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NUR2125: Pathology Muscoskeletal, Genitourinary system, NUR2125:…

- - - - Chronic inflammatory response will continue until damage done
  - - - Children: long bones of appendicular skeleton
      - Adults: vertebrae, sternoclavicular, sacroiliac, symphysis pubis
      - Less commonly begins in the joint and goes to adjoining bone
      - Vascularised fragments: sequestrum
    - - Pain on movement of affected extremity
      - Loss of movement
      - Bacteremia: chills, fever, malaise
      - Local tenderness
    - - Antimicrobial agents/antibiotics once bacteria identified (parentally then orally)
      - Supportive measures: pain relief, rest (Varies on severity and degree of infection)
      - Surgical procedure
  - - - Virtually any traumatised bone. These bones are devitalised, unable to resist infection. Microorganisms thrive in here
        
        Vascular insufficiency
        
        Chronic foot disease (diabetes?)
    - - Persistent/recurrent fever
      - Increased pain at operative trauma site
      - Poor incisional healing
    - - Culture and sensitivity
      - Convetional radiology (Scans)
    - - Antibiotics
      - Surgical interventions: surgical depression, prosthesis removal
      - Depend on severity of infection
  - - - Occurs secondary to an open wound
      - Usually in adults
      - May occur spontaneously after minor trauma or when resistance lowered
        
        Delayed treatment of acute haematogeneous ostemyelitis
      - Sequestrum: infected dead bone
    - - Antimicrobial
      - Surgical procedures to remove foreign material or sequestrum
      - Supportive measures, external fixation device or immobilisation
    - - Scans like X-ray (show sequestrum)
      - Wound culture
  - - - Immobility
      - Muscle atrophy
      - Pain
      - Joint swelling
      - Mild fever
      - Leukocytosis (high WBC count)
      - Complication: neurologic compromise: spinal deformity and epidural abscess formation
    - - TISSUE BIOPSY
      - Culture findings
    - - Mycobacterium tuberculosis
      - Infection spread from the lungs/lymph nodes
      - Spine most common site, followed by knees and hips
        
        Bodd's disease (spine)
        
        Infection spreads through intervertebral discs and involve multiple vertebrae and extends to the soft tissues forming acesses
      - HARD TO DESTROY: very destructive and spreads through large medullary cavity of bone causing necrosis
    - - 3/4 antibiotic therapy
      - Conservative treatment as effective as surgery if early or mild cases
- - - - Crush injuries
    - - Long bone
    - - Spiral vs oblique: round vs break diagnonally
      - Stress fracture: usually in athletes due to overuse
    - - Complete/incomplete: break through entire bone
      - Open/closed: breaks through skin
      - Nondisplaced: fragments remain in alignment
        Displaced: bone ends are separated
        Depressed fracture: fragment below level of bone surface (common in flatbones due to trauma)
  - - - Clotting at fracture site
      - Resorption and bone deposition: living bone replaces dying bone
      - Callus formation (new bone formation at edges of periiosteum
      - Remodelling: replacement of mature lamellar bone
    - - Resorption and bone deposition: living bone replaces avascular bone
      - Primary woven bone: formed by ostreogenic cells in the trabeculae
      - Necrosis at bone site prevented: rich blood supply hence necrosis prevented
      - Lamellar bone: replaces woven bone
      - Bone fracture: formation of internal callus
  - - - Reduced fracture should be maintained in proper alignment
    - - Casts, splints, braces
    - - Restore to normal anatomic position as possible
        Potential neurovascular compromise or ischaemia to distal limb = emergency
  - - - Malunion: improper alignment of fracture fragments
      - Nonunion: not healed by >6mths after fracture
      - Delayed union: 3-6mth after fracture, bone pain and tenderness are continuously increasing beyond expected healing period
      - Causes: smoking, immune response low
    - - Nerves damage, infection
    - - Build up pressure in soft tissue compartment is restricted by unyielding fasciae
      - Blood vessels collapse, impeding blood floww: leading to further hypoxia and oedema
      - Eventual necrosis of soft tissue
      - Pain out of proportion to injury, paralysis and PARAESTHESIA (altered sensation)
      - TREATMENT: Emergent decompression
    - - damage to veins, decreases blood./stops = thrombus form, goes to lungs and forms pulmonary embolism
      - TREATMENT: ventilatory support, anticoagulation
        
        intermittent pneumatic compression devices, early mobilisation
    - - Fat particles released from bone marrow into bloodstream and lodge into lung vasculature
      - Patient present with shortness of breath, rapid breathing, hypoxemia, PETECHIAL RASH on torso and neck area, altered mental status
      - CT scan or chest vintulation perfusion scan
      - TREATMENT: ventilatory support
        Prevention: early mobilisation
    - - Patient willl likely present with pain, alteration in normal contour of joint, change in extremity length and loss of normal mobility
      - Treatment:consideraiton of local soft tissue trauma and healing
  - - - Skin
      - Joint function (range of motion, contracture, arthritis)
        
        Compared two sides if can move to same extent
      - Neuro status: circulation + neurological
        
        Peripheral vascular integrity
        
        color
        
        capillary refill time
        
        temperature
        
        presence of ppulses
        
        degree of swelling
        
        sensation
    - - Pre
        
        Consent, knowledge
        
        Pre-admission testing
      - Post
        
        Vital signs + pain assessment
        
        Neurovascular
        
        Wound assessment
        
        Patient education: pain management, exercises, incisional care and healing process, manage and prevent complication
        
        Follow up: physiotherapy, follow up appointment, medication adherence
    - - Cast care: do not et, scratch beneath plaster, do not put weigh
      - Monitoring care: pain assessment/management, neurovascular assessment, elevation and positioning
      - Complication: compartment syndrome, pressure ulcer, disuse syndrome
- - - - Increased age
      - Joint trauma
      - Long-term mechanical stress
        
        Wear and tear
      - Obesity
        
        excess fat = direct metabolic effects on the cartilage (not just mechanical stress)
      - Hormonal status: postmenopausal women higher chances of getting OA
    - - Inflammation
      - New bone formation of joint margins
      - Loss and damage of articular cartilage
      - Subchondral bone changes
      - Thickening of joint capsule
      - Variable degrees of mild synovitis
        More common in rheumatoid arthritis
      - Narrow joint space!
    - - Pain worsens with activity, if progresses: even minimal activiity
      - Stiffness
      - Tenderness
      - Limited motion
      - Deformity
        
        Usually feel hard, compared to soft spongy feeling of joints with rheumatoid arthritis
      - Most frequent joints affected:
        
        Hips
        
        Knees
        
        Lumbar/cervical vertebrae
        
        Proximal/distal joints of hands
        
        First metacarpal/metacarsal joints of feet
      - Several or single joint may be affected. Initially one, but additional stress on others will develop other side
      - Advance stages: bony enlargement:
        Bouchard nodes (proximal)
        Heberden nodes (distal)
        refer to pic in Word
    - - Conservative
        
        Pharmaco: Analgesics/anti-inflammatory drugs + nutritional supplements
        
        Exercise and weight loss
      - Surgical
        
        Improve joint movement, correct deformity/malalignment OR create new joint with artificial implants
      - Nursing management
        
        Preventing injuries
        
        Using side rails, moving patient gently when turning, assisting in ambulation
        
        Assess environment
        
        Promote optimal level of health and function
        
        Exercise to strengthen abdominal and back muscles to imrpve posture
        
        Eat diet high in protein, calcium, vitamins C and D and Iron
        
        Avoid alcohol and coffee
        
        Maintain adequate fluid intake
  - - - Women
      - 40-50 years of age
    - - Swelling/redness due to increased blood flow of inflammatory response
      - Synovitis
      - Painful, tender. stiff joints
      - Joint defermities
      - Rheumatoid nodules: Caplan syndrome: combination of RA and pneumoconiosis
      - Joints are affected bilaterally compared to osteoarthritis (single)
      - Criteria
        
        Serology
        
        Involvement of swollen and tender joints
        
        Duration of synovitis
        
        Acute phase reactants
    - - Fever/fatigue/weakness
      - Anorexia/weight loss
      - Inflammation
      - Generalised aching and stiffness
    - - Conservative
        
        Pharmaco: NSAIDS, DMARDS, corticosteroids, biologic agents
        
        Pain management, minimise stiffness/swelling, maintenance of mobility
      - Surgery?
      - Nursing management
        
        Reduce pain
        
        Medication as prescribed
        
        Immobilise affected join
        
        Position joints in function in position and avoid flexion of knees and hips
        
        Nutrition
        
        Well balanced diet
        
        Maintain weight within normal range
        
        Physical mobility
        
        Limit exercise when joint inflammation is severe
        
        Balance activity wiwth rest
  - - - Common in older men
    - - Monoarticular: usually first metatarsophalangeal joint
      - Precipitated by excessive exercise, certain medications, food, alcohol or dieting
      - Abrupt pain onset, redness and swelling
      - Patient may be asymptomatic in the early stages of gout (after initial attack subsides)
        
        Frequency of gout attacks increase, joint changes become more obvious and more permanent
    - - Tophi or accumulation of crystalline deposits: bony and connective tissue
      - Renal system impairment/Uric acid calculi (kidney stones)
      - Acute gouty arthritis: recurrent attacks of severe articular and periarticular inflammation
    - - Termination/prevention of acute attacks of gouty arthritis
        
        Correction of hyperuricemia
      - Pharma: NSAIDS, probenecid: eliminates uric Allopurinol: reduces production of uric acid
      - Lifestyle modifications:
        weight maintenancec, purine-rich foods avoidance
        
        Purine rich foods: red meat, seafood: ikanbilis
      - Nursing management
        
        Acute attack stage
        Bed rest with affected extremity elevated
        Monitorjoint range of motion ability
        Provide heat/cold for local treatment to affected joint as prescribed
        
        Diet modification
        
        High fluid intake of 2000ml/day
        
        Encourage weight reduction
        
        Low purine diet: no orgam meats, wines and aged cheese
        
        Avoid alcohol
- - - - Criteria
        4/11
        ANA titer
        Immunological
  - - - Personal care
        
        Monitor skin integrity
        
        Avoid exposure to sunlight
        
        Use creams for any rash as prescribed
        
        Frequent oral care
      - Provide emotional support and encourage patient to verbalise feelings
      - Encourage conserving energy: pacing activities
      - Provide information regarding support groups and encourage the use of community resources
- - - - Static: increase in prostrate size
        
        Weak urinary stream, dribbling, frequency, nocturia
      - Dynamic: prostratic smooth muscle tone
        
        Affected by Alpha-1-adrenergic receptors
  - - - More common in Europe/west
    - - Dihydrotestosterone (DHT) main adrogen in the prostrate. Active part in development of BPH.
  - - - Palpate, but not smooth = BPH
    - - PSA must be done if there is suspicion of cancer, results may not differ much from BPH, so need to see overall picture
  - - - Degree of symptoms determine treatment. Some can just be observed if they want
      - Pharma
        
        Alpha blocker: Prazosin
        
        Dynamic
        
        5 Alpha-reductase inhibitors: Finasteride
        
        Static
        
        Used around 6 months
      - Transurethral prostratectomy: last resort, gold standard of surgical treatment
        
        1-2 days of hospital stay
    - - Facilitating urinary elimination
        
        Encourage to increase oral fluid intake
        
        Palpate and check for bladder distension
        
        Provide privacy for patient and allow enough time for voiding
        
        Assist with catheter insertion
      - Relieving of pain
        
        Assess patient
        
        Provide calm/quiet environment
        
        Provided rest periods
- - - - Correctiion of volume status, and obstructive causes of AKI priior to classification
      - Differs from RIFLE, it also utilise changes in creatine and urine output and without GFR (staging for children below age of 18)
  - - - Nephrotoxic insult: use of contrast media from imaging scans (Renal vasoconstriction, direct tubular damage) Rich blood supply and ability to concentrate toxins
        
        Ischaemic insults = sepsis = interrenal hyperperfusion
        
        Kidney can repair itself but injury sustained = end stage renal disease
      - Most common cause: Acute Tubular necrosis (ATN)
        
        Manifestations
        
        Oliguric
        
        Decreased GFR, hypervolemia
        
        Oliguria: progressive uremia. Dialysis may be required
        
        May last up to 8 weeks (typically 1-2 weeks)
        
        Post-oliguric
        
        Fluid volume deficit last until kidneys recover
        
        Full recovery 1 year after (patient’s creatine, nitrogen urea levels same)
        
        STARTING TO RECOVER not all patients recover
        
        RENAL INSUFFICIENCY MAY PERSIST
        
        Prodromal
        
        BUN and Creatinine begin to rise
        
        Normal, declining urine output
        
        Lab results differentiate prerenal or intrinsic AKI
        
        Urine osmolality higher in pre-renal
        
        Urine sodium concentration higher in intrarenal
        
        Proteinuria absent in pre-renal
        
        REFER TO PIC IN DOCS
      - Afferent arteriolar vasoconstriction = decreased glomerular capillary filtration pressure
    - - Obstruction in urinary collecting system = elevated pressure in Bowman's capsule; impedes glomerular filtration
      - Manifestation
        
        One kidney overworked to compensate so that fluid/electrolyte balances
        
        (Prolonged post renal leads to intrtinsic KI)
        
        Blockage happen in various parts (e.g. bladder or urethra) with stones
    - - Edema (collection in extravascular spaces) = decreased renal perfusion
      - Drug use: NSAIDs, ACE inhibitors, ARB = interfere with renal vascular autoregulation
      - Fluid volume deficits: Hypovolemia, renal artery obstruction, hypotension, overuse of diuretics, edema, ascites
      - Manifestations
        
        (Prolonged pre-renal can lead to intrinsic/intra-renal KI)
        
        Fluid overload may be present
        
        Low BP, hypoperfusion: damage to kidney
  - - - May progress to end stage renal disease
      - High mortality rates
        
        Elderly susceptible
    - - Monitor: vital signs, daily weight, consciousness, urine (and its characteristics)
        
        Lab: BUN, creatine, electrolyte
        
        Monitor urinalysis for protein level, signs of infection
        
        Lung function: wheezes indicate fluid overload
      - Emotional support
    - - Judicious fluid administration and haemodialysis/continuous renal replacement therapy
        
        Nitrogeneous waste/water balance not kept in control = can consider going for haemodialysis
      - Adequate caloric intake
- - - - Poor circulation: Reduces WBC's ability to travel in body and fight the infeection
      - High glucose levels, increase risk of UTI
    - - Body measures are not working:
        Washout (micturition)
        Physical barrier
        Indigeneous proteins
        Inflammatory response
  - - - Fever
      - Pain in the lower back
    - - Pain in pelvic, perineal areas
      - Urinary retention, bladder enlarged
      - Dysuria, frequency, fever
    - - Dysuria, urinary frequency and urgency
      - Pain happens at the end of urinartion
      - Pass out red urine
  - - - Pharm
        
        Amoxycillin-clavulanate: augmentin
        
        Cotrimoxazole: folic acid inhibitors combination
    - - Patient education
        
        Pass urine regularly
        
        Avoid alcohol
        
        Increase fluids up to 3000mL/day as tolerated
        
        Take medication as prescribed
      - Assessment
        
        History, sign and symptom
        
        Patient frequency, urgency and hesitancy and changes in urine
        
        Patient knowledge about medicaiton
- - - - 4: dialysis/transplant planning
      - 5: renal replacement therapy needed or death will ensue
      - 3: symptoms start to appear, treatment needed
      - 1 + 2: minimise risk factors
  - - - Metabolic acidosis prescribe sodium bicarbonate
      - Fluid electrolyte imbalance: sodium, potassium intake restriction
      - Hypertension/cardio disease: BP goal <130/80mmHg, ACE + antiogensin II receptor blocker, statins to decrease dyslipidemia
      - Bone and mineral disorders: Vitamin D, Calcimimetics (suppress PTH)
      - ATN: ACE inhib + angiotensin II blockers to reduce proteinuria
      - Depression: antidepressants may exacerbate renal function problems
  - - - Complex, requires multidisplinary approach
        
        Slowing progress of CKD is focus (Address primary foci/comorbidities and risk factors
      - Dialysis
        
        Peritoneal
        
        Continuous Ambulatory Peritoneal Dialysis (CAPD) and Continuous Cycling Peritoneal Dialysis (CCPD) can be done at home
        
        Hemodialysis
        
        Continuous renal replacement therapy
        
        CRRT is a slower type of dialysis that puts less stress on the heart. Instead of doing it over four hours, CRRT is done 24 hours a day to slowly and continuously clean out waste products and fluid from the patient.
      - Transplantation
    - - Restrict fluids
      - Nutrition education
        
        Low in protein and sodium
      - Monitor vitals, Intake and output
  - - - Kidneys amazing compensatory ability = functional hypertrophy as a means of compensating for nephrons lost
- - - - Dementia
      - Medications
      - Obesity
      - Environmental barriers to toilet access
  - - - bladder training + pelvic muscle exercises
        
        Strengthen pelvic floor muscle and increase overall muscle tone
      - Behavioural therapies: good bladder habits
        
        1: maintain appropriate fluid intake
        
        2 + 3: practice good toilet habits and maintain
        
        4: exercise of pelvic floor muscles
      - Sufficient water, no coffee (Do not drink water before sleeping)
      - Quit alcohol/smoking
- - - - Oral/IV antibiotics
      - Supportive management: adequate hydration, pain relief
      - (Must be immediate to prevent complications!)
    - - Apply antibiotics
      - Keep skin clean
      - Promote rest
      - Apply warm compresses as prescribed to promote circulation/decrease comfort if no restrictions
- - - - Frequent position change
      - Meticulate monitoring of skin integrity
      - Meticulous skin care
    - - Exercises: provide active and passive exercise, turn and reposition the immobile patient according to schedule
      - Skin integrity
        
        Remove pressure on skin
        
        Apply wound dressing/moisture barrier as prescribed to protect skin
        
        Monitor for changes in skin integrity
      - Nutrition: adequate nutritional intake to promote tissue integrity
    - - Stage 2-3: semi permeable dressings
      - Debridement:: removal of necrotic tissue (Stage 3-4)
      - Wound dressing: protect from contamination
      - Adjunctive therapy