Family Nurse Practitioner - Quiz 4 with complete verified solutions already graded A+

RA causes

Unknown

Suspected: Infection, Genetic, and Smoking

OA - causes

Idiopathic

or secondary to injury or inflammatory pathway

RA- Signs and Symptoms

WAXES and WANES

morning stiffness that lasts more than 1 hour before able to move

Maliase

usually symmetrical, starting with smaller joint of hands, feet, wrists and then moving to bigger joints

OA - Signs and Symptoms

asymmetric joint pain, insidiously: slow without s/s at 1st

follows physical activity, morning stiffness last less than 1 hour, WORSE at the end of the day, crepitus (bone on bone), cool joints, limited ROM, nodes

MC in fingers, thumbs, neck, knees, hips, lower back

RA - Differentials

Lupus, psoriatic arthritis, fibromyalgia

OA - Differentials

joint injury, RA, gout

RA - Diagnostics

CBC, ESR, WBC, CMP, Rheumatoid Factor

Synovial Fluid - cloudy and WBC

Anti-CCP

OA - Diagnostics

GOLD - xray - used to r/o other arthritis

shows the osteophytes and joint narrowing

**usually diagnose based off S/S

NEGATIVE: sed rate, rheumatoid factor, ANA

RA - Pharm Dose

1st line - NSAIDS or DMARDS (Celebrex)

400 mg day one, then 200mg daily after (maybe add PPI)

methotrexate

7.5mg PO once a week

RA - Pharm SE

1st line

Celebrex

SE: increased risk for MI/Stroke, and fatal GI events

methotrexate

SE: elevated LFTs, nausea, infection, anemia, abdominal discomfort

!!!Can cause hepatotoxicity, monitor CBC, liver profile THIS IS ESSENTIAL !!!!!

OA - Pharm and SE

conservative tx first- exercise and heat

THEN:

-NSAIDS, SE: gastric ulceration, renal impairment, fluid retention ** give PPI if long-term

-steroid injection, SE: wt gain, increased appetite, mood changes

RA - nonpharm

rest with flare-ups

exercise when no flare-ups

- joint replacement if extensive damage

OA - nonpharm

prevent further cartilage destruction - prevention is best (maintain wt, prevent injury)

Supervised activty

rest, braces, heat/cold, local creams

surgery

RA - pt edu

Diagnosis and Prognosis

Med SE

Balance between rest and exercise

OA - pt edu

muscle strengthening

diagnosis and prognosis

med SE

*Set reasonable goals, as being pain free is not likely due to the progressive nature of the disease but the goal is to make activities of daily living and least amount of pain

RA - referral

Refer to rheumatologist ASAP

OA - referral

PT and supervised exercise

surgery or RA

RA - F/U

3-4 months during tx

OA - F/U

regular eval for pain and med management

if on NSAIDS: CBC, renal and occult stool (be off NSAIDS for 3 days before this test)

taper corticosteroids

taper dosage by 50% of physiological values over 7 days, switch from multi doses to one dose

*mx for s/s of insufficiency: muscle weakness, lethargy, hypoglycemia

Cox 1 - Tissue Sites

all tissues

protecting gastric mucosa,

supporting renal function

promoting platelet aggregation

Common COX 1 and COX2 medication

Tylenol, NSAIDS

Cox 1 - Benefits

works as protection to MI/stroke

Cox 1 - Bad effects

gastric ulceration

renal impairment

bleeding

Cox 2 - Tissue sites

injured tissue site

-mediates inflammation

-sensitizes receptors to painful stimuli.

in the brain: where it mediates fever and contributes to perception of pain

in kidneys: where it supports renal function

blood vessels: where it promotes vasodilation

in the colon where it can contribute to colon cancer

COX 2 ONLY - Common Medications

celebrex

Cox 2 - Benefits

suppresses inflammation

protective against colorectal cancer

alleviates pain

Cox 2 - Bad Effects

bleeding

gastric ulceration

renal impairment

increased risk of MI/stroke

Who Gives NP prescriptive authority?

Texas State Board of Nursing

What do you need for Prescriptive Authority?

DEA #

obtain certification from State Board of Nursing

collaborative agreement with an doctor

*can only Rx C111-CV

Can only prescribe in an ER in Hospital, pt in hospital after 24 hours, and in terminally ill pt or hospice situation

Gout - Causes/RF

Renal impairment

Purine High Diet

cirrhosis

HTN

Obesity

Polynesian Race

Gout - Diagnostics

Synovial fluid aspiration- presence of MUC (monosodium urate crystals) crystals in joint fluid or tophus

Gout - Nonpharm

rest

dietary changes (decrease purine intake)

maintain healthy wt

increase water intake 3L/day

Gout - Pharm 1st line Acute

less than 3 flare-ups a year

- NSAIDS: Naproxen 500mg BID

Glucocorticosteroids (in contra to NSAIDS)

- prednisone 30mg daily x 5 days

Gout - Pharm 1st line Preventative

Allopurinol - 100mg once initially then 100mg weekly to maintain serum urate levels

max 800 mg/day

EDU: initial treatment may illicit gout attack

Gout- Pt EDU

Avoid Purine Rich Foods

and Alcohol

Gout - Referral

disease progressing despite uric lowering treatment

unclear gout diagnosis

if tx is effective but drug toxicity occurs from drugs

attack has not responded to tx

Gout - F/U

mx for recurrent attacks and tophi development

*uric lowering tx - every 1-3 months then every 6- 12 months

*NSAIDs, colchicine, and allopurinol,

complete blood count, renal function tests, and liver function tests should be obtained every 3 to 6 months.

Rotator Cuff Injury - Body parts Involved

supraspinatus

infraspinatu

teres minor

subscapularis.

Rotator Cuff Injury - Diagnostics

Supraspinatus test

Drop-arm test

Neer Impingement test

Hawkins-Kennedy impingement test,

Apprehension test

MRI after PE exam tests to locate extent of injury

Supraspinatus test

identifies tear and/or impingement of supraspinatus tendon or possible suprascapular nerve neuropathy

Drop Arm Test

Positive result if: Severe pain or inability of the patient to return the arm to the side slowly

A positive result indicates a rotator cuff tear.

Rotator Cuff Injury - s/s

pain and weakness - will not be able to hold arm straight up

loss of ROM

inclination to keep shoulder inactive

Rotator Cuff Injury - nonpharm

Rest

Ice/heat therapy

work activity modifications

PT for strengthening and stretching exercises

Rotator Cuff Injury - pt EDU

NSAID use or steroid injection

Rest shoulders

complications if left untreated: loss of shoulder function

Rotator Cuff Injury - F/U and Referral

2-4 weeks for evaluation

if not responding to treatment within 3-6 weeks

if rotator cuff tear - need surgery in 2 weeks

Low Back Pain - MC cause top 3

70% lumbar strain

4% herniated disc

4% Osteoporotic Fracture

Low Back Pain - Differentials

Low back strain, Osteoarthritis, Osteomyelitis

Kidney disease, ovarian cancer/cysts, appendicitis

Low Back Pain - Diagnostics for top 3

Herniated Discs- Straight Leg test or Crossed Leg Test, Xray and MRI, Toe and Heel walk

pulses for abdominal aneurysm

squat test, point-point discrimination, Reflexes

Low Back Pain - Pharm

1st line: NSAIDS, Tylenol, muscle relaxants, and opioids

NSAIDS - long-term use PPIs and mx CBC, liver fx, renal fx,

Muscle relaxants - Flexeril 5mg TID

SE: drowsiness and physical dependence

2nd line: steroid injections

3rd line: conservative therapy, surgical

Low Back Pain - nonpharm

restrict activities that would aggravate condition

heat and cold therapy

spinal manipulations

90% resolves within 4-6 weeks

Low Back Pain - RED FLAGS

younger than 20, older than 50

hx of IV drug use

hx of chronic steroid use

hx of cancer

recent bacterial infection

wt loss with back pain

nocturnal or unrelenting back pain that is worse in supine position

hx of immunosuppression

hx of recent trauma or TB

Low Back Pain - F/U

severe pain 24-72 hours

moderate pain 7-10 days, then every 2-4 weeks until pain is resolved

Sprain and Strain- Mj Differences

Sprain: tendon and muscle involvement

Strain: ligament involvement

Sprain and Strain - Diagnostics

PE first: location of pain, description of pain, neurovascular exam

Ask: How injury occurred, sport or movement that caused injury

Anterior/Posterior Drawer Test

Talar Tilt test

External Rotation Test

Squeeze Hopkins Test

Ottawa Rules for Imaging. Xray if fracture suspected, MRI if sprain/strain is severe

Sprain Grades

1) some stretching and micro tears in ligament

2) large but incomplete tear

3) complete tear of the ligament

Strain Differentials

sprain, fracture, tendonitis

Sprain and Strain - nonpharm Grades 1, 2, 3

GRADES 1-2

Protection (brace, splint, crutches)

Rest

Ice (every 20 min every 2 hours)

Compression

Elevation

Rehabilitation (PT ROM)

- muscle conditioning

-functional exercises

- electrotherapeutic modalities

Grade 3 - refer

Sprain and Strain - Pharm and SE

NSAIDS

SE: renal impairment, hepatic impairment, gastric ulceration, bleeding

Tylenol

SE: blistered skin, hoarseness, difficulty breathing/swallowing

Opioids

SE: constipation, dependency, respiratory depression

Sprain and Strain: EDU

when and how to take pain medication

difference between sprain and strain

PRICE treatment

ROM exercises

Sprain and Strain - Referral

eversion or Grade 3, no improvement in a week - orthopedist

after 48 hours refer to PT for ROM

Sprain and Strain - F/U

2 weeks to evaluate pain and swelling

after 48 hours refer to PT for ROM

Ankle Fracture - Assessment

PE: point of tenderness, swelling, symmetry, poor ROM, effusions or crepitus

Ankle Fracture - RF

osteoporosis, smoking, malignancies, menopause, sedatives in elderly, falls

Ankle Fracture - Differential

sprain, strain, contusion, dislocation

Ankle Fracture - Diagnostics

PE: neuro exam to r/o nerve and BV involvement

Xray and MRI

Ankle Fracture - nonpharm SPICE

Splint

Protect

Ice

Compression

Elevation

Ankle Fracture - referral

Casting/Traction - Orthopedist

Ankle Fracture - Pt EDU

signs of infection

wound management if applicable

edema and pain control methods

appropriate activity and rest

Medication SE and Use

Ankle Fracture - F/U

depends on severity 6-8 weeks for repeat xray

ACL or PCL tear - Define

anterior cruciate ligament (ACL)

Posterior cruciate ligament (PCL)

ACL or PCL tear - Causes

twisting and hyperextension

ACL or PCL tear - Differentials

meniscus tear, PCL sprain or strain, MCL sprain

ACL or PCL tear - s/s

ACL tear has 4 classic symptoms:

-Hear a pop from inside the knee

-Feel the knee give away at the time of the injury

-Swollen immediately, or within a few hours

-Severe pain - can not continue to play

ACL tear - Diagnostics and Positives

Lachmans Test

*positive test indicated by noticing abnormal anterior displacement of tibia forward

Meniscus Tear - Diagnostics

McMurray test-

*Positive test: hearing a crepitus associated with pain.

Thessaly's test-

*Positive test: locking movement or "pop"

sensation with pain in knee.

PCL tear - Diagnostics and Positives

Posterior drawer test -

Posterior sag test-

*Positive test is indicated when the posterior displacement of the tibial tuberosity is more in the affected limb

Herniated Disc - Diagnostics

Straight Leg Test

Phalen Test - What is it?

Hold hand inverted for 60 seconds

Positive signs = pain, numbness, tinging.

VERY SPECIFIC TO CARPAL TUNNEL

ACL or PCL tear - nonpharm

RICE or PRICE

ACL or PCL tear - pharm and DI

NSAIDS, Opioids, tylenol

ACL or PCL tear - pt EDU

avoid aggravating movements

safe use of crutches, braces

PRICE

ACL or PCL tear - Referral

ALWAYS for a complete tear to orthopedist/surgery

ACL or PCL tear - F/U

1 week with ortho

Hurt Knee - Diagnostics

MRI for extent of injury

Hurt Knee - Differentials

fracture, joint or ligament injury

Hurt Knee - nonpharm

conservative treatment - PRICE

exercise and physiotherapy needed to decrease adhesions

surgery

Hurt Knee - Referral

if grade 3 sprain

acl complete tear

fracture

Hurt Knee - F/U

ACL tear- 1 week

Sprain/Strain - 2 weeks to evaluate for pain, swelling, weight bearing status