N406: Unit 10 - Exam 3

Scleroderma

- chronic hardening and tightening of the skin and connective tissue

What are the signs and symptoms of rheumatoid arthritis (RA)?

1. Sunrise stiffness (morning stiffness that lasts at least 1 hour) 2. Soft tissue swelling of 3 or more joints 3. Swelling of the proximal interphalangeal, metacarpophalangeal, or wrist joints 4. Symmetric arthritis 5. Subcutaneous nodules 6. Positive test for RF rheumatoid factor 7. radiographic erosions or periarticular osteopenia in hand or wrist joints

What is the biggest risk for fatality in lupus?

INFECTION

A nurse is assigned a client with an acute exacerbation of rheumatoid arthritis (RA). Which medical facts about RA are essential in developing a plan of care? Select all that apply: a. The client experiences stiff, swollen joints bilaterally b. The client may not exercise once the disease is diagnosed c. Onset is acute and usually occurs between ages 20 and 40 d. Erythrocyte sedimentation rate (ESR) is elevated, and x-rays show erosions and decalcification of involved joints e. The first-line treatment is gold salts and methotrexate f. Inflamed cartilage triggers complement activation, which stimulates the release of additional inflammatory mediators.

a, d, f Rationale: RA is a chronic disorder where individuals experience stiff, swollen joints due to a severe inflammatory reaction. Elevated ESR and x-ray evidence of bony destruction are indicative of severe involvement. RA starts insidiously, with fatigue, persistent low-grade fever, anorexia, and vague skeletal symptoms, usually in middle age between the ages 35 and 50 years. Maintaining the ROM by a prescribed exercise program is essential, but clients must rest between activities. Salicylates and non steroidal anti-inflammatory drugs are considered the first-line treatments.

A client is being placed on a purine-restricted diet. What foods will the nurse include in the client's diet plan? a. dairy products b. shellfish c. organ meats d. alcohol

a. dairy products Rationale: Primary hyperuricemia may be caused by severe dieting or starvation, excessive intake of foods that are high in purines (shellfish, organ meats, and alcohol), or heredity.

A client is admitted with a possible diagnosis of osteomyelitis. Based on the documentation shown, which laboratory result is the priority for the nurse to report to the health care provider? a. rheumatoid factor b. blood culture c. alkaline phosphatase d. ESR

b. blood culture Rationale: Osteomyelitis is a bacterial infection of the bone and soft tissue that occurs by extension of soft tissue infection, direct bone contamination following surgery, or spreading from other infection sites in the body. A positive blood culture should be reported immediately to the health care provider so that specific antibiotic therapy can begin or be adjusted based on the positive culture. A negative rheumatoid factor would be expected in a possible diagnosis of osteomyelitis. An alkaline phosphatase level of 60 IU/L is within the normal range, and an ESR of 10 mm/hour is also within the normal range.

How long does a patient taking biphosphonates need to stay upright after administration? a. 10 minutes b. 20 minutes c. 30 minutes d. 60 minutes

c. 30 minutes

Osteoporosis

- A condition in which the body's bones become thin, weak and break easily - Bones become porous and density decreases - The body constantly absorbs and replaces bone tissue - Osteoclasts outwork the osteoblasts in this disease

Osteoclasts

- Bone-destroying cells - break down bone matrix for remodeling and the release of calcium

Diagnostic Evaluation

- Imaging Procedures: - X-ray - Computed Tomography (CT) - MRI - Arthrography - Bone densitometry

Osteoarthritis Treatment

- NSAIDs - muscle relaxants - analgesics - corticosteroid injections - splint - braces - avoid large pillows under head or nose - provide head or foot cradle - encourage 10 hours of sleep a night or 1-2 hour nap in afternoon - well balanced nutrition

Osteoarthritis Surgical Interventions

- Osteotomy: when a bone is cut to prevent joint deformity and promotes realignment - Total Joint Replacement: can happen in hips and knees when pain is too much and other interventions do not work - Viscosupplementation

Osteocytes

- a bone cell, formed when an osteoblast becomes embedded in the matrix it has secreted - mature bone cell

Systemic Lupus Erythematosus

- a chronic autoimmune disease in which the body's immune system mistakenly attacks healthy tissue - It can affect the skin, joints, kidneys, brain, and other organs

Ankylosing Spondylitis

- a chronic inflammatory and systemic autoimmune disease that cause vertebrae to fuse - This fusing makes the spine less flexible and can result in a hunched posture - If ribs are affected, it can be difficult to breathe deeply - HALLMARK SIGN: back pain at base of spine and pelvis where SI joints fuse - other s/s: stiffness, persistent and progressive pain, pain gets worse with prolonged rest and alleviated by movement - can develop in primary adolescence (primary AS) - older group of patients = secondary AS

Rheumatoid Arthritis

- a chronic inflammatory disorder in which the joints and some organs of other body systems are attacked - typically affects joints in the hands and feet - clients experience stiff swollen joints due to a severe inflammatory reaction - elevated ESR - x-ray evidence of bony destruction

Gout

- a metabolic bone disorder in which purine metabolism is altered & the byproduct, uric acid accumulates - urate crystals are placed in joints which increases uric acid levels - usually occurs in the big toe - Primary Gout: caused by inherited defect of purine metabolism which leads to decreased renal excretion; 95% males - Secondary Gout: an acquired condition following hematopoietc (multiple myeloma, polycythemia vera & leukemia) or renal disorders

Viscosupplementation

- a procedure for arthritis that involves injecting hyaluronic acid, a gel-like fluid, directly into the joint - helps reduce swelling in arthritic joint and thought to repair cartilage - most common in the knee

Angiography

- a radiographic study of the blood vessels after the injection of a contrast medium

Polymyalgia Rheumatica

- a rheumatic disorder associated with moderate-to-severe musculoskeletal pain and stiffness in the neck, shoulder, and hip area

Arthrography

- a type of imaging test used to look at a joint, such as the shoulder, knee, or hip - It may be done if standard X-rays do not show the needed details of the joint structure and function - it shows a series of images of a joint after injection of a contrast medium, usually done by fluoroscopy or MRI - The injection is normally done under a local anesthetic such as Novocain or lidocaine

Characteristics of Joints

- allow the movement between bones - formed where two bones join - surfaces are covered with cartilage - enclosed in a capsule - contain cavity filled with synovial fliid - articulation = the meeting of 2 or more points

Immunosuppression Education

- always explain to the client that the dosage of any corticosteroids has to be increased and decreased gradually - never abruptly stop - long term steroid use can increase risk for infection

Myelography

- an x-ray of the spinal subarachnoid space - taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture

Ankylosing Spondylitis Treatment

- anti inflammatories - analgesics - exercise - sleep in supine position and use 1 small pillow - proper positioning is important!!

Risk Factors of Osteoporosis

- autoimmune disorders - calcium deficiency - degenerative conditions - falls - hyperuricemia - infection - having 2 or more alcoholc drinks a day - thin women - white or asian ethnicity - family hx - calcium intake - tobacco use - hyperthyroidism - low testosterone - eating disorders (anorexia) - stomach surgery (gastrectomy or weight loss surgery) - certain medications: steroids, prednisone, cortisone, deximethosone, breast cancer meds, SSRIs, methotrexate, dilantin, Phenobarbital

Osteoporosis Medications

- biphosphonates: treatment that normalize the balance of bone turnover - other meds: Fosamax, Actonel, Boniva, and Reclast

Osteoblasts

- bone forming cells - function in bone formation by secreting the bone matrix, matrix consist off collagen and ground substances

Signs and Symptoms of Paget's Disease

- bone pain is the most common complaint from fractures of brittle bone, deformity of bone, advanced arthritis of joints near affected bone, compression on neighboring nerves from enlarged bones, leading to a loss of sensation or movement

Systemic Lupus Erythematosus Clinical Manifestations

- butterfly rash - facial erythema - weight loss - pericarditis - pleuritis - fever

Osteoarthritis

- degenerative and progressive disease - most common form of arthritis - occurs when the protective cartilage that cushions the ends of the bones wears down over time - the disorder most commonly affects joints in your hands, knees, hips and spine - CT scan or MRI used to diagnose - this disease does NOT cause joint deformities

How is SLE diagnosed?

- diagnosis is based on clinical findings (hx/physical symptoms) supported by lab results (ex: +ANA) - also patient will have low RBCs and low WBCs

What are the functions of bone?

- framework of the body - support - movement - shape - maintain position - attachment of muscles - protects organs - storage - hematopoiesis - remodeling - reformation - moveable joints

Medical Management for Rheumatoid Arthritis

- goal: to relieve pain, decrease inflammation, protect articular surfaces, maintain function, and control systemic involvement - Aspirin and NSAIDs: relieve PAIN; they control local inflammatory mediators (arachidonic acid, prostaglandins, and oxygen radicals) - Low dose oral glucocorticoids: suppress inflammation and slow bone erosion - DMARDs: decrease elevated levels of acute phase reactants and modify the destructiveness of the disease; begin in early phases of disease! - Gold salts, antimalarials, and immunosuppressive agents stop the underlying disease - Immunosuppressive and Cytotoxic drugs: may improve disease process in some patients

Osteomyelitis

- inflammation or swelling that occurs in the bone - It can result from an infection somewhere else in the body that has spread to the bone, or it can start in the bone — often as a result of an injury

Paget's Disease

- interferes with your body's normal recycling process, in which new bone tissue gradually replaces old bone tissue - Over time, bones can become fragile and misshapen - The pelvis, skull, spine and legs are most commonly affected - overgrowth of bones can compress brain and can cause altered mental status

Osteomalacia Risk Factors

- little exposure to sunlight - vitamin D deficiency - certain surgeries that disrupt stomach - celiac disease - kidney/liver disorders

Osteomalacia

- metabolic disease marked by softening of the bone caused by calcium and vitamin D deficiency - soft bones - most common in pregnancy - bones can break in ribs, spine, and legs

Metabolic Bone Disease

- osteoporosis - osteomalacia - Paget's Disease

ANA test

- plasma is tested for antibodies that are present in patients with systemic lupus erythematosus

Paracentesis

- removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions

Raynaud's Disease

- results from reduced blood flow to the extremities when exposed to cold or stress - It's commonly associated with connective tissue disorders such as SLE - Signs and symptoms include pallor, coldness, numbness, throbbing pain, and cyanosis

Mature Bone

- rigid connective tissue consisting of cells: collagen, calcium, and phosphate

What is primary hyperuricemia usually caused by?

- severe dieting or starvation - excessive intake of foods that are high in purines (shellfish, organ meats) or hereditary

Arthrocentesis

- surgical puncture to aspirate synovial fluid from the joint space

Polymyositis

- systemic disease, which means it affects the whole body - muscle weakness and tenderness

Gout Education

- teach LOW purine diet - avoid organ meats, wines, aged cheese - encourage HIGH fluid intake, 2000 ccs a day to prevent kidney stones from happening - avoid alcohol - avoid starvation diets because that can cause gout attack - increase urine ph by drinking dairy products - elevate extremities and protect affected joint during acute attack by taking off sheets and blankets, avoid heat, extreme cold - weight loss - administer NSAIDs and colchicine to reduce pain and inflammation (give with meals, n/v means toxicity) - Allopurinol: blocks formation of uric acid (Side effects: GI upset, headache, dizziness, give with meals) - Probenecid: promotes resorption of uric acid deposits & excretion of uric acid

Peak Bone Mass

- the maximum bone density attained at any time in life, usually occurring in young adulthood - occurs at 30 years old

Antidepressants with RA

- used for sleep deprivation in patients with RA

You are caring for a 69-year-old patient who has just been admitted to your unit. The patient asks the nurse what the difference is between osteoarthritis (OA) and rheumatoid arthritis (RA). What is the best response by the nurse? A."OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." B. "OA and RA are very similar. OA affects the smaller joints, and RA affects the larger, weight-bearing joints." C. "OA affects joints on both sides of the body. RA is usually unilateral." D. "OA is more common in women. RA is more common in men."

A."OA is a considered a noninflammatory joint disease. RA is characterized by inflamed, swollen joints." Rationale: RA is part of an autoimmune reaction and inflames joints

A client with osteoarthritis presents to an orthopedic surgeon with worsening symptoms over a period of years. The client complains of intractable pain in the right knee. An x-ray shows arthritis of the knee. Which of the following procedures would the surgeon most likely schedule for this client? a. A total knee replacement b. A joint arthroplasty c. An osteotomy d. An arthroscopy

a. A total knee replacement Rationale: Total knee replacement is performed if the client has intractable pain and X-ray films show evidence of arthritis of the knee.# 2 is incorrect. A joint arthroplasty is the reconstruction or replacement of a joint. Arthroplasty is usually indicated when the client has severely restricted joint mobility and pain at rest. # 3 is incorrect. An osteotomy, an incision into or transection of the bone, may be performed to realign an affected joint, particularly when significant bony overgrowth or osteophyte formation has occurred. # 4 is incorrect. An arthroscopy is a surgical procedure in which an arthroscope (a thin tube that is lighted and has a camera in one end) is inserted into a joint. It may be done to diagnose the type of arthritis or to perform debridement by smoothing rough cartilage and flushing out the joint to remove debris.

Finding urate crystals during an arthrocentesis exam indicates? a. gout b. osteoporosis c. pseudogout d. osteomalacia

a. gout

The nurse is completing a health history with a client in a clinic. What assessment finding best correlates with a diagnosis of osteoarthritis? a. joint stiffness that decreases with activity and movement b. erythema and edema over the affected joint c. anorexia and weight loss d. fever and malaise

a. joint stiffness that decreases with activity and movement Rationale: A characteristic feature of osteoarthritis (degenerative joint disease) is joint stiffness that decreases with activity and movement. Erythema and edema over the affected joint, anorexia, weight loss, and fever and malaise are associated with rheumatoid arthritis, a more severe and destructive form of arthritis.

When caring for a patient with systemic sclerosis, the nurse knows it is important to instruct the patient related to (select all that apply): a. avoiding the consumption of high-purine foods b. strategies for good dental hygiene and mouth care c. protecting the extremities from hot and cold temperatures d. maintaining joint function and preserving muscle strength e. performing mouth excursion (yawning) exercises on a daily basis

b, c, d, e Rationale: Systemic sclerosis (SS), or scleroderma, is a disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. The nurse should include the following in the teaching plan for a patient with SS: daily oral hygiene (neglect may increase tooth and gingival problems); protection of hands and feet from cold exposure and possible burns or cuts (wounds heal slowly); avoidance of emotional stress and cold ambient temperatures (they aggravate Raynaud's phenomenon); isometric exercises for arthropathy (no joint movement occurs); use of assistive devices as appropriate and organization of activities to preserve strength and reduce disability; and mouth excursion (i.e., yawning with an open mouth) (helps maintain temporomandibular joint function).

A nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan? a. "Exposure to sunlight will help control skin rashes." b. "Monitor your body temperature." c. "Corticosteroids may be stopped when symptoms are relieved." d. "There are no activity limitations between flare-ups."

b. "Monitor your body temperature." Rationale: The nurse should instruct the client to monitor body temperature. Fever can signal an exacerbation and should be reported to the physician. Sunlight and other sources of ultraviolet light may precipitate severe skin reactions and exacerbate the disease. Fatigue can cause a flare-up of SLE. Clients should be encouraged to pace activities and plan rest periods. Corticosteroids must be gradually tapered because they can suppress the function of the adrenal gland. Abruptly stopping corticosteroids can cause adrenal insufficiency, a potentially life-threatening situation

The pathophysiology underlying gouty arthritis may be attributed to: a. The presence of fibrous adhesions within bony cartilage b. An alteration in purine metabolism resulting in hyperuricemia c. Excessive bone remodeling secondary to increase levels of phosphorus d. Increased immune complexes within the joint cavity

b. An alteration in purine metabolism resulting in hyperuricemia

You are doing the initial assessment of a patient admitted to your unit with systemic lupus erythematosus. What skin manifestation would the nurse expect to find on this patient? a. Petechiae b. Butterfly rash across bridge of nose and cheeks c. Absence of wrinkles d. Weight gain

b. Butterfly rash across bridge of nose and cheeks

A nurse assesses a client in the health care provider's office. Which assessment findings support a suspicion of systemic lupus erythematosus (SLE)? a. Photosensitivity, polyarthralgia, and painful mucous membrane ulcers b. Hypothermia, weight gain, lethargy, and edema of the arms c. Facial erythema, pericarditis, pleuritis, fever, and weight loss d. Weight gain, hypervigilance, hypothermia, and edema of the legs

c. Facial erythema, pericarditis, pleuritis, fever, and weight loss Rationale: An autoimmune disorder characterized by chronic inflammation of the connective tissues, SLE causes fever, weight loss, malaise, fatigue, skin rashes, and polyarthralgia. Nearly half of clients with SLE have facial erythema, (the classic butterfly rash). SLE also may cause profuse proteinuria (excretion of more than 0.5 g/day of protein), pleuritis, pericarditis, photosensitivity, and painless mucous membrane ulcers. Weight gain, hypervigilance, hypothermia, and edema of the legs and arms don't suggest SLE.

A clinic nurse is caring for a patient with suspected gout. While explaining the pathophysiology of gout to the patient, the nurse would include which of the following as a causative agent in gout? a. Thrombocytopenia b. Hypouricemia c. Hyperuricemia d. Hypocalcemia

c. Hyperuricemia Rationale: Oversecretion of uric acid or a renal defect resulting in decreased excretion of uric acid, or a combination of both occurs in gout. Hyperuricemia occurs. Thrombocytopenia is indicative of systemic lupus erythematosus. Hypercalcemia can cause kidney stones related to gout.

A group of students are reviewing information about osteoporosis in preparation for a class discussion. The students demonstrate a need for additional review when they state which of the following as a risk factor? a. Excess caffeine intake b. Prolonged corticosteroid use c. Hypothyroidism d. Prolonged immobility

c. Hypothyroidism Rationale: Factors associated with an increased risk for osteoporosis include: family history of osteoporosis, chronic low calcium intake, excessive intake of caffeine, tobacco use, Cushing's syndrome, prolonged use of high doses of corticosteroids, prolonged periods of immobility, hyperthyroidism, hyperparathyroidism, eating disorders, malabsorption syndromes, breast cancer (especially if treated with chemotherapy that suppresses estrogen, excluding Tamoxifen, which may reduce the risk of fractures), renal or liver failure, alcoholism, lactose intolerance, and dietary deficiency of vitamin D and calcium.

Which newer pharmacological therapy, used to treat osteoarthritis, is thought to prevent the loss of cartilage and repair chondral defects, as well as have some anti-inflammatory effects? a. Glucosamine b. Capsaicin c. Viscosupplementation d. Chondrotin

c. Viscosupplementation

The nurse teaches the client with a high risk for osteoporosis about risk-lowering strategies, including which action? a. Increase fiber in the diet b. Decrease the intake of vitamin A and D c. Walk or perform weight-bearing exercises outdoors d. Reduce stress

c. Walk or perform weight-bearing exercises outdoors Rationale: Risk-lowering strategies for osteoporosis include walking or exercising outdoors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine in moderation

A female client has been taking prednisone for her asthma for 1 month. The nurse will teach her to gradually decrease her dose of prednisone to avoid: a. hypokalemia b. gastrointestinal problems c. adrenal insufficiency d. menstrual irregularities.

c. adrenal insufficiency Rationale: The client may develop adrenal insufficiency (addisonian crisis), which is characterized by glucocorticoid insufficiency without mineralocorticoid insufficiency. Hypokalemia occurs as a result of hyperaldosteronism. Gastrointestinal distress and menstrual irregularities are common adverse effects of the drug, but these effects are not as serious as preventing adrenal insufficiency

A patient with OA uses NSAIDs to decrease pain and inflammation. The nurse teaches the patient that common side effects of these drugs include: a. allergic reactions, fever, and oral lesions b. fluid retention, hypertension, and bruising c. skin rashes, gastric irritation, and headache d. prolonged bleeding time, blood dyscrasias, and hepatic damage

c. skin rashes, gastric irritation, and headache

A patient is suspected of having rheumatoid arthritis and her diagnostic regimen includes aspiration of synovial fluid from the knee for a definitive diagnosis. The nurse knows that which of the following procedures will be involved? a. Angiography b. Myelography c. Paracentesis d. Arthrocentesis

d. Arthrocentesis Rationale: Arthrocentesis involves needle aspiration of synovial fluid. Angiography is an x-ray study of circulation with a contrast agent injected into a selected artery. Myelography is an x-ray of the spinal subarachnoid space taken after the injection of a contrast agent into the spinal subarachnoid space through a lumbar puncture. Paracentesis is removal of fluid (ascites) from the peritoneal cavity through a small surgical incision or puncture made through the abdominal wall under sterile conditions.

A patient is undergoing diagnostic testing for symptoms of polyarthralgia, fatigue, and hair loss. Laboratory results include the presence of anti-DNA, antinuclear antibodies, and anti-Smith in the blood. The nurse recognizes that these findings are most likely to be related to which diagnosis? a. Systemic sclerosis b. Rheumatoid arthritis c. Chronic fatigue syndrome d. Systemic lupus erythematosus

d. Systemic lupus erythematosus Rationale: No specific test is diagnostic for systemic lupus erythematosus (SLE), but a variety of abnormalities may be present in the blood. SLE is characterized by the presence of antinuclear antibodies (ANAs), and its identification establishes the existence of an autoimmune disease. Other antibodies include anti-DNA, antineuronal, anticoagulant, anti-WBC, anti-red blood cell (RBC), antiplatelet, antiphospholipid, and anti-basement membrane. Tests that are most specific for SLE include the anti-double-stranded DNA and the anti-Smith (Sm). High levels of anti-DNA are rarely found in any condition other than SLE, and anti-Sm seems to be found almost exclusively in SLE. The lupus erythematosus (LE) cell prep test is a nonspecific test for SLE and is positive in other rheumatic diseases.

Clinical manifestations of rheumatic disease include which of the following? a. Joint swelling b. Limited movement c. Pain d. All of the above

d. all of the above Rationale: Clinical manifestations of rheumatic disease include pain, joint swelling, limited movement, stiffness, weakness, and fatigue

What is the single most important medication used in the treatment of SLE? a. NSAIDs b. immunosuppressives c. antimalarials d. corticosteroids

d. corticosteroids Rationale: Corticosteroids are the single most important medication available for treating SLE. They are used topically for cutaneous manifestations, in low oral doses for minor disease activity, and in high doses for major disease activity.

In teaching a patient with SLE about the disorder, the nurse knows that the pathophysiology of SLE includes: a. circulating immune complexes formed from IgG autoantibodies reacting with IgG b. an autoimmune T-cell reaction that results in destruction of the deep dermal skin layer c. immunologic dysfunction leading to chronic inflammation in the cartilage and muscles d. the production of a variety of autoantibodies directed against components of the cell nucleus

d. the production of a variety of autoantibodies directed against components of the cell nucleus Rationale: Systemic lupus erythematosus (SLE) is characterized by the production of many autoantibodies against nucleic acids (e.g., single-and double-stranded DNA), erythrocytes, coagulation proteins, lymphocytes, platelets, and many other self-proteins.