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Name one noninflammatory and two inflammatory connective tissue diseases
- Noninflammatory: OA
- Inflammatory: RA, SLE
Describe Osteoarthritis (OA)
- Also called Degenerative Joint Disease (DJD)
- Progressive deterioration and loss of cartilage (esp articulating cartilage)
- Synovial fluid decreases (esp with age)
- With the erosion of cartilage and decrease in synovial fluid, the joint space narrows and osteophytes (bone spurs) form
- Deterioration of the joint occurs faster than the body can repair it
- Eventually pieces of bone and cartilage break off and float in the joint space causing crepitis
What are the s/s of osteoarthritis? What may be found upon assessment?
- Joint pain- first with movement and then continuously
- Joint stiffness- esp in morning, and then with any movement
- Decreased mobility
- Slowed Gait
What is the etiology of primary and secondary OA?
- Primary: aging (esp in hands), genetics, obesity, smoking
- Secondary: heavy manual occupation (construction, carpet installer), sports, trauma
What medications can be used for OA?
- Acetaminophen (Tylenol)
- Salicylic Acid (Aspirin)
- Celecoxib (Celebrex)
- Cyclobenzaprine (Flexeril)
Describe Acetaminophen (Tylenol) use for OA
- Action: lowers the hypothalmic set point to reduce fever and activates the descending inhibitory seroteonergic pathways to produce analgesic effect
- Classification: Antipyretic and analgesic
- Anti-inflammatory effect is so small it is not clinically significant
- AE: hepatotoxic
Describe Salicylic Acid (Aspirin) use for OA
- Actions: Inhibits platelet aggregation by inhibiting the generation of thromboxane. Blocks prostaglandin production and has analgesic effect
- Classification: NSAID, analgesic, antipyretic, platelet inhibitor
- SE: Monitor for toxicity (Acetylcysteine is the antidote, common sign is tinnitus), stomach upset or bleed, and always check for anticoag therapy prior to surgery
Describe Celecoxib (Celebrex) use for OA
- Action: celecoxib blocks the enzyme that makes prostaglandins resulting in a lower amount and decreased pain
- Classification: cox-2 inhibitor, NSAID
- AE: stomach bleed or perf, CVA, MI
Describe Cyclobenzaprine (Flexeril) use for OA
- Action: decreases firing of alpha motonneuron results in decreased muscle tone
- Classification: muscle relaxant primarily acts on CNS
- SE:HA, dry mouth, confusion, dizziness, anxiety, tachycardia, n/v/d, hallucinations, seizures, allergic reaction
- Considerations: half life doubled over 65 y/o, higher dose needed
Describe Glucosamine use for OA
- Nutritional supplement taken for OA that may decrease inflammation
- Made of glucose and amino acids, stimulates cartilage production and inhibits degradation of joint
- Considerations: Do not take if you have HTN, are pregnant or BF, May increase BS if diabetic, bleeding precautions if taking with chondroitin or anticoag meds
- SE: rash, diarrhea, drowsiness, HA
Describe cortisone use for OA/RA
- Actions: modulates the synthesis an release of a number of chemical mediators of inflammation, including prostaglandins and histamines
- Classification: Steroid, anti-inflammatory
- Considerations: may be injected directly into the joint
- SE: muscle weakness, osteoporosis, CHF, n/v/d, peptic ulcers, HA, seizures, cushingoid symptoms, cataracts, hypokalemia
What non-pharmaceutical treatments may be used for OA?
- Rest, both of the joint and overall
- Heat/Cold therapy (safety concern to prevent burns)
- Use of cane on strongest side of body
What surgical intervention may be done for OA? What is the indication and what is the main contraindication?
- Total Joint Arthroplasty (TJA) or replacement (TJR)
- Total Hip Arthroplasty (THA) or replacement (THR)
- Total Knee Arthroplasty (TKA) or replacement (TKR)
- Total Shoulder Arthroplasty (TSA)
- Total Elbow Arthroplasty (TEA)
- Indicated when pain/mobility are uncontrolled
- Contraindicated if any infection is present
What is the difference between a primary and revision arthroplasty?
- Primary is the initial surgery
- Revision is surgery done for loosened component or fixation around component
What is the preop nursing care for someone receiving joint replacement?
- CBC & UA Labs and assessment for any infection, which contraindicates the procedure
- D/C all anticoag therapy, incl aspirin, 1-2 wks prior to procedure
- Type and cross match, autologous blood is banked, H/H
- Chest Xray
- Pt teaching prior to surgery
- Preop vital signs, allergies, site marking
- Cephazolin (Ancef) antibiotics given IV 1 hr prior to cut time
What is the intraoperative nursing care for a patient receiving joint replacement?
- General or spinal anesthesia
- Foley catheter with sterile insertion, most likely after the patient is under
- Autologous blood admin
- Maintain sterility to prevent infection
- Maintain contact with family
- Maintain safety of machinery- saws, drills, irrigation, cautery
Describe the different access points and components used for a THA
- Anterolateral approach- used for obese patients due to the low risk of dislocation
- Anterior approach- primary only, decreased muscle damage
- Acetabular cup is screwed or cemented in
- Femoral head is friction fit to shaft or in one piece with fem shaft
- Bone grows into the trochanteric area of femoral shaft
- Cement called methyl methacrylate sets in 7 minutes and a main SE is hypotension
What post-op nursing care should be done for a client receiving THA?
- Prevent dislocation/subluxation by preventing 90 degree angles of hips (no knees above hips)
- Abductor pillow and raised toilet seat used
- No crossing of legs
- Assess for dislocation with external rotation and leg shortening
- Neuro checks should be done distal to the incision site
- Always check for DVTs and FE (always applicable when long bones are involved)
What are some ways to prevent infection during a joint replacement?
- Use sterile techniques for all dressing changes and drain care
- Maintain hemovac vaccuum
- Proper hand washing for personal and client
- Assess incision sites for q8hr
- CBC labs for WBC differential (elderly may not get feverish with infection)
How can thromboembolisms be prevents after a joint replacement?
- Low Molecular Weight Heparin
- Compression devices on legs
- Early ambulation
- TED hose
- Leg exercises
What risk factors put a person at risk of needing a TKA?
- OA, reduced joint space
- Pain, esp with stairs
- Decreased mobilities and ADLs
What special intraoperative and post operative care should be taken for a TKA?
- IV antibiotics 1 hr prior to cut time
- Components are usually friction fit with cement
- Continuous passive motion (CPM) may be used to keep prosthetic in motion
- Ice packs to the knee first 24 hrs, then as comfortable
- No special positioning, CMS checks distal to site
What is RA?
- Chronic, progressive, systemic inflammatory autoimmune disease that affects synovial joints
- Affects primarily european americans
- Fluid accumulates in the joint space, articular cartilage is eroded, calcification forms
- Permanent joint damage occurs (Can be prevented or reduced if diagnosed early)
- Remissions and exacerbations occur
What are the early vs. late S/S of RA?
- Early S/S:
- Morning joint stiffness (gel phenomenon)
- Late S/S:
- Nodular joint deformity
- Late S/S (systemic):
- low-grade fever
- Cardiac and pulmonary involvement
How is RA diagnosed and treated?
- Diagnosed with x-ray, Rheumatoid factor (Serum) and ESR lab
- May be treated with a Total joint replacement (TJR)
- Medications include NSAIDS, corticosteroids (prednisone), Disease-modifying antirheumatic drugs (DMARDs) (methotrexate), Biologics (humira)
Describe the differences and similarities between TKA and THA
Describe the differences and similarities between OA and RA