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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 a lot 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.

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.

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.

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

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

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

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

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

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.

Past Medical History Or Past Surgery History: Hypertension. Diabetes Mellitus. Total abdominal hysterectomy bilateral salphingooophorectomy ( 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.

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

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.

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

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

LABORATORY RESULT
HAEMATOLOGY FULL BLOOD COUNT HAEMOGLOBIN HEMATOCRIT TOTAL RED BLOOD CELL MEAN CORPUSCULAR VOLUME MEAN CORPUSCULAR HAEMOGLOBIN MEAN CORPUSCULAR HAEMOGLOBIN CONC. RED BLOOD CELL DISTRIBUTION WIDTH PLATELETS PLATELECTRIT PLATELET DISTRIBUTION WIDTH MEAN PLATELET VOLUME TOTAL WHITE BLOOD CELL NEUTROPHIL LYMPHOCYTE MONOCYTE 13.1 G 39.9 % 4.29 10^6/L 93.0 F1 ( 37- 45 ) ( 4.0 5.4 ) ( 76 - 96 )

30.6 PG

( 28 33 )

32.9 G/DL

( 15 45 )

11.6 % 240 10^9/L 0.209 % 19.0 %

( 11.6 14 ) ( 150 400 )

8.73 F

20.5 10^9/L 18.1 10^9/L 1.14 10^9/L 1.14 10^9/L

( 4 11 )

EOSINOPHIL BASOPHIL NEUTROPHIL PERCENTAGE LYMPHOCYTE PERCENTAGE MONOCYTE PERCENTAGE EOSINOPHIL PERCENTAGE BASOPHIL PERCENTAGE

0.039 10^9/L 0.066 10^9/L 88.4 % ( 40 75 )

5.56 %

( 20 45 )

5.56 %

( 2 10 )

0.190 % 0.320 %

(14) ( 0.0 1 )

NURSING MANAGEMENT

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

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

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

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.

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.

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 o

http://www.medicinenet.com/scoliosis/article.htm http://www.scoliosis.com/

CASE STUDY

ARTHRITIS
NAME: NUR IZZATI BT MOHAMMAD HANIFF ID NUMBER: 01-200904-00421 IC NUMBER: 910413-03-5168

SEMESTER: 6 GROUP: 200904 ( 1 ) DATE OF SUBMISSION: 21/04/2011 NAME OF CI: MADAM TENGKU FARIZAN