Question

TEMPLATE FOR PRE-CONFERENCE PRESENTATIONS ON ASSIGNED PATIENTS (Jared Griffin)

1. Who is my client? (for example: age, marital status).

❖ Patient’s initials

❖ Patient’s sex and gender

❖ Patient’s age

❖ Admission date

2. State significant events of this hospitalization (admitting diagnosis, surgery, emotional crises, fracture).

❖ Admission reason

❖ Pertinent medical and surgical history

Medical Hx

Surgical Hx=

3. What are your major concerns for this patient today?

Reason for seeking care (history of present illness) .

❖ Paint a picture of the patient’s problem(s), including:

➢ Discussion of the pathophysiology

4. Discussion of how the medical and surgical history impacts the current problem(s)

• Impact on normal body function

• Signs and symptoms (and rationale for those signs and symptoms)

• Important laboratory and diagnostic exam results and the significance

• Discuss Common complications experienced because of your patient’s problem(s)

5. Patient’s current treatment plan (Discuss diet, activity, medications, therapy, etc.)

5. Discuss the nursing plan of care for your patient –

• What will you focus on?

• What are your key safety considerations for the day?

PATIENT'S DATA

Location: Orthopedic unit 0800

SBAR report from a night nurse:

Situation: Jared Griffin is a 63-year-old African American male who had a right total knee arthroplasty (TKA) yesterday morning.

Background: Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammertoe. A nasal swab was done in the office during his recent preoperative check that came back positive for MRSA. Decolonization protocol was initiated prior to the admission for the total knee procedure and he is currently under contact precautions per hospital policy. He has a history of osteoarthritis and mild hypertension.

Assessment: Mr. Griffin is afebrile with a temp of 37.2 °C (99.8 °F), and vital signs have been stable during the night. Pain level has been at a 2–3. He has dangled his feet off the side of the bed and will have physical therapy in his room at 1000. He has been able to bend his knee to a 75-degree angle and the goal is 90 degrees. The surgeon changed Mr. Griffin’s dressing, and discontinued the drain and IV fluids, at 0700 on his morning round. His labs just came up, but I haven't had a chance to look at them yet.

Recommendation: You'll need to go in and do your morning assessment. Continue with contact precautions, and observe for signs and symptoms of infection. (Vsim online)

Please this question need to be answered in full. Questions 1 - 5

Answer 1

My patient is Jared Griffin, 63-year-old African American male admitted in orthopedic unit 0800. Mr. Griffin has a history of MRSA, which was diagnosed 3 years ago when he had surgery for a hammerto

Patient gives history of osteoarthritis and mild hypertension.

He has underwent right total knee replacement recently.

On examination, Mr. Griffin is afebrile with a temp of 37.2 °C (99.8 °F), and vital signs have been stable during the night. Pain level has been at a 2–3. He has dangled his feet off the side of the bed and will have physical therapy in his room at 1000. He has been able to bend his knee to a 75-degree angle and the goal is 90 degrees.

➢ Discussion of the pathophysiology

OA is a debilitating condition characterized by pain, joint inflammation and joint stiffness, and results in a substantial degree of physical disability.
patients with OA required human assistance in carrying out four
(stair climbing, walking a mile, housekeeping and carrying bundles) of seven functional activities. In this respect, OA was ranked equally with heart disease, congestive heart failure and chronic obstructive pulmonary disease as a cause of physical disability .
OA is caused primarily by the degradation of the collagen and
proteoglycans in cartilage, leading to fibrillation, erosion and
cracking in the superficial cartilage layer. Over time this process spreads to the deeper layers of cartilage, and eventually large,
clinically observable erosions are formed. The pathophysiology of OA involves many mediators, including leukotrienes
(LTs), prostaglandins (PGs) and proinflammatory cytokines. The
levels of PGs and LTs in joint tissues and synovial fluid are increased in OA , resulting not only in inflammation and
pain, but also increasing production of the proinflammatory
cytokines interleukin-1 (IL-1) and tumour necrosis factor -(TNF) In turn, IL-1 and TNF
stimulate increased production of matrix metalloproteinases , which are thought to
play a key role in cartilage degradation.
The direct cause of OA is unknown, but it is thought that it results from intrinsic alterations of the articular tissue, or as a
response to cumulative mechanical stress [17]. The proximal and distal interphalangeal joints of the hand are most commonly
affected. The involvement of these joints is, however, often asymptomatic, and is usually only detected radiographically .The second and third most commonly involved joints are those of the knee and hip respectively, and OA in these joints, as well as being radiographically detectable, is almost always symptomatic.
Early on in the disease, patients experience stiffness and localized pain in the affected joints, which are relieved by rest. In more
severe forms of the disease, however, pain may also be felt at rest. Eventually, weight-bearing joints may ‘lock’ or ‘give way’
as a result of excessive internal damage to cartilage. The net results
of these symptoms are pain, functional limitation and emotional
suffering.
Risk factors associated with osteoarthritis
Although OA is found in almost all age groups, the strongest
predictive factor for the development of radiographically detect-
able damage is increasing age, with almost every individual over
the age of 90 yr suffering from this disease In fact, more
than 13% in aged 55–64 yr and more than 17% in those aged
65–74 yr have pain and functional limitation due to knee OA
It is thought that the influence of age
may be a result of insufficient cartilage repair, hormonal changes
and cumulative exposure to damaging environmental effects.
There may also be a genetic component to OA.
Mechanical stress resulting from a high body mass index is also
known to be a risk factor for the development of knee OA. It has
been calculated that a reduction of 2 kg/m2 would decrease the risk
of developing knee OA by 20–30% . Mechanical stress due to
extreme sporting activity or heavy physical workload can result in OA.

Comorbidities in patients with osteoarthritis
The impact of OA may be worsened by the presence of other
diseases or conditions. A large proportion of patients with OA
suffer from comorbidities, including hypertension, cardiovascular
disease, peripheral vascular disease, congestive heart failure, renal
function impairment, diabetes and respiratory disease.

Figure 1 – The stages of osteoarthritis, as demonstrated in the knee joint

Clinical Features

The most common joints affected by osteoarthritis are the small joints of the hands and feet, the hip joint, and the knee joint.

Patients typically present with symptoms that are insidious, chronic, and gradually worsening. Clinical features include pain and stiffness in joints, worsened with activity* and relieved by rest. Pain tends to worsen throughout the day, whereas stiffness tends to improve. Prolonged OA results in deformity and a reduced range of movement.

On examination, inspect for deformity; there are some common characteristic findings depending on the joint affected, such as Bouchard nodes (swelling of PIPJs) or Heberden nodes (swelling of DIPJs) in the hands, and fixed flexion deformity or varus malalignment in the knees.

Feel for crepitus throughout the range of movement. Movement of the joint is generally reduced and painful.

*Joint stiffness and pain that improves with activity is characteristically seen in inflammatory arthropathies (e.g. rheumatoid arthritis).

Figure 2 – Heberden’s nodes (DIPJs) and Bouchard’s nodes (PIPJs) are both features of osteoarthritis

Investigations

Osteoarthritis is primarily a clinical diagnosis.

Investigations can be used to exclude differential diagnosis; routine blood tests can be useful to exclude inflammatory or infective causes and radiographs are useful for confirming the diagnosis and excluding fractures.

The classical radiological features of osteoarthritis are:

• Loss of joint space
• Osteophytes
• Subchondral cysts
• Subchondral sclerosis

Figure 3 – Radiographic evidence of osteoarthritis affecting (A) hip (B) elbow (C) ankle

The social and economic impacts of osteoarthritis
Social impact. Economic impact
Disability and pain
(chronic/short-term)
Decreased ability to
perform activities of
daily living
Direct costs
Non-pharmacological

pharmacological
treatment
Caregiver time
Hospital resource use
Increased depression

/anxiety
Decreased overall
quality of life

Management of side-effects

caused by
pharmacological treatments
for osteoarthritis
Indirect costs
Lost time from work
Decreased productivity
Premature mortality
Disability compensation/
pension/benefits

Management

The management of osteoarthritis involves options ranging from conservative to medical to surgical.

Conservative

Patients should be educated about their condition and its progression, including advise on joint protection and emphasising the importance of strengthening and exercise. Patients who are overweight should also be advised on weight loss.

Some non-pharmacological interventions that can be offered include local heat or ice packs, joint supports, and physiotherapy (most effective option for longer-term outcomes).

How can diet help with osteoarthritis?

Consuming a balanced and nutritious diet may help prevent further damage to the joints.

It is not possible for specific foods or nutritional supplements to cure osteoarthritis, but, according to the Arthritis Foundation, certain diets can improve people’s symptoms.

Some foods have anti-inflammatory capabilities which can help reduce symptoms while other foods may amplify them.

The right diet can help to improve osteoarthritis in the following ways:

Reducing inflammation and preventing damage

A balanced, nutritious diet will give the body the tools it needs to prevent further damage to the joints, which is essential for people with osteoarthritis.

Some foods are known to reduce inflammation in the body, and following an anti-inflammatory diet can improve symptoms. Eating enough antioxidants, including vitamins A, C, and E, may help to prevent further damage to the joints.

Reducing cholesterol

People with osteoarthritis are more likely to have high blood cholesterol, and reducing cholesterol may improve the symptoms of this disease. On the right diet, people can quickly improve their cholesterol levels.

Maintaining a healthy weight

Being overweight can put extra pressure on the joints, and excess fat stores in the body can cause further inflammation. Maintaining a healthy weight can lessen the symptoms of osteoarthritis.

Keeping to a healthy weight can be difficult for some people, especially those who have a medical condition that reduces their mobility, such as osteoarthritis. A doctor or dietitian will be able to provide advice.

Eight foods to eat and why

Including specific foods in the diet can strengthen the bones, muscles, and joints and help the body to fight inflammation and disease.

People with osteoarthritis can try adding the following eight foods to their diet to ease their symptoms:

1. Oily fish

Salmon contains lots of omega-3 fatty acids, which have anti-inflammatory properties.

Oily fish contain lots of healthful omega-3 fatty acids. These polyunsaturated fats have anti-inflammatory properties so they may benefit people with osteoarthritis.

People with osteoarthritis should aim to eat at least one portion of oily fish per week. Oily fish include:

• sardines
• mackerel
• salmon
• fresh tuna

Those who prefer not to eat fish can take supplements that contain omega-3 instead, such as fish oil, krill oil, or flaxseed oil.

Other sources of omega-3 include chia seeds, flaxseed oil, and walnuts. These foods can also help to fight inflammation.

2. Oils

In addition to oily fish, some other oils can reduce inflammation. Extra virgin olive oil contains high levels of oleocanthal, which may have similar properties to nonsteroidal anti-inflammatory drugs (NSAIDs).

Avocado and safflower oils are healthful options and may also help to lower cholesterol.

3. Dairy

Milk, yogurt, and cheese are rich in calcium and vitamin D. These nutrients increase bone strength, which may improve painful symptoms.

Dairy also contains proteins that can help to build muscle. People who are aiming to manage their weight can choose low-fat options.

4. Dark leafy greens

Dark leafy greens are rich in Vitamin D and stress-fighting phytochemicals and antioxidants. Vitamin D is essential for calcium absorption and can also boost the immune system, helping the body to fight off infection.

Dark leafy greens include:

• spinach
• kale
• chard
• collard greens

5. Broccoli

Broccoli contains a compound called sulforaphane, which researchers believe could slow the progression of osteoarthritis.

This vegetable is also rich in vitamins K and C, as well as bone-strengthening calcium.

6. Green tea

Polyphenols are antioxidants that experts believe may be able to reduce inflammation and slow the rate of cartilage damage. Green tea contains high levels of polyphenols. Green tea is available for purchase online.

7. Garlic

Scientists believe that a compound called diallyl disulfide that occurs in garlic may work against the enzymes in the body that damage cartilage.

8. Nuts

Nuts are good for the heart and contain high levels of calcium, magnesium, zinc, vitamin E, and fiber. They also contain alpha-linolenic acid (ALA), which boosts the immune system.

Medical

Simple analgesics and topical NSAIDs are the mainstay of most medical management for OA, alongside the conservative measures.

There is varying success with the use of intra-articular steroid injections*. These are commonly administered in the outpatient clinic in cases where the presence of pain remains despite oral analgesics.

*Steroid injections are typically mixed with local anaesthetic; whilst this improves the patients symptoms for a few hours, there is often a subsequent ‘steroid flare’, during which the patient’s symptoms worsen for a few days.

Surgical

If conservative and medical interventions fail, then surgical intervention may be considered, especially if their joint symptoms have a substantial impact on their quality of life.

Surgical management choice will depend on the site affected. Options include:

• Osteotomy
• Arthrodesis (joint fusion)
• Arthroplasty

Nursing care should focus on

1. Heat and Cold. Heat increases blood flow which reduces swelling
2. Exercise. Exercise increased flexibility, decrease pain, and help improve blood flow
3. Rest
4. Weight Control
5. Prevention of falls
6. Emotional Support
7. Non-Pharmacological pain control
8. Medication
9. Physiotherapy
10. Compliance with diet.
11. Infection control.
12. Alcohol abuse control.
13. Positioning therapy.
14. Bedbound care.