ArthritisArthritisOsteoarthritis (OA)Osteoarthritis (OA)

Osteoarthritis Most common form of joint (articular) disease Previously called degenerative joint disease RiskRisk 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 Family history

Osteoarthritis (OA)Osteoarthritis (OA) Etiology & Pathophysiology Etiology & Pathophysiology

Idiopathic (primary) Cause – unknownIdiopathic (primary) Cause – unknown SecondarySecondary

Trauma / Mechanical stressTrauma / Mechanical stress Overused joints from work or sports related Overused joints from work or sports related

activitiesactivities InflammationInflammation Joint instabilityJoint instability Neurologic disordersNeurologic disorders Skeletal deformitiesSkeletal deformities Side Effects of MedicationsSide Effects of Medications Weakened immune system Weakened immune system

Chronic illness such as diabetes, cancer or liver Chronic illness such as diabetes, cancer or liver diseasedisease

Infections such as Lyme disease.Infections such as Lyme disease.

Risk Factor: Risk Factor: ObesityObesity

Osteoarthritis (OA)Osteoarthritis (OA)Etiology & PathophysiologyEtiology & Pathophysiology

Cartilage damages that triggers a metabolic Cartilage damages that triggers a metabolic responseresponse

Progressive degeneration—cartilage becomes Progressive degeneration—cartilage becomes softer, less elastic, and less able to resist wear softer, less elastic, and less able to resist wear and heavy useand heavy use

Body’s attempt cannot keep up with Body’s attempt cannot keep up with destructiondestruction

Cartilage erodes at the articular surfacesCartilage erodes at the articular surfaces Cartilage thins; bony growth increases at joint Cartilage thins; bony growth increases at joint

marginsmargins Incongruity in joint surfacesIncongruity in joint surfaces

Uneven distribution of stress across the jointUneven distribution of stress across the joint Reduction in motionReduction in motion

Inflammation is not a characteristic of OAInflammation is not a characteristic of OA

OsteoarthritisOsteoarthritisEtiology & Etiology &

PathophysiologyPathophysiology

OsteoarthritisOsteoarthritisClinical ManifestationsClinical Manifestations

Systemic: Systemic: NoneNone Joints: mild discomfort to significant Joints: mild discomfort to significant

disabilitydisability In early disease- joint pain increasing with use In early disease- joint pain increasing with use Relieved by restRelieved by rest In advanced disease – joint stiffness and pain In advanced disease – joint stiffness and pain

after rest “early morning stiffness”after rest “early morning stiffness” Resolved within 30 minutes after movement

Overuse – joint effusionOveruse – joint effusion Crepitation – grating sensation caused by Crepitation – grating sensation caused by

loose particles – contributes to stiffnessloose particles – contributes to stiffness

OsteoarthritisOsteoarthritisMost Involved JointsMost Involved Joints

OsteoarthritisOsteoarthritisEtiology & Etiology &

PathophysiologyPathophysiology Affects joints asymmetricallyAffects joints asymmetrically Most commonly involved jointsMost commonly involved joints::

Distal interphalangeal (DIP)Distal interphalangeal (DIP)Proximal interphalangeal (PIP)Proximal interphalangeal (PIP)Carpometacarpal joint of the thumbCarpometacarpal joint of the thumbWeight-bearing joints (hips, knees)Weight-bearing joints (hips, knees)Metatarsophalangeal (MTP) joint of the Metatarsophalangeal (MTP) joint of the

footfootCervical and lumbar vertebraeCervical and lumbar vertebrae

OsteoarthritisOsteoarthritisEtiology & Etiology &

PathophysiologyPathophysiology DeformityDeformity

Specific to the involved jointSpecific to the involved joint

Herberden’s nodes – DIP jointsHerberden’s nodes – DIP joints Bouchard’s nodes – PIP jointsBouchard’s nodes – PIP joints Both are red, edematous, tender-painfulBoth are red, edematous, tender-painful Do not usually cause loss of functionDo not usually cause loss of function

OsteoarthritisOsteoarthritisDiagnostic StudiesDiagnostic Studies

Bone Scan Bone Scan CTCT MRIMRI General x-rayGeneral x-ray

Radiologic changes do not Radiologic changes do not correlate with the degree of correlate with the degree of diseasedisease

OsteoarthritisOsteoarthritisTreatment GoalsTreatment Goals

No cureNo cure

Focus:Focus:

Managing painManaging painPreventing disabilityPreventing disabilityMaintaining and improving joint Maintaining and improving joint

functionfunction

OsteoarthritisOsteoarthritisTreatment GoalsTreatment Goals

Rest and Joint ProtectionRest and Joint ProtectionBalance of rest and activityBalance of rest and activityAssistive devicesAssistive devices

Heat and Cold ApplicationsHeat and Cold ApplicationsHot packs, whirlpools, ultrasound, paraffin Hot packs, whirlpools, ultrasound, paraffin

wax baths, pool therapywax baths, pool therapy Nutritional Therapy & ExerciseNutritional Therapy & Exercise

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

Osteoarthritis - Tx GoalsOsteoarthritis - Tx Goals

Drug TherapyDrug Therapy Tylenol Tylenol – up to 1000 mg q6h– up to 1000 mg q6h AspirinAspirin Nonsteroidal anti-inflammatory drugs Nonsteroidal anti-inflammatory drugs

Motrin (OTC) 200 mg qid++Motrin (OTC) 200 mg qid++ Traditional NSAID – decrease platelet aggregation – Traditional NSAID – decrease platelet aggregation –

prolong bleeding timeprolong bleeding time Newer generation – Cox inhibitors (cyclooxygenase) Newer generation – Cox inhibitors (cyclooxygenase)

e.g., e.g., Celebrex Celebrex Intraarticular injections—knees; shoulderIntraarticular injections—knees; shoulder Intraforamenal-intervertebral Injections – vertebral Intraforamenal-intervertebral Injections – vertebral Corticosteroids – decrease local inflammation & Corticosteroids – decrease local inflammation &

effusioneffusion Hyaluronic Acid – increased production of synovial Hyaluronic Acid – increased production of synovial

fluid – Hyalgan, Synviscfluid – Hyalgan, Synvisc

OsteoarthritisOsteoarthritisTreatment GoalsTreatment Goals

Surgical TreatmentSurgical Treatment

Joint ReplacementJoint Replacement

Hip, Knee, ShoulderHip, Knee, Shoulder

Spinal Surgery – Spinal Surgery –

Diskectomy /spinal fusionDiskectomy /spinal fusion

Spine Surgery for Spine Surgery for ArthritisArthritis

The Spine

Degenerative Disc Degenerative Disc DiseaseDisease

Lumbar Spinal Lumbar Spinal StenosisStenosis

OsteoarthritisNursing Diagnoses

Acute & Chronic Pain r/t physical Acute & Chronic Pain r/t physical activityactivity

Disturbed sleeping patternDisturbed sleeping pattern Impaired physical mobilityImpaired physical mobility Self-care deficits r/t joint deformity & Self-care deficits r/t joint deformity &

painpain Imbalanced nutritionImbalanced nutrition Chronic low self-esteem r/t changing Chronic low self-esteem r/t changing

physical appearancephysical appearance

OsteoarthritisOsteoarthritisNursing Management Nursing Management

GoalsGoals Maintain or improve joint function Maintain or improve joint function

through balance of rest and activitythrough balance of rest and activity

Joint protection measures to improve Joint protection measures to improve activity toleranceactivity tolerance

Maintain independence and self-careMaintain independence and self-care

Use drug therapy safely to manage pain Use drug therapy safely to manage pain without side effectswithout side effects

REHABILITATIONREHABILITATION

Rheumatoid Arthritis Rheumatoid Arthritis (RA)(RA)

Chronic, Chronic, systemic diseasesystemic disease

Inflammation of connective tissue in Inflammation of connective tissue in the diarthrodial (synovial) jointthe diarthrodial (synovial) joint

Periods of remissions & exacerbationPeriods of remissions & exacerbation

Extraarticular manifestationsExtraarticular manifestations

Rheumatoid Arthritis (RA) Rheumatoid Arthritis (RA) Etiology & PathophysiologyEtiology & Pathophysiology

Cause – unknownCause – unknown AutoimmuneAutoimmune – most widely accepted theory – most widely accepted theory

Antigen/abnormal Immunoglobulin G (IgG)Antigen/abnormal Immunoglobulin G (IgG) Presence of autoantibodies – Presence of autoantibodies –

rheumatoid factorrheumatoid factor IgG + rheumatoid factor form deposits on IgG + rheumatoid factor form deposits on

synovial membranes & articular cartilagesynovial membranes & articular cartilage Inflammation results – pannus (granulation tissue at Inflammation results – pannus (granulation tissue at

the joint margins) – articular cartilage destructionthe joint margins) – articular cartilage destruction GeneticGenetic – predisposition/familial occurrence of – predisposition/familial occurrence of

“human leukocyte antigen (HLA) in white RA “human leukocyte antigen (HLA) in white RA patientspatients

Rheumatoid ArthritisRheumatoid Arthritis

Osteoarthritis Osteoarthritis Rheumatoid ArthritisRheumatoid Arthritis

Rheumatoid ArthritisRheumatoid ArthritisAnatomic 4 StagesAnatomic 4 Stages

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

osteoporosisosteoporosis Stage II – ModerateStage II – Moderate

X-ray osteoporosis; no joint deformities; possible X-ray osteoporosis; no joint deformities; possible presence f extraarticuloar soft tissue lesionspresence f extraarticuloar soft tissue lesions

Stage III – SevereStage III – Severe X-ray evidence of cartilage and bone destruction in X-ray evidence of cartilage and bone destruction in

addition to osteoporosis; joint deformity—addition to osteoporosis; joint deformity—subluxation, ulnar deviation, hyperextension, bony subluxation, ulnar deviation, hyperextension, bony ankylosis; muscle atrophy, soft tissue lesionsankylosis; muscle atrophy, soft tissue lesions

Stage IV – TerminalStage IV – Terminal Fibrous or bony ankylosis; criteria of Stage IIIFibrous or bony ankylosis; criteria of Stage III

Rheumatoid ArthritisRheumatoid ArthritisClinical ManifestationsClinical Manifestations

Insidious – fatigue, anorexia, weight Insidious – fatigue, anorexia, weight loss, generalized stiffnessloss, generalized stiffness

JointsJointsStiffness becomes localized—pain, edema, Stiffness becomes localized—pain, edema,

limited motion, inflammation, joints warm limited motion, inflammation, joints warm to touch, fingers—spindle shapedto touch, fingers—spindle shaped

““Morning Stiffness” – 60+ mins to several Morning Stiffness” – 60+ mins to several hours depending on disease progressionhours depending on disease progression

Rheumatoid ArthritisRheumatoid ArthritisClinical ManifestationsClinical Manifestations

Extraarticular ManifestationsExtraarticular ManifestationsSjorgren Syndrome – decreased lacrimal Sjorgren Syndrome – decreased lacrimal

secretion—burning, gritty, itchy eyes with secretion—burning, gritty, itchy eyes with decreased tearing and photosensitivitydecreased tearing and photosensitivity

Valvular lesions/pericarditisValvular lesions/pericarditisInterstitial fibrosis / pleuritisInterstitial fibrosis / pleuritisLymphadenopathyLymphadenopathyRaynaud’s PhenomenonRaynaud’s PhenomenonPeripheral neuropathy & edemaPeripheral neuropathy & edemaMyositisMyositis

Rheumatoid ArthritisRheumatoid ArthritisClinical ManifestationsClinical Manifestations

Rheumatoid ArthritisRheumatoid ArthritisDiagnostic StudiesDiagnostic Studies

Lab StudiesLab StudiesRheumatoid Factor – 80% of patientsRheumatoid Factor – 80% of patientsESRESRC-Reactive ProteinC-Reactive ProteinWBC up to 25,000/ulWBC up to 25,000/ul

Synovial biopsy – inflammationSynovial biopsy – inflammation

Bone ScanBone Scan

Rheumatoid ArthritisRheumatoid ArthritisTreatment GoalsTreatment Goals

Drug TherapyDrug TherapyNSAIDs NSAIDs Disease-modifying antirheumatic drugs Disease-modifying antirheumatic drugs

(DMARDS) - (DMARDS) - Anti-inflammatory actionAnti-inflammatory action Mild Disease – Plaquenil (antimalarial drug)Mild Disease – Plaquenil (antimalarial drug) Moderate – Severe Disease -- MethotrexateModerate – Severe Disease -- Methotrexate Severe Disease - Gold Therapy (weekly Severe Disease - Gold Therapy (weekly

injections x 5 months)injections x 5 months)Corticosteroid TherapyCorticosteroid Therapy

Nutrition – balanced dietNutrition – balanced diet

Rheumatoid ArthritisRheumatoid ArthritisNursing DiagnosesNursing Diagnoses

Chronic pain r/t joint inflammationChronic pain r/t joint inflammation Impaired physical mobilityImpaired physical mobility Disturbed body image r/t chronic Disturbed body image r/t chronic

diseasedisease Ineffective therapy regimen Ineffective therapy regimen

management r/t complexity of management r/t complexity of chronic health problemchronic health problem

Self-care deficit r/t disease Self-care deficit r/t disease progressionprogression

Rheumatoid ArthritisRheumatoid ArthritisNursing Management Nursing Management

GoalsGoals Satisfactory pain reliefSatisfactory pain relief Minimal loss of functional ability of Minimal loss of functional ability of

affected jointsaffected joints Patient participation in planning Patient participation in planning

and carrying out therapeutic and carrying out therapeutic regimenregimen

Positive-self imagePositive-self image Self-care to the maximum Self-care to the maximum

capabilitycapability

Rheumatoid ArthritisRheumatoid Arthritis

Rest alternating with activityRest alternating with activity as as tolerated -- Energy conservationtolerated -- Energy conservation

Joint protectionJoint protectionTime-saving joint protective devicesTime-saving joint protective devices

Heat / Cold TherapyHeat / Cold Therapy – relieve – relieve stiffness, pain, and muscle spasmstiffness, pain, and muscle spasm

Exercise Exercise –individualized –Aquatic –individualized –Aquatic TherapyTherapy

Psychological TherapyPsychological Therapy – individual & – individual & family support systemfamily support system

ArthritisArthritisGerontologic Gerontologic

ConsiderationsConsiderations Sensitivity to medicationSensitivity to medication

NSAIDs – GI BleedNSAIDs – GI BleedCorticosteroid therapy – osteopenia adds Corticosteroid therapy – osteopenia adds

to inactivity-related loss of bone density to inactivity-related loss of bone density Pathological fracturesPathological fractures

Challenges to Self-Care & Challenges to Self-Care & DecisionsDecisionsAutonomousAutonomousAssisted LivingAssisted Living