L12

Question 1

Osteoarthritis (OA)

Answer 1

• Non-inflammatory disease; gradual loss of hyaline cartilage
• in high-load bearing cartilage
• pain and stiffness

Question 2

Causes of OA

Answer 2

1. Joint instability
2. Neurological disorder
3. Trauma
4. Obesity
5. Skeletal deformities
6. Drug (collagen-digesting enzymes)

Question 3

Clinical manifestations of OA

Answer 3

1. Usually affect later side of the body
2. Joint pain, increase with joint use
3. Difficulty in sitting down and rising from chairs
4. Loss of joint function
5. Stiffness after sitting down or prolonged unchanged of position; overactivity causes stiffness and swelling
6. Crepitation
7. Knee OA causes deformity

Question 4

Diagnostic test for OA

Answer 4

• physical and history assessment
• CT scan, MRI, bone scan
• synovial fluid analysis by arthrocentesis (to rule out infection)

Question 5

Arthrocentesis

Answer 5

• joint aspiration of synovial fluid or injection of medication
• USG guided to prevent tendon and neurovascular damage
• diagnostic: gouty, hemarthrosis, septic arthritis, acute joint effusion
• therapeutic: reduce effusion and pressure

Question 6

Treatment of OA

Answer 6

1. Medication:
   - reduce inflammation: NSAIDS, COX-2 inhibitors, corticosteroids
   - intra-articulate hyaluronic acid: to replace hyaluronic acid that is responsible for the viscosity and elasticity of synovial fluid
2. Weight management
3. Avoid immobilisation, standing, kneeling and squatting for long periods
4. Surgical treatment: arthroplasty

Question 7

Gouty arthritis (GA)

Answer 7

Accumulation of uric acid crystals
- Primary gout: error of purine metabolism
- Secondary gout: drugs that increase uric acid production
- Acute: sudden swelling with excruciating pain at night, accompanied by low-grade fever; last 2-10 days
- chronic: visible deposits of sodium urate crystals; caused joint deformities and cartilage destruction

Question 8

Diagnostic test of GA

Answer 8

1. History and physical assessment
2. Sodium urate crystals in synovial fluid
3. Increased serum uric acid
4. CT scan (bone erosion)
5. MRI: detect crystal deposit; determine severity and rule out other diagnosis

Question 9

Treatment of GA

Answer 9

1. Medication:
   - Colchicine: treat gout attack; side effect: diarrhea
   - Allopurinol: prevent urate formation
   - NSAID, corticosteroid, intra-articular corticosteroid
2. Avoid food with high purine
3. Avoid drinking alcohol
4. Maintain hydration

Question 10

Rheumatoid Arthritis (RA)

Answer 10

• Chronic, autoimmune disease
• Autoantibodies (Rheumatoid factor) combines with IgG to form immune complex that deposit on synovial membrane or superficial articular cartilage in the joints
• occur in small joints
• synovial fluid: cloudy and high in WBC
• laboratory findings:
  RF +ve, elevated ESR and CRP shows inflammation

Question 11

Clinical manifestations of RA

Answer 11

1. Joint involvement: pain, stiffness, limited motion
2. Sign of inflammation: heat, swelling, tenderness
3. Symmetrical joint involvement; usually involve in hands and feet
4. Morning stiffness
5. Deformity: ulnar deviation of fingers, swan neck deformity

Question 12

Diagnostic test for RA

Answer 12

1. History and physical assessment
2. CBC
3. Rheumatoid factor (RF)
4. Erythrocyte sedimentation rate (ESR) and C reactive protein (CRP): produced by the liver in response to inflammation
5. Anti-citrullinated protein antibodies (ACPA): highly specific for RA; directed against proteins and peptides
6. X-ray of involved joints
7. Synovial fluid analysis

Question 13

Treatment for RA

Answer 13

1. Rest and protect the joint, e.g. use of assistive device
2. Therapeutic exercise
3. Heat (stiffness) and cold (acute inflammation) application
4. Medications:
   - disease-modifying anti-rheumatic drugs: suppress immune and inflammatory response
   E.g. Methotrexate: for early RA, lower toxicity, side effects include bone marrow suppression and hepatotoxicity, require monitor of CBC and LFT
   E.g. Hydroxychloroquine for mild to moderate RA, side effects include risk of damage of retina of the eyes
   - intra-articular/systemic corticosteroids
   - NSAID
   - biological response modifiers

Question 14

Possible nursing diagnosis for RA

Answer 14

1. Impaired physical mobility due to joint pain, stiffness and deformity
2. Chronic pain due to joint inflammation
3. Disturbed body image

Question 15

Ankylosing spondylitis

Answer 15

• Chronic inflammatory disease affecting axial skeleton: sacroiliac joints, intervertebral discs, costovertebral articulations
• Inflammation in joints and adjacent tissue causes formation of granulation tissue
• dense fibrous scar causes joint fuse
• genetic cause

Question 16

Clinical manifestations of ankylosing spondylitis

Answer 16

1. Lower back and spine pain; stiffness
2. Limited motion (worsening at night and in the morning); improved when mild activity
3. Disability if develop into severe postural abnormalities and deformity
4. Risk of spinal fracture
5. Ventilation impairment due to restricted chest wall

Question 17

Diagnostic test of ankylosing spondylitis

Answer 17

1. Assess chest wall expansion
2. X-ray: bamboo spine
3. CT scan and MRI

Question 18

Treatment of ankylosing spondylitis

Answer 18

1. Use of assistive devices
2. Use firm mattress; avoid posture with spinal flexion
3. Heat application
4. Hydrotherapy for spinal extension
5. Therapeutic exercise for chest expansion
6. Medication:
   - NSAID
   - Disease-modifying anti-rheumatoid drugs
   - local corticosteroid injection
   - salicylates
   - biological response modifiers

Question 19

Syme’s amputation

Answer 19

Amputate at the ankle joint, heel pad is preserved; can withstand full-weight bearing

Question 20

Forequarter amputation

Answer 20

Cut before the shoulder, at the clavicle)

Question 21

Nursing assessment of amputation

Answer 21

1. Compare neurological status with the unaffected side
2. Assess underlying problems, e.g. peripheral vascular disease, DM
3. Assess psychological status

Question 22

Possible nursing diagnosis of amputation

Answer 22

1. Acute pain
2. Impaired skin integrity
3. Disturbed body image
4. Inefficient coping
5. Inefficient health maintenance
6. Risk for disturbed sensory perception (Phantom limb pain)

Question 23

Stump care

Answer 23

Shaping and molding for prosthesis fitting
Prevent edema and promote wound healing

Question 24

Post-op complications

Answer 24

1. Risk of infection
2. Haemorrhage
3. Phantom limb pain: caused by the serving of peripheral nerves, pain received in the amputated limb
4. Joint contracture: caused by positioning or protective fracture, leading to limited range of motion of joint
5. Dehiscence裂開 wound

Question 25

Measures to prevent knee contracture

Answer 25

1. Maintain knee flexion 2. Avoid placing pillow under the knee unless it supports the whole stump 3. Support the stump with a chair while sitting; use a stump board on wheel chair

Question 26

Measures to prevent hip flexion contracture

Answer 26

1. Maintain hip in a neural position 2. Avoid prolonged sitting; suggest prone-lying to prevent shortening of hip flexors and abductors; avoid abduction and external rotation of the lower limb 3. Avoid placing pillow under the stump 4. Encourage patient to turn from side to side

Question 27

Negative pressure wound therapy

Answer 27

Use suction to remove drainage and promote wound healing 1. Provided a moist and protected environment 2. Reduce peripheral edema around the wound 3. Promote wound circulation 4. Decrease bacterial colonisation 5. Increase granulation tissue formation and epithelization