Unit c musculoskeletal_chpt_46 part iii voice and no underline

Understanding Medical Surgical Nursing, 3rd Edition
Linda S. Williams / Paula D. Hopper

Rheumatoid Arthritis
 Chronic, Progressive, Systemic
Inflammatory Disease
 Destroys Synovial Joints and Other
Connective Tissues
 includes Major Organs
 Juvenile rheumatoid arthritis is also known
as Stills disease


Pathophysiology
 Synovitis
 Synovium Thickens, Fluid Accumulates
 Destructive Pannus (new growth) Erodes
Joint Cartilage, Destroys Joint Bone
 Pannus Converted to Bony Tissue
 Joint Deformity
 Other Connective Tissue Affected


Etiology
 Unknown
 Genetic Predisposition
 Environmental
 Autoimmune Response - Antibodies
(Rheumatoid Factor)
◆ Local and Systemic Inflammation


Signs and Symptoms
 Remissions and Exacerbations
 Varies by Individual


Signs and Symptoms
 Early Symptoms
◆ Bilateral, Symmetrical Joint Inflammation
◆ Reddened, Warm, Swollen, Stiff, Painful
◆ Stiffness After Resting
◆ Activity Decreases Pain and Stiffness
◆ Low Grade Fever, Weakness, Fatigue,
Anorexia


Signs and Symptoms
 Late Symptoms
◆ Joint Deformity
◆ Secondary Osteoporosis


Joint Abnormalities in


Therapeutic Interventions
 Medication
◆ Disease-modifying antirheumatic drugs
• Leflunomide (Arava)
• Etanercept (Enbrel)
◆ Gold salts have been used but may not
produce results for 2-4 months.


 Medication con’t
◆ Methotrexate
◆ Gold
◆ Prednisone
◆ NSAIDS
◆ Aspirin has anti inflammatory properties which makes it
a good drug for rheumatoid arthritis patients.
◆ Large does of aspirin may cause tinnitus (ringing of the
ears)


 Heat/cold
 Balanced Rest and Activity
 Surgery – Total Joint Replacement

 Rehabilitative procedures are used to primarily
help keep the patient as independent as possible.

 Range of motion exercise will help patients from
developing contractures


Nursing Diagnoses
 Acute Pain
 Disturbed Body Image
 Fatigue
 Self-care Deficit
 Impaired Physical Mobility
 Deficient Knowledge


Patient Education
 Disease Process
 Medication Management
 Rest and Exercise
◆ Exercise helps to prevent the joints from becoming
immobile
◆ When resting joints should be support in a position of
extention
 Vocational Counselor
 Community Resources


Total Hip Replacement
 Acetabular Cup Inserted Into Pelvic
Acetabulum
 Femoral Component Inserted Into Femur

http://medicalimages.
allrefer.com/large/701
9.jpg


 Preoperative Care
◆ Total Joint Education Programs
◆ Autologous Blood Donation


 Postoperative Care to Prevent
Complications
◆ Hip Dislocation
• Prevent Adduction or Hyperflexion
• Usually a maximum of 60 degree flexion is allowed
• Internal rotation is also restricted
◆ Skin Breakdown
• Prevent Pressure Ulcers


Abductor Pillow


Hip Flexion after Total Hip
Replacement


◆ Pain
• Provide Pain Relief
◆ Infection
• Prophylactic Antibiotics
• Coughing and Deep Breathing
• Incisional Care


◆ Bleeding
• Monitor Incision/drainage From Drain
◆ Neurovascular Compromise
• Neurovascular Checks


◆ Ambulation
• Physical Therapy
• Use Walker/crutches


 Thromboembolitic Complications
◆ Compression Devices
◆ Leg Exercises
• Enoxaparin (Lovenox)
◆ The chief cause of mortality for total hip
patients is pulmonary embolism.


 Postop care includes:
◆ Proper positioning to maintain abduction
◆ Monitoring amount of wound drainage
◆ Planned administration of an analgesic prior to
exercise


 Self-care
◆ Assistive Dressing Devices
◆ Raised Toilet Seat
◆ Rehabilitation


Total Knee Replacement
 Femoral Component, Tibial Component, Patellar Button

 Dislocation Not a Concern

 Care like Total Hip Replacement

 Frequent monitoring of vital signs is essential
 Continuous Passive Motion Machine (CPM) http://www.kneereplacement.co.i
n/images/2%20Knee
%20replacement
%20implant.JPG
 Knee Arthroplasty is surgery to reshape, reconstruct, or replace a
diseased or damaged knee joint. (A new knee joint made with a
prosthesis)


 The nerve that could be compromised in the total
knee patient is the peroneal or fibular nerve

 The peroneal nerves wraps around the head of
the fibula and innervates the knee joint, skin of
the lateral calf and dorsum of the foot. Also the
muscles that dorsiflex the foot are innervated.


 Nursing care after total knee surgery

◆ Obtain a walker to minimize weight-bearing on the
affected leg

◆ Apply knee immobilizer brace before getting the patient
up (primary method of protecting knee joint)

◆ elevate the leg while sitting in a chair


Continuous Passive Motion
Machine
Flexion and
extension are
important in
the overall
rehabilitation
process for
total knee
replacement
patients.


Amputation
 Surgical Amputations
◆ Ischemia From Peripheral Vascular Disease
◆ Bone Tumor or cancer of the bone
◆ Frostbite
◆ Congenital Problems
◆ Infections
◆ Burn injury


Amputation
 Traumatic Amputations
◆ Accidents


Amputation
 Replantation
◆ Wrap Severed Body Part in Cool, Slightly Moist
Cloth
◆ Place in Sealed Plastic Bag Submerged in
Cold Water
◆ Transported to Hospital


Amputation
 Levels Of Amputation
◆ Below-the-knee (BKA)
◆ Above-the-knee (AKA)
◆ Below-the-elbow (BEA)
◆ Above-the-elbow (AEA)


Amputation
Nursing Care
 Preoperative
◆ Deficient Knowledge
• Teach Preoperative Procedures
◆ Disturbed Body Image
◆ Begin Support Services

 Factors that can influence a persons reaction to an amputation
include:
◆ Previous dealings with loss
◆ Economic status
◆ Emotional stability


Amputation
Nursing Care
 Postoperative
◆ Hemorrhage Prevention
◆ Infection
◆ Pain Control
• Phantom Pain
◆ Mobility and Ambulation


Bandaging for Above-the-
Knee Amputation


Amputation
Nursing Care
 Postoperative
◆ Prosthesis
• Fitting a patient for a prosthesis at the time of surgery
– Helps to get the patient out of bed as soon as possible
– Improve the patients mental outlook and reduce anxiety
• Patient can not be hurried through the stages of grieving and
acceptance
◆ Lifestyle Adaptation
• New amputees are very likely to be concerned about their
dependence on family and friends.


Amputation
Nursing Care
 Postoperative
◆ The patient will be scheduled to spend some time in
the prone position each day to prevent contractures of
the hip

◆ Exercise of operative as well as unoperative side
prevents muscle weakness and atrophy

◆ Patients usually begin walking in 2 – 4 days after an
amputated leg.


Congenital Hip Dysplasia
 Abnormal development
of tissue in hip

 Affected side knee may
be higher than the
unaffected side

 Skin folds of the thigh of
the affected are deeper
than the unaffected side
http://www.pediatric-
orthopedics.com/Topics/Bones/Hip/Gal.jpg


Congenital hip dysplasia
 Treatment may include:
◆ Surgery
◆ Splints or braces
◆ Traction


Scoliosis
 A lateral curvature of the spine
http://img.youtube.com/vi/BR5XHARFmoA/0.jpg

 80% are attributed to
idiopathic causes

 A Milwaukee Brace and
exercise is frequently the
treatment of choice

 Treatment is aimed a
correcting the curvature


Temporomandibular Joint
Dysfunction
 Painful condition involving the joint
that opens and closes the mouth, the
temporomandibular joints

 Patient may experience clicking and
popping when moving jaw during
chewing

 Medical management includes moist
heat or cold therapy
 http://www.aurorahealthcare.org/yourhealth/healthgate/getcontent.asp?
URLhealthgate=%2211502.html%22

Unit c musculoskeletal_chpt_46 part iii voice and no underline

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