Rheumatology

▪ Conective tissue disease (CTD) is a major focus of rheumatology

▪ Rheumatic disease is any disease or condition involving the mecvuloskeletal system
▪ Arthritis means inflammation of one or more joints
▪ Non-inflammatory arthritis is not systemic (For ex OA = osteoarthritis)
▪ Inflammatory arthritis (systemic)
▪ Rheumatiod arthritis
▪ Systemic Lupus erythematosus
 Rheumatoid Arthritis = RA
1. A most common connective tissue disease and the most destructive to the joints
2. Chronic, progressive, systemic inflammatory autoimmune disease primarily affecting the
synovial joints
3. Autoantibodies (rheumatoid factors) formed that attack healthy tissue (DIAGNOSIS w/
antibodies)
4. Affects synovial tissue of any organ or body system
5. HANDS – Boutonniere – deformity of thumb; Ulnar deviation of metacarpophalangeal; Swan-
neck deformity of fingers (SYMMETRICAL – both hands)
Signs and symptoms
1. §Malaise, weight loss
2. §Onset may be triggered by physical/emotional stress
3. §Joint swelling with stiffness, warmth, tenderness, and pain; “boggy” joints on palpation
4. §Stiffness prominent in the morning and subsides during the day
5. §Stiffer after rest; If they say they are more stiff when they first wake up
6. §Most often symmetrical & in PIPs (Proximal interphalangeal), metacarpophalangeal joints,
and wrists
7. §May develop permanent deformity – ulnar deviation
 Rheumatoid arthritis not only affects joints.  RA is systemic which may affect other organs of
body including skin, lungs, heart and kidney;
Collaborative Management
▪ Assessment
▪ Physical assessment and clinical manifestations
▪ Psychosocial assessment
▪ Laboratory assessment: rheumatoid factor, antinuclear antibody titer, erythrocyte
sedimentation rate (sed rate), serum complement (when complement protein is elevated
there is inflammation), serum protein electrophoresis – measures serum
immunoglobulins; C-reactive protein (CRP) – when elevated there is inflammation;
▪ Warmth, bogginess, Wrist, hands, shoulders, knees (RA/OA), ankle, ball of foot & Toes
▪ Involves synovial joint (destructs synovial membrane)
▪ Early disease manifestations
▪ Late disease manifestations
▪ Joint involvement
▪ Systemic complications
▪ Associated syndromes
Other diagnostic assessments
Drug Therapy for RA
Mild disease
▪ Nonsteroidal anti-inflammatory drugs (NSAIDs), for instance, celecoxib, rofecoxib,
valdecoxib with cox-2 inhibiting properties
▪ Cox2 inhibitors;
▪ Disease modifying antirheumatic drugs (DMARDs), such as hydroxychloroquine,
sulfasalazine, and minocycline
▪ High RISK for GI Bleeds; DRINK lots of water with “sulfa” drugs;
Moderate to severe disease
▪ Methotrexate (Sun sensitivity)
▪ Leflunomide
▪ Biological response modifiers such as etanercept, infiximab/(Remicabe), adalimumab, anakinra
Nonpharmacologic Modalities in the Treatment of RA
1. Plasmapheresis: Take out pt plasma and replace it with healthy plasma
2. Large needle in both arms blood is withdrawn and its gone in special machine, red blood cell
goes to bottom and takes out plasma- OUTPT)
3. Complementary and alternative therapies
4. Yoga, meditation, massage
5. Promotion of self-care
6. Management of fatigue
7. Enhancement of body image
8. Health teaching
 
Osteoarthritis= DJD
1. ·         Degenerative disease of movable joints that results in degeneration of cartilage and
hypertrophy of bone
2. ·         AGE, heredity, obesity, and mechanical factors contribute
3. ·         20 million Americans
4. ·         Onset between 55 and 65 years of age; before 50 more ♂, p 50 more ♀, esp AA &
Native Americans
5. ·         Signs and symptoms
-Joint stiffness, pain with motion in weight bearing joints (hips and knees)
- Stiffness worsens as day progresses (OPPOSITE Of RA PT)
- Aggravated by activity, relieved by rest
- Swelling/edema in joints without redness or warmth; usually not symmetrical
- Herbeden’s nodes (DIPs) (beside fingernail)
- Bouchard’s nodes (PIPs) (Major knuckle)
- Coarse crepitus; effusions; cracking and fluids in joints;
- Decreased ROM in affected joint
 
-  Lab
- ESR elevated (Maybe)
-  X-ray
- Unequal narrowing of joint space
- Bone cysts
-  Interventions
- Weight loss
- Rest
- Positioning
- Heat to joints (Hot tub)
- Physical therapy
- Cane use
-Drug Therapy – NSAIDs & cortisone injections into joint (directly into affected joint) ---
can destroy joint, most dr will only do this a certain amt of time
-Replacement of the joint
RISKS:  infections (sticking needle into joints if not really good aseptic tech… could get
osteomylitis)
Joint Replacement
▪ Post-op care : Cell-Saver; pt gets own blood, no typing and cross-matching; we worry about
some getting contaminated; Jackson-Pratt, hemovac (Look for hematoma…. Hardness)
look at labs (hgb, hct) Watch for anemic pt not recouping;        
▪ Risk for infection; pain; Risk for DVT; Risk for bleeding (more important) Heparin/Lovenox; 
ADUCTED leg- pop prosethetis OUT… ***PREVENT this by having ABDUCTION
pillow – it holds it away from midline position;  NEVER go 90degree Flexion…
▪ Out of bed…. How much wt bearing ; KNOW CRUTCH AND WALKER!!! Which leg goes
first etc;  As long as they are having pain walking or limping they need walker; 
▪ Need INR 2.5-3; Don’t eat dark leafy greens b/c its vit K an will interfere with Warfin –
miphyton antidote for overdose;  Patient Teaching following Joint replacement
▪ Signs and Symptoms of Infection
▪ Anticoagulant therapy – Coumadin
▪ Need INR 2.5-3; Don’t eat dark leafy greens b/c its vit K an will interfere with Warfin –
miphyton antidote for overdose;
▪ Avoidance of MRI in future (also alert anyone with metal scanners)
▪ Prophylaxis for infection with antibiotics prior to invasive procedures
CPM – continuous passive motion; machine in bed that flexs and extends (obtain and regain
mobility of joint) some take the CPM machine home 
NO MRI
 
?
The client is to get out of bed to a chair on the first postoperative day after total knee
replacement. The nurse would plan to do which of the following to protect the knee joint?
 
a.         Apply a knee immobilizer before getting the client up and elevate
 the client’s surgical leg while sitting
b.         Apply an Ace wrap around the dressing and put ice on the knee while sitting
c.         Lift the client to the bedside chair, leaving the CPM machine in place
d.         Obtain a walker to minimize weight bearing by the client on the affected leg
Answer: D 
 
Home Modifications:  Armchair raiser unit; Levers on sinks etc; front door leer handle,
wire basket to catch letters and key turner, different devices on plugs, different can openers
ELECTRICAL, wider sissor openings; mugs betters than tea cups; padding utensils; 
Dressing stick, bottom wiper, sock aid
 
Assessment
▪ Posture with spinal curvatures
▪ Gait including balance, steadiness, ease, asymmetry
▪ Mobility -  ADLs without pain or assistive devices
▪ Head and Neck
▪ Spine
▪  Upper Extremities
▪ Lower Extremities
▪ Muscular system with grading of strength
GAIT the moment you see them; normal swing (head, shoulder, and hips) Balance, steadiness,
posture, ht of shoulders, level of major parts; C- concave, T- Convex, L- concave Straight ; may
alter lungs due to diminished lung capacity;
LOOK OVER ROM!!!!!!! GONIOMETER – Actual ROM
Diagnostic Tests
       -Labs
-Calcium (9.0-10.5 mg/dl) & phosphorus (3.0-4.5 mg/dl); integrated role of parathyroid &
kidney & bone to maintain WNL
« Hypercalcemia – cancers, bone in repair, confusion
« Hypocalcemia – osteoporosis, clotting, contractility
Tap facial nerve…. Nerves twitching CHEVOCEK
                         Blood pressure cuff… low serum cal.. tingling,etc. Trosseu signs
                                    TETANY (BAD) no air going past larynx; DEADLY!!!
- Alkaline phosphatase – Increase bone, liver diseases
- Muscle enzymes – Increases with muscle diseases - RHABDO
« Creatine kinase (CK-MM) RISK FOR RENAL!!  Muscle died and it is releasing protein;
IF high keep them HYDRATED QUESTION: if pt has high CK-MM what is the priority
intervention?  IV FLUIDS!!!!!
« AST
« LDH
-   Radiographic Exams
-X-ray – not good for soft tissues, ligaments, etc.
- Tomography/CT scans
- Myelography- inject dye in epidural space which will show up CSF in spinal cord,
-  Arthrography
 Magnetic Resonance Imaging= MRI
Closed tunnel is better; deeper tunnel the better Artifical joint, pace maker, bullet fragments,
welding workers all; anuersm repair (stapels); HR long; Dye is not nephrotoxic; can cause
sleroderma though (Harding of skin)
- Best for visualization of joints, soft tissue, (muscles, tendons, ligaments), and tumors of the
bone
- Exclusions-persons with surgical clips, pacemakers, feromagnetic or metal fragments;
claustrophobia; unable to tolerate constant loud clicking; position for test; life-support
 
Additional Diagnostic Tests
▪ Bone biopsy –  Sticking needle in and extracting tissue
▪  Muscle biopsy
▪ Electromyography- small amt electricity in muscle and record the activity of muscle
23/25 gauge needles
▪ Bone scan – small amt of dye injection; metabolic active areas will show up black Boney
metastatic
▪  Ultrasound
▪   Gallium/Thallium scans- different substance, no radioactive
 Done Density = DEXA – looks at bone density in wrist, spine and hips;;; tells if pt starting
osteoporosis
Hypocalcemia; renal failure; pulmonary (due to steroids); postmenopausal women; thyroid
problems; family hx of osteoporosis;
 
Arthroscopy – generally out-pt surgeryPre-procedure
▪ NPO night before (they will get anesthesia); needs to take dial because its antibacterial;
uPost-procedure (Someone needs to drive them home)
«Neurovascular checks
«Rx for mild discomfort
«Activity instructions
Compartmental Syndrome 5 p’s!!   EMERGENCY
Fasciotomy- incision to skin thru fascia to allow fluid out;
 
Fractures
Types
 Complete
 Incomplete
 Open (compound) – high priority, risk for infection;
 Closed (simple) femur (bigger bone bigger blood loss); tibia
Blood goes into tissues look for bruising, palpate for hardness, HR will increase and get weaker
(epinephrine will be release due to anxiety so BP could go up or down)
LABS: Hgb, Hct serial (series) 1gm down = 1L of blood
Hip bone tends to penetrate bladder;
Colles fracture (wrist breaking falls)
LOOK AT THE GRADES!!
 
Fractures
 Complications of fractures
 Compartment syndrome
 Shock
 Fat embolism
 Infection
 Avascular necrosis
 Delayed union, nonunion, malunion
 
Fat Embolism
          SS:   (BM oily, high possibility of oily BM substance getting in blood vessel and
traveling to lungs) usually this happens first few days
S/S SOB petechiae (Axillary area); looks like pulmonary edema; crackles
   Go in room, look at respiratory, validate VS; listen to breath sounds (do we have equal bilateral
sounds, hear any adventitious sounds, elevate HOB) Pt symptomatic; Put them on oxygen; look
for the petechiae; CBC (check for anemia, infection) Chest X-ray; Blood gases; Clot – D-Dimer
(lab test shows clot breaking down) CAT scan of chest  (wont if they have any at risk problems)
Nuclur medicine dep-Ventilation perfusion scan  (inj. Small amt radioactive sub in blood, no
precaution, activity scan to see how well blood flows into lungs, if it’s a clot, bacterial in alveoli
(pt breath oxygen with radioactivity)
PTT & INR  therapeutic IV alcohol to separate the fat;
Compartmental Syndrome
Fracture is gonna bleed, high risk for this; 5 P’s
Fasciotomy
Avascular Necrosis - head of femur fractures, poor blood supply and may not heal
 
?
The nurse is caring for a client being treated for fat embolus after multiple fractures.
Which of the following data would the nurse evaluate as the most favorable indication of
resolution of the fat embolus?
 
a.         Arterial oxygen level of 78 mm Hg
b.         Minimal dyspnea
c.         Clear chest radiograph (x-ray)
d.         Oxygen saturation of 85%
Answer: C
 
Fractures
  Rib fractures most common
  Femoral shaft fractures
  History
 Preceding events
 Other history
  Labs
  Radiographic assessment
 CT scan, MRI, Bone scan
 
Fractures – Nursing Diagnoses
 Risk for Peripheral Neurovascular Dysfunction related to bone and soft-tissue trauma and
immobility
 Acute Pain related to bone disruption, soft-tissue damage, muscle spasm, and edema
 Risk for Infection related to bone trauma and soft-tissue damage
 Impaired Physical Mobility related to pain
 Imbalanced Nutrition: Less Than Body Requirements related to additional metabolic need
for healing of bone and soft tissues
 
Fractures
-Interventions
 Emergency care - Immobolization
 Neurovascular monitoring – the P’s
 Closed reduction
« Bandages and splints
« Casts
▪ •   Types
▪ •   Cast care
▪ •   Complications
« Traction
▪ •   Types
▪ •   Traction care
----- Surgical management
 Open reduction internal fixation= ORIF; plates and screws placed on fracture
(yellowish/odor sign infection)
 External fixation (Stabilization) Risk for infection, Pain, Injury,
« Care of external fixator
- - -  Interventions
 Drug therapy PCA – morphine, demerol (DON’T USE IN ELDERS)
  Promotion of mobility – Look over how to use these
 Crutch use – powerpoint slides
 Walker use
 Cane use
  Nursing Concerns:
?
A client in skeletal leg traction with an overbed frame is not allowed to turn from side to
side. Which action by the nurse would be most useful in trying to provide good skin care to
the client?
A. Ask the client to lift up by digging into the mattress with the unaffected leg
B. Push down on the mattress of the bed while administering care
C.  Have another nurse turn the client
D.  Ask the client to pull up on a trapeze to lift the hips off the bed
Answer D
 
Skeletal Traction – 5 P’s check!!  PRIMARY  Risk for pneumonia; (Cough, deep breath,
incentive spirometer) Turn to unaffected side, HOB can be elevated; NEVER Take off weights;
risk for pulmonary embolism; Pressure (circulation –constant pressure prevents cap circulation
leading to skin break down) Back of ear, sacral; Thomas splint (round device around thigh
pressing around groin; do passive and active ROM on foot  (device there to prevent foot drop)
weights MUST hang free, shouldn’t bump against bed, sit on floor, etc. rope must be able to
freely move through pulley; give trapeze bar so that he can move up and back in bed;  Immobility
issues, boredom;
 
BIGGEST RISK FOR INFECTION: Pin care, cleaning with cloroheaxaden;  (red swollen warm
purulent drainage)
 
Pt with spinal cord injury, HALO (allows pt to be mobile, pins in scull); Gardner-Wells Tongs –
immobile; eventually will go to a HALO
 
Skin Traction – Nursing concerns: Buck’s traction; at risk for skin breakdown; remember hang
free; 
Old lady falls think hip fracture, besides pain whats another indicator; affected leg with be shorter
with internal rotation of hip; When we get leg realign, pain will be significantly less,
 
Ciatica vs. herniated/ruptured disk Herniated/ ruptured Disk
--- HCPs use physical examination maneuvers to help seek out the cause of sciatica. When a
straight leg raise reproduces the pain, a herniated disk is often the cause. If the leg raise has
no effect, the crossed leg test shown below can be used to stretch the piriformis muscle to
test for a pelvic location of the sciatic nerve entrapment.
    Sciatica     
----  The pain often starts in the low back - (due to a herniated disc) - or in the buttock -
(due to piriformis syndrome) - and extends toes. It can be accompanied by numbness, 'pins
and needles' ("paresthesias") or, in more severe cases, actual weakness affecting the ankle
or toes may accompany the sciatica.
-----  The earliest signs of spinal cord compression or myelopathy can be detected by
abnormalities in the examination performed by a HCP. Some of these signs include very
brisk reflexes when tapping the correct spot below the knee cap, a bouncing reflex when the
ankle is stretched called clonus, and unsteadiness when standing with the eyes closed – a
positive Romberg sign.
 
Microdiscectomy
Go in with laproscopic pull out nucleous pulposus (inter jelly like substance inside intervertebral
disc, like inside of a jelly doughnut); can also inject medication to dissolve disc
 
Cervical is usually (anterior neck incision to get to spine) AIRWAY any surgery in the neck,
swelling, etc. HOB elevated; whole lot more room in chest, bleeding (incision, behind neck)
swelling puts pressure on nerves to perineum, inability to void (More men have lumbar
laminectomy, voiding problems) SLIDE ON SHOES ( NOT BENDING, TWISTING, Turning)
If Sacral- problems voiding
Laminectomy   
- Excision of dorsal arch of vertebrae with/without spinal fusion of two or more vertebrae
Post-op Care  
-  Cervical disk – respiratory concerns, swallowing
  -Lumbar disk – neurovascular assessments, urinary/bowel concerns, logroll, no extreme
knee or hip flexion
---  Teach – proper body mechanics, exercise program
Carpel Tunnel Syndrome (remember Phalen’s & Tental Tests from 310)
Use braces, if brace don’t work surgery; losen brace if brace makes hand go to sleep, numbness,
etc;
Phalen’s test: 90 sec, and u get pain that means you have carpel tunnel  
Tintel: positive if you tap and it feel awful;
?
The nurse is caring for a client who has had spinal fusion with insertion of hardware. The
nurse would be concerned especially with which of the following assessment findings?
 
a.         complaints of discomfort during repositioning
b.         Temperature of 101.6o  F    orally
c.         Old, bloody drainage outlined on the surgical dressing
d.         Discomfort during coughing and deep breathing exercises
Answers: B
Amputations
-  Removal of a part of the body (diabetic or trauma)
-  Psychosocial ramifications
- Loss is complete and permanent
- Change in body image and self-esteem
-  Types
- Surgical
- Traumatic
-  Levels
-  Complications
- Hemorrhage
 Infection
- Phantom Limb Pain
- Neuroma
- Flexion contractures
http://www.amputee-coalition.org/military-instep/wound-skin-care.html
---  Interventions
-Assessment of tissue perfusion
 -Management of pain
-- Drug therapy
« Beta-blockers (olol)
« Anticonvulsants tegetrol & neurontin   
« Antispasmodics baclofen (lipresal)
-Alternative therapies (Ultrasound, massage, exercises, distraction, hypnosis,
psychotherapy)
--- Prevention of infection
-Promotion of ambulation – elevation (help minimize swelling) shouldn’t stay this way
because we want to keep our flexion (play him prone and supine)
 
-  Exercise
-  Prostheses
-  Promotion of body image
-  Promotion of lifestyle adaptations
-  Teaching
 
Osteoporosis
---  Irreversible osteopenia
------Metabolic disease After peak bone mineral density, bone resorption exceeds bone-
building activity à â bone density
- Bone mineral density peaks between age 30 and 35
-  Bone demineralization à decreased density à fractures
-  Wrist, hip, and vertebral column most often affected
-  Between 25 and 35 million Americans
-  Women > men ; 50% of women over 65 years of age have symptomatic osteoporosis
 
-  $14 billion each year in health care costs
- 2 types
- Primary : lack of hormones decreased Ca++ absorption
- Secondary: med conditions, medications (steroids), immobility
-  Etiology unknown
-  Risk factors
- Clients greater than age 60
- Family history of osteoporosis
- Caucasian or Asian race
- Thin, lean body build
- Low, lifetime calcium intake
- Estrogen/ Androgen deficiency
- Smoking history
- High alcohol intake
- Lack of physical exercise or prolonged immobility
 
Osteoporosis Clinical Manifestations
- Kyphosis – hunch back (old lady stance)
- Height shortened by 2-3 inches within previous 20 years
- Back pain with lifting, bending, stooping
- Constipation, abdominal distention, reflux esophagitis, respiratory compromise
- Fracture – often first indication of disease– most likely of vertebrae between T8 and L3,
distal end of radius, and upper third of femur (hip)
- Fallophobia
Osteoporosis Diagnosis
- History
- Index of suspicion
- Laboratory: Ca++, Phos, Vit D, etc
- Radiographic assessment: x-rays & DEXA
Bone Density = DEXA
Osteoporosis Interventions
Prevention
Drug Therapy
« HRT
« Calcium: TUMS, OsCal (w food, & H20)
« Vitamin D (400-800 u/d) Calcitriol
« Bisphosphonates – Fosamax, Boniva: SE: esophagitis  SIT UP after
« Selective estrogen receptor modulators (SERMs) (mimic estrogen) not used alot
« Calcitonin – inhibits osteoclastic activity—given IM, subq, or nasal; SE: hypersensitivity,
anaphylaxis;
uDiet therapy:       increase protein, Mg++, Ca++, Vit D; (see list)
uAvoid ETOH, caffeine, smoking, laxatives
-   Prevention of falls                 
-  Exercise
- Pain management – as needed for fractures: opioids, muscle relaxants, NSAIDS
- Orthotic devices
 
Teaching = prevention & focus on ADLs, safety
Good lighting; natural, exercise,
 
Types of Casts: plaster, fiberglass (plaster takes forever to dry!!)
DO NOT PUT STUFF DOWN IN CAST, risk for injury and infection; Split cast when cold,  bad
circulation (pulse cap refill) splinting casts like in compartmental syndrome; cast cutter wont cut
legs, TLC for leg meaning rub them put lotion on, etc. 
Elevate, put ice on leg (REDUCE SWELLING) Baby: Pedals, application of tape around margin
of cast to prevent irritation to skin Spica cast;