who have stooped posture), falls/trauma, weight history (obesity), sports, family history of arthritis, previous medical conditions that may cause joint problems/injuries, metabolic disorders (diabetes, sickle cell) § Typical pt is a middle-aged or older woman reporting chronic joint pain & stiffness. · Most commonly affects weight-bearing joints in your hands, knees, hips and spine · Symptoms often develop slowly over years, and is ASYMMETRICAL · Pain & Tenderness: assess pain on scale of 0-10 § Pain _______________________________ § Tenderness to palpation or with ROM § Pain may occur with minor movement/motion or at rest later in the disease. § Vertebral/radiating pain affected by cervical/lumbar compression of nerves · STIFFNESS/LOSS OF FLEXIBILITY/PAIN especially in the morning that lasts less than 30min · CREPITUS (popping/cracking/crunching/grinding) felt/heard during ROM · Bone spurs (May feel like hard lumps). · JOINT MAY BE ENLARGED/INFLAMED/WARM (BONY HYPERTROPHY) & may feel hard to palpation (synovitis). It can result in bone malalignment, DEFORMITY, and ankylosis · JOINT EFFUSIONS (excess joint fluid) is common when knees are inflamed. · NODES: common on hands; they appear red, hot, painful (discomfort on palpation) § Heberden's nodes: bony nodules at the distal interphalangeal joints (tip of finger) § Bouchard's nodes: bony nodules at the proximal interphalangeal joints (knuckles, joints closer to palm) § OA is NOT typically a bilateral/symmetric disease, but these nodes typically appear bilaterally. Usually it is worse in one hand than the other § Often in women, and with familial history · *observe for any ATROPHY OF MUSCLE because OA discourages movement of painful joints, which can cause contractions, muscle atrophy, and further pain. § Loss of function or decreased mobility can result, especially walking with hip/knee pain (results in limping) · OA can affect the SPINE, resulting in radiating pain, stiffness, and muscle spasms in extremities · Psychosocial: impaired QOL, sexual function, depression, anxiety, impaired body image

free hanging (not on floor) and DO NOT pull them up in bed with weights on. If weights are displaced, replace the weights. If weight is still not correct, notify the physician

Skeletal Traction Nursing Implications · Assess neurovascular status to detect impaired perfusion/circulation/tissue integrity. · Circulation is monitored every hour for 24 hours then every 4 hours · Check equipment, ropes, knots, and pulleys every 8-12 hr for loosening, fraying, and positioning. AVOID lifting/moving weights · Check the wight for consistency with prescription (sometimes people bump into it). Make sure weights are _______________________________________________________________ · Ensure that pulley ropes are free of knots, fraying, loosening, or improper positioning q8-12h · The foot plate needs to be at 90 degree angle and not touching the end of the bed! · If the patient reports severe pain from muscle spasm, the weight may be too heavy or the bone may need realignment. Report to the physician if body realignment does not improve comfort · Move the client with a halo traction as a unit, without applying pressure to the rods to prevent pain and loosening of pins · Use heat/massage, relaxation, etc as ordered to treat muscle spasms · Drug therapy: pain management. Never use meperidine because it can cause seizures · Prevent Pressure Ulcers: Special mattress, moving as much as possible, collaborate with physical therapy · Prevent DVT: hydration, SCD on unaffected limb, movement, anticoagulants · Prevent infection (osteomyelitis, UTI, pneumonia): TCD, incentive spirometer, nutrition, hydration, pin care · Prevent constipation: hydration, dietary fiber, PRN stool softeners Traction- Pin Care · Based on provider preference and facility protocol (chlorhexidine) · Monitor for infection/complications: drainage, redness, foul odor, loosening pins, tenting of skin at pin site (skin raising up pin) · Peroxide/cleaning solution soaked cotton swab: Use one cotton swab for each pin and move in the direction from the skin up the pin · Daily or every shift. Frequency may be increased if infection is suspected

90 degree angle and not touching the end of the bed! (prevents foot drop)

Skeletal Traction Nursing Implications · Assess neurovascular status to detect impaired perfusion/circulation/tissue integrity. · Circulation is monitored every hour for 24 hours then every 4 hours · Check equipment, ropes, knots, and pulleys every 8-12 hr for loosening, fraying, and positioning. AVOID lifting/moving weights · Check the wight for consistency with prescription (sometimes people bump into it). Make sure weights are free hanging (not on floor) and DO NOT pull them up in bed with weights on. If weights are displaced, replace the weights. If weight is still not correct, notify the physician · Ensure that pulley ropes are free of knots, fraying, loosening, or improper positioning q8-12h · The foot plate needs to be at ____________________________________ · If the patient reports severe pain from muscle spasm, the weight may be too heavy or the bone may need realignment. Report to the physician if body realignment does not improve comfort · Move the client with a halo traction as a unit, without applying pressure to the rods to prevent pain and loosening of pins · Use heat/massage, relaxation, etc as ordered to treat muscle spasms · Drug therapy: pain management. Never use meperidine because it can cause seizures · Prevent Pressure Ulcers: Special mattress, moving as much as possible, collaborate with physical therapy · Prevent DVT: hydration, SCD on unaffected limb, movement, anticoagulants · Prevent infection (osteomyelitis, UTI, pneumonia): TCD, incentive spirometer, nutrition, hydration, pin care · Prevent constipation: hydration, dietary fiber, PRN stool softeners Traction- Pin Care · Based on provider preference and facility protocol (chlorhexidine) · Monitor for infection/complications: drainage, redness, foul odor, loosening pins, tenting of skin at pin site (skin raising up pin) · Peroxide/cleaning solution soaked cotton swab: Use one cotton swab for each pin and move in the direction from the skin up the pin · Daily or every shift. Frequency may be increased if infection is suspected

any infection, Advanced osteoporosis, severe medical problems (HTN, DM), rapidly progressive inflammation, A1C greater than 7% (infection risk)

Surgical Management of Osteoarthritis (OA) · Total Joint Arthroplasty (total joint replacement) procedure most often used to manage the pain of OA and improve mobility when injections don't work. If the patient is having joint replacement for the first time, it is primary arthroplasty. If the implant loosens or fails, revision arthroplasty is performed. · Contraindications: __________________________________________________________________________ · *the special needs of older adults often complication the perioperative period and may result in postoperative complications · PRE-OP CARE TJA/TJR: § Collaborate with PT and OT § Assess CBC (H/H, RBC, Platelet, WBC), CMB (BUN, creatinine, LFT, electrolytes), A1C, PT/INR, urinalysis, Chest x-ray, and ECG to rule out anemia, infection, pulmonary tumor/infection, or dysrhythmias. § Blood type and screen: looking at blood to find your blood type and antibodies. Screening only the person (often done for knee replacement) § Blood type and cross match: taking your blood and finding blood in the bank that matches your blood. Pulling the blood from the bank to have on hand. THEY GET A BLOOD BAND (never take it off unless the t/cm has expired) § Educate on autologous blood donation, cell saver systems, or reinfusion systems that may be used to restore lost blood during procedure § If patient has anemia or low blood count, surgeon may prescribe epoetin alfa to promote RBC growth (useful for older adults with mild anemia before surgery or for those with religious beliefs that contraindicate infusions) § Assess clotting (VTE) risk: history of VTE, smoking, obesity, limited mobility, advanced age § Discontinue Rx that increase r/f clotting and bleeding: anticoagulants, NSAIDs, Vit. C & E, hormone replacement therapy or oral contraceptive drugs at least one week-10 days before surgery. § Assess the patient's understanding; provide them with notebook/DVD information on post-op mobility that they can take home to review and share with family (especially useful for patients with poor reading or memory) § Teach the patient about transfers, positioning, incentive spirometry, and ambulation, muscle exercises, surgical drains, dressings, and pain control measures that will be used after surgery § Assess for mobility issues, need for assistive or adaptive equipment (walkers, commode chairs, crutches, shower chairs, grab bars). § Rehab for a few weeks PREOP to build up muscles and learn exercises § Patients need to have dental procedures done at least 2 weeks before surgery (prevents infection) § Teach patients to tell any future providers that they have had a total joint arthroplasty § They NEED to take a shower or scrub the surgical site with special antiseptic soap 1-3 nights before and the MORNING OF SURGERY. They will wear clean nightwear and sleep on clean linens the night before. § If medications aren't contraindicated before surgery (GERD/HEART drugs: antiHTN, BB, omeprazole, PPIs), take with SMALL amount of water to prevent n/v and aspiration

Rx that increase r/f clotting and bleeding: anticoagulants, NSAIDs, Vit. C & E, hormone replacement therapy or oral contraceptive drugs at least one week-10 days before surgery.

Surgical Management of Osteoarthritis (OA) · Total Joint Arthroplasty (total joint replacement) procedure most often used to manage the pain of OA and improve mobility when injections don't work. If the patient is having joint replacement for the first time, it is primary arthroplasty. If the implant loosens or fails, revision arthroplasty is performed. · Contraindications: any infection, Advanced osteoporosis, severe medical problems (HTN, DM), rapidly progressive inflammation, A1C greater than 7% (infection risk) · *the special needs of older adults often complication the perioperative period and may result in postoperative complications · PRE-OP CARE TJA/TJR: § Collaborate with PT and OT § Assess CBC (H/H, RBC, Platelet, WBC), CMB (BUN, creatinine, LFT, electrolytes), A1C, PT/INR, urinalysis, Chest x-ray, and ECG to rule out anemia, infection, pulmonary tumor/infection, or dysrhythmias. § Blood type and screen: looking at blood to find your blood type and antibodies. Screening only the person (often done for knee replacement) § Blood type and cross match: taking your blood and finding blood in the bank that matches your blood. Pulling the blood from the bank to have on hand. THEY GET A BLOOD BAND (never take it off unless the t/cm has expired) § Educate on autologous blood donation, cell saver systems, or reinfusion systems that may be used to restore lost blood during procedure § If patient has anemia or low blood count, surgeon may prescribe epoetin alfa to promote RBC growth (useful for older adults with mild anemia before surgery or for those with religious beliefs that contraindicate infusions) § Assess clotting (VTE) risk: history of VTE, smoking, obesity, limited mobility, advanced age § Discontinue ____________________________________________________________________________________ § Assess the patient's understanding; provide them with notebook/DVD information on post-op mobility that they can take home to review and share with family (especially useful for patients with poor reading or memory) § Teach the patient about transfers, positioning, incentive spirometry, and ambulation, muscle exercises, surgical drains, dressings, and pain control measures that will be used after surgery § Assess for mobility issues, need for assistive or adaptive equipment (walkers, commode chairs, crutches, shower chairs, grab bars). § Rehab for a few weeks PREOP to build up muscles and learn exercises § Patients need to have dental procedures done at least 2 weeks before surgery (prevents infection) § Teach patients to tell any future providers that they have had a total joint arthroplasty § They NEED to take a shower or scrub the surgical site with special antiseptic soap 1-3 nights before and the MORNING OF SURGERY. They will wear clean nightwear and sleep on clean linens the night before. § If medications aren't contraindicated before surgery (GERD/HEART drugs: antiHTN, BB, omeprazole, PPIs), take with SMALL amount of water to prevent n/v and aspiration

GERD/HEART drugs: antiHTN, BB, omeprazole, PPIs

Surgical Management of Osteoarthritis (OA) · Total Joint Arthroplasty (total joint replacement) procedure most often used to manage the pain of OA and improve mobility when injections don't work. If the patient is having joint replacement for the first time, it is primary arthroplasty. If the implant loosens or fails, revision arthroplasty is performed. · Contraindications: any infection, Advanced osteoporosis, severe medical problems (HTN, DM), rapidly progressive inflammation, A1C greater than 7% (infection risk) · *the special needs of older adults often complication the perioperative period and may result in postoperative complications · PRE-OP CARE TJA/TJR: § Collaborate with PT and OT § Assess CBC (H/H, RBC, Platelet, WBC), CMB (BUN, creatinine, LFT, electrolytes), A1C, PT/INR, urinalysis, Chest x-ray, and ECG to rule out anemia, infection, pulmonary tumor/infection, or dysrhythmias. § Blood type and screen: looking at blood to find your blood type and antibodies. Screening only the person (often done for knee replacement) § Blood type and cross match: taking your blood and finding blood in the bank that matches your blood. Pulling the blood from the bank to have on hand. THEY GET A BLOOD BAND (never take it off unless the t/cm has expired) § Educate on autologous blood donation, cell saver systems, or reinfusion systems that may be used to restore lost blood during procedure § If patient has anemia or low blood count, surgeon may prescribe epoetin alfa to promote RBC growth (useful for older adults with mild anemia before surgery or for those with religious beliefs that contraindicate infusions) § Assess clotting (VTE) risk: history of VTE, smoking, obesity, limited mobility, advanced age § Discontinue Rx that increase r/f clotting and bleeding: anticoagulants, NSAIDs, Vit. C & E, hormone replacement therapy or oral contraceptive drugs at least one week-10 days before surgery. § Assess the patient's understanding; provide them with notebook/DVD information on post-op mobility that they can take home to review and share with family (especially useful for patients with poor reading or memory) § Teach the patient about transfers, positioning, incentive spirometry, and ambulation, muscle exercises, surgical drains, dressings, and pain control measures that will be used after surgery § Assess for mobility issues, need for assistive or adaptive equipment (walkers, commode chairs, crutches, shower chairs, grab bars). § Rehab for a few weeks PREOP to build up muscles and learn exercises § Patients need to have dental procedures done at least 2 weeks before surgery (prevents infection) § Teach patients to tell any future providers that they have had a total joint arthroplasty § They NEED to take a shower or scrub the surgical site with special antiseptic soap 1-3 nights before and the MORNING OF SURGERY. They will wear clean nightwear and sleep on clean linens the night before. § If medications aren't contraindicated before surgery (_____________________________________________________________________), take with SMALL amount of water to prevent n/v and aspiration

temporary change in mental state immediately after surgery as a result of anesthesia and unfamiliar sensory stimuli. Reorient frequently

Surgical Management of Osteoarthritis (OA): Total Joint Arthroplasty (total joint replacement) -Special Post-Op TJR/TJA Considerations for Older Adults: § For posterior approach: use abduction pillow or splint to prevent adduction after surgery if patient is restless or has altered cognition § For anterior approach: no abduction pillow is needed § Keep heels off bed to prevent pressure sores § Do not rely on fever as sign of infection (older adults can have infection without fever). Alert to decreased mental status or elevated WBC § Assisting patient out of bed: move slowly (orthostatic hypotension), allow them to sit on the bed before standing, have them stand for a period before walking § Encourage deep breathing, coughing, and incentive spirometry q2h to prevent atelectasis/pneumonia § As soon as allowed, get patient out of bed to recliner to prevent immobility complications § Anticipate need for pain meds (especially if they can't verbalize pain). Assess the need to medical for break-through pain § Expect a ______________________________________________________________________

on the same side of the bed as the affected let. Remind them to stand on the unaffected leg and pivot to the chair with guidance

Surgical Management of Osteoarthritis (OA): Total Joint Arthroplasty (total joint replacement) § Use an abduction pillow or splint. Keep the leg in a neutral rotation § Keep heels off the bed (pressure ulcers) § Promote mobility: Assist with movement, move slowly. Often they get out of bed the night of surgery · Caution for orthostatic hypotension in the older adult. · Put a gait belt on them and stand ________________________________________________________ · To avoid injury, do not lift the patient! · Use raised toilet seats and reclining chairs to prevent flexing hips beyond 90 degrees (posterior). · Avoid twisting the body or crossing legs · Collaborate with PT on weight-bearing instructions. Most older adults use walkers, but younger adults often use crutches · Extensive physical therapy is needed. Discharge can be to home or rehab, but if to home, home care is needed for 4-6 weeks. § Manage pain: regional epidural/spinal blocks (good for older adults), morphine, PCA, acetaminophen. Often they do not need IV analgesics after the first day § Ice therapy: max of 20 minutes on, monitor skin integrity, document education § Monitor surgical site, vitals, H/H q4h for 24hr, observe for infection (altered mental state in elderly, drainage, odor, possible fever) § Neurovascular assessment q2-4h: color, temp, distal pulses, cap refill, movement, sensation; compare operative leg to unaffected leg § Prevent VTE: SCDs, antiembolism stockings, anticoagulant therapy for 10 days after surgery (warfarin, LMWH), early ambulation · Monitor PT/INR · Plantar flexion and dorsiflexion (heel pumping) · Circumduction (circles) of the feet · gluteal and quadriceps muscle setting: push heels into bed and achieve quad sets by straightening the legs and pushing the backs of knees into bed · straight-leg raises (SLRs) § Promote self management: supply assistive devices to help with ADLs · Use extended handles on shoehorns and dressing sticks for reaching to prevent bending, stooping, and flexing hips beyond 90 degrees · Use grab bars, raised toilet seats, walkers, shower chairs · Often takes 6 weeks or more for complete recovery § *maintain correct positioning at all times. When patient returns from PACU, place them in a supine position with head slightly elevated. Do not turn on operative side § Posterior approach: keep legs slightly abducted with abduction pillow between legs to prevent adduction beyond the midline of the body · prevent hip flexion beyond 90 degrees · Some hospitals have straps to help restless patients or those with delirium/dementia. But one or two pillows is often enough to remind them do keep legs abducted § Anterior Approach: do not need abduction; prevent hip hyperextension and external rotation of the leg

LOW-GRADE FEVER, WEAKNESS, FATIGUE, paresthesia, anorexia (weight loss of 2-3lb)

Symptoms of Rheumatoid Arthritis (RA): SYMMETRICAL, SYSTEMIC/JOINT SYMPTOMS · Early Rheumatoid Arthritis (RA) Symptoms: common in hands, fingers, knees, feet § Joint: INFLAMMATION, REDNESS, WARM, STIFF, SWOLLEN, TENDER/PAINFUL (palpitation), often BILATERAL/SYMMETRIC upper extremity joints first (hands) § Systemic: __________________________________________________________________ § *MIGRATORY arthritis: migrating symptoms early in disease § *if only one joint is severely inflamed, it can mean infection, which warrants immediately notifying provider for treatment

dry eyes ["gritty", like sand in eyes], dry mouth, dry vagina (treated with eye drops, artificial saliva, fluids with meals)

Symptoms of Rheumatoid Arthritis (RA): SYMMETRICAL, SYSTEMIC/JOINT SYMPTOMS · Late Rheumatoid Arthritis (RA) Symptoms: common in hands, fingers, knees, feet § Joint: DEFORMITIES, moderate to severe pain & MORNING STIFFNESS (gel phenomenon, which LASTS SEVERAL HOURS after awakening), pannus · Boutonniere deformity, swan-neck deformity, ulnar deformity, Hitchhiker's thumb deformity (all caused by pannus: severe proliferation of synovium) · on palpation joint is soft and puffy due to synovitis and effusions · FINGERS APPEAR SPINDLE-LIKE; may have atrophy and decreased ROM · with mandibular joint involvement, patient can have trouble eating · *CERVICAL RA can result in subluxation, especially with 1st/2ndvertebrae. THIS IS LIFE THREATENING due to nerves that supply diaphragm and respiratory function. Patient is in danger of becoming a quadriplegic. If cervical pain, loss of ROM if present, keep neck straight/neutral and notify provider immediately · Baker's cysts: enlarged popliteal bursae behind knee (do not palpate due to risk of Achilles tendon rupture) § Systemic: · OSTEOPOROSIS, FEVER, WEAKNESS · SEVERE FATIGUE, ANEMIA, MODERATE-SEVERE WEIGHT LOSS, DRY MOUTH · SUBCUTANEOUS NODULES (moveable, nontender, can disappear or reappear) on arm, fingers, or Achilles tendon · PERIPHERAL NEUROPATHY, paresthesia (burning/tingling) · VASCULITIS: can lead to ischemia of organs, which causes small, brownish spots around nail beds known as periungual lesions · OCULAR: episcleritis, scleritis · CARDIAC complications: pericarditis, myocarditis · RESPIRATORY complications: fibrotic lung disease, pleurisy, pulmonary HTN · kidney disease (GIVE O2) · SJOGREN'S SYNDROME: _____________________________________________________ · FELTY'S SYNDROME: hepatosplenomegaly, leukopenia · CAPLAN'S SYNDROME (rheumatoid nodules in the lungs).

DEFORMITIES, moderate to severe pain & MORNING STIFFNESS (gel phenomenon, which LASTS SEVERAL HOURS after awakening), pannus

Symptoms of Rheumatoid Arthritis (RA): SYMMETRICAL, SYSTEMIC/JOINT SYMPTOMS · Late Rheumatoid Arthritis (RA) Symptoms: common in hands, fingers, knees, feet § Joint: _____________________________________________________________________________ · Boutonniere deformity, swan-neck deformity, ulnar deformity, Hitchhiker's thumb deformity (all caused by pannus: severe proliferation of synovium) · on palpation joint is soft and puffy due to synovitis and effusions · FINGERS APPEAR SPINDLE-LIKE; may have atrophy and decreased ROM · with mandibular joint involvement, patient can have trouble eating · *CERVICAL RA can result in subluxation, especially with 1st/2ndvertebrae. THIS IS LIFE THREATENING due to nerves that supply diaphragm and respiratory function. Patient is in danger of becoming a quadriplegic. If cervical pain, loss of ROM if present, keep neck straight/neutral and notify provider immediately · Baker's cysts: enlarged popliteal bursae behind knee (do not palpate due to risk of Achilles tendon rupture) § Systemic: · OSTEOPOROSIS, FEVER, WEAKNESS · SEVERE FATIGUE, ANEMIA, MODERATE-SEVERE WEIGHT LOSS, DRY MOUTH · SUBCUTANEOUS NODULES (moveable, nontender, can disappear or reappear) on arm, fingers, or Achilles tendon · PERIPHERAL NEUROPATHY, paresthesia (burning/tingling) · VASCULITIS: can lead to ischemia of organs, which causes small, brownish spots around nail beds known as periungual lesions · OCULAR: episcleritis, scleritis · CARDIAC complications: pericarditis, myocarditis · RESPIRATORY complications: fibrotic lung disease, pleurisy, pulmonary HTN · kidney disease (GIVE O2) · SJOGREN'S SYNDROME: dry eyes ["gritty", like sand in eyes], dry mouth, dry vagina (treated with eye drops, artificial saliva, fluids with meals) · FELTY'S SYNDROME: hepatosplenomegaly, leukopenia · CAPLAN'S SYNDROME (rheumatoid nodules in the lungs).

Kyphotic posture, widened gait

Terminology · Rheumatic disease: any condition (or disease) involving the musculoskeletal system. § Connective tissue disease is the major focus of rheumatology. Most Connective tissue diseases are autoimmune. · Autoimmune diseases: a disorder where antibodies attack normal, healthy cells & tissue. The causes are unclear. The immune system does not recognize the bodies cells and triggers an immune response. · Most common Connective tissue diseases are characterized by chronic pain, and progressive joint deterioration. Some are localized, some are systemic. · Arthritis: inflammation of one or more joints. It is either inflammatory, or non-inflammatory Musculoskeletal Changes Associated with Aging · Osteopenia is decreased bone density (bone loss) that occurs as a person ages § Teach tips to prevent falls and reinforce the need to exercise (weight-bearing) · Increased bone prominence: prevent pressure on bone prominences · ______________________________: teach proper body mechanics, instruct the patient to sit in supportive chairs with arms · Cartilage degeneration (arthritis): provide most heat (shower or warm, moist compress) · Decreased ROM: assess patient's mobility and performance of ADLs · Muscle atrophy, decreased strength: teach isometric exercises · Slowed movement: do not rush the client, be patient

A. Unexpected snow storm

The administrator of an assisted-living facility cancels a scheduled outing for residents because of an increased risk of falls. What occurred that caused the outing to be cancelled? A. Unexpected snow storm B. Access bus had a flat tire C. Blood-pressure clinic was scheduled for the same time D. Drug representative arrived with donuts to talk about medications

D. I should take my calcium pills first thing in the morning

The nurse instructs a group of senior citizens with osteoporosis on nonpharmacologic measures to prevent further bone deterioration. Which statement indicates that teaching has been effective? A. I should take a 30 minute walk 3 times a week B. I should not smoke and have an alcoholic beverage together C. I should use antacids with aluminum D. I should take my calcium pills first thing in the morning

C. Perform balance exercises when washing the dishes

The nurse observes an older person stumble when getting up from sitting in a chair. Which recommendation should the nurse make to this person? A. Hire a personal trainer to develop an exercise plan B. Encourage to practice scooting on the floor in a seated position C. Perform balance exercises when washing the dishes D. Practice drawling on the floor in prone position

a. "Don't take more than 3000-4000 mg of this drug each day." c. "Tell your health care provider if you notice any yellowing of your skin or eyes." e. "Check over-the-counter drugs to see if they contain acetaminophen."

The primary health care provider prescribes acetaminophen for a client with osteoarthritis. Which health teaching will the nurse provide for the client regarding this drug? (SATA) a. "Don't take more than 3000-4000 mg of this drug each day." b. "Stop taking the drug if unusual bleeding occurs and call your health care provider." c. "Tell your health care provider if you notice any yellowing of your skin or eyes." d. "Expect fluid accumulation in your legs and feet that usually gets worse during the day." e. "Check over-the-counter drugs to see if they contain acetaminophen."

walking for 30 minutes 3-5x/week, dancing, stairs

Treatment for Osteoporosis · Nutrition: Calcium (1500mg/day) & vitamin D supplements, vegetables, low-fat diary, fruits, protein, increased fiber, magnesium, vitamin K § Avoid alcohol, carbonated drinks, and caffeine, stop smoking · Lifestyle change: § Exercise, physical therapy, have a hearing/vision screen regularly § ABD muscle tightening, deep breathing, and pectoral stretching as stressed to increase lung capacity § Extremity strengthening: muscle tightening, resistive or ROM exercises § Weight-bearing exercises: _____________________________________________ § Avoid jarring activities: jogging, horseback riding § Home assessment for safety: remove throw rugs, adequate lighting, clear paths, assistive devices, clearly marked doorways or steps, no slippery floors/shoes (thin non-slip shoes are good; avoid sneakers/slippers with deep treads), wear hip protectors, keep temperature at a comfortable level

Refrigerate

Treatment for Rheumatoid Arthritis (RA): · Biologic agents/ biologic response modifiers: newer class of DMARDs includes abatacept, etanercept, anakinra, certolizumab, adalimumab golimumab, infliximab, rituximab, tocilizumab, and tofacitinib. § These drugs can target parts of the immune system that trigger inflammation that causes joint and tissue damage. They increase the risk of infections. Avoid sick people and large crowds. Get TB test prior to starting, and do not give to those with positive TB tests or other serious infections § Avoid live immunizations while taking DMARDS/Biologic response modifiers § ____________________________ all DMARDS/Biologic response modifiers § Monitor WBC level § Biologic DMARDs are usually most effective when paired with a nonbiologic DMARD, such as methotrexate

Avoid sick people and large crowds. Get TB test prior to starting, and do not give to those with positive TB tests or other serious infections § Avoid live immunizations while taking DMARDS/Biologic response modifiers

Treatment for Rheumatoid Arthritis (RA): · Biologic agents/ biologic response modifiers: newer class of DMARDs includes abatacept, etanercept, anakinra, certolizumab, adalimumab golimumab, infliximab, rituximab, tocilizumab, and tofacitinib. § These drugs can target parts of the immune system that trigger inflammation that causes joint and tissue damage. They increase the risk of infections. ___________________________________________________________________ § Refrigerate all DMARDS/Biologic response modifiers § Monitor WBC level § Biologic DMARDs are usually most effective when paired with a nonbiologic DMARD, such as methotrexate

thinning of bones/osteoporosis, weight gain, decreased immunity, fluid/electrolyte imbalance, glaucoma/cataracts, HTN, and diabetes

Treatment for Rheumatoid Arthritis (RA): · Corticosteroids (prednisone): are given for fast-acting anti-inflammatory and immunosuppressive effects, managing pain, and slow joint damage for acute problems. § Side effects: _____________________________________________________________. § Monitor BP, glucose, weight, vision, impaired healing, bloody stools § Avoid large crowds and sick people. § Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication. § Take a calcium and vitamin D supplement § May give as pulse therapy: high dose for short duration.

·1 Monitor CBC ( low WBC/platelet), LFTs, serum creatinine ·2 *risk of infection due to decreased immunity. Avoid crowds and sick people. Report mouth sores and dyspnea (pneumonitis) ·3 Avoid alcohol due to liver toxicity ·4 Folic acid may be given to relieve side effects ·5 *strict birth control is needed because Methotrexate causes birth defects

Treatment for Rheumatoid Arthritis (RA): · Disease-modifying antirheumatic drugs (DMARDs): These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. § methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, minocycline § Side effects: liver damage, bone marrow suppression (decreased WBC and platelets) and severe lung infections. § Methotrexate takes 4-6 weeks to begin to control joint inflammation 1 2 3 4 5 § Leflunomide can cause hair loss, decreased WBC/platelets (bone marrow suppression), and liver damage. Avoid alcohol, and use strict birth control § Hydroxychloroquine can cause retinal damage, so report blurred vision, headache. Have yearly eye exam before taking and every 6 months after starting

retinal damage, so report blurred vision, headache. Have yearly eye exam before taking and every 6 months after starting

Treatment for Rheumatoid Arthritis (RA): · Disease-modifying antirheumatic drugs (DMARDs): These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. § methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, minocycline § Side effects: liver damage, bone marrow suppression (decreased WBC and platelets) and severe lung infections. § Methotrexate takes 4-6 weeks to begin to control joint inflammation · Monitor CBC ( low WBC/platelet), LFTs, serum creatinine · *risk of infection due to decreased immunity. Avoid crowds and sick people. Report mouth sores and dyspnea (pneumonitis) · Avoid alcohol due to liver toxicity · Folic acid may be given to relieve side effects · *strict birth control is needed because Methotrexate causes birth defects § Leflunomide can cause hair loss, decreased WBC/platelets (bone marrow suppression), and liver damage. Avoid alcohol, and use strict birth control § Hydroxychloroquine can cause _________________________________________________________________________

GI protectant: Take PPI, omeprazole, stomach protectant to prevent GI ulcers and bleeding

Treatment for Rheumatoid Arthritis (RA): · Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Usually treatment beings with these, but monitor for GI effects! § Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription. § Meloxicam § Pt needs ____________________________________________________ § Side effects: ringing in ears, stomach irritation, heart problems, liver and kidney damage, GI bleeding (coffee-emesis, dark/tarry stools) § Take medication with food or full glass of water/milk. AVOID alcohol!!!

nausea, belching and a fishy taste in the mouth (take with food). Fish oil can interfere with medications, so check with your doctor first.

Treatment for Rheumatoid Arthritis (RA): · Synovectomy (removes inflamed synovium), plasmapheresis (removes antibodies) · NONPHARM TREATMENT FOR RHEUMATOID ARTHRITIS (RA) § Adequate rest, proper positioning, ice/heat applications § Heated paraffin (wax) drips can improve comfort. Finger and hand exercises are often done more easily after treatment § Take a hot shower rather than a bath to relive morning stiffness § Music therapy, distraction, hypnosis, imagery, acupuncture, spirituality § Fish oil. Some preliminary studies have found that fish oil supplements may reduce rheumatoid arthritis pain and stiffness. Side effects can include _________________________________________________________ § Plant oils. The seeds of evening primrose, borage and black currant contain a type of fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side effects may include nausea, diarrhea and gas. Some plant oils can cause liver damage or interfere with medications, so check with your doctor first. § Tai chi. This movement therapy involves gentle exercises and stretches combined with deep breathing. Many people use tai chi to relieve stress in their lives. Small studies have found that tai chi may reduce rheumatoid arthritis pain. When led by a knowledgeable instructor, tai chi is safe. But don't do any moves that cause pain.

Tai chi

Treatment for Rheumatoid Arthritis (RA): · Synovectomy (removes inflamed synovium), plasmapheresis (removes antibodies) · NONPHARM TREATMENT FOR RHEUMATOID ARTHRITIS (RA) § Adequate rest, proper positioning, ice/heat applications § Heated paraffin (wax) drips can improve comfort. Finger and hand exercises are often done more easily after treatment § Take a hot shower rather than a bath to relive morning stiffness § Music therapy, distraction, hypnosis, imagery, acupuncture, spirituality § Fish oil. Some preliminary studies have found that fish oil supplements may reduce rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a fishy taste in the mouth (take with food). Fish oil can interfere with medications, so check with your doctor first. § Plant oils. The seeds of evening primrose, borage and black currant contain a type of fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side effects may include nausea, diarrhea and gas. Some plant oils can cause liver damage or interfere with medications, so check with your doctor first. § ___________________. This movement therapy involves gentle exercises and stretches combined with deep breathing. Many people use tai chi to relieve stress in their lives. Small studies have found that tai chi may reduce rheumatoid arthritis pain. When led by a knowledgeable instructor, tai chi is safe. But don't do any moves that cause pain.

nausea, diarrhea and gas. Some plant oils can cause liver damage or interfere with medications, so check with your doctor first.

Treatment for Rheumatoid Arthritis (RA): · Synovectomy (removes inflamed synovium), plasmapheresis (removes antibodies) · NONPHARM TREATMENT FOR RHEUMATOID ARTHRITIS (RA) § Adequate rest, proper positioning, ice/heat applications § Heated paraffin (wax) drips can improve comfort. Finger and hand exercises are often done more easily after treatment § Take a hot shower rather than a bath to relive morning stiffness § Music therapy, distraction, hypnosis, imagery, acupuncture, spirituality § Fish oil. Some preliminary studies have found that fish oil supplements may reduce rheumatoid arthritis pain and stiffness. Side effects can include nausea, belching and a fishy taste in the mouth (take with food). Fish oil can interfere with medications, so check with your doctor first. § Plant oils. The seeds of evening primrose, borage and black currant contain a type of fatty acid that may help with rheumatoid arthritis pain and morning stiffness. Side effects may include ________________________________________________________ § Tai chi. This movement therapy involves gentle exercises and stretches combined with deep breathing. Many people use tai chi to relieve stress in their lives. Small studies have found that tai chi may reduce rheumatoid arthritis pain. When led by a knowledgeable instructor, tai chi is safe. But don't do any moves that cause pain.

the affected leg is in extension. this traction involves the use of a Velcro boot (Buck's), belt, or halter, which is secured around the affected leg to decrease painful muscle spasms that accompany hip and femur fractures. A weight is used as the pulling force which is limited to 5-10lb to prevent skin injury · Used for fractures of the hip/femur before surgery to prevent flexion contractures and hip dislocation

Types of Traction · Upper extremity traction: § Sidearm traction (skin or skeletal): forearm is flexed and extended 90 degrees from the upper part of the body. It is used for fractures of the humerus without shoulder/clavicle involvement § Overhead or 90-90 traction (skin or skeletal): the elbow is flexed, and the arm is at a right angle to the body over the upper chest. It is used for fractures of the humerus without shoulder/clavicle involvement · Lower extremity traction: § Buck's (skin) traction: __________________________________________________________________________________________________________ § Russel's Traction: similar to Buck's traction but a sling under the knee suspends the leg. It is used for hip fractures or fractures at distal end of femur § Balanced traction (skin or skeletal): the limb is elevated in a Thomas splint with Pearson's attachment, or a Bohler-Braun splint is used. It is used for fractures of the femur or pelvis (acetabulum) · Spinal Column and Pelvic traction: § Cervical halter: strap under chin. Used for cervical muscle spasms, strain/sprain, or arthritis § Cervical skeletal: halo brace. Used for cervical fractures of spine and muscle spasms § Pelvic Belt: a strap around the hips at the iliac crest is attached to weights at the foot of the bed. It is used for pain, strain, sprain, or muscle spasms in lower back § Pelvic sling: a wide strap around the hips is attached to an overhead bar to keep the pelvis off the bed. It is used for pelvic fractures and other pelvic injuries

1. Acetaminophen 2. Topicals (lidocaine patches or bio freeze: use for 12 hours, up to 3 patches at a time!) 3. NSAIDs (short term use only): Celoxib causes cardio and kidney problems AND GI bleeding!) 4. Corticosteroid joint injections (4x/yr) 5. Hyaluronic acid (HA) injections 6. Muscle relaxants (cyclobenzaprine: caution with elderly due to confusion) 7. Weak opioids: tramadol

What are the Pharmacologic Methods for use in Osteoarthritis (OA)?

1. Calcium supplements or from food 2. Vitamin D 3. Bisphosphonates: Alendronate, ibandronate, pamidronate, risedronate, zoledronic acid 4. Estrogen Agonist/Antagonists: Raloxifene 5. Monoclonal antibodies: Denosumab 6. Estrogen hormone supplements 7. Calcitonin (salmon) 8. Teriparatide

What medications are used to treat Osteoporosis?

1 .Nonsteroidal anti-inflammatory drugs (NSAIDs): ibuprofen, naproxen sodium, meloxicam 2. Corticosteroids (prednisone) 3. Disease-modifying antirheumatic drugs (DMARDs): methotrexate, leflunomide, hydroxychloroquine, sulfasalazine, minocycline 4. Biologic agents/ biologic response modifiers: abatacept, etanercept, anakinra, certolizumab, adalimumab golimumab, infliximab, rituximab, tocilizumab, and tofacitinib

What types of drugs are used to treat rheumatoid arthritis?

A. Tobacco use, especially smoking B. Alcohol use each day C. Exercise and activity level D. Dietary intake of vitamin D E. Use of calcium supplements F. Medication history

Which additional assessment data will the nurse collect from an older-Euro-American (white) woman to determine the client's risk for osteoporosis? (SATA) A. Tobacco use, especially smoking B. Alcohol use each day C. Exercise and activity level D. Dietary intake of vitamin D E. Use of calcium supplements F. Medication history

a. Bony nodes in finger joints b. Subcutaneous nodules c. Severe weight loss d. Joint deformity e. Thrombocytosis

Which assessment findings will the nurse expect for the client with late-stage rheumatoid arthritis? (Select all that apply.) a. Bony nodes in finger joints b. Subcutaneous nodules c. Severe weight loss d. Joint deformity e. Thrombocytosis

D. "I'm going to jog every day for at least 30 minutes."

Which statement by the client regarding lifestyle changes to prevent osteoporosis indicates a need for further teaching by the nurse? A. "I'm going to continue having my DXA scans as my doctor orders." B. "I'll drink only a half glass of wine occasionally to help me sleep." C. "I plan to increase calcium and vitamin D foods in my diet." D. "I'm going to jog every day for at least 30 minutes."

C. Wearing shoes that are loose or untied

While observing people walking in the community, the nurse is concerned that an older person is at risk for falling. What did the nurse observe to make this decision? A. Pushing the walking ahead before taking a step B. Talking with others while walking C. Wearing shoes that are loose or untied D. Stopping periodically to sit on a park bench

OLDER ADULTS and OBESE

o Complications of Total Joint Arthroplasty: § Dislocation: "pop", pain, internal/external rotation of leg, shortened leg · Prevent by positioning correctly · Posterior approach: keep legs slightly abducted and prevent hip flexion beyond 90 degrees · Anterior Approach: prevent hip hyperextension · Assess for pain, rotation, and extremity shortening · Perform neurovascular assessments q4h for 24h · report dislocation immediately § Infection: fever, redness, swelling, purulent drainage · Use aseptic technique for wound care/drains · Wash hands thoroughly when caring for patient · Culture drainage fluid if it changes in color/odor · Monitor temperature, report excess inflammation or drainage § Venous thromboembolism: swelling, redness, pain in calf · *_____________________________________ patients are at high VTE risk · Have patient wear elastic stockings or SCDs · Teach leg exercises: plantar flexion, dorsiflexion, circumduction · Encourage fluid intake · Signs of DVT: redness, swelling, pain · Monitor for mental status changes, SOB, = PE · Administer anticoagulants as prescribed · DO NOT massage legs or flex knees for prolonged time § Hypotension, bleeding: · Take vitals q4h for 24h, observe for bleeding, report low BP or bleeding

§1 Do not sit or stand for prolonged periods. §2 Do not cross legs. §3 Do not bend hips more than 90 degrees. §4 Do not twist body when standing. §5 Do not overexert

· Care After Total Hip Replacement §1 Do not ____________________________________ §2 Do not ____________________________________ §3 Do not ____________________________________ §4 Do not ____________________________________ §5 Do not ____________________________________ § Use assistive devices for dressing. § Report increased pain to surgeon, especially if it suddenly starts on day 8-10 § Inspect incision daily for s/s infection: "dressing is dry and has strikethrough" means what has come through the dressing (like blood) because the dressing stays on for several days § Neurovascular assessment especially below the incision § Perform post-op exercise as instructed. Document if they refuse rehab/ice packs

sock aids, shoehorns, dressing sticks, reachers

· Care of Patients with Total Hip Arthroplasty after hospital discharge. § Hip Precautions: · Do not sit or stand for prolonged periods · Do not cross legs beyond midline of body · Posterior approach: do not bend hips more than 90 degrees · Anterior approach: do not hyperextend operative leg behind you · Don't get into low cars because you have to bend over to get in. · Do not twist the body, do not use tight, "hard to put on" clothes · Use ambulatory aids, walkers, when standing. Wear slip on, sturdy shoes · Use adaptive devices (__________________________________________________________________) · Do not put more weight on affected leg than allowed · Resume sexual intercourse based on surgeon's advice § Pain Management · Report increased hip or anterior thigh pain immediately · Take oral analgesics as prescribed PRN · Do not overexert yourself, take frequent rests · Use ice to decreases/prevent swelling and pain § Incisional care · Follow instructions. Some surgeons use specialty dressings that don't need changing. No dressing may be needed if skin sealant was used · Inspect incision daily for heat, redness, drainage (report) · Do not bath the incision or apply anything directly to it unless prescribed.. Shower according to instructions § Other care · Continue walking and performing the leg exercises as learn in hospital. Do not increase amount of activities unless instructed to · Do not cross legs to prevent clots · Report pain, redness, swelling in legs · Call 911 for acute chest pain or SOB (PE) · With anticoagulants, follow precautions learned in hospital to prevent bleeding; use electric razor and report excessive bleeding · Follow up with surgeon as instructed

bath the incision or apply anything directly to it unless prescribed.

· Care of Patients with Total Hip Arthroplasty after hospital discharge. § Hip Precautions: · Do not sit or stand for prolonged periods · Do not cross legs beyond midline of body · Posterior approach: do not bend hips more than 90 degrees · Anterior approach: do not hyperextend operative leg behind you · Don't get into low cars because you have to bend over to get in. · Do not twist the body, do not use tight, "hard to put on" clothes · Use ambulatory aids, walkers, when standing. Wear slip on, sturdy shoes · Use adaptive devices (sock aids, shoehorns, dressing sticks, reachers) · Do not put more weight on affected leg than allowed · Resume sexual intercourse based on surgeon's advice § Pain Management · Report increased hip or anterior thigh pain immediately · Take oral analgesics as prescribed PRN · Do not overexert yourself, take frequent rests · Use ice to decreases/prevent swelling and pain § Incisional care · Follow instructions. Some surgeons use specialty dressings that don't need changing. No dressing may be needed if skin sealant was used · Inspect incision daily for heat, redness, drainage (report) · Do __________________________________________________________. Shower according to instructions § Other care · Continue walking and performing the leg exercises as learn in hospital. Do not increase amount of activities unless instructed to · Do not cross legs to prevent clots · Report pain, redness, swelling in legs · Call 911 for acute chest pain or SOB (PE) · With anticoagulants, follow precautions learned in hospital to prevent bleeding; use electric razor and report excessive bleeding · Follow up with surgeon as instructed

great toe metatarsophalangeal joint (podagra)

· Clinical Stages Of Gout: § Asymptomatic hyperuricemia · Patient usually unaware § Acute gouty arthritis · First attack: pain, inflammation, redness of one or more small joints · Most commonly the ____________________________________________ § Increased SED rate, NORMAL WBC § Chronic gout · 3-40 years after initial episode · Urate crystals develop under the skin and in renal system

a type of inflammatory joint disease closely linked to purine metabolism and kidney function. Abnormal purine metabolism results in overproduction/underexcretion of uric acid, which leads to crystal deposits in joints and other tissues -> inflammation

· Gout (gouty arthritis): ___________________________________________________________. · Risk Factors for Gout: have alcohol intake, binge eating, dehydration, non-potassium sparing diuretics, fasting, infection, surgery, family history, high-purine diet, obesity · Primary gout: Inborn error of purine metabolism = increased uric acid... Kidney's cannot excrete the amount produced = deposited in joints § most common type § Strong family history link § Middle age and older men, ALCOHOLICS, postmenopausal women, peak onset is between 40-50 yrs old. · Secondary gout: § Caused by other diseases (renal insuff, crash dieting, diuretics, chemo, multiple myeloma) § Older adults with co morbidities are most common

iron, folic acid, and vitamin supplements prescribed by the doctor · Assess for drug-related blood loss, like that caused by NSAIDS, by checking stools for blood (older white women are most at risk)

· Nursing Interventions for Rheumatoid Arthritis (RA) § Adequate nutrition. Lose weight if obese § Promote mobility: do not perform ADLs for patient unless asked because those with RA often don't want to be dependent. Immobility results in complications for the older adult (pressure ulcers, worsening disease, loss of independence). Use ROM, exercise program, STAY ACTIVE to promote muscle strength and support damaged joints; but rest painful joints to prevent overuse, provide support, and maintain function § Collab with dietician for china or heavy plastic cups that are easier to manipulate than Styrofoam/paper cups (which collapse easily when they attempt to hold them) § When fine motor activities (squeezing toothpaste tube), become impossible, use large joints and body surfaces. Teach patient to use palm of hand to press the toothpaste onto the brush. Use long-handled hairbrushes for brushing hair § Anemia can be treated with ___________________________________________________ - § Fatigue and decreased mobility can result from atrophy. Initiate an aggressive physical therapy program to strengthen muscles and prevent atrophy § Heat/cold therapy: stiffness (hot shower), pain in hands (paraffin), edema (cold) § Fatigue can result from decreased sleep (discomfort). Promote a quiet environment, give warm beverages, and administer hypnotics if prescribed § Energy conservation: pacing activities, allowing rest periods, setting priorities, obtaining assistance when needed (swimming, low-impact activities) · Balance activity with rest. Take 1-2 naps per day · Pace yourself, do not plan too much in one day · Use progressive muscle relaxation · Set priorities and determine which activities are most important to do first · Delegate responsibilities and tasks to family/friends · Plan ahead to prevent last-minute rushing and stress · Learn your own activity tolerance and do not exceed it § Enhance self-esteem · Steroids can cause buffalo humps, acne, striae, moon-face · Some patients can appear manipulative, demanding, or having "arthritis personality". Avoid these terms. Patents are trying to cope with illness and need respect, patience, and understanding. · Emphasize strengths and positive coping § Home Care and Self-Management: · Structural changes to promote ADLs: wide doors for wheelchairs or walkers, ramps for wheelchairs, handrails, toilet teats, shoes, splints · Emphasize asking for help when needed; rest periods with repetitive movements

pacing activities, allowing rest periods, setting priorities, obtaining assistance when needed (swimming, low-impact activities) · Balance activity with rest. Take 1-2 naps per day · Pace yourself, do not plan too much in one day · Use progressive muscle relaxation · Set priorities and determine which activities are most important to do first · Delegate responsibilities and tasks to family/friends · Plan ahead to prevent last-minute rushing and stress · Learn your own activity tolerance and do not exceed it

· Nursing Interventions for Rheumatoid Arthritis (RA) § Adequate nutrition. Lose weight if obese § Promote mobility: do not perform ADLs for patient unless asked because those with RA often don't want to be dependent. Immobility results in complications for the older adult (pressure ulcers, worsening disease, loss of independence). Use ROM, exercise program, STAY ACTIVE to promote muscle strength and support damaged joints; but rest painful joints to prevent overuse, provide support, and maintain function § Collab with dietician for china or heavy plastic cups that are easier to manipulate than Styrofoam/paper cups (which collapse easily when they attempt to hold them) § When fine motor activities (squeezing toothpaste tube), become impossible, use large joints and body surfaces. Teach patient to use palm of hand to press the toothpaste onto the brush. Use long-handled hairbrushes for brushing hair § Anemia can be treated with iron, folic acid, and vitamin supplements prescribed by the doctor · Assess for drug-related blood loss, like that caused by NSAIDS, by checking stools for blood (older white women are most at risk) § Fatigue and decreased mobility can result from atrophy. Initiate an aggressive physical therapy program to strengthen muscles and prevent atrophy § Heat/cold therapy: stiffness (hot shower), pain in hands (paraffin), edema (cold) § Fatigue can result from decreased sleep (discomfort). Promote a quiet environment, give warm beverages, and administer hypnotics if prescribed § Energy conservation: __________________________________________________________________ - - - - - - § Enhance self-esteem · Steroids can cause buffalo humps, acne, striae, moon-face · Some patients can appear manipulative, demanding, or having "arthritis personality". Avoid these terms. Patents are trying to cope with illness and need respect, patience, and understanding. · Emphasize strengths and positive coping § Home Care and Self-Management: · Structural changes to promote ADLs: wide doors for wheelchairs or walkers, ramps for wheelchairs, handrails, toilet teats, shoes, splints · Emphasize asking for help when needed; rest periods with repetitive movements

wide doors for wheelchairs or walkers, ramps for wheelchairs, handrails, toilet teats, shoes, splints

· Nursing Interventions for Rheumatoid Arthritis (RA) § Adequate nutrition. Lose weight if obese § Promote mobility: do not perform ADLs for patient unless asked because those with RA often don't want to be dependent. Immobility results in complications for the older adult (pressure ulcers, worsening disease, loss of independence). Use ROM, exercise program, STAY ACTIVE to promote muscle strength and support damaged joints; but rest painful joints to prevent overuse, provide support, and maintain function § Collab with dietician for china or heavy plastic cups that are easier to manipulate than Styrofoam/paper cups (which collapse easily when they attempt to hold them) § When fine motor activities (squeezing toothpaste tube), become impossible, use large joints and body surfaces. Teach patient to use palm of hand to press the toothpaste onto the brush. Use long-handled hairbrushes for brushing hair § Anemia can be treated with iron, folic acid, and vitamin supplements prescribed by the doctor · Assess for drug-related blood loss, like that caused by NSAIDS, by checking stools for blood (older white women are most at risk) § Fatigue and decreased mobility can result from atrophy. Initiate an aggressive physical therapy program to strengthen muscles and prevent atrophy § Heat/cold therapy: stiffness (hot shower), pain in hands (paraffin), edema (cold) § Fatigue can result from decreased sleep (discomfort). Promote a quiet environment, give warm beverages, and administer hypnotics if prescribed § Energy conservation: pacing activities, allowing rest periods, setting priorities, obtaining assistance when needed (swimming, low-impact activities) · Balance activity with rest. Take 1-2 naps per day · Pace yourself, do not plan too much in one day · Use progressive muscle relaxation · Set priorities and determine which activities are most important to do first · Delegate responsibilities and tasks to family/friends · Plan ahead to prevent last-minute rushing and stress · Learn your own activity tolerance and do not exceed it § Enhance self-esteem · Steroids can cause buffalo humps, acne, striae, moon-face · Some patients can appear manipulative, demanding, or having "arthritis personality". Avoid these terms. Patents are trying to cope with illness and need respect, patience, and understanding. · Emphasize strengths and positive coping § Home Care and Self-Management: · Structural changes to promote ADLs: ___________________________________________________________________________ · Emphasize asking for help when needed; rest periods with repetitive movements

Gout

· Symptoms of ____________________: § Urate crystals in peripheral joints -> pain, inflammation, destruction § Pain, warmth, swelling in metatarsophalangeal joint (big toe) § Periarticular erythema § Over time, attacks affect knees, wrists, ankles, elbows, hands, or bursa § Systemic: malaise, fever, chills § Mild attacks = a few hours; severe attack = several weeks § *in older adults, pain can be so bad that they can't tolerate weight of sheet or blanket § High WBC, ESR

Osteoporosis

· Symptoms of __________________________: § Dowager's hump: kyphosis of the dorsal spine (they may say they've gotten shorter by as much as 2-3in in the past 20 years § Back pain, especially after lifting, bending, or stooping § Pain worse with activity/palpation and relived by rest § Back pain accompanied by tenderness and voluntary restriction of spinal movements suggests compression of vertebral fractures § Fractures in spine, wrist, femur § Suffering, spinal deformity, disability, dependence, restriction in movement § Insomnia, fear of falling, depression

with this traction, screws are surgically inserted into the bone to allow longer traction time and heavier weights (15-30lb). It aids in bone realignment but impaired mobility. · Use pressure reduction measures and monitor for impaired skin integrity. · Pin site care is needed to prevent infection (keep clean and document drainage)

· Traction: The application of pulling force to a part of the body. With running/straighttraction, the pulling force is in one direction, and the patient's body acts as countertraction, such as skin traction (movement can alter traction). Balancedsuspension provides the countertraction with devices so the pulling force of traction is not altered when the ped/patient is moved (skeletal traction). - Purposes: § Reduce muscle spasms and pain, prevent tissue injury § Reduce, align, and immobilize fractures § Reduce deformity § Increase space between opposing forces - Straight/Running Traction: the counter traction is provided by the client's body by applying a pulling force in a straight line. Movement of the client's body can alter the traction provided § Skin traction: Primary purpose is to decreased muscle spasms and immobilize the extremity prior to surgery. The pulling force is applied by weighs that are attached by rope to the client's skin with tape/straps/boots/cuffs. Examples: Bucks traction and Bryant's traction - Balanced Suspension: the countertraction is produced by devices (slings/splints) to support the fractured extremity off the bed while pulling with ropes and weights. The client's body can move without altering the traction. § Skeletal Traction: _______________________________________________________ - -

Osteoarthritis (OA)

· _____________________________ (degenerative joint disease (DJD): Progressive deterioration & loss of articular cartilage & bone in one or more joints. The most common form of arthritis, a major cause of disability. · Pathophysiology of ______________________: § Hyaline cartilage (aka cartilage) contains H2O & a matrix of: proteoglycans (incl. chondroitin), collagen (elastic stuff), & chondrocytes (cartilage-forming cells). § Proteoglycans & H2O decrease in joints. Production of synovial fluid (joint lubrication & nutrition) declines with age. § Enzymes break down the articular matrix. As cartilage erodes, joint space narrows & bone spurs (osteophytes) develop. § With progression, fissures, calcifications, and ulcerations develop and cartilage thins. § Inflammatory cytokines enhance the deterioration. § Normal repair processes cannot overcome the degeneration. § Secondary joint inflammation occur when joint involvement is severe. § The cartilage eventually disintegrates & pieces of bone & cartilage "float" in the joint resulting in crepitus (a grating sound). § Joint effusions (excess joint fluid) is common when knees are inflamed.

Rheumatoid Arthritis (RA)

· ___________________________________________: CHRONIC, PROGRESSIVE, SYSTEMIC,INFLAMMATORY, AUTOIMMUNE disease affecting ANY synovial joints (and other tissues). Unlike OA, you assess the whole body because this condition affects theENTIRE BODY and has REMISSIONS/EXACERBATIONS · Pathophysiology of ___________________________________________: § Transformed autoantibodies (rheumatoid factors (RFs)) are formed and attack healthy tissue, resulting in inflammation. § Begins to involve articular cartilage, joint capsule, and surrounding ligaments & tendons. § Cartilage is broken down, inflammatory response occurs, bone is broken down. § Disease is characterized by remission & exacerbations. § Etiology appears to be genetic & environmental factors. § Women are affected more than men (may have hormonal influences).