Osteoporosis Risk Factors
Low calcium and vitamin D intake, Age (women after menopause), lifestyle factors such as smoking, excessive alcohol intake, sedentary life, immobility, Caucasian and Asian women, family history, underweight/malabsorption disorder, Long-term use of corticosteroids, anticonvulsants, levothyroxine, or PPIs.
Osteoporosis Testing
Bone Density Test- Dual-Energy X-Ray Absorptiometry (DEXA), this process takes X-Ray images, measuring calcium, and other minerals in the bones.
Patient Education for Non-Pharmacologic Management of Osteoporosis
Food sources of Vitamin D such as cod liver oil, oysters, mackerel, most fish, egg yolk, fortified milk, some ready-to-eat cereals, and margarine
Pharmacological Management of Osteoporosis
Vitamin D, Calcium, Bisphosphonates, Calcitonin, Denosumab
Risk Factors for Osteoarthritis (OA)
Obesity, older age, females, heavy labor occupations, genetics
Patient Education for Non-Pharmacologic Management of Osteoarthritis
Occupational Therapy, Physical Therapy, Exercise, Walking Aids (Canes), Orthotic Devices (Splints, Knee Braces), weight loss. - Pulsed electromagnetic fields. Transcutaneous electrical nerve stimulation (TENS) and music therapy. Acupuncture, acupressure, copper bracelets or magnets
Pharmacological Interventions for Osteoarthritis
Analgesics (NSAIDs and Acetaminophen). Other medications that may be considered are nonopioids, such as tramadol, opioids in severe cases, and intra-articular corticosteroids. Also, Capsaicin and Methyl salicylate, Methotrexate, Colchicine, Diclofenac, Oxicam Derivatives (Meloxicam (Mobic)
Capsaicin and Methyl salicylate
Topical diclofenac sodium gel has been FDA approved for the use of osteoarthritic joint pain in the hands and knees
Methotrexate & Colchicine
typically prescribed for treating RA and gout, respectively, may also be considered for some patients with OA who are refractory to other treatments. The pathophysiologic antecedents of these diseases are like those in OA, and it is believed that may explain the effectiveness of these medications in some select patients with OA
Visco supplementation
the injection of gel-like substances (hyaluronates) into a joint (intra-articular), is thought to supplement the viscous properties of synovial fluid. These Viscos supplements aim to prevent the loss of cartilage and repair chondral defects but lack strong evidence that support their use
Diclofenac
Reversibly inhibits COX-1 and COX-2 to produce an anti-inflammatory response. 99% bound to albumin. Transdermal patch has half-life of 12 hours. Oral preparation is 1-2 hours. Used to relieve inflammatory symptoms of RA, OA, and ankylosing spondylitis
Foods to Avoid in Gout
Alcohol, large meals, especially red meat can lead to increases in free fatty acid concentrations and trigger gout attacks
Probenecid
Uricosuric Agent that inhibits renal reabsorption of urates and increases the urinary excretion of uric acid. Prevents tophi formationBe alert for nausea and rash
Colchicine (Mitigare, Colcrys)
Antigout agent.MOA: Lowers the deposition of uric acid and interferes with leukocyte infiltration, thus reducing inflammation. Does not alter serum or urine levels of uric acid. Used for both acute and chronic managementFor acute management - administer when attack begins. Dosage increased until pain is relieved, or diarrhea develops - then stop med. For Chronic Management - Causes GI upset in most patientsRelieves acute attacks and prevents future but DOES NOT decrease inflammation.Side effects include vomiting, abdominal pain, and diarrhea BLACK BOX WARNING OF RISK OF BONE MARROW SUPPRESSIONPatient education is to take with full glass of water, increase fluid intake to 2-3 L/day (may produce urine output of 2 L/day), avoid organ meats, and it does take several months to work
Allopurinol (Aloprim, Zyloprim, Lopurin), & Febuxostat
Uric acid inhibitor/Xanthine oxidase inhibitorsMOA: Interrupt the breakdown of purines before uric acid is formed. Inhibit xanthinoxidase because uric acid formation is blocked. Prevents gout attacks but does not help with acute attacks.Side effects include nausea, vomiting, abdominal pain, diarrhea, and skin rashes (may indicate SJS - stop med)Patient education is to take with full glass of water, increase fluid intake to 2-3 L/day (may produce urine output of 2 L/day), avoid organ meats, and it does take several months to work. Uric acid deposits can cause kidney stones (fluids help prevent this)BLACK BOX WARNING Taking this med with aspirin increase uric acid levels TAKE ACETAMINOPHEN INSTEAD
Long term options for treatment of Osteoarthritis
Total joint arthroplasty, also known as total joint replacement, involves the replacement of all components of an articulating joint.
Oxicam Derivatives
Meloxicam (Mobic) - Another type of NSAID, A COX-1 & COX-2 inhibitor.MOA: Produces anti-inflammatory, analgesic, and antipyretic effects.Side effects include dyspnea, hemoptysis, bronchospasm, pharyngitis, and rhinitis, bleeding, platelet inhibition, decreased hemoglobin, and hematocrit, along with bone marrow depression and edema, Nausea, dyspepsia, diarrhea, vomiting, headaches, dizziness, drowsiness, and insomnia.BLACK BOX WARNING increased risk for cardiovascular events and GI bleeding.Patient education: Take with food to decrease GI upset, do not drive until effects are known, Report sore throat, dyspnea, edema, and tarry stools
Bisphosphonates
End in "DRONATE" - Alendronate (Binosto), Etidronate (Didronel), Ibandronate (Boniva), Pamidronate (Aredia), Risedronate (Actonel), Zoledronic Acid (Reclast, Zometa).MOA: They are bone resorption inhibitors, inhibiting normal and abnormal bone reabsorption to increase bone mineral density.Side Effects: Nausea, Diarrhea, Dyspepsia, Acid Reflex, Abdominal PainNursing Consideration: Should not be used in evidence of osteopenia, Monitor serum Calcium Levels before, during and after therapy (should be 9-11 mg/dL)Patient Education: Take with full glass of water, on an empty stomach. Separate iron, antacids, and multiple vitamins by at least 30 mins. Encourage intake of calcium and vitamin D, perform weight-bearing exercises to preserve bone mass
Calcitonin
Salmon (Miacalcin)MOA: Hormone/Hypocalcemia Agent, that lowers serum calcium levels in the blood by inhibiting bone reabsorption (because we don't want calcium in the blood we want it in the BONES). Prevents further bone loss in the presence of adequate calcium and vitamin D, inhibits osteoclasts (cells that cause bone breakdown), treats, and prevents postmenopausal osteoporosisSide Effects: GI upset, nasal irritation, and dryness (intranasal route)Single injection decreases calcium levels in approximately 2 hours and lasts approximately 6-8 hours.
Denosumab (Prolia, Xgeva)
Antiresorptive Drug. Used to treat osteoporosis in postmenopausal women at high risk of fracture.MOA: Prevents skeletal-related events in bone metastases from solid tumors. Decreases bone resorption and increases bone mass and strengthSide Effects: Fatigue, Weakness, Back Pain, Extremity Pain, Hypocalcemia, Hypophosphatemia, Nausea, Diarrhea, Peripheral Edema, Hypertension, Headache, Skin Rash, and DermatitisAdministered SubQ at 7-month intervals
Rheumatoid Arthritis (RA) Assessment Findings
Rheumatoid Nodules, Joint Inflammation Detected on Palpation, bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in joints.
Rheumatoid Arthritis (RA) Diagnostic Findings
X-Ray, US for baseline joint evaluation/assess erosion and synovitis, Arthrocentesis - synovial fluid cloudy, milky, or dark yellow with inflammatory components
Extra-Articular Changes in RA
Weight loss, sensory changes, lymph node enlargement, and fatigue. Raynaud's, arteritis, neuropathy, pericarditis, splenomegaly, and Sjogren's Syndrome (dry eyes & dry mucous membranes)
Rheumatoid Arthritis (RA) Lab Findings
Rheumatoid Factor Present in 80-80% - NOT DIAGNOSTIC - ANTI-CCP (Antibodies to cyclic citrullinated peptide) 95% DETECTION OF RA - ESR & CRP significant elevation in acute phase of RA, monitor for active disease and disease progression (NON-SPECIFIC) - CBC - for baseline prior to medications
Autoimmune Disorders
Develop antibodies to their own cells or cellular material. Antibodies attack the individual tissues, Destruction of tissue via inflammatory process. Chronic and long standing pain
Rheumatoid arthritis (RA)
An autoimmune disease of unknown origin that affects 1% of the population, with females having greater incidence than males. It may occur at any age, but the onset commonly occurs between the third and sixth decade of life. The incidence of RA increases after the sixth decade of life.
Rheumatoid arthritis (RA) Risk Factors
Environmental factors such as pollution and smoking, family history of first-degree relatives, and illnesses such as bacterial and viral illnesses.
Nursing Education for Rheumatoid Arthritis (RA)
Pain, fatigue, and depressive symptoms can interfere with the patients ability to learn. They should be addressed before education is began.
Patient Education & Self-Care for Rheumatoid Arthritis (RA)
Maintain as much independence as possible. Joint pain will be worse in the morning but will improve with movement. - Take meds accurately and safely. Teach side effects, and how to use meds (topic is sparingly, avoiding open skin). Use adaptive devices correctly. - Provide genetic counseling for young women. - Exercise should be scheduled with periods of rest in between activities and avoid high impact exercise. Water exercises are good. - Maintain skin integrity - give sleep tips (avoid caffeine and heavy meals close to bedtime) - Anemia - helps to eat dark leafy green veggies and protein from meat.
Azathioprine (Imuran)
Decreases the production of antibodies at the cellular level. Directly effects the disease. The one that really makes a difference in the disease process where others just treat symptoms.
Celecoxib (Celebrex)
Helps decrease pain and swelling. You know it is working when there is less pain and swelling
Naproxen (Naprosyn)
Provides pain relief and decreases joint inflammation. Used with caution in long-term use as they can cause gastric ulcers
Anakinra (Kineret)
Self-Administered SubQ
Amitriptyline (Elavil)
May be given to help with sleep, as patients can become depressed with the emotional, physical, and financial burden of the disease.
Corticosteroid (Prednisone)
Decreases inflammation. Must monitor laboratory results of C-Reactive Protein & Blood Glucose. THEY ARE A BRIDGE - NOT MEANT FOR LONG-TERM USE. Can lead to serious side effects
Methotrexate
Preferred nonbiologic therapy. Blood tests liver and kidney function. Serum aspartate amino transferase and CBC. Teratogenic - must use contraception
DMARD
The targeted biologic therapy. Prevents inflammation and joint damage. You know it is effective if pain is less and joints are moving easier
System Lupus Erythematous (SLE)
An inflammatory, autoimmune disorder that affects nearly every organ in the body. It occurs 6 to 10 times more frequently in women than in men and occurs 3 times more in African American populations than among Caucasians.
System Lupus Erythematous (SLE) Expected Findings
Fatigue, malaise, photosensitivity, malar rash (butterfly shaped rash around bridge of nose and cheeks), alopecia, blurred vision, pleuritic pain, anorexia, weight loss, depression, joint pain, swelling, tenderness.
Patient Education in Systemic Lupus Erythematous (SLE)
Photosensitivity is common and can cause further complications. Suggest walks in the evening. Use soft toothbrush, as there is a risk for bleeding. Avoid crowds as they are immunocompromised. Allow rest periods to prevent fatigue
Education for Nurses in Systemic Lupus Erythematous (SLE)
Provide rest periods to prevent fatigue, creatinine should be monitored to watch for nephritis and neuron damage. Antibodies are produced by B cells. Anti-smith antibody (Anti-Sm) test is used to diagnose. Oral contraceptives can exacerbate lupus. Corticosteroid education about osteoporosis is needed
Corticosteroid Therapy
Can be used for severe exacerbations but should not be used long-term. Patients should be educated to report signs of infection, increase calcium in the diet, yearly eye exams are needed, may need to increase dose in times of stress, DO NOT stop abruptly.
Monoclonal Antibodies
Decreases Disease Activity by halting production of antibodies
Antimalarial Agents
Hydroxychloroquine may be used to treat fatigue and skin/joint problems. However, long-term use may cause retinopathy
Immunosuppressive Agents
Such as azathioprine or cyclophosphamide, methotrexate
NSAIDs
Used to treat polyarthralgia, (musculoskeletal manifestations), monitor for GI and renal side effects
Trick to remember side effects of Corticosteroids
Sugar- hyperglycemiaSoft bones- causes osteoporosisSick- decreased immunity/ sepsisSad- depressionSalt- water & salt retention (hypertension) fluid volume excessSex- decreased libidoSwollen- water gain= weight gainSight- risk for cataracts- risk for cataracts
Causes of Fluid Volume Loss
Vomiting, diarrhea, fistulas, fever, excess sweating, burns, blood loss, GI suction, third-space shifts, and decreased intake as in anorexia, nausea, and inability to gain access to fluid. Diabetes insipidus and uncontrolled diabetes can contribute
Causes of Fluid Volume Excess
Compromised regulatory mechanisms such as kidney injury, heart failure, and cirrhosis. Overzealous administration of sodium-containing fluids, and fluid shifts (treatment of burns). Prolonged corticosteroid therapy, severe stress, and hyperaldosteronism
Hypovolemia
Occurs when loss of ECF volume exceeds the intake of fluid. Occurs when water and electrolytes are lost in the same proportion as they normally exist
Hypervolemia
An expansion of the ECF caused by abnormal retention of water and sodium in approximately the same proportions in which they normally exist
Lab Values that Correlate with Fluid Volume Excess
Decreased hemoglobin and hematocrit. Decreased serum and urine osmolality. Decreased urine sodium and specific gravity
Lab Values that Correlate with Fluid Volume Deficiency
Increased hemoglobin and hematocrit. Increase serum and urine osmolality and specific gravity. Increased BUN and creatinine. Decreased urine sodium
Assessment Findings that Correlate with Fluid Excess
Acute Weight Gain, peripheral edema and ascites. Distended Jugular Veins. Crackles, SOB, Elevated CVP. Increased BP, pulse and cough. Increased respiratory rate. Increased urine output
Assessment Findings that Correlate with Fluid Deficiency
Acute weight loss. Decreased skin turgor, oliguria, concentrated urine. Prolonged capillary refill time, Low CVP. Decreased BP, flattened neck veins. Dizziness, Weakness, thirst & confusion. Increased pulse, muscle cramps, sunken eyes. Nausea, increased temp, cool, clammy, pale skin
Hypovolemia Treatment
Fluid Replacement either PO or IV. Monitor for fluid overload in IV. Safety precautions as they are at risk for falls with orthostatic hypotension, daily intake and output, and daily weight. Watch for hypovolemic shock.
Hypernatremia
Results from increased insensible losses and diabetes insipidus
Hypokalemia
Occurs with GI and renal Lossses
Hyponatremia
Occurs with increased thirst, and ADH release
Hyperkalemia
Occurs with adrenal insufficiency
Hypotonic Solutions
Out of the Vessel and into the Cell - Cell Expansion. Examples include 0.45% Normal Saline, 2.5% Dextrose, 0.33% Normal Saline
Hypotonic Solutions are used in
Intracellular dehydration such as diabetic keto acidosis, helps kidneys excrete excess fluids. NEVER given in burns or liver disease
Normotonic Solutions
Equal Water & Particle Ratio. Examples include 0.9% Normal Saline, Lactated Ringers. 5% Dextrose (D5W)
Normotonic Solutions are used in
Blood products, hypovolemia, burns, hemorrhage, surgery, dehydration, fluid maintenance
Hypertonic Solutions
More concentrated & increased Osmolality. Examples include 5% Dextrose in 0.9% NS (D5NS), 5% Dextrose in 0.45% Saline, 5% Dextrose in Lactated Ringers
Hypertonic Solutions are Used in
Cerebral Edema, Hyponatremia, Metabolic Alkalosis, Maintenance Fluid, and Hypovolemia
Air Embolism
Symptoms include palpitations, dyspnea, continued coughing. JVD, wheezing, cyanosis, hypotension, weak, rapid pulse, altered mental status, chest, shoulder, and low back pain. - Immediately clamp cannula and replace the leaking system, and place patient in a Trendelenburg Position.
IV Infection
Symptoms include backache, headache, increased pulse, increased respiratory rate, nausea and vomiting, diarrhea, chills and shaking, and general malaise. Additional symptoms include erythema, edema, and induration, or drainage at the insertion site. In sepsis vascular collapse and septic shock may occur.
Phlebitis
Inflammation of a vein, can be from irritating medication, long periods of cannulation, large catheter gauges, poorly secured catheters. Characterized by reddened, warm area around the insertion site or along the path of the vein, pain or tenderness at the site or along the vein, and swelling
Infiltration
Can occur from the IV cannula dislodging, or perforation of the vein wall. Characterized by edema around insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the affected area, and significant decrease in flow rate. Sloughing can occur when solution is really irritating.
Extravasation
Often caused by vasopressors, K+, and calcium preparations or chemotherapeutic agents. Characterized by pain, burning, redness, blistering, inflammation, and necrosis.
Thrombophlebitis
The presence of clot plus inflammation in the vein. Evidenced by localized swelling around insertion site or along the path of a vein. Immobility of the extremity may occur because of swelling, discomfort, and sluggish flow rate, fever, malaise, and leukocytosis
Hematoma
Blood leaks into tissues surrounding the IV insertion site. Results if the vein wall is perforated during venipuncture, the needle slips out of the vein, or the cannula is too large. Symptoms include ecchymosis, immediate swelling at the site, and leakage of blood at the insertion site.
Respiratory Buffer Systems
Hyperventilation. The increase RR helps blow out excessive hydrogen ions (decreases hydrogen ions). Hypoventilation occurs to increase hydrogen ions.
Kidney Buffer Systems
Produce more bicarbonate if needed. If there are high hydrogen ions, bicarbonate reabsorption and production occurs. If there is low hydrogen ions, bicarbonate excretion occurs
pH Level
The measurement of how acidic or alkalotic your blood is. It is regulated by both the lungs and kidneys. -- 7.35-7.45 (Lower = Acidosis, Higher = Alkalosis)
HCO3 Level
Measurement of the bicarbonate in the blood. It is regulated by the kidneys -- 22-26
PaCO2 Level
Measurement of the Carbon Dioxide in the blood. It is regulated by the Lungs. -- 35-45
Respiratory Acidosis Symptoms
Decreased BP & RR, increased HR (tachycardia), dysrhythmias, ventricular fibrillation, anxiety, restless, confusion, headache, sleepy/coma, pale/cyanotic
Respiratory Alkalosis Symptoms
Increased RR (tachypnea) over 20 breaths/min, increased HR (tachycardia), confused and tired, tetany, EKG changes, and Chvostek's Sign (twitching of the facial muscles when tapping the facial nerve)
Metabolic Acidosis Symptoms
Increased RR- Kussmaul breathing (deep, rapid breathing greater than 20 per minute), hyperkalemia (muscle twitching, weakness, arrythmias), decreased BP, confusion, skin warm, dry, pink.
Metabolic Alkalosis Symptoms
Decreased RR (hypoventilation less than 12 per minute), decrease potassium (dysrhythmias, muscle cramps/weakness), vomiting, tetany, tremors, EKG changes, hyper-reflexes, convulsions
Causes of Metabolic Acidosis
Ketoacidosis, lactic acid accumulation (shock), severe diarrhea, kidney diseases
Causes of Respiratory Acidosis
Hypoventilation, respiratory failure, respiratory depression, airway obstruction
Causes of Respiratory Alkalosis
Hyperventilation, hypoxemia from asphyxiation, high altitudes, shock, or early stage asthma/pneumonia
Causes of Metabolic Alkalosis
Prolonged vomiting or gastric suction