Degenerative Joint Disease
Arthritis= joint inflammation.
Arthralgia= joint pain
Different types of arthritis:
Most common form of arthritis, noninflammatory,
One or many joints undergo degenerative and
progressive changes, mainly wt. bearing joints.
Stiffness, tenderness, crepitus and enlargement
Deformity, incomplete dislocation and synovial
effusion may eventually occur.
Treatment: rest, heat, ice, anti inflammatory drugs,
decrease wt. if indicated, injectable corticosteroids,
Osteoarthritis- Risk Factors
Decreased muscle strength
Possible genetic risk
Early in disease process, OA is difficult to dx
Hx of Trauma to joint
OA- Signs and Symptoms
Joint pain and stiffness that resolves with rest
Pain with joint palpation or ROJM
Crepitus in one or more joints
Heberden’s nodes enlarged at distal IP joints
Bouchard’s nodes located at proximal IP
What to assess for:
ESR, Xrays, CT acans
Degree of functional limitation
Levels of pain/fatigue after activity
Range of motion
Proper function/joint alignment
Home barriers and ability to perform ADLs
Pharmacotherapy- tylenol, NSAIDS, ASA, Cox-2
Intra-articular injections of corticosteroids
Glucosamine- acts as a lubricant and shock
absorbing fluid in joint, helps rebuild cartilage
Balance rest with activity
Use bracing or splints
Apply thermal therapies
Arthroplasty- joint replacement can relieve pain and
restore loss of function for patients with advanced
Inflammatory and immune response are normally
BUT these responses can fail to recognize self cells
and attack normal body tissues.
Called an auto-immune response
Can severly damage cells, tissues and organs
EG. RA, SLE, Progressive systemic sclerosis,
connective tissue disorders and other organ specific
Chronic, systemic, progressive inflammatory
disease of the synovial tissue, bilateral,
involving numerous joints.
Synovitis-warm, red, swollen joints resulting
from accumulation of fluid and inflammatory
Classified as autoimmune process
Exacerbations and remissions
Can cause severe deformities that restrict
RA- Risk Factors
Age 20-50 years
Epstein Barr virus
Rheumatoid Arthritis- Dx
Rheumatoid Factor antibody- High titers
correlate with severe disease, 80% pts.
Antinuclear Antibody (ANA) Titer- positive
titer is associated with RA.
C- reactive protein- 90% pts.
ESR: Elevated, moderate to severe elevation
Arthocentesis- synovial fluid aspirated by
RA – Signs and Symptoms
Joints- bilateral and symmetric stiffness, tenderness,
swelling and temp. changes in joint.
Pain at rest and with movement
Pulses- check peripheral pulses, use doppler if
necessary, check capillary refill.
Edema- observe, report and record amt. and location
ROM, muscle strength, mobility, atrophy
Anorexia, weight loss
Fever- generally low grade
RA- Sign and Symptoms
1. Fatigue- unusual fatigue, generalized weakness
2. Morning stiffness lasting longer than 30 minutes
after rising, subsides with activity.
3. Red, warm, swollen, painful joints
4. Systemic S&S
5. Pain- at rest and with movement
What should we monitor?
Rheumatoid Arthritis- Tx
Rest, during day- decrease wt. bearing stress.
ROM- maintain joint function, exercise –water.
Medication- analgesic and anti-inflammatory
(NSAIDS), steroids,Gold therapy, topical meds.
Immunosuppressive drugs- Imuran, Cytoxan,
methotrexate. Monitor for toxic effects
Biological response modifiers (BRM):Inhibit action of
tumor necrosis factor (Humira, Enbrel, Remicade)
Ultrasound, diathermy, hot and cold applications
Surgical- Synovectomy, Arthroplasty, Total hip
Assist with/encourage physical activity
Provide a safe environment
Utilize progressive muscle relaxation
Refer to support groups
Very painful joint inflammation, swollen and reddened
Primary-Inborn error of uric acid metabolism- increases production
and interferes with excretion of uric acid
Secondary- Hyperuricemia caused by another disease
Excess uric acid – converted to sodium urate crystals and
precipitate from blood and become deposited in joints- tophi or in
kidneys, renal calculi
Meds- colchicine, NSAIDS, Indocin (indomethacin), glucocorticoid
Allopurinol, Probenecid-reduce uric acid levels
Diet- excludes purine rich foods, such as organ meats, anchovies,
sardines, lentils, sweetbreads,red wine
Avoid ASA and diuretics- may precipitate attacks
SLE- Chronic Inflammatory disease affecting many
Women between 18-40, black>white, child bearing
Autoimmune process- antibodies react with DNA,
immune complexes form- damage organs and blood
Includes: vasculitis; renal involvement; lesions of skin
and nervous system.
Initial manifestation- arthritis, butterfly rash,
weakness, fatigue, wt. loss
Symptoms and tx. depend on systems involved.
Pathologic changes-Autoimmune process
1. Vasculitis in arterioles and small arteries
2. Granulomatous growths on heart valves- non
3. Fibrosis of the spleen, lymph node adenopathy
4. Thickening of the basement membrane of
5. 90% swelling and inflammatory infiltrates of synovial
6. Renal- Lupus nephritis
7. Pleural effusion or PN
8. Raynaud’s phenomenon- about 15% cases
9. Neuro- psychosis, paresis, migraines, and
ANA- hallmark test, + in 98% pts.
Antimalarial meds- hydroxychloroquine (Plaquenil)
Immunosuppressive agents- pt teaching
Systemic Lupus- Education
Encourage to avoid undue emotional/ physical
stress and to get enough rest
Alternate exercise + planned rest periods.
Teach how to recognize the symptoms of a flare
Teach how to prevent and recognize infection
Avoid sunlight, use sunscreen
Eat a well balanced diet,vitamins and iron.
Establish short term goals
Teach re: meds.
Meds avoid- Pronestyl, Hydralazine.
On the second day, the knee was better, and on
the third day, it had completely disappeared.
While in the emergency department, she was
examined, X-rated, and sent home
The patient will need disposition, and therefore,
we will get Dr. Blank to dispose of him.
Patient was admitted through the emergency
department. I examined her on the floor.
Joint Replacement Indications
Total Hip Replacement
Indications for surgery:
Femoral neck fractures
Congenital hip disease
Assess medication history.
Assess Respiratory, neurovascular,
nutritional and integumentary status.
Presence of other diseases- COPD, CAD,
Hx. Of DVT or pulmonary embolism.
Discuss surgical procedure, informed
Prepare for autologous blood donation.
Presence of drains and hemovac
Pain management (epidural/PCA).
Coughing and deep breathing.
Use of incentive spirometer
ROM exercises to unaffected extremities.
Need to avoid bending beyond 90 degrees
Importance of leg abduction post-op.
Post-op Management of THR
Assess neurovascular status of involved
Incision site, wound drains, hemovac.
Note excessive bleeding or drainage
Respiratory status- elderly population.
Position of affected joint and extremity
Assess Hgb and Hct
Total hip replacement-
Dislocation of hip prosthesis
Loosening of the prosthesis
Dislocation of prosthesis
Increased pain, swelling
Acute groin pain
Shortening of the leg
Abnormal internal or external rotation
Restricted ability or inability to move leg
Reported popping sensation in hip.
Impaired physical mobility r/t joint
replacement and pain
Maintain bed rest with affected joint abducted
with wedge pillow.
Perform passive and teach active ROM to
unaffected joints, quad, isometric, gluteal
Ambulate with assistance, WB restrictions
Turn pt. as ordered, monitor skin for
Altered Tissue perfusion r/t
reduced flow and immobilization
Administer parenteral fluids with electrolytes
to increase tissue perfusion.
Monitor VS q4h and prn, I and O.
Assess NV status q1h for first 12 hrs., then
q4h. Color, temp., pulse, sensation.
Ambulation and exercises
Monitor CBC, electrolytes, PT/INR
Administer anticoagulants - phlebitis
Pain r/t surgical intervention and
Assess location, intensity, quality pain.
Administer analgesics, sedatives, anti-
inflammatories, assess effectiveness,
Monitor PCA or continuous epidural
Change position frequently, back rubs.
Provide diversional activities- reduce
attention on pain.
Monitor - severe chest, affected joint pain.
Knowlwdge deficit R/T…
Stress importance of rehab program and
exercises, no flexion greater than 90
Discuss and demonstrate incision care
Medication teaching- especially
anticoagulants, instruct pt to be checked,
observe for bleeding, etc.
High protein, high fiber and increased fluid to
Safety: stairs with hand rails, no scatter rugs,
grab bars tub and toilet, good light.
Height of bed and chair for easy transfer.
Elevated toilet seat, fracture pan, urinal
Ability to care for wound, correct supplies and
hand washing technique.
Correct transfer techniques, ability to follow
rehab plan and exercises.
Pre-op: lab work- Hgb, Hct, Pt/PTT, urine,
History of underlying problem, meds.
Post-op- N/V assessment, pulses distal to
Teach: ROM to unaffected extremities,
limitations post-op, crutch walking prn, pain
management, reinforce explanation of
Total Knee Replacement
arthritis, posttraumatic arthritis, bleeding into
Post-op compression bandage and ice.
Assess N/V status of leg, active flexion q1h.
While awake, CPM machine.
Wound suction drain
OOB within24 hrs., knee immobilizer and
elevated while sitting.
Care of the patient undergoing an
Pre-op monitor N/V status both extremities
Observe for ulceration, edema, necrosis.
Baseline VS and lab data, doppler studies,
angiography, ECG, chest x-ray.
Time for verbalization fears, anxieties.
Teach re; overhead trapeze, C and DB,
Stump dressing, amt. and color of drainage,
Respiratory status and VS.
Presence of phantom limb pain.
Monitor for complications; infection, hemorrhage,
phantom pain, contractures, scar formation,
PT, diet, rest, activity, wound care
Phantom limb pain
Body image disturbance r/t loss
Allow time for pt. to grieve, assess need for
Encourage pt. to discuss and view stump
Assist in identifying positive coping strategies, praise
Provide a supportive environment.
Demonstrate positive regard for pt. and acceptance
of personal appearance.
Assess religious beliefs re: care of amputated limb
Verbalize feelings re: change in role, job, family,
Discharge/ Home care
Hand rails- tub toilet, stairs, no scatter rugs.
Wide doorway to accommodate wheelchair,
walker, Ht. of bed, chair ok.
Ability to care for wound and has correct
Ability and desire to follow prescribed rehab
plan and exercises.
Prosthesis fitting with orthotist
Primary or Secondary
Metabolic bone disorder- progressively porous,
brittle, fragile bones, low bone density, susceptible
Occurs in postmenopausal women
Bone resorption (osteoclast) > bone formation
Dowager’s hump – progressive kyphosis – gradual
collapse of vertebrae.
Post menopausal lose height, c/o fatigue.
Osteopenia, precursor to osteoporosis
Dx tests: Radiographs, Dexa scans
Osteoporosis- Risk Factors
Gerontologic- over 80 yrs. old, 84% have
Family hx, thin, lean body build
Postmenopausal estrogen deficiency
Hyperparathyroidism – increases bone
Hx of low Ca intake and low levels of Vit D
Long tem corticosteroid use
Lack of physical activity/ prolonged immobility
Hx of smoking, high alcohol intake
Pt. teaching- osteoporosis
Adequate dietary calcium- 1200mg/day with
Exercise, wt. bearing beneficial.
Walking outdoors- vitamin D absorption.
Good body mechanics
Safe home environment, fall prevention
Balanced diet- protein, Mg, Vit K & D, Ca
Modify lifestyle choices- smoking, alcohol and
caffeine intake and sedentary lifestyle.
Patient teaching- Meds
PTH- Forteo Subcut
Bisphosphonates- Fosamax,Boniva, Actonal
Calcitonin, Vit D
Infection of the bone
Extension of soft tissue infection- infected pressure
ulcers or incision.
Blood borne (spread from other body sites)
At risk- poorly nourished, elderly, obese, impaired
immune systems, corticosteroid therapy, chronic
Prevention- proper tx. of infections, aseptic post op
Organism enters from outside the body. Eg. Open fx
Signs and symptoms-
High fever, chills, increased HR, general
malaise, swelling, tenderness, heat and
erythema, painful movement.
Draining ulcers, bone pain
Dx- increased WBCs, elevated ESR, positive
blood cultures, X-rays, bone scan, MRI.
Long term IV antibiotics
Hickman or other CVAD catheter
Strict sterile technique for tx
Hyperbaric oxygen tx
Surgery- bone exposed and necrotic tissue
removed, debridement, bone grafts,
Contusions, Strains, Sprains
Contusion-soft tissue injury, hematoma,
Strain- “muscle pull” over use over stretching.
Sprain – an injury to ligaments surrounding
joint, caused by twisting.
Management- RICE = rest, ice, compression,
Joint dislocation- out of joint. If not treated
promptly, avascular necrosis can occur.
Reduced- put back in place = closed
reduction. Neurovascular status- check.
Rotator cuff injury/tear
Complete- a break across the entire cross- section
and is frequently displaced.
Incomplete (Greenstick)-break occurs through only
part of the cross-section of the bone.
Closed Fracture (simple)- doesn’t break through the
Open fracture (compound) - extends through the skin
Comminuted- splintered into fragments
Depressed- fragment(s) is(are) indriven
Pathologic- through an area of diseased bone
Signs and Symptoms
Pain- continuous and increases in severity
Swelling- usually over affected area, but can
also occur in adjacent structures.
Reduction- open or closed
Treatment- Casting and/or traction
DVT, thromboembolism or pulmonary
Used to immobilize a body part so that a
fracture of a bone or dislocation can heal.
Pressure from hard casting materials can
produce complications such as:
Casting materials- plaster or fiberglass.
Provide protection and healing of fractures
Maintain therapeutic alignment- body parts
Protect soft tissue injuries
Provide support after orthopedic surgery
Correct skeletal malformations.
While cast is drying, check C/M/S or NV status
hourly and then q4-8h
Circulation/ vascular checks- Warmth, color, pulses,
capillary refill, swelling.
Motion checks- ask pt. to wiggle fingers or toes.
Sensation checks- can pt. feel pressure, ask about
pain, this may detects if cast is too tight.
Check for odor and drainage
Electrical Bone Stimulation
Application of electrical current at fracture
site, invasive or non-invasive.
Stimulates osteogenesis to fracture site.
Invasive- inserts cathode to site.
Non-invasive- Coil encircles cast or skin,
attached to external generator, used 3-10
hrs. per day.
Contraindicated in presence of infection.
Factors inhibit fracture healing
Extensive local trauma
Bone loss- demineralization, osteoporosis
Space/tissue between bone fragment
Infection, malignancy, bone disease
Irradiated bone (radiation necrosis)
Age- impaired healing process
Corticosteroids inhibit repair rate
1. Used to minimize muscle spasm
2. Used to reduce, align, and immobilize fractures
3. Used to correct/prevent deformity
4. Tx of dislocated, degenerated, rutured
intravetebral discs and sc compression
Maintain line of pull.
Pt. is in center of bed, with good alignment
Weights hanging freely.
Types of traction
1. Skin traction (straight) - Buck’s, Bryant’s,
pelvic girdle. The pull is transmitted to
muscle structure, indirect traction.
2. Skeletal traction – pins or wires inserted in
bone and attached to traction, may be used
to treat fractures of humerus, tibia, fibula
3. Continuous- for fractures
4. Intermittent- for back muscle sprains
Ropes unobstructed and in straight alignment.
Skin care- check skin traction for intact skin, pin care
for skeletal traction.
Circulation- fat emboli, thromboembolism.
Respiratory- pneumonia, exercise, ROM.
GI- high fiber diet, increased fluids.
Renal- to prevent stones- increase fluids.
MS- isometric exercises
5P’s Assessment for
Pain- location, severity
Pulse- distal to injury, check bilaterally.
Parasthesias- numbness, tingling, compare
bilaterally. Sensaton check
Pallor- check skin color and temp.
Paralysis- Assess mobility, watch for foot
drop, compartment syndrome.
Amt traction, type, weight, changes in tx
Pt tolerance and pain
Pt assessment of NV checks, skin condition,
respiratory status, elimination pattern
Note condition of any pin sites and any care
High incidence in elderly due to risk for falls,
Intracapsular- fx. Neck of femur, may
damage blood supply, aseptic necrosis.
Extracapsular- base of neck and lesser
tronchanter of femur- heals more easily.
ORIF- open reduction with internal fixation.
Symptoms of Fractures
Deformity Impaired sensation
Swelling Loss of normal
Muscle spasms Abnormal mobility
Risk for injury r/t subluxation or dislocation
Pain related to surgical incision
Risk for infection r/t impaired skin integrity
Impaired physical mobility
Risk for Peripheral Neurovascular
Review of anatomy
Low back pain
Signs and Symptoms
Back Pain- Assessment and
Posture and gait
Cervical Disc Pain and stiffness
Loss of muscle strength
Assess bowel and bladder control
MRI, CT scan, Neuro exam
Electromyelography and Nerve conduction
Firm mattress and back board
Exercise and physical therapy
Heat and Ice
PT with manipulation, shoes insoles, back
Complementary and alternative therapies
Conventional open Procedures:
Diskectomy with fusion
Minimally Invasive Surgeries:
Percutaneous lumbar diskectomy
Laser assisted laparoscopic lumbar diskectomy
Interbody cage fusion
Direct current stimulation for bone fusion
Fluid volume deficit
Acute urinary retention
Persistant or progressive lumbar radiculopathy
Back Surgery- Patient
Takes 6 weeks for ligaments to heal
Schedule rest periods
Avoid heavy labor 2-3mos postop
Cervical Disc Herniation or
Usually occurs at C5, C6, or C7 interspaces
Surgical tx is MIS cervical diskectomy with or
without fusion using an anterior or posterior
Check dsg for CSF
Check for hoarseness and inability to cough
Check for swallowing ability
Assess pt ability to void
Assist with ambulation
Assess for complications