Remediation Block 5 Assessment

Carrows Review
Esophageal cancer y Fast growing & aggressive o Upper esophageal usually squamous cell o Lower esophageal usually adenomas y Heartburn y Difficulty swallowing (lump in pt throat) y Inability/difficulty swallowing solid foods y Pain w/swallowing y Wt. loss y Regurgitation of undigested food y Vomiting blood/passing old blood w/bowel movements y Risk Factors o Smoking o Alcohol use o Nitrates o GERD o Barretts esophagus (precancerous) y Findings o Wt. loss o Halitosis o Regurgitation o Hiccups y Never, ever, ever put a NG tube into a pt w/esophageal varices o R/f bleeding Nausea and vomiting complications and causes y Rapid emptying of stomach contents y Medicated through the medulla oblongata y Originate in the stomach/duodenum in response to distention/irritation y Stimulated by chemicals such as syrup of Ipecac y Stimulated by an area adjacent to the vomiting center, called the chemoreceptor trigger zone o Stimulated by rapid motion changes y Increased cranial pressure (ICP) can also stimulate vomiting y Excessive vomiting will cause the pt to become alkalotic Peptic Ulcer Disease y Erosion of mucosal layer anywhere in the GI tract y Refers to the stomach/duodenum y Gastric ulcer is the stomach only y 2 Main causes of PUD o Too little mucus production  Can be caused by blood flow to the gut which causes hypoxia of the tissues (septic shock) aka ischemic ulcer  Chronic stress (stress ulcer)  H. pylori bacteria y H. pylori colonize & reduce the mucous production y 90% of duodenal ulcers & 70% of gastric ulcers have H. pylori o Too much acid being produced  Vagal stimulation can cause an in acids  Pt. may have overactive parietal cells

o o y S/Sx o Burning abdominal pain (dyspepsia) o Pain when stomach is empty (1 2 hrs after eating) o Pain that comes & goes o Wt. loss o Nausea o Anorexia o Pallor o Epigastric tenderness o Hyperactive bowel sounds y Tx & Diagnostics o Esophagogastroduodenoscopy (EGD)  Allows the practitioner to look at the areas & obtain Bx o Lifestyle changes o Dietary changes o Meds (P. 1268 1269 Chart 58-3 Know info)  Maalox, Mylanta, Zantac, Pepcid, Prilosec, Prevacid, Protonix, Nexium, Flagyl o Most pt in the hospital get gastric acid inhibitors to keep them from developing an ulcer Bariatric surgery y 10,000 performed yearly y Most surgeries are done laparoscopically y Factors to determine if the pt is a candidate are o BMI  Over 40 extremely obese  35 39.9 obese o Wt. related issue  Diabetes & HTN o Most docs will make the pt go through a psychiatric evaluation as part of the eligibility process y Most insurance companies pay for the procedure if you meet the criteria y Types o Roux-en-Y  Preferred method of performing gastric bypass surgery  Stomach is stapled to create a small pouch and passage for food to go around (bypass) a section of the small intestine o Biliopancreatic diversion w/duodenal switch  80% of stomach removed forming a think sleeve like stomach  Surgery bypasses the majority of the intestine y Connects the end portion of the intestine to the duodenum near the stomach (bilipancreatic diversion)  Risks y Malnutrition y Vitamin deficienes  Used for people who have a BMI > 50 o Lap-Band adjustable gastric banding (LAGB)  Inflatable band that divides the stomach into 2 parts y Wraps the band around the upper part of the stomach  A tiny channel is created between the two pouches restricts the amt of food that can be eaten  Can stay in place indefinitely y Can be adjusted/surgically removed if necessary  Lower complication rate than other procedures

 Excessive caffeine/alcohol intake  Some meds The use of NSAIDS/ASA can cause erosion of the stomach ulcers & GI bleeding Rapid movement of food to the intestinal tract (dumping syndrome) duodenal ulcers

Less & slower wt. loss than other procedures Not recommended for pt that have certain medical conditions y Crohns disease, large hiatal hernias, or h/o gastric ulcers o Vertical banded gastroplasty (stomach stapling)  Divides stomach into 2 parts y Limits space for food & forcing the pt to eat less  No bypass y Because it doesnt lead to adequate long0term wt. loss  Not a popular surgery o Sleeve Gastrectomy  BMI 50 may have a sleeve gastrectomy as alternative gastric bypass  Sleeve gastretomy is the 1st part of the biliopancreatic diversion w/duodenal switch that has recently been studied as a primary procedure for wt. loss  Structure of the stomach is changed to a tube like shape restricts amt of calories the body absorbs  Sleeve gastrectomy is a staged procedure in order to lose some wt. initially before the 2nd stage, the biliopancreatic diversion Complications o Vit B 12 & mineral deficiencies o Blood clots (DVTs) o Dehydration o Leaking at the staple lines in the stomach o Gallstones o Narrowing of the opening between the o Bleeding stomach ulcers stomach & intestine o Hernia @ incision site o Dumping Syndrome o Intolerance to certain foods o Pneumonia o Kidney stones o Death o Low blood sugar (Hypoglycemia) Dumping Syndrome o Undigested contents of the stomach are transported/ dumped into the small intestine too rapidly o Fluids shift into the gut causing abdominal distention o Usually occurs about 30 min. after eating o Symptoms: Dizziness, tachycardia, N/V, syncope, diaphoresis, pallor; palpitations o Can resolve on its own after adjustment to dietary changes Late Dumping Syndrome o Occurs 1 3 hrs after eating o Caused by fluctuations in blood glucose levels among pt whose digestive anatomy has been altered by bariatric surgery o When sugars/high fat foods are eaten, its rapidly absorbed into the bloodstream triggering a rapid rise in blood sugar levels o Pancreas responds by secreting a large amt of insulin o Causes hypoglycemic event: confusion, diaphoresis, dizziness, palpitations Considerations for the Pt o Lifestyle changes  Diet: they have to eat, small frequent meals  Vit supplements for life o Body aches o Fatigue o Feeling cold o Dry skin o Hair thinning & hair loss o Mood changes o May require surgeries to remove excess skin on their body  Surgeries arent covered by their insurance most of the time Benefits o Resolution  Type 2 diabetes  High BP

 

     

High cholesterol Obstructive sleep apnea Gastroesophageal reflux disease (GERD) They can expect to lose 50 60% of their excess wt. in the first two years after surgery Better quality of life Can get around easier

Diverticulitis y Inflammation of the diverticula y Blood supply is to the area causing bacteria to invade & form an abscess y If a perforation occurs it can progress into intra-abdominal perforation & peritonitis y Bleeding can be from minor to severe y Pt. will have severe pain y Present w/ a fever, distention, low H&H, & WBC count y If peritonitis/ perforation exists they may have hypotension, bleeding, or hypovolemic shock y Tests o WBC  indicates infection/inflammation o Hemoglobin  # of RBC in the blood o Hematocrit  % of RBC in the blood sample (3X the hematocrit) o Colonoscopy  May/may not be done in bleeding heavily b/c of the risk of perforating the diverticula o Abdominal ultrasound o CT scan w/ contrast  ALWAYS check the pts creatinine prior to giving them contrast y Teaching: Dietary Considerations o High fiber-low fat diet o Fresh fruits & veggies o Lots of fluids o They should not use laxatives/enemas o Avoid foods containing seeds/indigestible material such as: nuts, corn, popcorn, cucumbers, tomatoes, figs, & strawberries o Some pt believe that high-fiber diet will eliminate the need to avoid these foods o Avoid alcohol o If diverticulitis is present they should consume a diet low in fiber, because high-fiber is considered an irritant at this stage Hypersensitivity reactions y Allergic Responses o Type I (Rapid Hypersensitivity Response)  Rapid/Atopic response  Most common  Results from an production of IgE (ellergic)  IgE responds to an allergen & causes a release of histamine from basophils, eosinophils, & mast cells  Examples y Anaphylaxis & allergic asthma y Atopic allergies o Hay fever, allergic rhitinis, latex, bee venom, peanuts, iodine, shellfish, drugs & others o Anaphylaxis  Most dramatic & life-threatening example of Type I hypersensitivity response  Occurs rapidly & systemically  Affects many organs w/in seconds to minutes after allergen exposure y Can cause massive tissue damage 4

Not common, but fatal Prevention is critical Many who have this type of reaction carry an Epipen (epinephrine) S/Sx y Feeling of uneasiness, apprehension, weakness, & impending doom y Anxious & frightened y Itching & uticaria (hives) y Histamine & other biochemical causes o Bronchoconstriction, mucosal edema, & excess mucous production y Facial edema & swelling of the eyes, lips, or tongue y Respiratory symptoms o Congestion o Rhinorrhea (runny nose) o Dyspnea o respiratory distress o May hear rales, wheezing, or breath sounds y May have laryngeal edema o Stridor, hoarseness or feel like they have a lump in their throat y Distress as tongue & larynx swells & more mucus is produced y Stridor & anxiety as the airway begins to close y Respiratory failure follows from laryngeal edema, suffocation, or lower airway constriction y May be hypotensive & weak irregular pulse d/t vasodilation y Diaphoretic y Confused y Dysrhythmias y Shock y Cardiac arrest eminent y Tx o Airway, airway, airway (possibly intubate) o Epinephrine (1: 1000) 0.3 0.5 mL SQ (know this) o Benadryl (25 100 mg IV, IM, or PO)  May make them drowsy o If you have a medication going IVSTOP IT! o Change IV line w/ new tubing to normal saline o Oxygen o Monitors (all of them) o ABGs o Suction to remove excess mucus o Elevate HOB o Type IV (Delayed Hypersensitivity Reactions)  Sensitized T cells (from a previous exposure) respond to an antigen by releasing chemicals & triggering macrophages to destroy it  Response occurs hours to days after re-exposure  Causes clumping of lymphocytes, macrophages at the site causing edema, induration, ischemia, & tissue damage  Ex: PPD test would be positive for someone exposed to TB Types of immunities (Passive, natural, etc.) y Recognition of Self vs. Foreign Antigens o Immune system usually recognizes itself from non-self (cell mediated immunity) o All cells before destruction are presented w/ a self-antigen so that the T cells can decide whether to destroy it or not o If antigen presented is a match to the host the body wont destroy it o If the antigen presented isnt an exact match & recognized as self the body will destroy it y Adaptive Immunity 5

   

Body learns/receives this immunity Can be active, passive, or natural  Active Immunity 1. Antigens enter the body 2. Body responds by making specific antibodies against the antigen (natural immunity) 3. Body is active in the response 4. Usually dont get this again (Ex: chickenpox) y This is the best type of immunity y Can be artificial (Vaccinations)  Passive Immunity y Antibodies arent made in the persons body y Ex: Mother to baby y Short-term protection y Body destroys these quickly  Natural (Innate) Immunity y Can be a barrier o Skin, mucosa y Can be an attacking force o NK cells y Cannot be transferred from one person to another y Inflammatory response is part of the innate immunity y Allergic Responses o Autoimmunity  Person develops an inappropriate immune response  Immune system fails to recognize itself as self  Attacks healthy cells & tissues  Both antibody & cell-mediated responses occur  Ex: RA, Systemic Lupus, Scleroderma  Tx is usually toward immune suppression y There is no cure Lupus teaching y Interventions o Meds o Topical skin meds for rash o Tx aggressively o Teach pt to avoid sun exposure o Clean skin w/ mild soap (Ivory) o Alopecia common  Recommend use of mild protein shampoos & avoidance of harsh Tx o Support groups Rheumatoid arthritis y Most common & destructive connective tissue disorder y Chronic, progressive, & systemic inflammatory autoimmune disease process that affects the synovial joints y Immune system doesnt recognize itself as self & attacks & destroys healthy cells y Erodes cartilage & bone y Causes major deformities & disabilities y Risk Factors o Could be environmental & genetic factors o Researchers suspect that female reproductive hormones could play a role  Affects more women than men o Infections o o 6

o Epstein-Barr virus o Physical / emotional stress o Exact cause is unknown Symptoms o Early  Joint inflammation  Systemic y Low grade fever y Fatigue y Weakness y Anorexia y Parasthesias (tingling, pin pricks, numbness)  Psoriasis o Late  Joint deformities & moderate to severe pain (morning stiffness)  Systemic y Osteoporosis y Severe fatigue y Anemia y Wt. loss y SQ nodules y Peripheral neuropathy y Vasculitis y Pericarditis y Fibrotic lung tissue y Sjogrens syndrome o Dryness of mouth, eyes, nose, throat, & skin y Renal disease Lab Values o Diagnostic Values  Rheumatoid factor (Normal 0 20) y > 80 usually RA y < 80 another autoimmune disease y Reactive IgM y Positive test doesnt mean the pt has RA; could be another autoimmune disease  Antinuclear antibody (ANA) y Helps to diagnose an autoimmune disease y They look at specific antibodies to determine which autoimmune process it is o Labs  Erythrocyte sedimentation rate (ESR) y Measures the rate at which RBCs settle in saline/plasma over a specified time y Acute/chronic infections or inflammatory processes the protein content of plasma, RBCs stack up on one another, their wt. making them descend fast  Albumin y levels indicate malnutrition/inflammation  Globulin y level possible in RA  Human leukocyte antigen (HLA) testing y Indicates tissue compatibility y If HLA antigens arent compatible w/ donor the body will accelerate rejection y Body doesnt recognize self as self  C-Reactive protein

y y y y y

Used to diagnose bacterial infectious diseases & inflammatory processes Usually doesnt rise w/ viral infections Produced by liver during acute inflammatory/infectious processes Can be used to help diagnose numerous conditions

Meds o NSAIDS  Inhibit prostaglandin synthesis (anti-inflammatory) o Immunosuppressive agents  Humira, Embrel o Methotrexate  Folic acid inhibitor o Prednisone  inflammatory response o Pain meds  No pt should be in pain o Biological response modifiers  immune response  Can cause infectious processes Modifiable risk factors for OA y Obesity y Smoking y Diabetes if controlled y Trauma? Types of leukemia s y Acute Myelogenous leukemia (AML) o Most common form of adult onset leukemia o Develops quickly in 60+ age group o S/Sx: Bleeding, fatigue, pallor, swollen bleeding gums, wt. loss y Chronic Myelogenous Leukemia (CML) o Philadelphia chromosome (translocation between chromosome 9 & 22) o More frequent in over 50 group o 3 Phases  Chronic: slow mild symptoms  Accelerated: spleen enlargement, night sweats, wt. loss  Blast: very aggressive y Acute Lymphocytic Leukemia (ALL) o Most common in children o May have the Philadelphia chromosome y Chronic Lymphocytic Leukemia (CLL) o Rare leukemia o Most often in 50+ age group o Hereditary component o Avg survival time 19 months to 10 years depending on the progression of the disease Hodgkin s and Non-Hodgkin s y Hodgkins Lymphoma (Hodgkins disease) o Cancer of the lymphoid tissue (lymphoid/spleen) o Four classifications depending on the cells involved o Staging is important b/c it will guide the Tx o Early stages are curable o Usually occurs in teens/young adults 15-25 y.o. or men age 50 60 o Stage 3&4 have a 60 75% cure rate o May have a genetic component to this o Usually present w/ enlarged lymph nodes in the neck, under the arms, mediastinum, evening fevers, & night sweats, & wt. loss

Nodes are usually painless, but can become painful w. ETOH consumption Will have Reed-Steinberg cells present on Bx Some possible causes  Epstein Barr virus  Human T cell leukemia/lymphoma virus (HTLV)  HIV  Exposure to chemicals  Viral infections  Possible genetic factors o Usually starts in a single lymphnode or chain of lymph nodes then spreads to other nodes in an orderly fashion y Non-Hodgkins lymphoma o Cancers of the lymph tissue that arent Hodgkins lymphoma o More prevalent in older white males o Cause is unknown, but viral infection, chemical exposure or autoimmune disease is suspected  Gene damage may result in the loss of tumor suppression gene function o Present w/ enlarged lymph nodes o Splenomegaly o GI complications o Fever; fatigue; night sweats o Wt. loss o Back & neck pain w/ hyper-reflexia o No Reed-Steinberg cells present as with Hodgkins o Can have nodal involvement/swelling anywhere (not a predictable pattern as in Hodkins) o Most common sites  GI tract  Skin  Bone marrow  Sinuses  Thyroid  CNS  Painless swelling of the cervical, axillary, inguinal, & femoral nodes is common Anemias o o o

 General Anemia y Decrease quantity of circulation RBCs or hg content y Caused by o Disorder in RBC production o Chronic bleeding o Sudden hemorrhage o Excessive cell lysis (destruction) y All anemias will result in a H&H and inadequate tissue perfusion y Anemias that result from disorder in RBC production occur if there is inadequate / inaccessible iron (iron deficiency anemia), lack of folic acid, Vit B12 or globulin y Can also be b/c of bone marrow disease o Cancer, leukemia, radiation exposure y Lack of erythropoietin would also be lead to reduction in RBC production (renal disease) y Anemias from low RBC production can cause the cells to be too small (microcytic) or too large (macrocytic) and hg content that is low (hypochromic) S/Sx y o HR & RR (SOB)  Body attempting to delivery more O2 o Dizziness blood flow to the brain  o Fatigue
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O2 to organs & tissues  o Skin pallor RBCs  o hair & skin quality o Nausea o GI & CNS blood flow ALOC Causes y o Iron deficient diet  Common w/ vegetarians or lack of intrinsic factor in the gut can cause absorption of Vit B12 o Chronic alcoholism o Malabsorption syndromes  Vitamin deficiency can cause iron stores o Gastric bypass surgery o Pregnancy  New evidence suggest women that take iron are at higher risk for HTN and preeclampsia y What do you teach the pt? o You want them to take their iron supplements o Ferrous sulfate 325 mg w/ green veggies or a source of Vit C o Body can only absorb 20% of iron intake unless is has the intrinsic factor & Vit C; then it absorbs up to 80% o Know which foods are rich in Vit B12  Kidney beans, spinach, and raisins o Red meat & organ meats are high in hg and iron. For vegetarians, the source of hg may be more difficult  Sources of iron y Beans, whole wheat, bran flakes, broccoli, brussel sprouts, collard greens o Iron supplement absorption is blocked by Ca (dairy products) and flouriquinolones (i.e. Cipro) o S/E of iron  Black stools and constipation y Teach your pt that if this occurs to take a stool softener  Megaloblastic anemia y Macrocytic anemia, defined as large RBCs y Pathophysiology: Cause is a B-12 deficiency which doesnt allow DNA synthesis and results in large, thin red blood cells. y Symptoms: pallor, jaundice, smooth tongue beefy red, weight loss, and nerve parasthesias. y Causes: Malabsorption of B-12 from lack of intrinsic factor in the stomach mucosa = pernicious anemia. Cure: B-12 s.q weekly/monthly o Folic acid deficiency o Surgeries that affect absorption o Small bowel resection o Gastrectomy o Gastric bypass o Infections that affect the mucosal lining of the stomach, i.e. Tapeworm o Diets poor in dairy products; some vegetarians will not eat any animal products (Vegan vegetarians)  Aplastic anemia

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Deficiency of circulating RBCs Bone marrow fails to produce the cells Usually occurs with leukopenia (reduction in WBCs) & thrombocytopenia (reduction in platelets) o Pancytopenia (reduction in all cells) is common with this anemia o The cause in 50% of cases of aplastic anemia cases is unknown o Can be caused by exposure to chemicals or toxins o Fanconis anemia is a hereditary version  Pernicious anemia (Vitamin B12 deficiency) y Caused by B12 deficiency y A slow developing disorder y May go unnoticed until the symptoms are severe y Found commonly in the elderly, vegetarians or gastric bypass clients y Can be the result of an autoimmune disease where the gastric mucosa develops antibodies against parietal cells y S/Sx o Infections, mood swings, weakness, & fatigue o Memory changes (B12 is needed for neurological function) o Paresthesia of fingers & feet (tingling) o Ataxia (Staggering or unsteadiness) o Abdominal pain o Beefy red tongue, pale, yellow skin o Hepatomegaly o Low hemoglobin o Can cause permanent, irreversible neurological damage  Iron deficiency anemia y The most common anemia y Highly common in women, older adults and people with poor diets y About 2/3 of iron is in hemoglobin y Other 1/3 stored in bone marrow, spleen, liver and muscle y With iron deficiency anemia the stored iron is depleted first then hemoglobin iron depleted y RN Interventions o Evaluate clients for abnormal bleeding especially from GI tract o Assess for weakness and pallor o Assess diet and INCREASE amounts of foods rich in iron: Red meat, organ meat, fish, egg yolks, kidney beans, tofu, leafy green vegetables, raisins and Vitamin C (promotes iron absorption) o Oral iron supplements: Ferrous sulfate. This should increase hemoglobin by 2gms/dl per week y y y
 Folic acid deficiency anemia y Folic acid helps make new red blood cells y Lack of folic acid will result in anemia y Pregnant women o Lack of folic acid can result in neural tube defects in the baby y Usually we get it from our diet, but poor nutrition, malabsorption syndromes (Crohns disease) or drugs (anticonvulsants and oral contraceptives )or ETOH abuse may inhibit absorption y Nervous system not afected by this deficiency (unlike B12) y Need dark, leafy green veggies, liver, yeast, citrus fruits, dried beans and nuts Hemophilia A (Factor VIII)

Hemophilia = Impairs the formation of stable fibrin clots

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y
y y y

Hemophilia A o Deficiency of Factor VIII o 80% of hemophiliacs o Most often in males w/ females being carriers Pt will present w/ longer bleeding times, ecchymoses, joint & muscle pain (bleeding into joints)

Can be treated by replacing the factors missing / blood transfusions Activities should be limited i.e. no contact sports, no invasive procedures, etc. Pt dont bleed more often or even more rapidly than those w/o the disease, but they do bleed for a longer period (prolonged partial thromboplastin time-PTT), normal bleeding time, and normal Prothrombin Time (PT) y Most common problem w/ hemophilia is degenerating joint function as a result of chronic bleeding into the joints, especially the hip and knee. y An x-linked recessive trait (Women are carriers and men have the disease) Labs for Paget s y Diagnostics o X-ray  Reveals characteristic changes o Serum & urinary Ca o Serum uric acid  levels can also indicate Gout o BNP  blood flow makes the heart work harder o Serum alkaline phosphatase (ALP)  New bone growth associated w/ high ALP levels  Can also be found w/ cirrhosis, RA, hyperparathyroidism & normal growing bones o 24hr urinary hydroxyproline level reflects bone collagen turnover o Radionuclide bone scan o Computed tomography (CT scan) Gout y Systemic disease in which urate crystals deposit in the joints & cause inflammation y Two major types o Primary  Results from errors of purine metabolism  An end product of purine metabolism is uric acid which is excreted by the kidneys  Uric acid production exceeds the kidneys ability to excrete it  Excess is deposited in other tissues causing inflammation (usually the joint at the base of the big toe)  Can be inherited & affects middle-age to older men & post-menopausal women  Three Stages 1. Asymptomatic hyperuicemic 2. Acute gouty arthritis o Most commonly seen o Inspect the toe for inflammation o Pt will be in pain 3. Chronic or tophaceous o Not seen much in the US y Common to renal calculi in these pt o Secondary  Usually secondary to another disease process  Excessive uric acid production  Can affect anyone at any age, but seen commonly in pt w/ cardiovascular problems Acute osteomyelitis y Symptoms o Fever > 101F or 38C o Area around site inflamed & red o Edema

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o Hot to touch o Tenderness o Bone pain o Circulatory compromise Osteoarthritis y Connective Tissue Disease: OA or Degenerative Joint Disease (DJD) o Most common type of arthritis o Major cause of disability in the US o Characterized by progressive deterioriation & loss of cartilage in one or more joints o Primarily wt. bearing joints (hips & knees), vertebral column, & hands o Primary (idiopathic) is most common o Secondary can occur from trauma or other musculoskeletal conditions o Can also be nodal (w/hand involvement) or non-nodal (w/out hand involvement) o Patho  Cartilage & bone begin to erode  Joint space narrows & bone spurs form  Bodys normal repair process cant overcome the rapid destruction o What Would You See?  Synovitis (synovial inflammation) seen w/ advanced disease  Subluxation (partial joint dislocation)  Joint deformities  Pain  Immobility  Muscle spasms  Localized inflammation  Nonsystemic  Unilateral, on one side  Pt may have normal or slightly elevated ESR  C-reactive protein may be elevated o Risk Factors  Exact cause unknown  Triggered w/ aging  Genetic changes  Obesity  Smoking  Trauma  Diabetes  Pagets disease  Hemophilia/ sick cell anemia  Women > 50 o History  Ask about joint stiffness or pain  Joint swelling  Med history  Is there any loss of function or mobility  Ask about their occupation & nature of their work  Trauma history  Smoking  Previous involvement in sports  H/o obesity  Family h/o arthritis o Physical Assessment  May appear similar to RA  Examine for crepitus (grating sensation)  Enlarged joints (check fingers)

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 Excessive joint fluid (knees)  Atrophy of skeletal muscle  Pt mobility Interventions  Pain control  Surgical management y Total joint arthroplasty y Total joint replacement y Osteotomy (bone resection)  Deep vein thrombosis (DVT) prevention  ROM exercises

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