Post on 15-Jan-2016
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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