Concepts of Care for Patients with Arthritis and Total Joint Arthroplasty
Osteoarthritis
Pathophysiology
Most common form of arthritis
Progressive deterioration and loss of articular cartilage and bone in one or more joints
Risk Factors
Primary Factors:
Aging: Natural wear and tear of joints.
Genetic Factors: Family history increases risk.
Secondary Factors:
Joint Injury: Past injuries may predispose individuals to OA.
Obesity: Excess body weight increases stress on joints.
Repetitive Stress to Joints: Occupation or activities that stress joints increase risk.
Health Promotion and Wellness
Maintain proper nutrition to support joint health.
Avoid injuries to minimize risk of joint damage.
Take work breaks to avoid repetitive strain.
Stay active to maintain joint function and mobility.
Nursing Care
Assessment
History:
Joint pain reported by patient.
Note that OA may be a secondary diagnosis following other conditions.
Physical Assessment/Signs & Symptoms:
Persistent Joint Pain: Pain that remains despite rest.
Stiffness: Typically worse in the morning or after inactivity.
Crepitus: A grating sound or sensation due to rough joint surfaces.
Joint Effusions: Accumulation of fluid in joints.
Psychosocial Assessment:
Evaluate lifestyle changes and their impact on the patient’s mental and emotional state.
Laboratory Assessment:
Aspirated Joint Fluid: Analyze for signs of inflammation or infection.
ESR: Erythrocyte sedimentation rate indicates inflammation.
hsCRP: High sensitivity C-reactive protein to assess inflammation levels.
Imaging Assessment:
X-rays: To visualize joint space narrowing and other degenerative changes.
MRI: Provides more detailed images of soft tissue and cartilage.
Analysis of Cues
Persistent pain is causing significant distress.
There is a potential for decreased mobility leading to loss of independence.
Planning and Implementation
Managing Persistent Pain: Utilize pharmacologic and non-pharmacologic strategies.
Promoting Postoperative Mobility and Activity:
THA: Total Hip Arthroplasty.
TKA: Total Knee Arthroplasty.
Care Coordination and Transition Management
Implement home care management strategies post-surgery.
Provide self-management education to empower patient involvement.
Connect patients with healthcare resources to maintain ongoing support.
Evaluation: Evaluate Outcomes
Pain control should reach a level of 2 to 3 on a scale of 0 to 10 that is acceptable to the patient.
Monitor for complications associated with total joint arthroplasty (if performed).
Assess the patient's ability to move and function independently, with or without assistive devices.
Rheumatoid Arthritis
Pathophysiology
Definition: Chronic, progressive, systemic inflammatory autoimmune process
Primarily affects synovial joints.
Characteristics: Remissions and exacerbations are typical.
Risk Factors
A combination of environmental and genetic factors contribute to pathogenesis.
Physical and emotional stresses may trigger exacerbations
Female
Euro-American people
Incidence and Prevalence
Approximately 1.5 million people in the US are affected.
More common in Euro-American populations.
Gender Disparity: Women are 2-3 times more likely to develop RA than men.
Nursing Care
Assessment
History:
Acute and severe symptoms or gradual and progressive symptoms.
How long has the fatigue and joint pain been occurring?
How long does it take to fully move in the morning?
Any associated weight loss or fevers?
Which specific joints are affected?
Physical Assessment/Signs & Symptoms:
Localized and systemic manifestations.
Generalized weakness and fatigue
Morning stiffness lasting greater than 1 hour
Unintentional weight loss
Myalgias (muscle pain)
Psychosocial Assessment:
Consider the emotional impact of chronic illness
If the patient expresses hope that rheumatoid arthritis will "go away":
Appropriate response: "This condition does not go away but can be effectively managed with drug therapy and lifestyle modifications."
Laboratory Assessment:
RF: Rheumatoid Factor measures the presence of unusual antibodies.
Anti-CCP: Anti-cyclic citrullinated peptide antibodies aid in diagnosis.
ANA: Antinuclear antibodies test for autoimmune issues.
ESR: Erythrocyte sedimentation rate assesses inflammation (Very high = RA)
hsCRP: High sensitivity C-reactive protein measures acute phase reactant.
Other Diagnostic Assessment:
X-rays: Visualize joint erosion and changes.
CT scan: Provides detail on soft tissue involvement.
Arthrocentesis: An aspiration procedure to analyze joint fluid.
Analysis: Analyze Cues & Prioritize Hypotheses
Chronic inflammation leads to persistent pain.
Potential for decreased mobility impacting quality of life.
Low self-esteem may arise due to chronic illness.
Planning and Implementation
Managing Chronic Inflammation and Pain:
Utilize drug therapy, including:
Tylenol
NSAIDs: Non-steroidal anti-inflammatory drugs.
TNF Inhibitors
Etanercept (Enbrel)
Anti-inflammatory drug
Treats chronic autoimmune condition
Block TNF-alpha protein
Key risks: serious infections, TB, malignancies
DMARDs:
Disease-modifying antirheumatic drugs
Hydroxychloroquine
Reduce immune system activity
Raise pH of lysosomes
Key risks: QT prolongation when combined with other drugs; hypoglycemia; take with food or milk
Focus on promoting mobility through physical rehabilitation.
Enhance self-esteem through support and education strategies.
Care Coordination and Transition Management
Home care management tailored to progress and needs.
Self-management education emphasizing active patient role in care.
Access to healthcare resources for ongoing support.
Evaluation
Pain control achieved at a level of 2 to 3 on a scale of 0 to 10.
Patient should be able to function and move independently, with or without assistive devices.
Encourage the expression of increased self-esteem and positive self-perception.
Fractures
Overview
Definition: A break in the continuity of bone.
Most common in patients experiencing trauma and older adults.
Fractures vary in type and location.
Pathophysiology
Classification of Fractures
Incomplete Fracture: Bone does not break all the way through.
Complete Fracture: Bone breaks into two or more parts.
Greenstick Fracture: An incomplete fracture typically seen in children.
Comminuted Fracture: Bone is shattered into many pieces.
Impacted Fracture: Two ends of the broken bone are driven into each other.
Compression Fracture: Bone is crushed, often occurring in vertebrae.
Etiology of Fractures
Two main factors contribute:
Strength of the Force acting against the bone.
Strength of the Bone itself.
Details: If the force exceeds the bone's strength, a fracture occurs.
Types of forces: Direct blow, compression, twisting, trauma, or repetitive stress.
Bone Strength Related To:
Nutritional status.
Presence of pathologic conditions, such as osteoporosis or bone cancer.
Phases of Fracture Healing
Inflammatory Phase (Reactive Phase):
Damage causes bleeding and inflammation.
Reparative Phase:
Fibroblasts, osteoclasts, and chondroblasts secrete collagen > fibrocartilage > soft callus > woven bone > hard callus
Risk Factors
Age:
Young patients - sports injuries
Older adults - falls and disease
Presence of Bone Disease:
Osteoporosis
Osteogenesis imperfecta
Bone cancer.
Poor Nutrition:
Inadequate intake of vital nutrients such as vitamin D, calcium, and phosphorus.
Lifestyle Habits:
Participation in dangerous activities contributes to fracture risk.
Prevention Strategies
Education:
Safety equipment
Good lifestyle habits.
Safe Living Environment:
Protective gates on stairs for children
Removal of rugs or clutter to prevent falls
Regular Screenings:
Osteoporosis
Fall prevention.
Clinical Manifestations
Pain: Typically localized to injury site.
Visible Fracture on X-Ray: Confirmatory imaging.
Other Manifestations:
Deformity observed.
Swelling present around the injury site.
Numbness or loss of blood may occur (internal or external).
Can lead to hypovolemic shock or ecchymosis (bruising).
Crepitus: Grating sensation felt.
Complications
Compartment Syndrome:
Edema or swelling causes pressure in muscle compartments, restricting blood flow and threatening muscle and nerve integrity.
Occurs in a continuous cycle: decreased blood flow > dilation of blood vessels > more edema
Symptoms:
Severe pain and tenderness in the affected area.
Swelling
Paresthesia
Pallor
Numbness
Decreased or absent pulses
Poikilothermia is distal limb
Should suspect if symptoms are disproportionate to negative x-ray findings
Commonly affects the lower leg and forearm.
Can affect: hand, foot, thigh, upper arm
Deep Venous Thrombosis (DVT):
Increased risk post-fracture.
Prevention:
Early immobilization
Exercise
Anticoagulants
Compression stockings or boots
Complications:
Pulmonary embolism
Myocardial infarction
Cerebral vascular accident (stroke)
Medical Treatment
Collaboration
Requires input from multiple healthcare professionals:
Nurses, physicians, surgeons, and physical therapists.
Nursing Roles:
Assessing patient status.
Maintaining patient comfort.
Assisting with procedures.
Providing patient education.
Referring to specialists as needed.
Surgery
Used for severe or complex fractures requiring direct visualization for repair.
Types of Surgery:
Open Fractures and Comminuted Fractures: May need surgical intervention.
External Fixation: Used when soft tissue damage prohibits internal fixation.
Open Reduction and Internal Fixation (ORIF): Common for long bones.
Potential Complications:
Infection risk
Neurovascular/vascular injuries
Leg length discrepancies
Pharmacologic Therapy
Analgesics: Manage pain effectively
For severe fractures, opioids and NSAIDs are indicated for pain and inflammation control
Antibiotics: Administered to prevent or treat infections
Anticoagulants: Prevent DVT occurrences post-fracture
Nonpharmacologic Therapy
Cast:
Rigid device for immobilization, protection, and support of fractured bones and surrounding tissues
Typically made of plaster or fiberglass, custom-fitted to the patient
Should encompass joints above and below the fracture
Functional Casts: Allow limited movement of nearby joints
Nursing Care Considerations:
Frequent neurovascular assessments to ensure limb health
Palpate for "hot spots" indicating infection
Monitoring for drainage
Assess for compartment syndrome
Splint: Provides less rigid support than a cast and can be adjusted as swelling changes.
Traction: Application of weights and devices to maintain proper alignment of a fractured bone.
Skin Traction:
Only is small amount of weight is needed for traction
Uses: control muscle spasms, maintain alignment before/after internal fixation, if skeletal pins must be removed
Skeletal Traction:
More invasive and used for more severe alignment requirements
Greater force required for alignment or skin traction contraindicated
May be used with skin traction
Involved surgical implantation of pins, wires, screws into bone then weights are attached to the implanted hardware
Monitor for infected pins
WEIGHTS SHOULD NOT TOUCH THE FLOOR
Nonpharmacologic Pain Management:
RICE Therapy:
Rest
Ice
Compression
Enough to provide support for injured areas
Not enough to decrease blood flow and cause compartment syndrome
Elevation
Lifespan Considerations
Infants:
Signs:
Inconsolable crying
Crying when area around fracture is touched
Limited movement of the extremity
Swelling
Deformity
Fractured collar bones: common in birth injuries
Risks for long bone fractures: c-section, breech birth
Adolescents:
Stress fractures
Repetitive force on specific bones
Imbalanced nutrition
Adults and Older Adults:
Lengthened recovery time due to slower tissue growth increases risks
Particularly post-menopause for women.
Altered mental status: increased risk
Osteoporosis: increased risk of hip fracture, DVT development, infection
Nursing Care
Implement the nursing process focusing on:
Pain management strategies.
Patient teaching for self-management and awareness.
Complications assessment continuously.
Providing emotional support and care.
Adjust care strategies based on the specifics of each patient, like fracture location and severity.
Nursing Diagnosis
Peripheral Neurovascular Dysfunction, Risk for
Ineffective Tissue Perfusion, Risk for
Infection, Risk for
Skin Integrity, Impaired
Pain, Acute
Physical Mobility, Impaired
Disuse Syndrome, Risk for
Deficient Knowledge
Disturbed Body Image
Anxiety
Medication Administration System
Overview
Importance: Medication administration is a critical component of patient care; errors can lead to harm, increased costs, and legal implications.
Goal: Enhance patient safety and streamline workflow
Objectives of MAS
Reduce Medication Errors
Improve Accuracy and Documentation
Supporting clinical decision-making
Enhance Communication among healthcare teams
Ensure compliance with regulatory standards
Key Components of MAS
Electronic Medication Administration Record (eMAR):
Digital tracking of medication orders and administration, reducing transcription errors.
Barcode Medication Administration (BCMA):
Verifies patient and medication for safety.
Clinical Decision Support (CDS):
Alerts for allergies, drug interactions, and dose limits, supporting prescribing safety.
Automated Dispensing Cabinets (ADCs):
Secure storage that improves medication availability and integration.
Integration with EHR Systems: Facilitates access to patient records.
Workflow of a Medication System
Provider enters medication order.
Pharmacist verifies the order.
Medication dispensed via ADC.
Nurse scans patient and medication together.
System confirms the “Five Rights” of medication administration.
eMAR automatically documents administration.
Benefits of MAS
Enhanced patient safety through standardized procedures.
Decreased medication errors.
Increased staff efficiency in medication management.
Better compliance with regulatory standards.
Improvement in communication across teams.
Real-time data for quality improvement activities.
Challenges & Limitations
High costs for implementation across healthcare facilities.
Requirement for comprehensive staff training on new systems.
Potential technical difficulties or downtimes during use.
Resistance from staff in adapting to new workflows.
Continuous need for system updates and maintenance.
Case Study Results
Hospitals reported a 45% decrease in medication errors post-implementation of BCMA and eMAR.
Documented improvements in documentation accuracy and medication delivery time.
Observations of increased staff satisfaction noted after system adoption.
Conclusions
Medicine Administration Systems are essential for modern healthcare.
They enhance safety, accuracy, and efficiency in medication delivery.
Adequate training and support are vital for successful implementation.
MAS plays a key role in improving overall patient outcomes.