Surgery Risk Classes and Treatment for Osteoarthritis and Rheumatoid Arthritis, Exams of Nursing

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NRNP 6560 MIDTERM EXAM (SOLVED)

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Surgery risk classes {{ANS}} Class 1: benefits outweigh risk, should be done Class 2a: reasonable to perform Class 2b: should be considered Class 3: rarely appropriate General rules for surgery: testing {{ANS}} ECG before surgery only if coronary disease, except when low risk surgery Stress test not indicated before surgery Do not do prophylactic coronary revascularization Meds before surgery {{ANS}}

• Diabetic agents: Use insulin therapy to maintain glycemic goals(iii) Discontinue biguanides, alpha glucosidase inhibitors, thiazolidinediones, sulfonylureas, and GLP-1 agonists
• Do not start aspirin before surgery
• Stop Warfarin 5 days before surgery. May be bridged with Lovenox.
• Do not stop statin before surgery
• Do not start beta-blocker on day of surgery, but may continue Assessment of surgical risk

{{ANS}}

• Unstable cardiac condition (recent MI, active angina, active HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF. arrhythmia, CVD
• patient stable or unstable?
• urgency of the procedure (oncology will be time sensitive)
• risk of procedure
• nutritional status
• immune competence
• determine functional capacity (need to be more than 4 METS, more than 10 METs makes low risk) Low risk surgeries {{ANS}} catarcts breast biopsy cystoscopy, vasectomy laporascopic procedures Plastic surgery intermediate risk surgeries {{ANS}} Head/ neck surgery thyroidectomy Intraperitoneal Prostate Laminectomy

Hip/ knee Hysterectomy cholecystectomy nephrectomy non majot intrathoracic High risk surgeries {{ANS}} aortic/ cabg transplants spinal reconstruction peripheral vascular surgery Lee's revised cardiac risk index {{ANS}} 6 points: High risk surgery = 1 CAD = 1 CHF = 1 Cerebrovascular disease = 1 DM 1 on insulin = 1 Creat greater than 2 = 1 1 = low risk 2 = moderate risk 3 = high risk

SCIP pre-operative infection measures {{ANS}}

• Prophylactic antibiotics should be received within 1 h prior to surgical incision
• be selected for activity against the most probable antimicrobial contaminants - be discontinued within 24 h after the surgery end-time Postoperative infection reduction methods {{ANS}}
• pre-op hair removal (clippers)
• wash hands
• normothermia
• maintain euglycemia
• urinary catheters are to be removed within the first two postoperative days Osteoarthritis: what, incidence {{ANS}} Slow destruction of bones/ joint followed by production of replacement collagen which causes inflammatory changes
• older than 60
• more female after 55
• more black than white women
• men and women equal risk between 45 - 55
• abnormal height or weight (obesity)

• repetitive movement
• prior trauma (sprains/ dislocations)

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diabetic neuropathy genetic Osteoarthritis findings and diagnostics {{ANS}}

• Pain in weight bearing joints
• stiffness after sitting, gets better when arising
• feeling of instability on stairs
• fine motor skills deficit
• larger affected joints
• Heberden nodules (bony bumps on the finger joint closest to the fingernail)
• Bouchard's nodules (bony bumps on the middle joint of the finger)
• limited ROM with crepitus
• xr shows narrowing of joint space (need anteroposterior and lateral knee films bilaterally) - synovial fluid is clear and without WBC Osteoarthritis treatment {{ANS}} Goal is to relieve symptoms, maintain/ improve function, and avoid drug toxicity Hand OA:

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• rest/ joint protection, with splinting
• heat/ cold therapy
• topical capsaicin topical NSAID (trolamine salicylate) (especially for older than 75) Oral NSAIDS, incl COX2 inhibitors such as celecoxib (Celebrex) (may cause cardiac problems) tramadol
• no opioids Hip/ knee OA:
• weight reduction, cardiovascular exercises
• transcutanous external nerve stimulator
• acetaminophen
• Topical NSAIDS (knee)
• intraarticular corticosteroid injections
• surgery (joint replacement) Rheumatoid arthritis: what, who {{ANS}} chronic, systemic autoimmune disease that causes inflammation of connective tissue, first that of jionts them other soft tissues (renal, cardiovascular, pulm). TNF-alpha plays a big role
• more women than men

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• unknown cause
• Epstein Barr virus Rheumatoid arthritis: Findings and diagnostics{{ANS}}- symmetric joint/ muscle pain, worse in the morning then gets better - weakness, fatigue
• anorexia, weight loss generalized malaise swollen joints/ boggy feeling of joints with deformity of joints warm, red skin on affected joints later:
• pleural effusions and pulmonary nodules
• inflammation of sclerea (scleritis)
• pericarditis, myocarditis
• splenomegaly (Felty's syndrome)
• anemia (hypochromic, microcytic) with low ferritin
• possibly: positive rheumatoid factor
• XR: joint swelling, later cortical and space thinning
• synovial fluid: yellow, thick with elevated WBC up to 100. Felty's syndrome{{ANS}}rheumatoid arthritis, splenomegaly, neutropenia Rheumatoid arthritis treatment{{ANS}}- early treatment better than stepwise

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• early referral rheumatologist
• disease-modifying anti-rheumatic drugs (DMARDs):
• methotrexate ( no alcohol, monitor renal and liver, give with folic acid)
• cyclosporine
• Gold preparations (can cause thrombocytopenia)
• Hydroxychloroquine: antimalarial drug (may cause visual changes, monitor)
• sulfasalazine, moderate RA
• Leflunomide, moderate to severe RA Etanercept monitor liver function with DMARDs screen for TB (skin test) and Hep B
• surgery: joint debridement, joint replacement Gout: what, who{{ANS}}Inflammatory disorder in response to high uric acid production/ levels in blood and synovial fluid causing crystallization which causes inflammation (Type A and Mediterranean)
• impaired renal function which causes excess uric acid
• foods high in purine, such as dairy, red meat, shellfish, beer Gout findings, diagnostics{{ANS}}- acute painful joint, often great toe (warm, swollen) - pain at night
• flank pain because of renal calculi

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• fever
• leukocytosis
• elevated erythrocyte sedimentation rate
• tophi (bump under skin) on ear
• limited joint motion
• elevated serum uric acid (greater than 7mg/dl)
• urate crystals seen with joint aspiration
• xr: joint erosion and renal stones Gout treatment{{ANS}}- NSAIDS: naproxen, ondomethacin, sulindac
• Colchicine for those who do not tolerate NSAIDS (caution with renal impairment). Also for prophylaxis Corticosteroids, if NSAIDS and colchicine not tolerated 24hr urine for uric acid Allopurinol after flare is over (100mg PO daily)
• Biological modifiers of disease (BMD): Pegloticase. Not for asymptomatic. Treat with prophylaxis first. Monitor serum uric acid ANA. Tests in rheumatic disease: what, normal level, abnormal with.{{ANS}}Antinuclear antibody (ANA). Normal: Titer 1. POsitive with: Sjogren's (SS), SLE (lupus),

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C4 Complement. Tests in rheumatic disease: what, normal level, abnormal with.{{ANS}}Determines hemolytic activity which speaks to level of inflammatory response Normal: men: 12-72. Women: 13-75 mg/dl Increased with: inflammatory disease Decreased with: RA, lupus, SS The radioallergosorbent test (RAST). Tests in rheumatic disease: what, normal level, abnormal with.{{ANS}}measures presence/ increase antigen IgE normal: 0.01 - 0.04 mg/dl Increased with allergic reaction Erythrocyte sedimentation rate (ESR). Tests in rheumatic disease: what, normal level, abnormal with.{{ANS}}rate at which RBC settle out of unclotted blood in 1 hr Normal: men: 0-7mm/hr, women: 0 - 25 mm/hr Increased with inflammation

CRP. Tests in rheumatic disease: what, normal level, abnormal with.{{ANS}}C-reactive protein, a nonspecific antigen antibody Normal: trace to 6mg/ml Increased with infection and inflammation, RA. Decreased with succesfull RA treatment RF. Tests in rheumatic disease: what, normal level, abnormal with.{{ANS}}Rheumatoid factor. antibody against IgG. Positive RF in most people with RA Corticosteroids and arthritis: what does it do and adverse effects{{ANS}}Not for maintenance Use lowest dose Suppresses flares nausea, hyperglycemia, weight gain, adrenal insufficiency, mask infections NSAIDS and arthritis: what and adverse effects{{ANS}}analgesic and anti-inflammatory give PPI concurrently to prevent GI complication Headache, htn, fluid retention, n/v, ulcers/ bleeding, abnormal liver function tests, rash, renal insufficiency Celebrex and Arthritis{{ANS}}Analgesic and anti-inflammatory Fewer ulcers than with other NSAIDS Not recommended in renal or liver failure Screen for sulfa allergy May cause cardiovascular thrombotic event

May cause GI adverse event subluxation: what, cause{{ANS}}partial dislocation of a joint. Common sites: shoulder, elbow, wrist, hip, knee, patella, ankle, spine trauma, blunt force neuromuscular disease inflammatory joint disease, RA Loose ligaments Ehlers-Dantos syndrome (loose ligaments and overflexible joints- congenital) Findings and diagnostics subluxation{{ANS}}Pain over affected area previous subluxation swelling around joints loss of ROM XR, CT, MRI show subluxation Increased WBC (stress response) Management of subluxation{{ANS}}Early reduction, many spontaneously immobilization (splint, sling) PT NSAIDS for pain/ swelling Dislocation: what, cause{{ANS}}Complete displacement of bone end and position in joint. Common sites: shoulder, elbow (nurse maid), wrist, hip, knee (emergency if loss of integrity of ACL and PCL), ankle/ foot

high energy blunt force trauma congenital neuromuscular disorder inflammatory joint disease, RA Loose ligaments younger than 35 often, due to sports Often associated with fracture Findings and diagnostics dislocation{{ANS}}severe pain over affected area hx of mechanism of injury numbness/ tingling distal to injury joint deformity shortened limb contusion/ laceration over affected joint decreased pulses distal to joint decreased rom decreased sensation distally due to nerve damage WBC elevated due to stress Hgb may be low due to bruising xr: dislocation (should get anteroposterior) CT scan for pelvic trauma to rule out hip/ pelvic fracture Order ultrasound for posterior knee dislocation: high incidence of popliteal artery injury McMurray test, Lachman Test, straight leg test{{ANS}}McMurray: turn foot and bend knee. Positive with Meniscus injury Lachman test: Hold upper and lower leg, around knee, stretch. Hyperstretch: ACL injury Straight leg test: Pain when raising leg, while supine. Positive for herniated disk.

Dislocation management{{ANS}}Early reduction is essential: closed/ manual if no fracture. If fracture then may need surgery. Postreduction immobilization (splint, cast, sling) surgical repair of ligaments PT/ OT NSAIDS Muscle relaxant for muscle spasms Narcotics for short term use Soft tissue injury: definition, classifications, incidence{{ANS}}Injury to non-bony tissue, such as muscle, ligament, tendon, bursa, cartilage, skin Classification:

• Closed injury: contusion, hematoma, crush, strain (muscle), sprain (ligament, first to third degree), rupture (muscle and ligaments: instability, inability to move)
• Open injury: laceration, abrasion, penetrating/ puncture, amputations trauma exercise/ overuse autoimmune (RA, SLE) obesity age (skin tear elderly) Findings and diagnostics soft tissue injury{{ANS}}pain

swelling feeling of instability of joint Ruptures/ muscle tear: decreased ROM, immediate swelling and hematoma, abnormal contour muscle, instability of joint, pain/ guarding, watch neurovascular integrity Ligaments/ sprain: pain on palpation and ROM, decreased ROM with moderate swelling, Lachman's test (hypermobile joint is positive sign) Strain/ muscle or tendon: swelling, decreased/ absent ROM, pain/ guarding Cartilage: swelling, click during McMurray's test (would indicate meniscus tear), pain/ guarding Bursa: swelling with boggy feeling, erythema over bursa, decreased ROM Skin: abrasion, laceration, puncture Soft tissue injury findings and diagnostics{{ANS}}WBC increased, especially with bursitis Hgb decreased with massive hematoma Synovial fluid aspiration: WBC with inflammation, RBC with bleeding into joint, crystals with gout Xr will reveal swelling MRI (knee/ shoulder) location and degree of injury Soft tissue injury management{{ANS}}PRICE (protection, rest, ice, compression, elevation) possible immobilization

surgery, if rupture, grade III ligaments sprain, septic bursa, wound closure PT NSAIDS Muscle relaxant Opioids - short term Broad spectrum ab's (cephalexin, cefazolin) Fracture Classification - Gustillo{{ANS}}- Closed

• Open: Type 1: wound smaller than 1cm Type 2: wound larger than 1cm, moderate contamination Type 3: high degree of contamination, severe fracture instability, soft tissue damage. T3A: soft tissue coverage adequate, T3B: extensive injury soft tissue, exposed bone, T3C: open fracture with arterial injury
• Incomplete or complete
• stress
• traumatic/ pathologic
• displaced/ non-displaced Type of fracture lines{{ANS}}Transverse Spiral Oblique Comminuted Logtitudinal butterfly segmental impacted

Salter-Harris Fracture Classification{{ANS}}Concerns growth plate S: straight across growth plate A: Above growth plate L: BeLow growth plate T: Through growth plate R: ERaser of growth plate (Rammed) Cause of fractures{{ANS}}Trauma, tumor, osteoporosis, drugs (prednisone), nutritional deficiency (Vit D), neuromuscular disorders Findings and diagnostics of fractures{{ANS}}Pain History of traumatic event Neuromuscular dystrophy: headache (autonomic dysreflexia) Deformity of limp Diminished/ absent pulses ecchymosis and swelling xr, always order anteroposterior and lateral CT scan for pelvic and spinal fractures MRI for suspected spinal cord injury Mortise view (leg inward) for ankle to check talus bone oblique films for humerus, femur, ankle

DEXA scan to determine degree of osteoporosis Acute Fractures Management{{ANS}}- ABC care (Airway, breathing, circulation), musculoskeletal second survey

• fluid resuscitation
• early reduction of fracture
• cover open wounds
• surgical irrigation and debridement for open fracture
• Ab's: Cefazolin for gram pos. Clindamycin for tetani infection
• pain: opioids
• tetanus shot of unknown
• calcium upon discharge for osteoporosis
• cement injection in bone with vertrebroplasty Fractures: Reduction{{ANS}}- Orthopedic surgeon referral
• buddy-tape toe fracture for immobilization
• radius/ ulna: splint with ace-wrap, unless open
• post reduction xr
• check neurovascular function pre and post reduction
• intramedullary rodding for closed femoral and tibial fracture
• external fixation for open fracture Compartment syndrome: what, who{{ANS}}Increased pressure in tissue limits the circulation and function of the contents within that space (compartment: bone, blood vessel, nerves, muscle, soft tissue). Most often in arms and legs (most compartments), also abdomen

Men under age 35 stemming from fracture of tibia stemming from splint, cast, scar increased swelling due to hemorrhage, coagulation disorder, infiltrated iv site, trauma/ surgery, burn, bite Compartment syndrome finding and diagnostics{{ANS}}pain out of proportion to injury hx of trauma paresthesia heaviness in affected extremity Six P's: Pain on passive stretch Paresthesia Paralysis of affected limb (late finding) Pulses, bounding first then pulseless later Pallor of affected limb Polar/ poikilothermia (ice cold limb) Elevated WBC Hyperkalemia (tissue necrosis) CPK and LDH elevated Myoglobin in urine Elevated compartment pressure (normal 0-8) Clinical diagnosis, MRI may confirm Acute renal failure (due to myoglobinuria)

Compartment syndrome management{{ANS}}Non surgical:

• limb at heart level (do not elevate)
• remove bandages/ immobilizers
• diuretic
• neurovascular checks
• CRRT/ dialysis to treat ARF
• intracompartmental pressure monitoring Surgical:
• fasciotomy, with delayed closure of wounds (negative pressure wound vac)
• skin grafting
• amputation if septic from necrotic tissue Restorative:
• functional splinting
• ROM
• early prostethic fitting post amputation Low back pain - four major syndromes{{ANS}}1. Back strain

2. Disk herniation
3. Osteoarthritis/ disk degenration; osteophyte (bone spur)
4. Spinal stenosis: narrowing spinal foramen leading to spinal nerve entrapment Specific findings for back pain{{ANS}}- numbness

• saddle anesthesia (CA, mass)
• bowel, bladder dysfunction (emergency surgery)

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pain worse at rest (CA, tumor, infection)

• Discitis, epidural abcess (IV drug use)
• Decreased rom
• Radiculopathy (pain down leg), not with OA
• Crossover straight leg test: herniated disk
• back, buttock, leg pain when ambulating (neurogenic claudication with spinal stenosis). Also positive straight leg raise test with spinal stenosis xr anteroposterior, to rule out scoliosis, bone spur MRI for soft tissue structure, bulging disk CT for bony imaging Cauda Equina Syndrome{{ANS}}Spinal cord compression from metastatic lesion to spine. Causes: gradual to sudden weakness and inability to move/ lift legs, bowel/ bladder incontinence, diminished sensation in legs: saddle. Surgical emergency! Low back pain management{{ANS}}Nonsurgical:
• rest
• ice/ heat (alternate)
• NSAIDS
• antispasmodics (diazepam, flexeril)
• opioid short-term, to promote mobility
• anticonvulsants and antidepressants for neuropathic pain
• PT
• weight loss
• epidural steroid injection

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Surgical:

• Foraminotomy or diskectomy
• spinal fusion Herniated disk: what, who{{ANS}}Bulging or protrusion of nucleus through a defect in the annulus of spine, may cause nerve entrapment
• Trauma
• Obesity/ sedentary lifestyle
• Age 35 - 45
• Often located at L4- L5, L5 - S1 Herniated disk findings and diagnostics{{ANS}}- Decreased/ absent reflexes
• Atrophy of muscles
• limp
• possible straight leg raise test/ radiculopathy
• limited rom spine
• xr anteroposterior and lateral of spine
• CT with and without dye: detects bony defects
• MRI: detects soft tissue defects
• myelogram
• EMG (tests nerve innervation)

Herniated disk L4 root finding (disk between L3 and L4){{ANS}}- quadriceps weak, difficulty extending quadriceps (have pt squat and rise) pain and numbness radiating into medial malleous

• diminished/ absent knee jerk Herniated disk L5 root finding (disk between L4 and L5){{ANS}}- dorsiflexion of great toe and foot weak (have pt walk on heels of feet)
• pain and numbness into lateral calf and between first toe web space Herniated disk S1 root finding (disk between L5 and S1){{ANS}}- weakness of plantar flexion of great toe and foot (have pt walk on toes)
• pain along buttock, lateral leg and lateral aspect of foot and posterior calf - diminished achilles calf Herniated disk management{{ANS}}Non surgical:
• functional bracing
• rest
• PT for muscle strengthening
• heat/ ice alternate
• weight loss
• transcutaneous electrical nerve stimulator
• NSAIDS
• antispasmodic
• Narcotics for short-term use
• epidural steroid injection Surgical: