Osteoarthritis

Question 1

What is Arthritis?

Answer 1

inflammation of a joint

Question 2

Most common types of arthritis?

Answer 2

osteoarthritis
rheumatoid arthritis
gout

Question 3

How does Arthritis Affect a Person?

Answer 3

OA is most common type of joint disease in Canada

It is a slowly progressive non-inflammatory disorder of the diarthrodial (synovial) joints.

Symptoms usually start at the age of 50 – 60 years

It is not part of normal aging, but the risk of developing arthritis goes up as a person gets older

Question 4

Fibrous Joints?

Answer 4

articulating surfaces are joined by fibrous tissue.

The DEGREE OF MOVEMENT depends upon the length of collagen fibers uniting the bones.

e.g. inferior tibio- fibular joint ; sutures of the vault of the skull

Question 5

Cartilaginous joints: TYPE 1?

Answer 5

the bones are united by a bar plate of hylaine cartilage.

e. g. the union ( of a growing bone) between the epiphysis and diaphysis of a growing bone.;

first rib and the manubrium sternum.

NO MOVEMENT IS POSSIBLE.

Question 6

Cartilaginous joints: TYPE 2?

Answer 6

the bones are united by a plate of fibrocartilage.

The articular surfaces are covered by a a thin layer of hylaine cartilage .

e. g. intervertebral joints;symohysis pubis .

LIMITED MOVEMENT.

Question 7

Synovial joints?

Answer 7

The articular surfaces of the bones are covered by a thin layer of hyaline cartilage, separated by a synovial joint cavity .

e.g. knees, hips, elbows, hands, feet.

GREATER DEGREE OF MOVEMENT.

synovial fluid allows joint movement

Question 8

Etiology of OA

Answer 8

No single cause;

can be idiopathic or triggered by an event (trauma) or condition that damages cartilage in the synovial joint.

Question 9

Risk factors of OA

Answer 9

Age
Obesity
Genetics
Skeletal deformities
Joint injuries
Repetitive stress injuries
Lack of exercise

Question 10


Pathophysiology?

Answer 10

The cartilage damage triggers a metabolic response at the level of the chondrocytes( cells that make up cartilage)

Normally smooth, white cartilage becomes yellow and granular, then softer and less elastic

Fissuring and erosion of the articular surfaces are the next steps in the damage

As the central cartilage breaks down, bits and pieces of cartilage float in the synovial space, causing pain and stiffness

Inflammation may occur as phagocytic cells try to rid the joint of these bits of cartilage

As the cartilage becomes thinner, cartilage and bony growth increase at joint margins

The resulting incongruity in joint surfaces creates an uneven distribution of stress across the joint & contributes to a reduction in motion

Question 11

Clinical Manifestations of joints?

Answer 11

Range from mild discomfort to significant disability;

localized pain and stiffness,

crepitation ( a grating sensation caused by loose particles of cartilage in the joint.

Question 12

Clinical Manifestations of deformity?

Answer 12

Specific to joint involved- Heberden’s nodes on the hands

Can appear as early as 20-30 years of age, majority at 40

Pain & stiffness- “ Ouch I know it’s going to rain!”

Loss of range of motion- altered gait as in OA of the hip 1 leg shorter than the other.

Radiological findings don’t always correlate with the degree of pain experienced by the patient.

Question 13

Progression of OA?

Answer 13

No cure for OA

Collaborative care focuses on managing pain and inflammation

Preventing disability

Maintaining and improving joint function THROUGH
Collaborative care

Question 14

Maintaining and improving joint function THROUGH

Collaborative care?

Answer 14

nutritional and weight management counseling, 
rest & joint protection
 therapeutic exercise ( with PT),
heat & cold applications
Occupational therapy
accupuncture
nutritional supplements ( glucosamine, chondrotin sulfate), yoga
massage
therapeutic touch
guided imagery

Question 15

Diagnostic Studies
?

Answer 15

Bone scan
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Radiological studies
Blood studies: 
Synovial fluid analysis

Question 16

Bone scan?

Answer 16

Injection of a radioactive isotope which is taken up by bone; degree of uptake is related to blood flow

Question 17

Computed tomography (CT)?

Answer 17

X-ray and computer used to provide 3D image; shows soft tissue abnormalities as well

Question 18

Magnetic resonance imaging (MRI)?

Answer 18

radio frequency and magnetic field used to view soft tissue

Question 19

Radiological studies?

Answer 19

X-rays give a 2 dimensional picture

Question 20

Blood studies?

Answer 20

ESR (erythrocyte sedimentation rate)

Question 21

Synovial fluid analysis

Answer 21

analyze fluid

Question 22

Review of Treatment for Osteoarthritis?

Answer 22

Focuses on:
Managing pain and inflammation
Preventing disability
Maintaining and improving joint function

Foundation for OA management is non-pharmacological interventions, known as collaborative care. ( see previous slide)

Drug therapy serves as an adjunct

Question 23

Drug Therapy for OA?

Answer 23

Based on severity of symptoms

1st line: starts with acetaminophen (Tylenol), & possibly a topical cream (capsaicin)

2nd line: Nsaids (non-steroidal anti-inflammatory); generic – Ibuprophen (Advil, Motrin), 200mg, QID

Initiated in low doses as it can lead to gastritis ( GI irritation)
GI irritation: dyspepsia, nausea, ulcer hemorrhage.

Question 24

GI irritation?

Answer 24

Nursing considerations:

Adm drug with food, milk or antacids as prescribed.

Teach pt to avoid all alcohol consumption.

Report signs of bleeding e.g. tarry stools, bruising,

nosebleeds, persistent headaches, petechiae, edema, skin rashes, visual disturbances.

Monitor BP for elevations related to fluid retention.

Drug must be administered regularly for maximal effect.

Question 25

Treatment for Osteoarthritis?

Answer 25

Arthroscopic surgery ( knee) Debridement (removal of unhealthy tissue) is usually not recommended However, can be effective in reducing pain and improving function when it is used to Repair ligament tears Remove bone bits or cartilage

Question 26

Nursing assessment?

Answer 26

``` Carefully assess and document patient’s joint pain and stiffness Type Location Severity Frequency Duration Physical examination ``` ``` Acute and chronic pain Insomnia Impaired physical mobility Imbalanced nutrition: more than body requirements Chronic low self-esteem Self-care deficits ```

Question 27

Planning?

Answer 27

Overall goals: Maintain or improve joint function through a balance of rest and activity Use joint-protection measures to improve activity tolerance Achieve independence in self-care and maintain optimal role Pharmacological and non-pharmacological pain control

Question 28

Nursing Interventions?

Answer 28

Health promotion: Community education should focus on alteration of modifiable risk factors. Athletic instruction and physical fitness programs should include safety measures.

Question 29

Other Aids for Patients with OA?

Answer 29

Orthoses: devices that help keep joints aligned and functioning correctly. Examples: Well-cushioned shoes and shoe inserts may reduce stress on leg and spinal joints Splits that immobilize the joints may reduce pain and inflammation Assistive devices: canes, walkers, raised toilet seats, bars in showers

Question 30

Nursing Interventions?

Answer 30

Acute interventions: Frequent complaints of patients with OA include pain, stiffness, limitation of function, frustration Instruct the pt to REST the JOINT when there is active inflammation ( Limit activity ) Ambulatory and home care Home and work environment modification Sexual counseling if necessary

Question 31

Positive Outcomes?

Answer 31

Experience adequate amounts of rest and activity Achieve satisfactory pain management Maintain joint flexibility and muscle strength through joint protection and therapeutic exercise Verbalize acceptance of OA as a chronic disease, collaborating with health care providers in disease management

Question 32

Rheumatoid Arthritis?

Answer 32

Inflammation of the connective tissues in the synovial joints with periods of exacerbation and remission.

Question 33

What is Rheumatoid Arthritis (RA)?

Answer 33

Chronic, systemic autoimmune disease RA usually develops between 25 and 50 years of age. 1% of Canadians have RA. Women are 2–3 times more likely to have RA Cause is unknown Autoimmunity Genetic factors

Question 34

What happens in RA?

Answer 34

Antigen triggers the formation of abnormal IgG (Immunoglobulin) Autoantibodies known as RF, are made against this abnormal IgG, combine with the IgG and land on ( deposited upon) the synovial membrane of the joints. This immune complex formation leads o the activation of complement and an inflammatory response results with consequent destruction of the articular cartilage.

Question 35

Clinical Manifestations RA?

Answer 35

Onset is insidious: fatigue, anorexia, weight loss, generalized stiffness Occasionally precipitated by a stressful event (infection, work stress, childbirth, etc) Joint symptoms occur symmetrically, especially in the small joints of the hands and feet Larger peripheral joints may then be affected: wrists, shoulders, ankles, etc Joint stiffness in the morning Joints are tender, painful, warm to touch

Question 36

Extra-articular manifestations RA?

Answer 36

Most common: Rheumatoid nodules Rheumatoid nodules develop in up to 25% of all patients with RA. Those affected usually have high titres of rheumatoid factor (RF)

Question 37

Complications RA?

Answer 37

Joint destruction begins as early as first year of disease without treatment Flexion contractures and hand deformities Nodular myositis and muscle fiber degeneration Cataracts and loss of vision Later, cardiopulmonary effects

Question 38

Diagnostic Studies RA?

Answer 38

Accurate diagnosis is essential to initiation of appropriate treatment and prevention of unnecessary disability. Diagnosis is often made from the following: History and physical findings Some laboratory tests are useful for confirmation and to monitor disease progression ``` Positive RF occurs in ~80% of patients tested Titres rise during active disease Antinuclear antibody (ANA) titres Synovial fluid analysis Bone scan ```

Question 39

Collaborative Care RA?

Answer 39

Care begins with a comprehensive program of education and drug therapy. Drug treatment is imitated as soon as there is a diagnosis to prevent joint destruction. Physiotherapy helps maintain joint motion and muscle strength. Occupational therapy develops extremity function and encourages joint protection. A caring, long-term relationship with an arthritis health care team can increase the patient’s self-esteem and positive coping. Balanced nutrition is important.

Question 40

Nursing Management: 
Rheumatoid Arthritis

Answer 40

Self-Care deficits: Chronic pain Impaired physical mobility Disturbed body image Ineffective self-health management

Question 41

Nursing Management: 
Rheumatoid Arthritis Planning?

Answer 41

Overall goals: Satisfactory pain relief Minimal loss of functional ability of affected joints Participate in planning and carrying out therapeutic regimen Maintain a positive self-image Perform self-care

Question 42

Nursing Management: 
Rheumatoid Arthritis Nursing implementation?

Answer 42

Health promotion: Education focuses on symptom recognition Acute intervention: Primary focus is reduction of inflammation, pain, maintenance of joint function: rest the joint(s), meds, joint protection Ambulatory and home care: Joint protection, heat and cold therapy, exercise, psychological support