Arthritis Osteoarthritis (OA)

Osteoarthritis
Most common form of joint (articular) disease Previously called degenerative joint disease Risk Factor: growing older

Not considered a normal part of the aging process

90% of adults are affected by age 40 Few patients show symptoms after age 60 60% of patients > 65 years show signs & symptoms Greater in women than men Family history

Osteoarthritis (OA) Etiology & Pathophysiology

Idiopathic (primary) Cause unknown Secondary

Trauma / Mechanical stress Overused joints from work or sports related activities Inflammation Joint instability Neurologic disorders Skeletal deformities Side Effects of Medications Weakened immune system

Chronic illness such as diabetes, cancer or liver disease Infections such as Lyme disease.

Risk Factor: Obesity

Osteoarthritis (OA) Etiology & Pathophysiology

Cartilage damages that triggers a metabolic response Progressive degenerationcartilage becomes softer, less elastic, and less able to resist wear and heavy use Bodys attempt cannot keep up with destruction Cartilage erodes at the articular surfaces Cartilage thins; bony growth increases at joint margins Incongruity in joint surfaces
Uneven distribution of stress across the joint Reduction in motion

Inflammation is not a characteristic of OA

Osteoarthritis Etiology & Pathophysiology

Osteoarthritis Clinical Manifestations

Systemic: None Joints: mild discomfort to significant disability

In early disease- joint pain increasing with use Relieved by rest In advanced disease joint stiffness and pain after rest early morning stiffness

Overuse joint effusion Crepitation grating sensation caused by loose particles contributes to stiffness

Resolved within 30 minutes after movement

Osteoarthritis Most Involved Joints

Osteoarthritis Etiology & Pathophysiology

Affects joints asymmetrically Most commonly involved joints:

Distal interphalangeal (DIP) Proximal interphalangeal (PIP) Carpometacarpal joint of the thumb Weight-bearing joints (hips, knees) Metatarsophalangeal (MTP) joint of the foot Cervical and lumbar vertebrae

Osteoarthritis Etiology & Pathophysiology

Deformity
Specific to the involved joint
Herberdens

nodes DIP joints Bouchards nodes PIP joints Both are red, edematous, tender-painful Do not usually cause loss of function

Osteoarthritis Diagnostic Studies

Bone Scan CT MRI General x-ray

Radiologic changes do not correlate with the degree of disease

Osteoarthritis Treatment Goals

No cure

Focus:
Managing pain Preventing disability Maintaining and improving joint function

Osteoarthritis Treatment Goals

Rest and Joint Protection

Balance of rest and activity Assistive devices

Heat and Cold Applications

Hot packs, whirlpools, ultrasound, paraffin wax baths, pool therapy

Nutritional Therapy & Exercise

Weight reduction Goal: decrease load on the joints & increase joint mobilization

Osteoarthritis - Tx Goals

Drug Therapy
Tylenol up to 1000 mg q6h Aspirin Nonsteroidal anti-inflammatory drugs

Motrin (OTC) 200 mg qid++ Traditional NSAID decrease platelet aggregation prolong bleeding time Newer generation Cox inhibitors (cyclooxygenase) e.g., Celebrex Intraarticular injectionsknees; shoulder Intraforamenal-intervertebral Injections vertebral Corticosteroids decrease local inflammation & effusion Hyaluronic Acid increased production of synovial fluid Hyalgan, Synvisc

Osteoarthritis Treatment Goals

Surgical Treatment
Joint Replacement
Hip,

Knee, Shoulder

Spinal Surgery
Diskectomy

/spinal fusion

Spine Surgery for Arthritis

Degenerative Disc Disease

Lumbar Spinal Stenosis

Osteoarthritis Nursing Diagnoses

Acute & Chronic Pain r/t physical activity Disturbed sleeping pattern Impaired physical mobility Self-care deficits r/t joint deformity & pain Imbalanced nutrition Chronic low self-esteem r/t changing physical appearance

Osteoarthritis Nursing Management Goals

Maintain or improve joint function through balance of rest and activity

Joint protection measures to improve activity tolerance Maintain independence and self-care Use drug therapy safely to manage pain without side effects

REHABILITATION

Rheumatoid Arthritis (RA)

Chronic, systemic disease

Inflammation of connective tissue in the diarthrodial (synovial) joint

Periods of remissions & exacerbation

Extraarticular manifestations

Rheumatoid Arthritis (RA) Etiology & Pathophysiology

Cause unknown Autoimmune most widely accepted theory

Antigen/abnormal Immunoglobulin G (IgG) Presence of autoantibodies rheumatoid factor IgG + rheumatoid factor form deposits on synovial membranes & articular cartilage

Inflammation results pannus (granulation tissue at the joint margins) articular cartilage destruction Genetic predisposition/familial occurrence of human leukocyte antigen (HLA) in white RA patients

Rheumatoid Arthritis

Osteoarthritis Rheumatoid Arthritis

Rheumatoid Arthritis Anatomic 4 Stages

Stage 1 Early
No destructive changes on x-ray; possible osteoporosis

Stage II Moderate
X-ray osteoporosis; no joint deformities; possible presence f extraarticuloar soft tissue lesions

Stage III Severe

X-ray evidence of cartilage and bone destruction in addition to osteoporosis; joint deformitysubluxation, ulnar deviation, hyperextension, bony ankylosis; muscle atrophy, soft tissue lesions

Stage IV Terminal
Fibrous or bony ankylosis; criteria of Stage III

Rheumatoid Arthritis Clinical Manifestations

Insidious fatigue, anorexia, weight loss, generalized stiffness Joints

Stiffness becomes localizedpain, edema, limited motion, inflammation, joints warm to touch, fingersspindle shaped Morning Stiffness 60+ mins to several hours depending on disease progression

Rheumatoid Arthritis Clinical Manifestations

Extraarticular Manifestations
Sjorgren Syndrome decreased lacrimal secretionburning, gritty, itchy eyes with decreased tearing and photosensitivity Valvular lesions/pericarditis Interstitial fibrosis / pleuritis Lymphadenopathy Raynauds Phenomenon Peripheral neuropathy & edema Myositis

Rheumatoid Arthritis Clinical Manifestations

Rheumatoid Arthritis Diagnostic Studies

Lab Studies
Rheumatoid Factor 80% of patients ESR C-Reactive Protein WBC up to 25,000/ul

Synovial biopsy inflammation

Bone Scan

Rheumatoid Arthritis Treatment Goals

Drug Therapy
NSAIDs Disease-modifying antirheumatic drugs (DMARDS) - Anti-inflammatory action
Mild

Disease Plaquenil (antimalarial drug) Moderate Severe Disease -- Methotrexate Severe Disease - Gold Therapy (weekly injections x 5 months)
Corticosteroid

Therapy

Nutrition

balanced diet

Rheumatoid Arthritis Nursing Diagnoses

Chronic pain r/t joint inflammation Impaired physical mobility Disturbed body image r/t chronic disease Ineffective therapy regimen management r/t complexity of chronic health problem Self-care deficit r/t disease progression

Rheumatoid Arthritis Nursing Management Goals

Satisfactory pain relief Minimal loss of functional ability of affected joints Patient participation in planning and carrying out therapeutic regimen Positive-self image Self-care to the maximum capability

Rheumatoid Arthritis
Rest alternating with activity as tolerated -- Energy conservation Joint protection

Time-saving joint protective devices

Heat / Cold Therapy relieve stiffness, pain, and muscle spasm Exercise individualized Aquatic Therapy Psychological Therapy individual & family support system

Arthritis Gerontologic Considerations

Sensitivity to medication
NSAIDs GI Bleed Corticosteroid therapy osteopenia adds to inactivity-related loss of bone density
Pathological

fractures

Challenges to Self-Care & Decisions

Autonomous Assisted Living