Arthritis Osteoarthritis (OA)   Osteoarthritis   Most common form of joint (articular) disease   Previously called degenerative joint disease  Risk  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 degeneration—cartilage becomes softer, less elastic, and less able to resist wear and heavy use  Body’s 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”   Resolved within 30 minutes after movement  Overuse – joint effusion  Crepitation – grating sensation caused by loose particles – contributes to stiffness

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  Herberden’s nodes – DIP joints  Bouchard’s 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 injections—knees; 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 The Spine

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 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 deformity—subluxation, 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 localized—pain, edema, limited motion, inflammation, joints warm to touch, fingers—spindle shaped  “Morning Stiffness” – 60+ mins to several hours depending on disease progression

Rheumatoid Arthritis Clinical Manifestations  Extraarticular Manifestations  Sjorgren Syndrome – decreased lacrimal secretion—burning, gritty, itchy eyes with decreased tearing and photosensitivity  Valvular lesions/pericarditis  Interstitial fibrosis / pleuritis  Lymphadenopathy  Raynaud’s 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