Orthopedic conditions

• Rheumatoid Arthritis


  Chronic, systemic autoimmune disease affecting the synovial tissue

  
• Rheumatoid Arthritis


  • Peaks between 30 and 50 years of age
  • Estimated 300 000 Canadians are affected
  • Women are more likely to have RA than men
  • Due to inflamed synovial fluid and membrane
  • Usually develops between 25 and 50 years of age
  • Systemic involvement: fever, weight loss, fatigue, anemia, lymph node enlargement, Raynaud's phenomenon
  • Bilateral
  • Starts in small joints then larger joints

  
• Ethology and pathophysiology


  Cause and underlying mechanisms of the disease
• Clinical manifestations of Rheumatoid Arthritis


  • Joint pain
  • Swelling
  • Warmth
  • Erythema
  • Limitation in function
  • Joint stiffness lasting from 60 mins to several hours

  
• Rheumatoid Nodules


  • Associated with advanced, destructive RA
  • Develops in 20% of clients
  • Non-tender, moveable SC tissue
  • Occur at bony prominences (Elbows)
  • Vary in size
  • Disappear and appear spontaneously

  
• Diagnostics for Rheumatoid Arthritis

  • Positive RF occurs in ~80% of patients
  • Antinuclear antibody (ANA) titres
  • Anti-citrullinated protein antibody
  • Synovial fluid analysis
  • Radiological studies
• Interprofessional Care for Rheumatoid Arthritis

  1. Early Stages (first 2 years): Education, balance of rest and exercise, referrals to community agencies, medications (NSAIDs, COX-2 inhibitors, antirheumatic agents, biologics, opioids)

  2. Medical Management: Nutritional therapy, OT/PT, immunosuppressants, corticosteroids, methotrexate, surgical therapy (synovectomy, arthroplasty)

  3. Nursing Management: Nursing assessment, nursing diagnoses, planning, implementation (warm compress, splints/OT)

  
• Osteoarthritis (OA)


  Rheumatic disease; "Wear & tear" disease due to cartilage deterioration; Not systemic

  
• Osteoarthritis


  • Affects weight bearing joints
  • Onset typically 30s & peaks 50-60s
  • 85% 75yo have evidence of OA but only 15-25% are symptomatic
  • Degenerative disease worsens over time
  • Gradual onset
  • Impacts functional status and quality of life
  • Primary OA has no prior related event/disease
  • Secondary OA is due to previous joint injury/inflammatory disease

  
• Risk Factors for Osteoarthritis

  • Older age
  • Gender (women more likely)
  • Obesity
  • Strenuous/repetitive work/activities
  • Previous joint injuries
  • Genetic factors
  • Anatomic deformities
  • Mechanical injury

  
• Clinical manifestations of Osteoarthritis

  • Range from mild discomfort to significant disability
  • Pain: hurts during heavy activities and can become unpredictable
  • Stiffness: usually lasts 30 minutes or less
  • Swelling: joints can become enlarged
  • Crepitus: cracking when moving
  • Instability: unable to use the joints
  • Joint dysfunction
  • Deformity specific to joint involved (hands, hips, knees)

  
• Assessment of Osteoarthritis


  1. Carefully assess and document the patient's joint pain and stiffness (type, location, severity, frequency, duration)

  2. Physical examination

  3. Diagnostic Studies: Bone scan, CT, MRI, Radiological studies, Blood studies, Synovial fluid analysis

  4. Health history

  
• Nursing Diagnoses for Osteoarthritis

  • Acute & chronic pain
  • Insomnia
  • Reduced physical mobility
  • Self-care deficits
  • Imbalanced nutrition: more than body requirements leads to weight issues
  • Difficulty coping
• Planning for Osteoarthritis


  Overall goals: Maintain/improve joint functions through a balance of rest & activity, Joint protection measures to improve activity tolerance, Achieve independence in self-care and maintain optimal role function, Pharmacological and nonpharmacological pain control
• Nursing Management of Osteoarthritis

  1. Health promotion: Prevention through alteration of modifiable risk factors, Community education

  2. Acute intervention: Medications and nonpharmacological strategies, Patient and caregiver teaching

  3. Ambulatory and home care: Home and work environment modification, Sexual counselling
• Pharmacological Therapy for Osteoarthritis


  • Salicylate (ASA): anti-inflammatory, analgesic
  • NSAIDs (Motrin): anti-inflammatory, analgesic
  • Antibiotics (Doxycycline): action on enzymes to reduce cartilage degradation
  • Topical analgesics (Capsaicin cream): depletes substance P, interrupting pain signals
  • Corticosteroids (Methylprednisolone acetate): anti-inflammatory, analgesic
• Surgical Management of Osteoarthritis


  • Osteotomy: surgery that cuts & reshapes the bone
  • Arthroplasty: surgical reconstruction/replacement of a joint

  
• Nursing Process for Pre-op Care for Orthopedic Surgery

  1. Pre-op assessment: Hydration status, Medication history, Possible infection, Knowledge, Support & coping

  2. Post-op care: PT/OT, Weight bearing status/activity level, Knee immobilizer, CPM device, Monitor VPCOWF, CSM, integument, wound drainage, edema, I/O, Deep breath & cough, Prevent and monitor for complications
• Osteoporosis


  The rate of bone resorption is greater than the rate of formation, leading to porous, brittle and fragile bones that fracture easily under stress

  
• Osteoporosis


  • 1 in 4 women and 1 in 8 men in Canada affected
  • Often called the "silent disease" because bone loss occurs without symptoms
  • Frequently results in compression fractures
  • Increases risk for falls

  
• Osteoporosis Assessment


  Routine x-rays, DEXA scan for diagnosis and Bone Mineral Density (BMD), Family history and physical exam, FRAX tool, Labs: Serum calcium, phosphate
• Nursing Diagnoses for Osteoporosis

  • Deficient knowledge about the osteoporosis process and treatment regimen
  • Acute pain related to fracture & muscle spasm
  • Risk for injury (additional fractures related to osteoporosis)

  
• Management of Osteoporosis


  1. Slow progression & maintain independence with ADLs

  2. Diet: Increase calcium intake, Greens

  3. Weight-bearing exercises

  4. Fall Reduction: Assess home for hazards

  5. Medication and Supplements: Encourage adequate vitamin D intake
• Dietary Teaching for Osteoporosis

  • Eliminate caffeine, alcohol, carbonated beverages and smoking
  • Calcium supplements
  • Consume a diet with adequate calcium (1000-1200 mg/day) and vitamin D
  • Key dietary sources of calcium: Milk, yogurt, green leafy vegetables, cottage cheese, seafood
• Pharmacological Therapy for Osteoporosis

  • Calcitonin
  • Biphosphates (Alendronate, Risedronate, Ibandronate)
  • Selective estrogen-receptor modulators (SERMs): Evista
  • Teriparatide: Forteo (treatment for men)
• Fractures


  A disruption in the continuity of bone when it is subjected to more stress than it can absorb

  
• Classifications of Fractures


  • Complete
  • Incomplete
  • Closed or simple
  • Open or compound, complex (Grade I, Grade II, Grade III)
• Interprofessional Care for Fractures

  Overall goals: Anatomical realignment of bone fragments, Immobilization to maintain realignment, Restoration of normal or near-normal function

  
• Ibandronate (Boniva)


  Selective estrogen-receptor modulators (SERMs): Evista
• Teriparatide


  Forteo (tx for men)
• Fractures are the second most common activity-limiting injury (Statistics Canada, Canadian Community Health Survey, 2015)

  
• Fracture


  A disruption in the continuity of bone when it is subjected to more stress than it can absorb

  
• Fracture classifications


  • Complete
  • Incomplete
  • Closed or simple
  • Open or compound, complex
  • Grade I
  • Grade II
  • Grade III

  
• Overall goals of fracture treatment

  • Anatomical realignment of bone fragments
  • Immobilization to maintain realignment
  • Restoration of normal or near-normal function of injured parts

  
• Closed reduction


  1. Nonsurgical, manual realignment of bone fragments to previous anatomical position

  2. Traction and counter traction manually applied to bone fragments to restore position, length, and alignment
• Open reduction


  1. Correction of bone alignment through surgical incision

  2. Includes internal fixation with use of wires, screws, pins, plates, intramedullary rods, or nails

  
• Purpose of any traction

  • Prevent or reduce muscle spasm
  • Immobilize joint or part of body
  • Reduce a fracture or dislocation
  • Treat a pathological joint condition

  
• Types of traction


  • Skin traction: Buck Traction
  • Skeletal traction
• Skeletal traction


  In place for longer periods, used to align injured bones and joints or to treat joint contractures and congenital hip dysplasia, provides a long-term pull that keeps injured bones and joints aligned
• Cast


  Temporary circumferential immobilization device, allows patient to perform many normal activities of daily living