A nurse is caring for a 68-year-old client with osteoarthrit… | 마이메르시 MyMerci
Adult Health
문제

A nurse is caring for a 68-year-old client with osteoarthritis of the knees. Which nursing intervention should be the priority to help manage the client's pain and maintain joint function?

해설
Gentle range-of-motion exercises maintain joint flexibility, reduce stiffness, and prevent muscle atrophy, effectively managing osteoarthritis pain and function. Other options like bed rest or excessive NSAIDs can worsen symptoms or cause harm.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing intervention for managing Osteoarthritis (OA), a degenerative joint disease. The core pathophysiology involves the breakdown of articular cartilage, leading to pain, stiffness, and loss of function. The primary management goals are to control pain, maintain joint mobility, and prevent disability. While rest is important during acute inflammation, prolonged inactivity is detrimental as it leads to joint stiffness and muscle atrophy, which worsen pain and functional decline.

Answer Rationale: Key Point! The correct answer is to teach gentle Range-of-motion (ROM) exercises. This intervention directly addresses the twin goals of pain management and functional maintenance. Regular, gentle movement helps:
1. Lubricate the joint (synovial fluid circulation), reducing stiffness.
2. Preserve muscle strength to support and stabilize the joint.
3. Prevent contractures and maintain functional independence.
This is a cornerstone of non-pharmacological management for OA, supported by Evidence-Based Nursing (EBN) guidelines.

Distractor Analysis:
Watch out for confusion! Option ① (Encourage complete bed rest) is harmful. While short-term rest during a severe flare-up is appropriate, prolonged immobility accelerates joint stiffness, muscle weakness, and functional loss, contradicting the goal of maintaining joint function.
Option ③ (Apply ice packs for 30 minutes every hour) is incorrect due to improper application time. Ice therapy is useful for acute inflammation or post-exercise pain, but the recommended duration is typically 15-20 minutes at a time. Applying ice for 30 minutes every hour risks cold-induced tissue injury (frostbite, nerve damage).
Option ④ (Advise OTC NSAIDs without consulting) is dangerous due to the lack of assessment. The nurse must first assess the client's renal function, history of GI bleeding, and current medications (e.g., anticoagulants) before recommending NSAIDs (Nonsteroidal Anti-inflammatory Drugs). Unsupervised use can lead to serious adverse effects like gastrointestinal bleeding or acute kidney injury.

Related Concepts: OA management is multimodal. It includes weight management (to reduce joint stress), proper use of heat/cold therapy, assistive devices (e.g., cane), pharmacological management (acetaminophen, NSAIDs, topical agents), and eventually joint replacement surgery for advanced disease. The nurse's role is to educate and empower the client for long-term self-management. Concept Summary
ConceptKey Points for Osteoarthritis (OA)
PathophysiologyProgressive degeneration of articular cartilage. Inflammation is secondary. "Wear and tear" disease.
Primary SymptomsJoint pain (worsens with activity, improves with rest), morning stiffness ( 1 hour)
Systemic SymptomsUsually absentPresent (fatigue, fever, weight loss)
Priority InterventionExercise to maintain functionRest during acute flares, then exercise
Anatomy, Physiology & Pharmacology Points
Joint Anatomy: OA primarily affects the articular cartilage, the smooth cushion at the end of bones. Its breakdown leads to bone-on-bone friction.
Exercise Physiology: Movement stimulates the production of synovial fluid, which nourishes cartilage and acts as a lubricant.
Pharmacology: NSAIDs work by inhibiting the cyclooxygenase (COX) enzyme, reducing prostaglandin production (pain and inflammation mediators). Must assess for Key Point! GI and renal risks. Memory Tips
OA Exercise Mantra: "Motion is Lotion." Gentle movement keeps joints fluid.
OA vs. RA Stiffness: "OA: Off quickly. RA: Rest a while." OA stiffness eases in

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario: Mr. Johnson, 68, is admitted for hypertension. During your assessment, he mentions his "bad knees" from arthritis keep him from walking much. He says, "The pain is worse when I get up in the morning or after I've been sitting, but if I walk to the mailbox, it feels a little better after a few steps."

Nursing Intervention Strategy:
1. Assessment: Perform a focused joint assessment. Use the Pain scale. Ask about his daily activities and what he has tried for pain relief. Assess his gait and need for assistive devices.
2. Planning & Implementation: Collaborate with physical therapy. Teach him a simple, seated knee ROM exercise: "Slowly straighten your leg, hold for 5 seconds, then slowly bend it back." Emphasize doing this gently and regularly, not just when in pain. Discuss weight management strategies if applicable.
3. Patient Education: Teach the proper use of heat (warm shower in the morning for stiffness) vs. cold (ice pack for 15 min after increased activity for pain). Review safe use of acetaminophen (do not exceed 3000 mg/day).

Patient Safety and Precautions:
- Exercise Caution: Instruct to stop exercise if it causes sharp, increased pain. "Hurting" is different from mild discomfort from moving a stiff joint.
- Medication Safety: Always ask about OTC medication use. Warn against combining multiple products containing acetaminophen.
- Fall Risk: Stiffness and pain increase fall risk. Ensure clear pathways and recommend proper footwear. Nursing Procedure & Medication Flow Teaching Gentle ROM Exercises:
1. Ensure the client is in a comfortable, supported position (sitting in a firm chair).
2. Demonstrate the movement slowly on your own limb.
3. Guide the client to perform the movement passively, then actively.
4. Instruct to perform 5-10 repetitions, 1-2 times daily.
5. Evaluate understanding by having the client teach-back the exercise.

Administering/Teaching about NSAIDs:
1. Assessment First: Check BUN/Creatinine, ask about history of PUD (Peptic Ulcer Disease) or GI bleed.
2. Administration: Give with food or milk. For chronic use, proton pump inhibitors (PPIs) may be co-prescribed.
3. Monitoring: Watch for black, tarry stools (melena), epigastric pain, changes in urine output. A Word from Your Senior Nurse Remember, for our patients with chronic conditions like osteoarthritis, our goal isn't to cure the disease but to maximize their quality of life and independence. That gentle ROM exercise you teach might seem small, but it's the key to keeping them out of a wheelchair and able to play with their grandkids. On the NCLEX, they're testing your nursing judgment: can you pick the action that promotes health and prevents harm? Always lean towards interventions that empower the patient and maintain function. You've got this!

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