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NCLEX Cram- Module V

NCLEX Cram- Module V. Musculoskeletal. Prepared by Lori Baker, RN, BSN 2013. Rheumatoid Arthritis. Chronic, systemic, progressive deterioration of the connective tissue (synovium) of the joints characterized by inflammation What happens… Normal cartilage in the joint becomes soft

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NCLEX Cram- Module V

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  1. NCLEX Cram-Module V Musculoskeletal Prepared by Lori Baker, RN, BSN 2013

  2. Rheumatoid Arthritis • Chronic, systemic, progressive deterioration of the connective tissue (synovium) of the joints characterized by inflammation • What happens… • Normal cartilage in the joint becomes soft • Fissures and pitting occur • Cartilage thins • Spurs form and inflammation sets in • Deformity is marked by immobility, pain, and muscvle spasm • Prescribed treatment regimen • Corticosteroids for inflammation • Splinting • Immobilization • Rest for joint deformity • NSAIDs for pain

  3. Rheumatoid Arthritis • Early detection can decrease the amount of bone and joint destruction • Disease will often go into remission • Activity recommendations to provide the client • Do not exercise painful, swollen joints • Do not exercise any joint to the point of pain • Perform exercises slowly and smoothly • Avoid jerky movements

  4. DJD (degenerative joint disease) • DJD and osteoarthritis are often described as the same disease • Both result in hypertrophic changes in the joints • Technically DJD is characterized by noninflammatory degeneration of the joints and OA is an inflammatory disease • Assessment shows • Morning stiffness • Pain which increases with activity and improves with rest • Asymmetry of affected joints • Crepitus (grating sound in the joint)

  5. Osteoporosis • Metabolic disease in which bone demineralization results in decreased density and subsequent fractures • At risk • Postmenopausal, thin, white women • Encourage • Exercise • Diet high in calcium with supplemental calcium • TUMS is an excellent source of calcium, it is high in sodium • Main cause of fractures in the elderly is osteoporosis • Main sites seem to be the hip, vertebral bodies, and Colles fracture of the forearm

  6. Lupus Both are autoimmune disorders • DLE – discoid lupus erythematosus • Affects skin only • SLE – systemic lupus erythematosus • Affects organs as well as skin • Avoiding sunlight is key in management of lupus • This is what differentiates it from other connective tissue diseases

  7. Lupus • Symptoms • DLE • Dry, scaly rash on face or upper body • On face it is termed a butterfly rash as it takes the shape of a butterfly • SLE • Joint pain and decreased mobility • Fever • Nephritis • Pleural effusion • Pericarditis • Abdominal pain • Photosensitivity

  8. Fractures • NCLEX tips • Questions focus on safety precautions • Improper use of assistive devices can be very risky • When using a non-wheeled walker, the client should lift and move the walker forward, then take a step into it • Clients should avoid scooting the walker or shuffling forward into it which takes more energy and is less stable than a single movement • Intracapsular fractures (in the neck of the femur) are more difficult to heal since blood supply enters the femur below the neck of the femur

  9. Fractures NCLEX tips • Fat embolism-syndrome • Fat globules migrate into the bloodstream and combine with platelets to form emboli • Greater risk in first 36 hours after a fracture • More common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis • Initial symptom is confusion due to hypoxemia which may only show up in ABGs • Assess for respiratory distress, restlessness, irritability, fever, and petechiae • If suspected, notify healthcare provider STAT, draw blood gases, administer oxygen, and assist with endotracheal intubation

  10. Fractures • Thromboembolism – blood clots • Most common complication of hip fractures • Prevention includes • Passive ROM • Elastic stocking use • Elevation of the foot of the bed 25 degrees to increase venous return • Low dose heparin therapy

  11. Fractures • Neurovascular Checks • Done with any client having an injury to an extremity or those with casts, splints, or edema to an extremity • Check vascularization distal to the injury or appliance • Skin color • Temperature • Sensation • Capillary refill • Mobility • Pain • Pulses • Assess the 5 P’s • Pain, Paresthesia, Pulse, Pallor, and Paralysis

  12. Fractures • Orthopedic wounds have a tendency to ooze more than other wounds • A suction drainage device usually accompanies the client to the postoperative floor (JP drain, Hemovac, etc.) • Questions about joint replacements usually focus on complications • The biggest complication is infection • Fractures predispose the client to anemia, especially if long bones are involved • Monitor hematocrit every 3-4 days to monitor erythropoiesis

  13. Fractures • For hip replacement – instruct not to lift the leg upward from a lying position or to elevate the knee when sitting – it can pop the prosthesis out of the socket (nurse responsibility is to avoid prosthesis displacement) • Immobile clients are prone to complications • Skin integrity problems • Formation of urinary calculi (may need to limit milk intake for a bit) • Venous thrombosis (may need to be on prophylactic anticoagulants) • Amputations • Residual limb (stump) should be elevated only on one pillow (if too high or for too long, it could cause contracture • Phantom pain is real – usually taken care of with neuroleptic meds, not pain meds

  14. Fractures • Simple or closed – no break in the skin • Compound or open – the skin surface is broken with these fractures • More danger of infection and osteomyelitis with compound fractures • Comminuted – causes damage to soft tissue nerves and blood vessels • Green stick – occur more often in children – the break occurs through only part of the bone • Pathological fracture – occur without major injury or trauma – seen often in osteoporosis patients

  15. Fractures • Traction • Manual traction – maintained by the caregiver’s hand – used with first responders • Skeletal traction – maintained by using pins or wires inserted into the bone • Examples are 90-90, Crutchfield tongs, and Halo vest traction • Weights should NOT be removed unless it is an emergency situation because removal of the weight can defeat the purpose of the traction and injure the client further • Skin traction – maintained by using straps or wraps applied to the skin • Examples are Buck’s traction and Bryant’s traction

  16. Compartment Syndrome 5 P’s of Compartment Syndrome: Pain Pallor Pulselessness Paresthesia Polar (cold) • Serious condition resulting from pressure within different compartments that cause decreased circulation to the area • Clinical manifestations • Cyanosis of extremity • Numbness • Pain • Pallor • Paresis/paralysis • Swelling • Tingling • Treatment • Bivalve cast • Fasciotomy – incision to split the fascia

  17. Osteomyelitis Prophylactic ATB’s should be given to anyone with a joint replacement prior to any dental procedures due to the risk of invading bacteria to settle on a joint, causing osteomyelitis of the surrounding bone. • Severe infection invading the bone • Symptoms • Fever • Malaise • Swelling in the infected area • Tenderness • Purulent drainage • Pain • Tachycardia • Treatment • ATB’s – maybe several weeks of IV ATB’s at home • Surgical debridement may be necessary

  18. Ankylosing Spondylitis • Also known as Marie-Strumpell disease and Rheumatoid spondylitis • Most often white males under age 40 • Cause associated with HLA B27 antigen • Symptoms • Arthralgia or achy joints • Malaise • Fatigue • Weight loss • Treatment • Same as osteoarthritis plus DMARDs (disease-modifying antirheumatic drugs)

  19. Gout • Formation of uric acid deposits in joints • Clients particularly experience podagra (pain and inflammation in the great toe) • Symptoms include • Painful joints • Tophi usually on outer ear, hands, and great toe • Kidney stones and renal abnormalities • Treatment • Diet directed at decreasing purine • See next slide

  20. Purine or No Purine – that is the question… • Low-purine foods • Cheese • Eggs • Fats • Gelatin • Milk • Most vegetables • Nuts • Sugar • Increased fluids • Citrus juices • Cherries • High-purine foods • Dried beans • Fish – especially sardines • Liver • Lobster • Oatmeal • Oysters • Peas • Asparagus • Poultry • Spinach

  21. Other NCLEX Tips • Tinel’s sign • Indicative of carpal tunnel syndrome • Inflate blood pressure to systolic pressure • If carpal tunnel exists, client will experience numbness and tingling • First responders – splint above and below a fracture • Keep wire cutters at the bedside of a mandibular fracture who has had jaw wired as treatment

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