NURS 5462 Test Exam 2024\2025.
Readings and Review Materials
▪ Please refer to this website as you review this presentation—select the joint/body area to go along with
the slides http://meded.ucsd.edu/clinicalmed/joints2.htm
Taking the History
May or may not involve trauma, OLDCARTS
Associated symptoms—warning signs
- History of substantial trauma—fracture, major soft tissue injury - Hot swollen joint—infection, RA, gout -
Constitutional symptoms [fever, malaise, weight loss, fatigue]—infection, sepsis - Focal neurological
weakness—radiculopathy - Diffuse weakness—degenerative, neoplastic disease, toxins - Neurogenic pain
[burning, numbness, paresthesia, asymmetric]—radiculopathy, entrapment, neuropathy - Claudication—
peripheral arterial/vascular, stenosis, arteritis 4/8/201
Taking the History 2
CHD - Medications: NSAIDS, Rx or OTC, HRT, calcium - LMP, menstrual cycles, menopause: female athletes,
post-menopausal • PMH - Previous injury or trauma—fracture, surgeries, arthroscopy - Cancer,
arthritis, sickle cell, osteoporosis, renal or neurologic disease
Taking the History 3
• FH - Congenital abnormalities of hip, foot - Scoliosis or back problems - Arthritis—RA, degenerative,
ankylosing spondylitis, gout - Genetic—osteogenesis imperfecta, hypercalciuria ▪ Personal/Social - Work,
exercise, hobbies 4/8/2018- Tobacco, alcohol, drug use
Physical Exam
▪ Height ▪ Weight ▪ Uncover and examine both sides ▪ Observe gait if weight bearing joint involved ▪
Inspection - Skin—injuries or contusions - Swelling, deformities, bruising, erythema ▪ Palpation—one
finger point tenderness - Compare non-injured to injured area - Palpate all surfaces—bones, joints, soft
tissue - Examine above and below area of injury
▪ Range of motion
—active and passive - Examine above and below area of injury - Internal and external rotation - Abduction
and adduction - Document ROM in degrees!!!
Traditional Management
▪ Rest ▪ Ice ▪ Compression/immobilization ▪ Elevation (RICE) ▪ Acetaminophen, NSAIDs, muscle relaxants
- Oral steroids may be considered in some cases ▪ Physical therapy, exercise ▪ The tincture of time ▪
Manipulation, acupuncture, other [ESI, TENS, etc], conservative Rx x4-6 weeks
NSAIDs
,NURS 5462 Test Exam 2024\2025.
Inhibit cyclooxygenase (COX) enzyme—provide anti-inflammatory/analgesic effects - Dose dependent -
NSAIDs differ in analgesic and anti-inflammatory effec
NSAIDs
- Gastritis, ulceration, bleed - Impaired renal function—NSAIDs inhibit renal prostaglandins, affecting
regulation of renal blood flow and glomerular filtration - Hypertension/Edema - Platelet inhibition and
bleeding - CV risk—potential damage to arterial wall, possible arterial clotting - Drug interaction with
ASA—they ↓ cardioprotective benefits and ↑ risk of GI bleed 4/8/2018
Evidence: BMJ Clinical Evidence 2007; 12: 1108
- Plateau for effectiveness; SE ↑ with dose ↑ - COX-2 ↓ risk for PUD but ↑ risk for MI/CV events -
Paracetamol similar to NSAIDs for acute MSK pain but ↓ effective than NSAIDs for OA [Paracetamol not
used in US 2nd to risk of GU malignancy] - **PPI > H2 antagonists ↓ GI SE - Insufficient evidence whether
topical NSAIDs beneficial
NSAIDs ▪ Adverse effects:
- Gastritis, ulceration, bleed - Impaired renal function—NSAIDs inhibit renal prostaglandins, affecting
regulation of renal blood flow and glomerular filtration - Hypertension/Edema - Platelet inhibition and
bleeding - CV risk—potential damage to arterial wall, possible arterial clotting - **Drug interaction with
ASA—they ↓ cardioprotective benefits and ↑ risk of GI blee
NSAIDs ▪ Recommendations:
- GI risk in general—nonacelated aspirin products lowest risk [Disalsid, Trilisate]; Ibuprofen/Naproxen
intermediate risk, Diclofenac/Piroxicam/Ketorolac greatest risk ▪ Use lowest dose possible , risk ↑ with
dose ▪ Short course best ▪ Use acetaminophen when possible - Avoid in patients > 65 yrs., H/O PUD, on
steroids, anticoagulants, ASA ▪ AGS, May, 2009: NSAIDs considered rarely and with extreme caution;
Acetaminophen, opioids best for elderly
Osteoarthritis
▪ Also referred to as Degenerative Joint Disease [DJD] ▪ Factors that influence DJD - Age - Heredity -
Repetitive stress - Prior joint disease - Diabetes - Weight, ▪ Common above 65 ▪ Decrease in the repair
process of the body ▪ Maximal stress to articular cartilage ▪ Worse over weight bearing joints and large
joints
Osteoarthritis 2
▪ Go slow, no cure ▪ Water aerobics are wonderful ▪ Use of cane, crutches, walker when needed ▪
Physical Therapy: heat, exercise, stretching ▪ Rest as needed ▪ Ice ▪ Stay off limb if possible ▪ TENS unit ▪
Analgesics / Anti-inflammatory ▪ May need joint replacement
Sprain
—acute injury to ligament when joint stressed beyond normal range of motion ➢Ligaments—surround
joint, responsible for stability/mobility ➢Stretching leads to ligament strain or rupture ➢Pain, marked
swelling, hemorrhage, loss of function
, NURS 5462 Test Exam 2024\2025.
• Severity of ligament sprains
➢Grade I—stretching or microscopic tearing, no joint instability/laxity [NSAIDS, RICE, progressive
weight bearing] ➢Grade II—partial, mild-moderate instability/laxity [immobilize 4-6 weeks, no to partial
weight bearing] ➢Grade III—complete rupture, obvious instability and laxity [immobilize, no weight
bearing—refer to ortho]
Muscle Strain—
—injury to muscle by overuse, improper use, or excessive stretching beyond functional capacity [acute]
leading to bleeding within the muscle, inflammation and pain ➢Partial or complete muscular tear
➢Pain, swelling, temporary weakness, spasm, contusion
Tendon Problems
▪ May be acute [tendonitis], chronic with acute [tendinosus with tendonitis], or chronic [tendinosus] ▪
Tendon inserts into bone—osteotendinous junction, most common site of overuse tendon injuries
➢Tendons relatively hypovascular, increases risk for hypoxic tendon degeneration ➢Acute rupture—
muscle will not function to move associated joint, requires surgical repair
Tendon Problems 2
Usually insidious onset, load-related localized pain coinciding with increased activity ➢Dull ache after
activities, sharp/stabbing during activities ➢Well-localized tenderness to palpation (TTP) ➢Can
reproduce pain with tendon loading movements ➢Rotator cuff, patellar, elbow, Achilles tendinopathy
Bursitis
found in areas subject to friction, contains fluid ➢Shoulder, elbow, hip, and knee ➢May be caused by
overloading, inflammatory disease [RA, crystal-induced/gout], or infection [GC, staph]
Fractures
- Within collagen structure, osteoclasts absorb and osteoblasts produce new bone matrix - Fracture—
load exceeds mechanical properties
• Nondisplaced fracture splint, immobilize, refer • Avulsion—joint capsule, ligament or muscle insertion
pulled from bone, associated with severe sprains • Displaced—fragments not in alignment, often require
surgery [10-15%]
Salter Harris Fracture Types
▪ Type I - Epiphysis is separated from end of bone [metaphysis] - Vital part of growth plate remain
attached to epiphysis
Type II - Most common type of growth plate fracture - Epiphysis, along with growth plate, is partially
separated from metaphysis, which is cracked, These usually have to be put back in place and immobilized
for normal growth to occur
Salter Harris Fracture Types +
Readings and Review Materials
▪ Please refer to this website as you review this presentation—select the joint/body area to go along with
the slides http://meded.ucsd.edu/clinicalmed/joints2.htm
Taking the History
May or may not involve trauma, OLDCARTS
Associated symptoms—warning signs
- History of substantial trauma—fracture, major soft tissue injury - Hot swollen joint—infection, RA, gout -
Constitutional symptoms [fever, malaise, weight loss, fatigue]—infection, sepsis - Focal neurological
weakness—radiculopathy - Diffuse weakness—degenerative, neoplastic disease, toxins - Neurogenic pain
[burning, numbness, paresthesia, asymmetric]—radiculopathy, entrapment, neuropathy - Claudication—
peripheral arterial/vascular, stenosis, arteritis 4/8/201
Taking the History 2
CHD - Medications: NSAIDS, Rx or OTC, HRT, calcium - LMP, menstrual cycles, menopause: female athletes,
post-menopausal • PMH - Previous injury or trauma—fracture, surgeries, arthroscopy - Cancer,
arthritis, sickle cell, osteoporosis, renal or neurologic disease
Taking the History 3
• FH - Congenital abnormalities of hip, foot - Scoliosis or back problems - Arthritis—RA, degenerative,
ankylosing spondylitis, gout - Genetic—osteogenesis imperfecta, hypercalciuria ▪ Personal/Social - Work,
exercise, hobbies 4/8/2018- Tobacco, alcohol, drug use
Physical Exam
▪ Height ▪ Weight ▪ Uncover and examine both sides ▪ Observe gait if weight bearing joint involved ▪
Inspection - Skin—injuries or contusions - Swelling, deformities, bruising, erythema ▪ Palpation—one
finger point tenderness - Compare non-injured to injured area - Palpate all surfaces—bones, joints, soft
tissue - Examine above and below area of injury
▪ Range of motion
—active and passive - Examine above and below area of injury - Internal and external rotation - Abduction
and adduction - Document ROM in degrees!!!
Traditional Management
▪ Rest ▪ Ice ▪ Compression/immobilization ▪ Elevation (RICE) ▪ Acetaminophen, NSAIDs, muscle relaxants
- Oral steroids may be considered in some cases ▪ Physical therapy, exercise ▪ The tincture of time ▪
Manipulation, acupuncture, other [ESI, TENS, etc], conservative Rx x4-6 weeks
NSAIDs
,NURS 5462 Test Exam 2024\2025.
Inhibit cyclooxygenase (COX) enzyme—provide anti-inflammatory/analgesic effects - Dose dependent -
NSAIDs differ in analgesic and anti-inflammatory effec
NSAIDs
- Gastritis, ulceration, bleed - Impaired renal function—NSAIDs inhibit renal prostaglandins, affecting
regulation of renal blood flow and glomerular filtration - Hypertension/Edema - Platelet inhibition and
bleeding - CV risk—potential damage to arterial wall, possible arterial clotting - Drug interaction with
ASA—they ↓ cardioprotective benefits and ↑ risk of GI bleed 4/8/2018
Evidence: BMJ Clinical Evidence 2007; 12: 1108
- Plateau for effectiveness; SE ↑ with dose ↑ - COX-2 ↓ risk for PUD but ↑ risk for MI/CV events -
Paracetamol similar to NSAIDs for acute MSK pain but ↓ effective than NSAIDs for OA [Paracetamol not
used in US 2nd to risk of GU malignancy] - **PPI > H2 antagonists ↓ GI SE - Insufficient evidence whether
topical NSAIDs beneficial
NSAIDs ▪ Adverse effects:
- Gastritis, ulceration, bleed - Impaired renal function—NSAIDs inhibit renal prostaglandins, affecting
regulation of renal blood flow and glomerular filtration - Hypertension/Edema - Platelet inhibition and
bleeding - CV risk—potential damage to arterial wall, possible arterial clotting - **Drug interaction with
ASA—they ↓ cardioprotective benefits and ↑ risk of GI blee
NSAIDs ▪ Recommendations:
- GI risk in general—nonacelated aspirin products lowest risk [Disalsid, Trilisate]; Ibuprofen/Naproxen
intermediate risk, Diclofenac/Piroxicam/Ketorolac greatest risk ▪ Use lowest dose possible , risk ↑ with
dose ▪ Short course best ▪ Use acetaminophen when possible - Avoid in patients > 65 yrs., H/O PUD, on
steroids, anticoagulants, ASA ▪ AGS, May, 2009: NSAIDs considered rarely and with extreme caution;
Acetaminophen, opioids best for elderly
Osteoarthritis
▪ Also referred to as Degenerative Joint Disease [DJD] ▪ Factors that influence DJD - Age - Heredity -
Repetitive stress - Prior joint disease - Diabetes - Weight, ▪ Common above 65 ▪ Decrease in the repair
process of the body ▪ Maximal stress to articular cartilage ▪ Worse over weight bearing joints and large
joints
Osteoarthritis 2
▪ Go slow, no cure ▪ Water aerobics are wonderful ▪ Use of cane, crutches, walker when needed ▪
Physical Therapy: heat, exercise, stretching ▪ Rest as needed ▪ Ice ▪ Stay off limb if possible ▪ TENS unit ▪
Analgesics / Anti-inflammatory ▪ May need joint replacement
Sprain
—acute injury to ligament when joint stressed beyond normal range of motion ➢Ligaments—surround
joint, responsible for stability/mobility ➢Stretching leads to ligament strain or rupture ➢Pain, marked
swelling, hemorrhage, loss of function
, NURS 5462 Test Exam 2024\2025.
• Severity of ligament sprains
➢Grade I—stretching or microscopic tearing, no joint instability/laxity [NSAIDS, RICE, progressive
weight bearing] ➢Grade II—partial, mild-moderate instability/laxity [immobilize 4-6 weeks, no to partial
weight bearing] ➢Grade III—complete rupture, obvious instability and laxity [immobilize, no weight
bearing—refer to ortho]
Muscle Strain—
—injury to muscle by overuse, improper use, or excessive stretching beyond functional capacity [acute]
leading to bleeding within the muscle, inflammation and pain ➢Partial or complete muscular tear
➢Pain, swelling, temporary weakness, spasm, contusion
Tendon Problems
▪ May be acute [tendonitis], chronic with acute [tendinosus with tendonitis], or chronic [tendinosus] ▪
Tendon inserts into bone—osteotendinous junction, most common site of overuse tendon injuries
➢Tendons relatively hypovascular, increases risk for hypoxic tendon degeneration ➢Acute rupture—
muscle will not function to move associated joint, requires surgical repair
Tendon Problems 2
Usually insidious onset, load-related localized pain coinciding with increased activity ➢Dull ache after
activities, sharp/stabbing during activities ➢Well-localized tenderness to palpation (TTP) ➢Can
reproduce pain with tendon loading movements ➢Rotator cuff, patellar, elbow, Achilles tendinopathy
Bursitis
found in areas subject to friction, contains fluid ➢Shoulder, elbow, hip, and knee ➢May be caused by
overloading, inflammatory disease [RA, crystal-induced/gout], or infection [GC, staph]
Fractures
- Within collagen structure, osteoclasts absorb and osteoblasts produce new bone matrix - Fracture—
load exceeds mechanical properties
• Nondisplaced fracture splint, immobilize, refer • Avulsion—joint capsule, ligament or muscle insertion
pulled from bone, associated with severe sprains • Displaced—fragments not in alignment, often require
surgery [10-15%]
Salter Harris Fracture Types
▪ Type I - Epiphysis is separated from end of bone [metaphysis] - Vital part of growth plate remain
attached to epiphysis
Type II - Most common type of growth plate fracture - Epiphysis, along with growth plate, is partially
separated from metaphysis, which is cracked, These usually have to be put back in place and immobilized
for normal growth to occur
Salter Harris Fracture Types +
