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Understanding Medical Surgical Nursing Ch 44


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occurs when articular cartilage & bone ends of joints deteriorate

S/S: joint deformities - pain - immobility - stiffness
When osteoarthritis occurs, the joint space 1_____, 2_____ _____ develop, and the joint may become inflamed. The joints affected most often include those that are 3_____-_____, hands, and the 4_____ _____.
1) narrows

2) bone spurs

3) weight-bearing

4) vertebral column
Heberden's and Bouchard's nodes are . . .
bony nodes on joints of fingers

caused by osteoarthritis

more commen in women than men
Three tests used to diagnose osteoarthritis are . . .
1) x-ray exam

2) computed tomography (CT) scan

3) magnetic resonance imaging (MRI)
Mr. Dennis, a 59-yr-old overweight carpenter, visits his physician with c/o of knee & wrist pain. He's noticed it's becoming increasingly difficult to climb a ladder or use a hammer. The physician suspects osteoarthritis.

What risk factors
~ overweight

~ in late middle-age

~ physically demanding job
What types of drugs are used to treat the symptoms of osteoarthritis? (5 types listed)
~ NSAIDS (incl. COX-2 inhibitors)

~ corticosteroids

~ gold therapy

~ immunosuppresives

~ antimalarials
Joint pain from osteoarthritis tends to be less severe in the _____. Activities should be scheduled at this time.

(pain decreases w/rest)
The patient with osteoarthritis usually prefers _____ therapy unless the joint is acutely inflamed.
joint replacement surgery

most common procedure for total joint replacement (TJR)
rheumatoid arthritis (RA)
chronic, progressive, systemic inflammatory disease

destroys synovial joints & other connective tissues (incl. major organs)
inflammation of the lining of joint capsule (synovium)

prelude to rheumatoid arthritis
The cause of rheumatoid arthritis is . . .

(genetic predisposition likely - those w/family hx are 2-3x more likely to get RA)
Early manifestations of RA include . . . (5 s/s listed)
~ inflammation

~ low-grade fever

~ fatigue

~ weakness

~ anorexia
Late manifestations of RA include . . .
~ deformities

~ pain & morning stiffness

~ osteoporosis

~ severe fatigue

~ anemia

~ weight loss

~ subcutaneous nodules
Gold therapy can be used to induce 1_____ _____ in 2_____ _____.
1) disease remission

2) rheumatoid arthritis
Mrs Summers is a 48-yr-old nurse who has had upper extremity joint pain & swelling for about 4 years. She was recently dx w/RA but has no systemic involvement other than extreme fatigue at this time. She is concerned that she will have to give up pro
~ balance rest w/exercise

~ use ice for very hot, swollen joints

~ use heat to decrease stiffness
hyperuricemia causes uric acid deposit in joints & other connective tissues resulting in severe inflammation

primary gout most common & is caused by inherited problem w/purine metabolism
excessive uric acid which results in urate crystal formation

(uric acid product of protein breakdown)
Diagnosis of gout is based on the 1_____ _____ _____ level. Any result above the maximum normal level of 2_____ mg/dL should be further evaluated.
1) serum uric acid

2) 7.5 mg/dL
The preferred drug for treatment of chronic gout is _____ (_____). It decreases uric acid production, necessitating several weeks of therapy before the medication becomes effective.
a. acetylsalicylic acid (aspirin)
b. naproxen (Naproxyn)
c. allopurinol (Zyloprim)

"ALLoPURinol now that the uric acid is gone"
Dietary recommendations for patients with gout include . . . (6 suggestions)
~ avoid high-protein foods

~ avoid alcohol

~ drink plenty of fluids

~ avoid all forms of aspirin

~ avoid diuretics

~ avoid excessive physical or emotional stress
systemic lupus erythematosus (SLE)
an autoimmune disease characterized by spontaneous remissions & exacerbations

S/S: butterfly rash - skin photosensitivity - fever - fatigue - arthralgia - myalgia - malaise - weight loss - mucosal ulcers
Treatment for SLE focuses on decreasing 1_____ and preventing life-threatening 2_____ _____. Medications are prescribed according to the patient's needs and may include 3_____, acetaminophen, corticosteroids, antimalarials, 4_____ _____, and immunomodula
1) inflammation

2) organ damage


4) topical cortisone
Preventative education for a patient with SLE should include . . . (four suggestions)
~ avoidance to prolonged exposure to sunlight

~ exercise (to prevent fatigue/weakness)

~ immunizations

~ stress reduction techniques
Muscular dystrophy has a _____ origin. However, the exact cause is unknown.
avascular necrosis (AVN)
condition in which bone tissue dies (usually the femoral head) as a result of impaired blood supply

can be caused by long-term use of steroids
Total joint replacement is most often performed for patients who have some type of 1_____ _____ disease in which their joints become severely 2_____. TJR may also be done for patients on long-term 3_____ _____, such as patients with SLE or asthma.
1) connective tissue

2) deteriorated

3) steroid therapy
The most common joint replacement surgeries are the 1_____ _____ _____ (_____) and 2_____ _____ _____ (_____), although any synovial joint can be replaced. Another term used for joint replacement is 3_____.
1) total hip replacement (THR)

2) total knee replacement

3) arthroplasty
The primary goal of total joint replacement is to 1_____ _____ _____ _____ and improve ability to 2_____ _____ _____ when no other treatment is successful.
1) relieve severe chronic pain

2) carry out ADLs
Rheumatoid arthritis (RA) affects women 1_____ more often than men and can occur at any age. The peak onset of RA is 2_____ to 3_____ years old.
1) 3x

2) 30

3) 60
The most common TJR surgeries are the 1_____ _____ _____ (_____) and 2_____ _____ _____ (_____). Another term used for joint replacement is 3_____. The replacement devices, sometimes referred to as prostheses, are made of metal, ceramic, plastic, or a co
1) total hip replacement (THR)

2) total knee replacement (TKR)

3) arthroplasty
The two-piece device consisting of an acetabular cup inserted into a pelvic acetabulum is used in what type of procedure?
total hip replacement (THR)
What is the most common postoperative complication for a patient having a THR?
subluxation or total dislocation

(femoral component dislodeges from acetabular cup)
The surgeon should be notified immediately if any of the s/s of hip dislocation are presented which include . . .
~ increased hip pain

~ shortening of surgical leg

~ rotation of surgical leg
The two primary nursing goals following a total hip replacement (THR) are . . .
1) prevent hip adduction

2) prevent hip hyperflexion (bending forward > 90 degrees)
For any musculoskeletal surgery or injury, frequent neurovascular assessments for 1_____, 2_____, 3_____, and 4_____ are performed when 5_____ _____ are checked.
1) color

2) warmth

3) circulation

4) movement

5) vital signs
Weight bearing to tolerance or full weight bearing ambulation following total hip replacement (THR) is used for what type of prostheses?
The knee is the second most commonly replaced joint. Compared with the hip, it is a much more complicated joint and requires three components for replacement: a 1_____ component, a 2_____ component, and a 3_____ _____.
1) femoral

2) tibial

3) patellar button
continuous passive motion machine (CPM)
motorized machine w/flexible extremity rest (for arm/leg) for purpose of keeping joint mobile

set at degree of flexion & speed ordered by physician then glides back & forth on a track
The main indication for surgical amputations is 1_____ from 2_____ _____ disease in the elderly. The rate of lower extremity amputation is much greater in the 3_____ patient than in the 4_____ patient.
1) ischemia

2) peripheral vascular

3) diabetic

4) nondiabetic
The most common surgical amputation is part of the _____ _____.
lower extremity
The loss of any or all of the small toes presents little problem. However, the loss of the great toe is more important because 1_____ and 2_____ are affected.
1) balance

2) gait
If a lower leg amputation must be performed, which procedure is preferred: a below-the-knee amputation (BKA) or an above-the-knee amputation (AKA)?
below-the-knee amputation (BKA)

(preserves joint function)
infection of bone resulting from invasion of bacteria into bone & surrounding soft tissues

can be acute or chronic

S/S: fever - tenderness - redness - heat - pain - swelling
Up to 80% of patients experience this form of discomfort following an amputation . . .
phantom limb pain

(most often occurs during the first year following amputation)
The postop amputee should avoid positions of flexion (such as sitting for long periods) to prevent this complication . . .

(limb should be checked periodically to ensure it lies completely flat on the bed)
soft tissue injury occuring when a muscle/tendon is excessivly stretched

can range from mild (minimal inflammation) to severe (separation of muscle from muscle, tendon from muscle, etc)

RICE is an acronym for . . .
R ... Rest
I ... Ice
C ... Compression
E ... Elevation
excessive stretching of one or more ligaments

usually results from twisting movements during sports, exercise, or a fall

range from mild (tearing of a few ligaments) to severe (instability of joint - surgery needed)
carpal tunnel syndrome
compression of median nerve within carpal tunnel when swelling in tunnel occurs

can result from edema, trauma, RA, repetative motion, etc.

S/S: slow-onset finger, hand, & arm pain/numbness - painful tingling - paresthesias - fine motor deficits - muscle weakness
Phalen's test
numbness with wrist flexion

utilized to dx carpal tunnel syndrome
Medical management of carpal tunnel syndrome includes wearing a 1_____, and medications such as 2_____ and 3_____. 4_____ may be injected into the carpal tunnel to decrease pain & inflammation. Surgery may be required.
1) splint

2) aspirin


4) Cortisone
When bone is broken, the body immediately begins to repair the injury. For an adult, within 1_____ to 2_____ hours after the injury a 3_____ forms at the fracture site. In about a week, a nonbony union called a 4_____ develops & can be seen on x-ray
1) 48

2) 72

3) hematoma

4) callus
Young, healthy adult bone completely heals in about 1_____ _____; however, it can take up to 2_____ _____ before the whole process of remodeling is complete. An 3_____ _____ takes longer to heal, and 4_____ tend to heal more quickly.
1) 6 weeks

2) a year

3) older person

4) children
Major factors leading to bone fractures include . . . (four examples)
~ trauma

~ bone disease (cancer, etc.)

~ malnutrition

~ regular drinking of soda pop
greenstick fracture
bone is bent and fractures on outer arc of bend

often seen in children
comminuted fracture
bone splintered/shattered into numerous fragments

often occurs in crushing injuries
impacted fracture
bone is forcibly pushed together

results in bone being pushed into bone
displaced fracture
bone pieces are out of alignment (one or both pieces)
pathological fracture
caused by bone's being weakened due to medical condition

AKA neoplastic fracture
closed reduction
physician manipulates bone ends into realignment by manually pulling on bone

most common treatment for simple fractures
applying pulling force to a part of body to provide fracture reduction, alignment, or pain relief

can be continuous or intermittent
skin traction
used for pain relief

~ Buck's traction (velcro boot)
~ Russell's traction (knee sling)
~ belt (pelvic)
~ halter

5-10 lbs of weight applied
Buck's traction
for pain relief with hip fractures

uses velcro boot
skeletal traction
AKA balanced suspension

involves use of pins, screws, wires, or tongs surgically inserted into bone

20-40 lbs of weight applied
open reduction with internal fixation (ORIF)
bone ends are reduced by direct visualiztion through surgical incision

bone ends held in place by internal fixation (IF) devices (metal plates & screws, prosthesis, etc)
Leg exercises, early ambulation, and anticoagulant therapy can help prevent the two most common complications that may develop in patients who are immobile due to trauma or surgery (particularly the elderly). The complications are . . .
1) deep vein thrombosis (DVT)

2) pulmonary embolism (PE)
acute compartment syndrome (ACS)
pressure within one+ extremity compartments increases, causing massive circulation impairment to the area

S/S: severe, increasing, intractable pain - pain occurs more on active than passive movement - decreased sensation followed by ischemia - pulselessness - paresthesia - pallor
Mr. Andrews has suffered a nondisplaced fracture of his right femur. He has a cast from his groin to the middle of his foot. An hour ago he received 10 mg of morphine IV. He is complaining of continuing & increasing pain.

What nursing acti
~ perform a neurovascular check

~ perform a further pain assessment

~ ask Mr. Andrews to move his limb & see if the pain worsens

~ take vital signs

~ assess for 6 Ps (pulselessness, paresthesia, paralysis, pallor, pain, poikilothermia)
Mr. Andrews has suffered a nondisplaced fracture of his right femur. He has a cast from his groin to the middle of his foot. An hour ago he received 10 mg of morphine IV. He is complaining of continuing & increasing pain.

What might be hap
He might be experiencing compartment syndrome.
Mr. Andrews has suffered a nondisplaced fracture of his right femur. He has a cast on from his groin to the middle of his foot. An hour ago he received 10 mg of morphine IV. He is complaining of continuing & increasing pain.

What intervent
Interventions may include . . .

~ bivalving cast (cutting along cast)

~ possible fasciotomy (incision into fascia that encloses compartment)
fat embolism syndrome (FES)
small fat globules are released from yellow bone marrow into bloodstream

fat travels to lung fields & causes respiratory distress

S/S: altered mental status due to low arterial oxygen - tachycardia - tachypnea - fever - high BP - severe SOB - petechiae over upper body
Fat embolism syndrome (FES) usually involves the 1_____ _____ or 2_____ _____and can occur up to 3_____ _____after the initial injury/procedure.
1) long bones

2) multiple fractures

3) 72 hours
Actions to be taken should a fat embolism be suspected include . . . (6 actions listed)
~ promote oxygenation (2L via n/c)

~ maintain bedrest

~ prep pt for chest x-ray

~ administer IV fluids as ordered

~ administer corticosteroids as ordered

~ provide emotional support & calm environment
The most important aspect of assessment for the patient with a fracture is frequent monitoring of 1_____ status 2_____ to the fracture site. Any time the patient complains of pain, neurovascular status should be 3_____.
1) neurovascular

2) distal

3) reassessed
A patient with osteomyelitis typically has an elevated 1_____ count and 2_____ _____ rate in addition to a positive 3_____ _____ for infection. MRIs, x-rays, and CT scans can show infected areas.
1) WBC

2) erythrocyte sedimentation

3) bone biopsy
Patients with osteomyelitis often have 1_____ _____ _____ _____ placed for long-term antibiotic therapy. Treatment may require 2_____ _____ _____ of medication.
1) central venous access devices

2) weeks to months
bone loses density resulting in fragile bones & possibly fractures (compression)

common metabolic disorder
Bone density peaks between 1_____ and 2_____ years of age. After these peak years, the rate of bone breakdown exceeds the rate of bone building.
1) 30

2) 35
Risk factors for primary osteoporosis include . . . (9 factors listed)
~ caucasian/Asian

~ postmenopausal

~ sedentary lifestyle

~ low calcium

~ lack of vitamin D

~ excessive alcohol consumption

~ cigarette smoking

~ excessive caffeine intake

~ petite body build
Secondary osteoporosis results from an associated medical condition, such as 1_____; long-term drug therapy, especially 2_____; and 3_____ _____, such as that seen with patients who have a spinal cord injury.
1) hyperparathyroidism

2) steroids

3) prolonged immobility
Two lab values that decrease with osteoporosis are . . .
1) serum calcium levels

2) vitamin D levels
Paget's disease
AKA osteitis deformans

metabolic bone disease in which increased bone loss results in large, disorganized bone deposits throughout the body

primarily seen in the elderly
The purpose of drug therapy for the patient with Paget's disease is to 1_____ _____ and 2_____ _____ _____. 3_____ (Calcimar) is a thyroid hormone that is often effective in initiating a remission of the disease.
1) relieve pain

2) decrease bone loss

3) Calcitonin
When providing postop care for a patient with a jaw fracture, have 1_____ available at the bedside at all times. If the patient states they feel nauseated, be certain an 2_____ is immediately available.
1) suction

2) antiemetic
When providing preop care, some of the nurse's responsiblities include . . . (4 responsibilities listed)
~ acting as a witness for consent form

~ taking baseline vitals

~ collecting lab info

~ educating patient

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