Rheumatoid Arthritis with Joint Arthroplasty Notes

Rheumatoid Arthritis with Joint Arthroplasty Rheumatoid arthritis, or RA, is an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body. RA mainly attacks the joints, usually many joints at once. RA commonly affects joints in the hands, wrists, and knees. In a joint with RA, the lining of the joint becomes inflamed, causing damage to joint tissue. Blood tests People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR, also known as sed rate) or C-reactive protein (CRP) level, which may indicate the presence of an inflammatory process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies. Imaging tests Your doctor may recommend X-rays to help track the progression of rheumatoid arthritis in your joints over time. MRI and ultrasound tests can help your doctor judge the severity of the disease in your body. Medications The types of medications recommended by your doctor will depend on the severity of your symptoms and how long you've had rheumatoid arthritis. ● NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter NSAIDs include ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve). Stronger NSAIDs are available by prescription. Side effects may include stomach irritation, heart problems and kidney damage. ● Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Side effects may include thinning of bones, weight gain and diabetes. Doctors often prescribe a corticosteroid to relieve symptoms quickly, with the goal of gradually tapering off the medication. ● Conventional DMARDs. These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall, Otrexup, others), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Side effects vary but may include liver damage and severe lung infections. ● Biologic agents. Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), sarilumab (Kevzara) and tocilizumab (Actemra). Biologic DMARDs are usually most effective when paired with a conventional DMARD, such as methotrexate. This type of drug also increases the risk of infections. ● Targeted synthetic DMARDs. Baricitinib (Olumiant), tofacitinib (Xeljanz) and upadacitinib (Rinvoq) may be used if conventional DMARDs and biologics haven't been effective. Higher doses of tofacitinib can increase the risk of blood clots in the lungs, serious heart-related events and cancer. Provide a variety of comfort measures (eg, application of heat or cold; massage, position changes, rest; foam mattress, supportive pillow, splints; relaxation techniques, diversional activities). Administer anti-inflammatory, analgesic, and slow-acting antirheumatic medications as prescribed. Therapy Your doctor may refer you to a physical or occupational therapist who can teach you exercises to help keep your joints flexible. The therapist may also suggest new ways to do daily tasks that will be easier on your joints. For example, you may want to pick up an object using your forearms. Assistive devices can make it easier to avoid stressing your painful joints. For instance, a kitchen knife equipped with a hand grip helps protect your finger and wrist joints. Certain tools, such as buttonhooks, can make it easier to get dressed. Catalogs and medical supply stores are good places to look for ideas. Surgery If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and improve function. Rheumatoid arthritis surgery may involve one or more of the following procedures: ● Synovectomy. Surgery to remove the inflamed lining of the joint (synovium) can help reduce pain and improve the joint's flexibility. ● Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint. ● Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn't an option. ● Total joint replacement. During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic. 1. Which nursing intervention related to the scheduled bone scan is most important to implement? a. Inform Terry that radioisotope will be administered 2 hours before the procedure. Rationale: Radiosotope is given 2 hours before the bone scan. Terry should also be instructed that because the dose of radioisotope is minimal, no special precautions are necessary. 2. Which etiologic factor is related to the onset of rheumatoid arthritis? a. Genetic predisposition. Rationale: Because the incidence of RA in persons with a positive family history is significantly greater than for the general population, genetic predisposition is probably a significant etiologic factor. In addition, increased stress has been linked to RA, and viral infections are believed to be a trigger for the onset of this autoimmune disease. 3. The nurse completes an assessment of Terry. In addition to the bilateral swollen tender joints, weight loss, and fatigue, what additional manifestations of RA might Terry exhibit? a. Joints tender, painful, and warm to the touch. R: In RA, joints are tender, painful, and warm to the touch. b. Fever. R: A persistent low-grade fever is a common early manifestation of this inflammatory disease. Remember, RA is both a local and systemic inflammatory disease with many generalized symptoms such as fever, fatigue, and weakness, along with multiple lung, cardiac, and renal manifestations. c. Bilateral symmetric joint involvement. R: The symptoms usually include bilateral, symmetric joint involvement. 4. Which assessment findings may indicate aspirin toxicity? a. Headache and confusion. b. Symptoms of aspirin toxicity include tinnitus, headache, confusion, weakness, GI bleeding, and diarrhea. c. Hyperventilation and agitation. d. Symptoms of aspirin toxicity include headache, hyperventilation, and agitation. 5. Which adverse effect of methotrexate places Terry at the highest risk for infection? a. Leukopenia. R: Decreased levels of leukocytes place the client at high risk for infection. The client with leukopenia should be instructed to institute measures to avoid infections. 6. Which information should be included when teaching Terry how to manage her chronic pain? a. Protect joints from stress. R: While RA is a progressive chronic disease, emphasis needs to be made to help Terry identify ways to alter her tasks to put less stress on joints. b. Alternate scheduled rest period with activity throughout the day. R: This will help to relieve fatigue and pain. 7. Terry is experiencing impaired mobility. Which nursing intervention is best to implement for this nursing diagnosis? a. Advise Terry to take a hot shower in the morning to prevent morning stiffness. R: Morning stiffness can be reduced by taking a hot shower in the morning. 8. Which nursing intervention will promote improved coping for Terry? a. Discuss with Terry how to work through problems that can arise while managing her condition. R: This is an important nursing intervention. Clients experiencing a high level of stress may need guidance to solve even simple problems. In addition, support groups are often beneficial for clients coping with chronic disease. 9. What is the nurse's best response? a. "You seem very concerned about how this is impacting your family and you." R: Clarification of Terry's feelings is a therapeutic technique which will encourage further communication. 10. Terry continues, "It is so hard on my husband and children. It seems I have no options in my life." What is the nurse's best response to this remark? a. "There are surgical options that may help. Would you like to discuss those options?" R: Making a client-focused suggestion offers Terry an alternative without being confrontational or belittling. 11. Which best describes arthroplasty? a. Surgical reconstruction or replacement of a joint. R: Arthroplasty is the term used for total joint replacement. Hip replacement is the most common joint arthroplasty, followed by knee replacement. Clients with rheumatoid arthritis may also benefit from elbow, wrist, or finger arthroplasty 12. Which postoperative intervention should the nurse expect to implement? a. Perform regular neurovascular assessment. R: Postoperatively, regular neurovascular assessments must be performed. 13. The nurse performs neurovascular assessment of Terry's feet every 2 hours. Which assessment finding should be reported to the healthcare provider? a. Capillary refill > 4 seconds. R: Capillary refill greater than 3 seconds may indicate neurovascular compromise. Following any trauma or invasive procedure of a lower extremity, adequacy of neurovascular function distal to the site must be assessed regularly. This includes assessment for the six Ps: Pulselessness, Pain, Pallor, Paresthesia, and Paralysis, as well as Prolonged (> 3 seconds) capillary refill. 14. Which instruction should the nurse include when teaching Terry about the PCA pump? a. "You can request additional pain medication if your pain is not controlled with the pump." R: It is the nurse's responsibility to assess Terry's response to the analgesia, including assessment of vital signs, level of consciousness, and effectiveness of the pain control. 15. Which intervention should the nurse implement first? a. Perform a neurovascular assessment. R: The nurse should always assess the client first because pain may indicate a complication that requires medical intervention. 16. Which tasks can be delegated to the UAP? a. Apply antiembolic hose. R: This is an activity that can be delegated to a UAP. Activities delegated to a UAP should fall within the intervention component of the nursing process, and should not require the expertise of a licensed nurse. b. Remove the CPM machine while assisting Terry to bathe. R: The UAP can remove the CPM machine while performing hygiene. 17. Which professional(s) have prescriptive authority that can provide a prescription for a different analgesic? a. Nurse practitioner. R: A nurse practitioner, an advanced practiced registered nurse, may legally prescribe medications either autonomously or as outlined in a collaboration practice agreement based on the state requirements. b. Physician's assistant. R: A physician's assistant (PA), working in collaboration with a physician, may legally prescribe medications. 18. The nurse contacts the surgical physician's assistant (PA), who provides the following verbal prescription: hydrocodone/acetominophen (Lortab) 7.5/500 mg, 2 tabs PO PRN for pain. What is the best nursing action in response to this prescription? a. Repeat the verbal order back to the PA for clarification and completeness of the order. R: The nurse should repeat the verbal order back to the prescriber for clarification and to verify that the order is complete. This prescription is incomplete and requires clarification from the prescriber. Remember the five rights: right client, drug, dose, route, and time. The PRN frequency (right time) is missing from this prescription. A correct medication prescription includes not only the five rights, but also the prescriber's signature and the date and time written. 19. Which intervention should the nurse implement first? a. Assess Terry's vital signs and check the surgical dressings.. R: Further assessment of Terry's condition is the highest priority. The nurse should first assess Terry's vital signs and the appearance of the surgical dressings. 20. Which intervention should the nurse prepare to implement? a. Obtain cold packs or a cooling blanket. R: Terry is exhibiting symptoms of sepsis. Infection is a significant postoperative problem following joint replacement. Wound and blood cultures should be obtained, antipyretics administered, and cooling packs applied to reduce the fever. 21. Which manifestations may indicate the onset of septic shock? a. Decreased urinary output. R: Decreased urinary output is a sign of septic shock. b. Altered mental status. R: Early signs of shock include altered mental status, agitation, and restlessness resulting from cerebral hypoxia. The nurse should assess carefully for these early symptoms. Other manifestations may include pallor, diaphoresis, hypotension, tachypnea, and tachycardia. 22. The nurse notifies the healthcare provider and obtains wound and blood cultures. Terry is started on levofloxacin 750 mg every 24 hours, a primary IV of Ringer's Lactate at 125 mL/hour, and a cooling blanket. The prescription for levofloxacin is in a 100 mL piggyback bag of 0.9% normal saline. How many mL/hour would the nurse set the infusion pump on to deliver the IV levofloxacin over 2 hours? a. 50 ml/hr 23. Which outcome is most important for this portion of the teaching plan? a. Terry successfully demonstrates the correct use of crutches for ambulation and transfers. R: The best method to evaluate that a skill has been learned is by the performance of a return demonstration by the client. 24. Which positioning indicates that the crutches are sized correctly? a. Arms flexed 30 degrees, crutch top 3 finger-widths from axilla. R: Correct positioning includes the arms flexed at no more than 30 degrees, with the tops of the crutches 2 to 3 finger-widths from the axilla when the crutch tips are at least 6 inches in front of the foot. Risk for Falls, Hip Fractures, and Pulmonary Embolism 1. Susan visits her primary healthcare provider (HCP). The nruse reviews Susan's electronic health record and notes her history of hypertension, osteoporosis, and osteoarthritis and her current medication regimen. The nurse understands that which information is correct about osteoarthritis? a. A noninflammatory condition involving formation of new joint tissue in response to cartilage destruction. Osteoarthritis results from cartilage damage that initiates a metabolic response of the chondroyctes. It is a slowly progressive disorder of the diathrodial (synovial) joints. 2. The nurse expects to see which manifestations of osteoarthritis in Mrs. Weil? SELECT ALL THAT APPLY a. Joint pain. Pain typically worsens with joint use and may be relieved with rest in the early stages. In advanced osteoarthritis, pain may worsen, causing sleep disturbances and interfering with activities of daily living. b. Swollen nodes of the joints. Heberden's nodes, bony bumps on finger joints closest to the fingernails, or Bouchard's nodes, bony bumps on the middle joint of the finger, can form on the joints and cause visible disfigurement and tenderness. c. Asymmetrical involvement of the joints. Osteoarthritis typically affects joints asymmetrically and most commonly involves the joints of the fingers, thumb, hips, knees, feet, and cervical and lower lumbar vertebrae. 3. Which symptom should Mrs. Weil report immediately while taking a non-steroidal antiinflammatory drug (NSAID)? a. Black, tarry stools. NSAIDS can cause bleeding tendencies in addition to ulcer formation. 4. When the nurse is teaching Susan about medications for osteoporosis, which instruction is more important, knowing that Susan takes alendronate (Fosamox), a biphosphonate? a. Remain upright (sitting or standing) for at least 30 minutes after taking this medication. b. Biphosphonates can cause erosion in the esophagus. Lying down or reclining after administration can allow regurgitation into the esophagus. INCORRECT: Take this medication at the same time every day. Alendronate (Fosamax) is given as a weekly dose. Always take alendronate (Fosamax) with the mid-day meal to prevent stomach upset. This drug should be taken on an empty stomach, before breakfast. 5. Which statement about the use of heat and cold for osteoarthritis pain by the client is of most concern to the nurse? a. "I wrap the heating pad around my knee and use an extension cord so I can walk around the house." The use of an extension cord creates a tripping hazard for the client. This statement should be addressed by the nurse. 6. Which statement about the use of heat and cold for osteoarthritis pain by the client is of most concern to the nurse? a. Knee pain. Musculoskeletal pain and decreased function associated with osteoarthritis heightens the risk for falls. 7. Which additional information is associated with an increased risk for falls? a. Throw rugs placed on hardwood floors in the home. Throw rugs are a tripping hazard, and they should be removed from the home to decrease fall risks b. Walks with short, shuffled steps. Shuffling steps indicate an abnormal gait pattern, and they increase the likelihood of tripping or falling. c. Uses the furniture to steady self. The use of furniture to steady oneself indicates a problem with balance and is a fall risk. d. Advanced age. e. The risk for falls increases over the age of 65. 8. Which clinical manifestation(s) of the affected extremity should the nurse practicing in the emergency department expect? SELECT ALL THAT APPLY a. External rotation. External rotation is rotation away from the center of the body and is a clinical manifestation of hip fracture. b. Shortening. Shortening of the affected extremity is a clinical manifestation of hip fracture. c. Muscle spasms. Muscle spasms caused by inflammation are a common clinical manifestation of hip fracture. 9. The affected extremity should be assessed for which of the following when neurovascular checks are performed? a. Color. A white or bluish color may indicate impaired circulation. b. Temperature. A cold temperature may indicate impaired circulation. c. Sensation. Pressure on the nerve from edema or compartment syndrome can cause changes in sensation. 10. The nurse understands that which is a correct description of compartment syndrome? a. Elevated pressure within a confined myofascial section compromises neurovascular function. Tissue viability is compromised when compartment syndrome occurs. It can cause necrosis of the affected extremity and lead to death. It is a life-threatening condition. 11. What is the priority action in preparation for Susan's surgery? a. Draw blood for type and cross match. The client is scheduled for surgery, and the type and cross match must be obtained prior to the surgical procedure. 12. Which ethical principle supports the decision to proceed with the emergency surgery when the client cannot give informed consent? a. Beneficence. Beneficence refers to the act of taking positive action to help others. It includes client advocacy. In this case, the client needs a life-saving procedure and the healthcare team is acting on the client's behalf. 13. Which are common components verified during an operating room time out? a. Client identity. A time out is a standardized procedure conducted immediately before invasive procedures are started or before a surgical incision is made. Correct client identity is an important component of the time out process to prevent error. b. Procedure to be done. A time out is a standardized procedure conducted immediately before invasive procedures are started or before a surgical incision is made. Identification of the correct procedure is an important component of the time out process to prevent error. c. Surgical site. A time out is a standardized procedure conducted immediately before invasive procedures are started or before a surgical incision is made. Identification of the correct surgical site is an important component of the time out process to prevent error. d. Allergies. A time out is a standardized procedure conducted immediately before invasive procedures are started or before a surgical incision is made. Identification of allergies is an important component of the time out process to prevent error. 14. Which action should the nurse take first? a. Determine the respiratory rate. The effects of anesthesia are often potentiated in the elderly and can cause respiratory suppression. 15. Which post-operative prescription should the nurse implement first? a. Apply oxygen 2 L via nasal cannula. The 02 saturation is low at 90%. Airway is the first priority. 16. Which task(s) are required before transfusing this unit of PRBCs? SELECT ALL THAT APPLY a. Confirm the right client, the right blood type, and the right unit of blood with another RN. b. Two nurses should verify the unit of blood, the blood type, and the client prior to hanging the blood. c. Ensure that the consent is signed and current. d. A consent for blood transfusion can be obtained in conjunction with the surgical consent; however, a separate consent must also be obtained for a blood transfusion. e. Gather supplies, including new blood tubing, new normal saline to hang with the blood, and a pump if it is required by hospital policy. f. The blood tubing currently hanging was used for two units that were infused during the surgery. Best practice is to use tubing for either two units of blood or for 4 hours, whichever comes first. 17. What is the priority intervention? a. Stop the blood transfusion and hang a new normal saline infusion. Headache, tachypnea, chills, hypotension, and elevated temperature are signs and symptoms of a blood transfusion reaction. 18. If the current order is cefazolin (Ancef) 2 grams every 6 hours for 24 hours, when will the last done be given? a. 0100 on Thursday. The last dose was 0100 on Wednesday . Cefazolin (Ancef) will be given q 6 hours for 24 hours (4 doses), which would be Wednesday at 0700, 1300, and 1900 and Thursday 0100, finishing before the 0230 surgical end time. 19. Which response is correct? a. "It is a type of anticoagulant that is given to prevent venous blood clots." Enoxaparin (Lovenox) is a low molecular weight heparin that works to prevent blood clots from forming by blocking the action of clotting factors X and II. 20. Enoxaparin (Lovenox) 30 mg is prescribed subQ once daily and is supplied in a prefilled syringe contained 20mg/mL. How many mL should a prefilled 30 mg syringe contain? a. 2 Dose = 40 mg On hand = 20 mg/1 mL40/20 = 2 21. When administering enoxaparin (Lovenox) in a prefilled syringe, which action(s) should the nurse take? a. Ensure that the bubble is nearest to the plunger end of the syringe. b. The bubble should be closest to the plunger. It is used to clear the syringe after the medication is injected. c. Administer in the posteriolateral or anteriolateral abdomen. d. The manufacturer suggests that the drug is best absorbed when administered in either of these sites. 22. Which finding is of most concern? a. Red, warm, and edematous area of the left calf. A red, warm, and edematous area of the calf is a possible indication of a life-threatening complication associated with orthopedic surgeries. 23. Which action should the nurse take before the client's room to call the surgeon? a. Place the client on strict bedrest and elevate the left leg on a pillow. The client's symptoms are consistent with a deep vein thrombosis (DVT). Bedrest is the safest intervention to prevent the thrombus from breaking off and elevation may decrease the edema. 24. What is the priority action? a. Call for a Rapid Response Team. The client has symptoms of DVT; therefore, it is appropriate to activate the Rapid Response Team. 25. What is the top priority action? a. Call for a Rapid Response Team. The client has symptoms of DVT; therefore, it is appropriate to activate the Rapid Response Team. 26. How should the ICU nurse answer Susan's question? a. "You will receive enoxaparin (Lovenox) injections and warfarin (Coumadin) pills until the target anticoagulation numbers are reached." Enoxaparin (Lovenox) is provided at the same time a client is starting warfarin (Coumadin) therapy until the desired INR is reached. Once the INR is 2-3, the enoxaparin (Lovenox) may be stopped and the client will follow-up with the monthly coagulation labs with adjustments to warfarin (Coumadin) doses controlling anticoagulation. 27. Which lab result requires immediate action by the nurse? a. International normalized ratio (INR) 5. Clients prescribed warfarin (Coumadin) require frequent monitoring of their blood levels. If the INR is outside the target range for anticoagulant therapy (usually 2.0 to 3.0 or 1.5 to 2.0 for Asian clients), then a high INR is indicative of bleeding while a low INR suggests the risk of a blood clot. People of Asian heritage have variation of the CYP2C19 gene that reduces the metabolism of warfarin (Coumadin), leading to an increased bleeding risk. They are more sensitive to anticoagulant therapy. 28. Which new prescriptions and/or medication changes should the nurse anticipate next? a. Vitamin K and holding the warfarin (Coumadin) dose today. This drug is the antidote for warfarin (Coumadin) overdose. 29. Which member of the healthcare team is most appropriate to help the client learn how to cook while using a walker? a. Occupational therapist. Occupational therapists help the client work with adaptive equipment to resume activities of daily living. 30. What is the maximum number of tablets that Susan is allowed to take in 24 hours without excreeding the maximum of 3000mg? a. 4 Maximum dose = 2000 mg On hand = 500 mg2000/500 = 4 31. Which resources are appropriate to promote safety and independence for the client? a. Shower chair. The use of adaptive equipment such as a shower chair or bath tub chair and lift can promote safety and independence for the client. b. Medical alert system. A medical alert system promotes autonomy by allowing the client to feel more secure that immediate medical response is available if an injury occurs or help is needed. c. Home healthcare referral. A homecare referral will allow for an in-home safety assessment and continuity of care while Susan continues to rehabilitate. d. Raised toilet seat. A raised toilet seat helps alleviate discomfort associated with squatting on low toilets.