NCLEX Cram- Module V

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