NRNP 6560 MIDTERM

NRNP 6560 MIDTERM Rheumatoid arthritis: what, who - chronic, systemic autoimmune disease that causes inflammation of connective tissue, first that of jionts them other soft tissues (renal, cardiovascular, pulm). TN ...

NRNP 6560 MIDTERM Rheumatoid arthritis: what, who - 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 - unknown cause - Epstein Barr virus Rheumatoid arthritis: Findings and diagnostics - - 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 100.000 Felty's syndrome - rheumatoid arthritis, splenomegaly, neutropenia Rheumatoid arthritis treatment - - early treatment better than stepwise - 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 Surgery risk classes - 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 - 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 - - 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 - - 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 - catarcts breast biopsy cystoscopy, vasectomy laporascopic procedures Plastic surgery intermediate risk surgeries - Head/ neck surgery thyroidectomy Intraperitoneal Prostate Laminectomy Hip/ knee Hysterectomy cholecystectomy nephrectomy non majot intrathoracic High risk surgeries - aortic/ cabg transplants spinal reconstruction peripheral vascular surgery Lee's revised cardiac risk index - 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 - - 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 - - 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 - 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) - diabetic neuropathy - genetic Osteoarthritis findings and diagnostics - - 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 - Goal is to relieve symptoms, maintain/ improve function, and avoid drug toxicity Hand OA: - 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) Gout: what, who - 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 - - acute painful joint, often great toe (warm, swollen) - pain at night - flank pain because of renal calculi - 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 - - 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. - Antinuclear antibody (ANA). Normal: Titer 1.32 POsitive with: Sjogren's (SS), SLE (lupus), C4 Complement. Tests in rheumatic disease: what, normal level, abnormal with. - 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. - 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. - 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. - C-reactive protein, a non-specific 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. - Rheumatoid factor. antibody against IgG. Positive RF in most people with RA Corticosteroids and arthritis: what does it do and adverse effects - Not for maintenance Use lowest dose Suppresses flares nausea, hyperglycemia, weight gain, adrenal insufficiency, mask infections NSAIDS and arthritis: what and adverse effects - 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 - 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 - 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 - Pain over affected area previous subluxation swelling around joints loss of ROM XR, CT, MRI show subluxation Increased WBC (stress response) Management of subluxation - Early reduction, many spontaneously immobilization (splint, sling) PT NSAIDS for pain/ swelling Dislocation: what, cause - 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 - 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