SIGNS AND SYMPTOMS Heberden’s nodes

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Painless bony enlargement of DIP (Distal interphalangeal joint) Swan neck deformity Rheumatoid arthritis Hyperextended PIP (Proximal Interphalangeal joint) Slightly flexed DIP


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Volar subluxation of MCP ( Metocarpophalangeal joint) Ulnar deviation of fingers


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Gout Painless, nodular swelling (uric acid deposits) Ears, hands, feet


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Morning stiffness Swelling of 3 or more joints Involves: wrist, MCP and PIP Subcutaneous nodules

Rheumatoid factor in serum Characteristics hand deformity:

Ulnar deviation of digits


“swan neck” deformity

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Joint erosions Periarticular bone erosion

OSTEOARTHRITIS Degenerative disease Progressive pain Relieved by rest Involves weight bearing joints hip joint, knee joint (also DIP and PIP in women)

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Loss of cartilage Narrowed joint space Subchondral cysts and sclerosis New bone formation (marginal osteophytes)


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Impaired mobility > risk of injury

IMPLEMENTATION Range of motion exercises Exercises to maintain muscle strength (but minimize weight – bearing activities) Encourage weight loss to reduce stress on joints

Warm tub baths to relief stiffness Note: proper use of cane: hold in hand opposite of “bad” leg. RHEUMATOID ARTHRITIS ANALYSIS

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Impaired mobility > risk of injury IMPLEMENTATION • Range of motion exercises Encourage self – care: provide privacy and pain relief Apply local heat or cold


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Anti – inflammatory drugs CLIENT EDUCATION Serious risk gastric ulceration from anti – inflammatory drugs

GOUT Deposits of urate crystal in synovial tissue > acute inflammation Note: 90% of cases are due to under-excretion of uric acid 10% of cases are due to over-production of uric acid ASSESSMENT • May be asymptomatic for a long time

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Acute attack: pain in joint of great toe (podagra) Elevate serum uric acid Tophi: urate deposits in subcutaneous tissue

IMPLEMENTATION • Bed rest during acute attack

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Use cradle to keep bedcovers elevated Encourage fluid intake (3L/day) Hot packs (reduce muscles spasm and pain)

Cold packs (reduce swelling and pain) MEDICATIONS: • Asymptomatic hyperuricemia: no medication necessary Mild attacks: analgesics (acetaminophen) Severe attacks: colchicine, NSAIDs Allupurinol: reduces uric acid production Probenecid: increases renal uric acid excretion

CLIENT EDUCATION • Encourage weight loss but avoid crash diets

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Avoid alcohol Limit food high in purines (anchovies, shellfish, organ meats)

Factors that inhibit uric acid secretion (increased risk of gout)

Alcohol - Aspirin – Diuretics

SPONDYLOARTHROPATHIES Autoimmune diseases involving spine and sacroiliac joint Ankylosing spondylitis (more common in young men)

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Gradual onset Reiter’s syndrome (more common in men) Sudden onset Urethritis Arthritis (knees, ankle) follows dysentery (Shigella) follows STD (Chamydia)

Psoriatic arthritis (more common in women)

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Variable onset Occurs in 20% of psoriatic patients Nail pitting Sausage toes


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Weakness, fatigue Anorexia, weight loss Photosensitivity Butterfly rash (spare nasolabial fold) Discoid rash Anemia Arthritis Nephrotic syndrome

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Leukopenia Thrombocytopenia Antinuclear antibodies False positive test for syphilis

Drug induced lupus • Often fairly mild

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History of hydralazine, procainamide, other drugs Reversible after drug cessation


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Emotional support Protective clothing and sun screen if clients is photosensitive Heat packs for joint pain Monitor for signs of renal damage: edema, hypertention


Steroids (topical for skin, systemic if organ involvement)

OSTEOPOROSIS Loss of the one mass > risk of fracture

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Elderly persons are at risk Bone loss is accelerated in postmenopausal women (lack of estrogen)


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Backache Kyphosis Los of height Serum calcium and phosphate levels are normal X-ray: decreased density of vertebrae

ANALYSIS Risk of injury: femur (hip) fractures, vertebral compression fractures IMPLEMENTATION DIET: High-protein diet Calcium and vit. D MEDICATIONS: Estrogen replacement

CLIENT EDUCATION • Encourage physical activity to prevent atrophy

Prevent falls: slippery bathroom floors, loose rugs..

Note: Estrogen slightly increase the risk of endometrial cancer. Regular check-ups for clients on estrogen replacement are recommended. HERNIATED DISK ASSESSMENT

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Severe lower back pain Pain radiating down buttocks and legs Usually unilateral Neurological exam: motor or sensory deficits are a serious sign Diagnosis: CT or MRI

ANALYSIS • Risk of injury to spinal cord and nerve roots

Level of mobility IMPLEMENTATION • Apply local heat or cold CERVICAL:

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Cervical herniation: collar or traction required LUMBAR • Bed rest until inflammation is reduced Provide firm mattress Recommend high-fiber diet with plenty of fluid (to prevent constipation and straining) CLIENT EVALUATION • Avoid prolonged sitting

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Use legs when lifting objects (keep spine straight) Exercise to strenghten abdominal and back muscles

CARPAL TUNNEL SYNDROME Compression of median nerve at wrist joint ASSESSMENT • Pain in wrist or palm or hand

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Paresthesias in radial palmar aspect of hand

Weakness of thumb IMPLEMENTATION • Relief pressure on median nerve:(hand elevation, splinting of hand and forearm) • Cortisone injections into carpal tunnel CLIENT EDUCATION • Avoid prolonged flexion of wrist

Teach proper hand position when typing or using computer

OSTEOMYELITIS Infection in bone, usually by staphylococcus aureus ASSESSMENT

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Malaise Pain and tenderness over bone Swelling and redness over bone Fever Diagnosis: bone scan or culture from needle biopsy

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IMPLEMENTATION Immobilization of affected limb

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No weight-bearing on affected limb

Explain client need for long-term antibiotics (oral for 6 weeks after fever normalizes) LEG AMPUTATION ASSESSMENT • Peripheral vascular disease > claudication (pain when walking, rapid relief when resting) • Cyanosis

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Ulcer formation Gangrene: foul smell, blackened wound


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Risk of injury Effective coping with altered body image

IMPLEMENTATION Watch for signs of infection and sepsis POSTOPERATIVE: • Bandages should be applied in a diagonal figure 8 pattern Elevate stump for first 12 hours Monitor wound drainage (keep tourniquet at bedside for emergencies) Exercise to improve arm strength

CLIENT EDUCATON • Explain “phantom pain”

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Encourage frequent repositioning in bed Massage stump to improve vascularity

CRUTCHES & CANES CRUTCHES Fitting • Measure from anterior fold of axilla to heel, add 6 inches

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There should be 2 inch space between axillary fold and underarm piece to prevent damage to brachial plexus (clutch paralysis) Basic stance Crutches should rest in front and lateral of feet 2-point gait Advance right crutch and left foot together Advance left crutch and right foot together

3-point gait (used if only one leg is injured) • Advance both crutches and involved leg forward

Advance healthy foot while keeping body weight on crutches

4-point gait (similar to 2-point gait, but slower and more stable)

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Advance right crutch Advance left foot Advance left crutch Advance right foot


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Highest point should be at level of greater trochanter Handpiece should allow 30deg. Flexion at elbow

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Hold cane in hand opposite to injured leg Advance cane and injured leg at same time Don’t lean body over cane

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