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Orthopedic 5

    1. Conservative management
      1. progressive resistive exercises
        1. quadriceps setting - isometric
        2. hamstrings - isotonic
      2. medication: NSAIDs
      3. nonmedication assistance: application of ice or moist heat
      4. activity restriction
    2. Surgical management
      1. indicated if findings remain after six months of conservative treatment
      2. arthroscopy (see Orthopedic Surgery section that follows)
      3. arthrotomy
        1. realignment of proximal and/or distal soft tissue
        2. tibial tubercle elevation
        3. patellectomy
    3. Nursing interventions (see previous Osteoarthritis section)
    4. Inflammatory Disorders
    5. Rheumatoid arthritis (RA)
      1. Definition - chronic systemic inflammatory disease of the connective tissue
      2. Findings
        1. starts in feet and hands, gradually destroys these peripheral joints
        2. affects diarthroidial joints
        3. bilateral involvement
      3. Etiology
        1. cause is not fully understood
        2. rheumatoid arthritis is an autoimmune disorder
        3. genetic tendency; but may involve bacteria, or viruses
        4. may affect the connective tissue of the lungs, heart, kidneys, or skin
      4. Incidence
        1. two to three times more common in women than in men
        2. strikes between the ages of 20 and 50 years of age
      5. Pathophysiology 
        1. synovitisimmune complexes initiate inflammatory response
          1. IgB antibodies are formed
          2. rheumatoid factor (RF)
            • pannus formation
            • destruction of subchondral bone
            • present in 85 to 90% of all cases
            • worsens the inflammatory response - can go on indefinitely
            • irreversible - will lead to ankylosisof joint
      1. Findings
        1. in early RA joints will be
          1. painful, stiff
          2. warm, red, swollen at capsules and soft tissues
          3. incapable of full range of motion
        2. in late RA, joints will show
          1. bony ankylosis
          2. destruction of joint - reactive hyperplasia
          3. adhesions
          4. inflammation and effusionthat will be
        3. general signs
          1. fatigue
          2. loss of appetite and weight
          3. enlarged lymph glands (illustration)
        4. rheumatic nodules
          1. in 20% of cases
          2. firm, oval, nontender masses under the skin
          3. presence indicates poor prognosis
        5. physical assessment should also include
          1. accurate patient history - history may include
            • malaise
            • fatigue
            • weakness
            • loss of appetite and weight
            • enlarged lymph glands
            • Raynaud's syndrome
          2. examination may reveal deformities
        6. neurological examination
          1. foot drop
          2. evidence of spinal cord compression
      1. Diagnostics
        1. laboratory analysis
          1. elevated ESR
          2. decreased RBC
          3. positive C-reactive protein
          4. positive antinuclear antibodyin 20% of cases
          5. positive rheumatoid factor (RF)
        2. radiographic studies
          1. bony erosion
          2. decreased joint spaces
          3. fusion of joint
        3. aspiration of synovial fluid; analysis shows
          1. cloudy appearance
          2. more white blood cells than normal
      2. Management
        1. (see previous Osteoarthritis section)
        2. psychological support
        3. splinting: resting, corrective, or fixation
    6. Systemic lupus erythematosus (SLE)
      1. Definition: chronic, systemic, inflammatory disease of the collagen tissues (illustration)
      2. Etiology unknown
        1. most cases are women
        2. African Americans, Hispanics, Asians, and Native Americans are two to three times as likely as whites to have lupus
        3. antigen stimulates antibodies, which form soluble immune complexes, deposited in tissues; number of T suppressor cells dwindles. (illustration)
        4. immune complex inflames tissue; inflammation creates findings
          1. the intensity and location of the inflammation reflects findings and organs involved.
          2. clients with central nervous system or renal involvement have poorer prognosis
  1. Findings: SLE is present if client has four or more of these:
    1. arthritis: characterized by swelling, tenderness and effusion; involving two or more peripheral joints
    2. malar rash: characteristic butterfly rash over cheeks and nose
    3. discoid lupus skin lesions
    4. photosensitivity
    5. oral ulcers
    6. serositis: pleuritis
    7. renal disorder: persistent proteinuria
    8. neurologic disorder: seizures or psychosis in the absence of drugs or pathology
    9. hematologic disorder: hemolytic anemiawith reticulocytosisor leukopenia
    10. immunologic disorder: positive LE (lupus erythematosus) cell preparation or anti-DNA or anti-Sm or false positive serologic test for syphilis
    11. antinuclear antibody: abnormal titer of antinuclear antibody by immunofluorescence or equivalent assay
    12. positive LE cell reaction
  1. Management
    1. expected outcomes
      1. control system involvement and symptoms
      2. induce remission
    2. prevent bad effects of therapy
    3. recognize flare-ups promptly
    4. medical
      1. salicylates
      2. nonsteroidal anti-inflammatory agents (NSAIDS)
      3. corticosteroids
      4. anti-infectives
    5. antineoplastics
  2. Nursing care
    1. pain management strategies
    2. strategies to combat weight loss
    3. emotional support