case study arthritis
TRANSCRIPT
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ACKNOWLEDGEMENT
Firstly, I would like to give a great pleasure to say a few words regarding the effort in
writing this folio, case study of Arthritis. I would like to thank for many members who give alot of cooperation and support to finish this folio completely. Through this folio effort, I wish
extend our thank a gratitude to my Clinical Instructor in Putrajaya Hospital, Madam Tengku
Farizan for her teaching, support and give me more time in making this folio. Thanks also to
staff nurse for their willingness to cooperate with us and give a lot of information. Thank you.
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ITRODUCTION
DEFINITION
Arthritis is inflammation of one or more joints. It can affect joints in any part of the body.
Joints are places in the body where two bones meet.
ETIOLOGY
Genetics:Exactly how much heredity or genetics contributes to the cause of arthritis is
not well understood. However, there are likely genetic variations that can contribute to
the cause of arthritis.
Age:Cartilage becomes more brittle with age and has less of a capacity to repair itself.
As people grow older they are more likely to develop arthritis.
Weight:Because joint damage is partly dependent on the load the joint has to support,
excess body weight can lead to arthritis. This is especially true of the hips and knees
that can be worn quickly in heavier patients.
Previous injury:Joint damage can cause irregularities in the normal smooth joint
surface. Previous major injuries can be part of the cause of arthritis. An example of an
injury leading to arthritis is a tibia plateau fracture, where the broken area of bone
enters the cartilage of the knee joint.
Occupational hazards:Workers in some specific occupations seem to have a higher
risk of developing arthritis than other jobs. These are primarily high demand jobs such
as assembly line workers and heavy construction.
Some high-level sports:It is difficult to determine how much sports participation
contributes to development of arthritis. Certainly, sports participation can lead to joint
injury and subsequent arthritis. However, the benefits of activity likely outweigh any
risk of arthritis.
Illness or infection:People, who experience a joint infection (septic joint), multiple
episodes of gout, or other medical conditions, can develop arthritis of the joint.
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TYPE
The two most common types of arthritis are OSTEOARTHRITIS and RHEUMATOID
ARTHRITIS. Arthritis can affect anyone at any age, including children. The incidence of
arthritis increases with age, but nearly three out of every five sufferers are under age 65.
If left undiagnosed and untreated, many types of arthritis can cause irreversible damage to the
joints, bones, organs, and skin.
Osteoarthritis:Also known as degenerative joint disease, results from wear and tear.
The pressure of gravity causes physical damage to the joints and surrounding tissues.
Rheumatoid arthritis:An autoimmune disease that occurs when the bodies own
immune system mistakenly attacks the synovial (cell lining inside the joint). Rheumatoid
arthritis is a chronic, potentially disabling disease.
Juvenile Arthritis:A general term for all types of arthritis that occur in children.
Juvenile rheumatoid arthritis is the most prevalent type of arthritis in children.
Psoriatic Arthritis: Similar to rheumatoid arthritis. About 5 percent of people with
psoriasis, a chronic skin disease, also develop psoriatic arthritis. In psoriatic arthritis,
there is inflammation of the joints and sometimes the spine.
Fibromyalgia:Pain in the muscles, ligaments and tendons. Fibromyalgia is a type of
soft tissue or muscular rheumatism and does not cause joint deformities.
Gout:A painful type of arthritis that causes sudden, severe attacks of pain, tenderness,
redness, warmth, and swelling in the joints, especially the big toe. The pain and
swelling associated with gout are caused by uric acid crystals that precipitate out of the
blood and are deposited in the joint.
Pseudo gout / CPPD:Also known as Calcium Pyrophosphate Dehydrate Deposition
Disease (CPPD), is caused by deposits of calcium phosphate crystals (not uric acid) in
the joints. CPPD is often mistaken as gouty arthritis. Since CPPD is a different disease
than gout, treatment is not the same as gout.
Scleroderma:A disease of the body's connective tissue that causes thickening and
hardening of the skin.
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Lupus / SLE: Systemic lupus erythematosus (SLE) is an autoimmune disease.
PATHOPHYSIOLOGY
Articular cartilage and bone ends deteriorate
Joint space narrows, bone spurs develop
Joint is inflamed
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CLINICAL MANIFESTATION
Warm, painful, swollen joint
Decreased range of motion
Chills
Fever
Leukocytosis ( Increased number of leukocytes in blood )
Redness of the skin around a joint
Stiffness, especially in the morning
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Inability to use the hand or walk
Malaise and a feeling of tiredness
Weight loss
Poor sleep
Difficulty moving the joint
Muscle weakness
COMPLICATION
Joint stiffness.
Social complications.
Reduced physical activity:Persons with arthritis and other rheumatic conditions are
significantly less active than the populations as a whole.
Reduced leisure activity.
Joint pain due to arthritis can limit sexual activity.
Rheumatoid arthritis affects the quality of the life. The complications of Rheumatoid
arthritis include joint distraction, heart failure, lung disease, low or high platelets, spine
instability, others.
Affected joints may worsen the ordinary tasks of the day to day life.
Rheumatoid arthritis complications of this disease may shorten survival in some
individuals.
TREATMENT
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Broad spectrum antibiotics
Analgesic ( Such as codeine )
NSAID ( To limit joint damage )
Joint aspiration to remove excessive fluid
Immobilized by splint
Balanced rest and exercise
Heat and cold therapy
Diet for weight loss
Complementary therapies
Surgery for total joint replacement
INVESTIGATION
Joint or synovial aspiration
Culture of synovial fluid
CT and MRI of the joint
Radioisotope scanning
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PATIENTS INFORMATION
Name: Mrs. A
Age: 65 Years Old
IC. No: 460417-01-xxxx
Sex: Female
Race: Malay
Address: 512, Parit Sakai Laut, Jalan Abdul Rahman, 8400 Muar, Johor
Marital Status: Married
Date Admit: 12/4/2011
Time admit: 11:45 AM
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Ward/Room/Bed: 3C/Orthopaedic Ward/Bed21
MRN: 0000321877
Phone No: 019-2168706
Route Of Admit: Wheel Chair
Accompanied By: Relatives
ADMISSION HISTORY
From SOC Ortho. Receive patient in ward. No known medical illness.
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Past Medical History Or Past Surgery History:
Hypertension. Diabetes Mellitus. Total abdominal hysterectomy bilateral salphingo-
oophorectomy ( Fibroid ). Lumpectomy ( Lump at axillar area ).
Family History:
Nil.
Gynae History:
Menopause.
Social History:
Married. Stays at Johor. Housewife.
On Examination:
New case admitted from SOC Ortho at 11:45 AM. On wheelchair escorted by relatives.
General condition alert and comfortable. Vital sign taken and recorded. Blood pressure: 164/71
mmHg, Pulse: 80/min, SPO2: 99%, Afebrile. For arthrotomy washout of right knee under
emergency. All consent printed, x-ray required. To NBM ( Nil by mouth ) at 12 midnight.
FBC/ GXM/ RP/ RBS/ ESR taken and to despatch. ECG required. Chest x-ray required PM.
On LSSD. No other complaint made.
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DAILY PROGRESS
DAY 1
13/4/2010
Dressing: Daily normal saline dressing cover with gauze then bandage done.
General condition: Patient alert and conscious. Vital sign checked and recorded, afebrile.
On QID GM and 3 AM. Reading at 10 PM was 26.0 mmol/l Dr. Hilmi noted. SC
insulatard 36 iu injected. Ripple mattress applied. Elevate right lower leg using pillow
done. Keep backslab intact. Patient has skin break down covered with duodem. Patient
had blister at right lower leg water ballon applied. Patient complaint had a lump at
buttock no redness but pain. ECG kept in folder. Knee x-ray done. Chest x-ray
done. Already transfused 4 pint pack cell. TED stokings with patient. Refer physio for
ambulation done. Hb%: 12.4 g/dL. To refer medical to optimize BP and GM control
done. On LSDD.
DAY 2
14/4/2010
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Dressing: Daily normal saline dressing cover with gauze then bandage done.
General condition: Patient alert and conscious. Vital sign checked and recorded, afebrile.
On QID GM and 3 AM. Ripple mattress applied. Elevate right lower leg using pillow
done. Keep backslab intact. Patient has skin break down covered with duoderm. Patient
had blister at right lower leg water ballon applied. Patient complaint had a lump at
buttock no redness but pain. ECG kept in folder. Knee x-ray done. Chest x-ray done.
Already transfused 4 pint pack cell. TED stokings with patient. Refer physio for
ambulation done. Hb%: 9.3 g/dL. To refer medical to optimize blood pressure and
glucometer control done. On LSDD. Tolerated well. No complaint off.
DAY 3
15/4/2010
Dressing: Daily normal saline dressing cover with gauze then bandage done.
General condition: Patient alert and conscious. Vital sign checked and recorded, afebrile.
To do 8 point GM for 2 days. Pre and 2 hour post meal + 3 AM. Ripple mattress applied.
Elevate right lower leg using pillow done. Keep backslab intact. Patient has skin break
down covered with duodem. Patient had blister at right lower leg water ballon applied.
Patient complaint had a lump at buttock no redness but pain. ECG kept in folder. Knee
x-ray done. Chest x-ray done. Already transfused 4 pint pack cell. TED stokings with
patient. Refer physio for ambulation done. Hb%: 9.3 g/dL. To refer medical to optimize
BP and GM control done. On LSDD.
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MEDICATION
PARACETAMOL
Trade Name: Panadol
System: Analgesics, Anti Pyretics
Indications: Mild to moderate pain and pyrexia
Contraindications: Not known
Adverse Reactions: Haematological, skin and allergic reactions
CELECOXIB
Trade Name: Celebrex
System: Anti Rheumatic, Anti Inflammatory, Analgesics
Indications: Relief of acute and chronic pain and inflammation in Osteoarthritis and
Rheumatoid Arthritis. Management of acute pain in adults and treatment of primary
dysmenorrhoea
Contraindications: Hypersensitivity to sulphonamides, aspirin or NSAIDs
Adverse Reactions: GI disturbances, dyspepsia, abdominal pain, diarrhoea, allergic
reactions, dizziness, headache, rash, upper respiratory tract infection
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TRAMADOL HCL
Trade Name: Tramal
System: Analgesics
Indications: Post-operative pain, chronic cancer pain, analgesia or pain relief, for
patients with impaired renal function
Contraindications: Narcotic withdrawal treatment, hypersensitivity, acute alcoholism
Adverse Reactions: Sweating, dizziness, vomiting, dry mouth, GI disturbances,
cerebral convulsions especially on co-medication with neuroleptics, physical
dependence
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LABORATORY RESULT
HAEMATOLOGY
FULL BLOOD COUNT
HAEMOGLOBIN 13.1 G
HEMATOCRIT 39.9 % ( 37- 45 )
TOTAL RED BLOOD CELL 4.29 10^6/L ( 4.0 5.4 )
MEAN CORPUSCULAR
VOLUME93.0 F1 ( 76 - 96 )
MEAN CORPUSCULAR
HAEMOGLOBIN30.6 PG ( 28 33 )
MEAN CORPUSCULAR
HAEMOGLOBIN CONC.32.9 G/DL ( 15 45 )
RED BLOOD CELL
DISTRIBUTION WIDTH11.6 % ( 11.6 14 )
PLATELETS 240 10^9/L ( 150 400 )
PLATELECTRIT 0.209 %
PLATELET
DISTRIBUTION WIDTH19.0 %
MEAN PLATELET
VOLUME8.73 F
TOTAL WHITE BLOOD
CELL20.5 10^9/L ( 4 11 )
NEUTROPHIL 18.1 10^9/L
LYMPHOCYTE 1.14 10^9/L
MONOCYTE 1.14 10^9/L
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1. ACUTE PAIN RELATED TO INFLAMMATORY DISEASE
Expected Outcome:
Patient will report relief from pain
Intervention And Rationale:
Assess the level of pain to provide further management
Ensure proper positioning and alignment to minimize discomfort and promote pain
relief
Encourage maintenance of normal weight to prevent excess wear and tear of joints
Manipulate the environment to promote periods of uninterrupted rest
Provide analgesics as ordered to relieve pain
Evaluation For Expected Outcome:
Patient expresses feeling of comfort and decreases frequency of pain
2. ACTIVITY INTOLERANCE RELATED TO PAIN
Expected Outcome:
Patient will participate in ADLs as tolerated
Intervention And Rationale:
Assist with ADLs as necessary to ensure patient does not become exhausted
Turn and reposition patient at least every 2 hours to prevent skin breakdown and
improve breathing
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Provide emotional support and encouragement to help improve patients self-concept
and motivation to perform activities of daily living
Provide pain relief measure prior to activity to help increase their activity level
Place things nearest to patient to ensure easy taking their owns
Evaluation For Expected Outcome:
Patient performs self-care activities at optimal level within restrictions imposed by
illness
3. DISTURBED BODY IMAGE RELATED TO CHANGES IN JOINT
FUNCTIONS AND STRUCTURE
Expected Outcome:
Patient will demonstrate acceptance of changes in body image
Intervention And Rationale:
Assess patients readiness for decision making related to care to give patient sense of
independence
Encourage patient to discuss feelings and concerns to make patient knows that nurse
understands what patient is experiencing
Provide information and clarify misconceptions to ensure that the patient is aware of
the expected problems and concerns
Encourage socialization to improve patients perception Encourage sharing with support groups to make patient discuss with others
experiencing the same problems
Evaluation For Expected Outcome:
Patient participate in discussion with support group composed of individuals with a
similar in body image
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HEALTH EDUCATION
Control Your Weight: Minimizing weight can reduce forces directed to weight
bearing joints. Weight control can have a variety of health benefits, including reducing
the risk of osteoarthritis. Once arthritis symptoms develop it can be difficult to exercise
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to help control weight, thus take a preventative outlook in minimizing the effects of
being overweight or obese.
Healthy Diet: Eat fruits and vegetables. There has long been a relationship between the
role of antioxidants and arthritis. Antioxidants have an anti-inflammatory affect on the
body. Our body naturally produces compounds called free radicals. As free radicals
become overly abundant in our body, they produce a state called oxidative stress.
Oxidative stress has been linked to many chronic diseases including arthritis. The role
of antioxidants is to neutralize free radicals, thus minimizing the condition of oxidative
stress. Deep colored fruits and vegetables are our best source of antioxidants, thus it is
important to eat a diet rich with these foods. As oxidative stress is reduced, so is
inflammation in the body. Not only does eating those fruits and vegetables reduce
oxidative stress, they also help provide the nutrients your body needs for healing.
Giving your body the nutrients it needs helps to support your immune system, provides
the nutrients for healing, and helps to provide the energy to fuel an active lifestyle.
Exercise: Our muscles act as shock absorbers. When muscles are strong, they function
to absorb shock, minimizing the stress directed to the joint. Doing so minimizes pain.
Many can have x-rays that indicate significant arthritis yet experience no pain, simply
because the muscles surrounding the joint are strong. By incorporating strength training
into your lifetime exercise routine, arthritis prevention can be an achievable goal. If
you've never done any strengthening exercises, seek the help of a professional such as a
physical therapist or personal trainer. As important as it is to start a strengthening
program, it is equally important to not injure yourself.
Protect Joints: Muscles are not the only means of protecting joints from abnormal
stress. For weight bearing joints such as feet, ankles, knees, and hips, proper shoe wear
can be invaluable. Joint protection strategies can also be important. Minimize deep
squatting to protect knees and hips, avoid kneeling when possible, repetitive bending
should be minimized to reduce low back stress, and maintain proper posture when
standing and sitting to avoid abnormal joint positions. The use of gadgets such as jar
openers can reduce hand joint stress.
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SUMMARY
While Im taking this case study, I already teach patient how to deal with scoliosis. And
then, I already explain and discuss with Miss Nor Azlin about the manifestation of disease. I
also give her some health education and advice as a guideline to cope with her daily life
activities. As a result, Miss Azlin was agrees to follow all the instruction.
CONCLUSION
Scoliosis is a disorder that causes an abnormal curve of the spine. The causes is
unknown and it can present in congenital and also may occur in adults. Symptoms of scoliosis
may include back pain, poor posture, cooked neck, lump at the back and can been seen by
visualization of deformity such as one shoulder higher than the other, one breast appearing
larger and uneven musculature on one side of the spine. A doctor can diagnose most cases of
scoliosis by performing a physical examination and from some investigation such as X-ray,
Magnetic Resonance Imaging ( MRI ) tests to confirm the diagnosis.
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REFERENCE
o Text book, Medical Surgical Nursing, Volume 2
o The Lippincott Manual of Nursing Practice, 5th Edition
o MSU 4003 Notes
o Nurses Dictionary, McGraw-Hill
o http://www.medicinenet.com/scoliosis/article.htm
o http://www.scoliosis.com/
http://www.medicinenet.com/scoliosis/article.htmhttp://www.scoliosis.com/http://www.medicinenet.com/scoliosis/article.htmhttp://www.scoliosis.com/ -
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CASE STUDY
ARTHRITIS
NAME: NUR IZZATI BT MOHAMMAD HANIFF
ID NUMBER: 01-200904-00421
IC NUMBER: 910413-03-5168
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SEMESTER: 6
GROUP: 200904 ( 1 )
DATE OF SUBMISSION: 21/04/2011
NAME OF CI: MADAM TENGKU FARIZAN