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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