Focus on Osteoarthritis (Relates to Chapter 65, “Nursing Management: Arthritis and Connective...

Focus onOsteoarthritis

(Relates to Chapter 65, “Nursing Management: Arthritis and Connective Tissue Diseases,” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Osteoarthritis (OA) Most common form of joint

disease in North America Slowly progressive

noninflammatory disorder of the diarthrodial joints

21 million Americans affected Expected to greatly increase as

population ages

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 2

Etiology and Pathophysiology Not considered a normal part

of aging process Growing older is a risk factor. Cartilage destruction can begin

between ages 20 and 30. Majority of adults affected by

age 40


Etiology and Pathophysiology OA occurs as

Idiopathic disorder Secondary disorder

Trauma, mechanical stress, inflammation, joint instability, neurologic disorder, skeletal deformities, hematologic/endocrine disorders, use of selected drugs


Etiology and Pathophysiology Single cause for OA has not

been identified. Number of factors have been

linked: Estrogen reduction at menopause Genetic factors Obesity

Regular moderate exercise decreases risk.


Etiology and Pathophysiology OA results from cartilage

damage that triggers a metabolic response at level of chondrocytes.

Cartilage becomes Dull, yellow, and granular Soft and less elastic Less able to resist wear with

heavy useCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Etiology and Pathophysiology


Fig. 65-1. Pathologic changes in osteoarthritis. A, Normal synovial joint. B, Early change in osteoarthritis is destruction of articular cartilage and narrowing of the joint space. There is inflammation and thickening of the joint capsule and synovium.C, With time, there is thickening of subarticular bone caused by constant friction of the two bone surfaces. Osteophytes form around the periphery of the joint by irregular overgrowths of bone. D, In osteoarthritis of the hands, osteophytes on the distal interphalangeal joints of the fingers are termed Heberden’s nodes and appear as small nodules.

Etiology and Pathophysiology Inflammation not characteristic

of OA Secondary synovitis may result.

Phagocytic cells try to rid joint of small pieces of cartilage torn from joint surface.

Inflammatory change contributes to early pain and stiffness.


Clinical ManifestationsSystemic Systemic manifestations are

not present in OA. Fatigue, fever, and organ

involvement Important distinction between

OA and inflammatory joint disorders (e.g., rheumatoid arthritis [RA])


Clinical ManifestationsJoints Joint pain

Predominant symptom ranging from mild discomfort to significant disability

Pain worsens with joint use. Early stages: rest relieves pain Later stages: pain with rest and

sleep is disturbed because of pain and increased joint discomfort


Clinical ManifestationsJoints Pain may be referred to

groin, buttock, or medial side of thigh or knee.

Sitting down becomes difficult, as does getting up from a chair when hips are lower than knees.


Clinical ManifestationsJoints Joint stiffness occurs after

periods of rest or static position.

Early morning stiffness usually resolves within 30 minutes.

Overactivity can cause mild joint effusion, temporarily ↑ stiffness


Clinical ManifestationsJoints Crepitation can also cause

stiffness. Grating sensation caused by loose

particles of cartilage in joint cavity Indicates loss of cartilage integrity Present in >90% of patients with

knee OA OA usually affects joints

asymmetrically.


Clinical ManifestationsJoints Most commonly involved joints

Joints of the fingers Distal interphalangeal (DIP) Proximal interphalangeal (PIP) Metacarpophalangeal (MCP) joint

Weight-bearing joints: hips, knees Metatarsophalangeal (MTP) joint

of foot Cervical and lower lumbar

vertebrae


Clinical ManifestationsJoints


Fig. 65-2. Joints most frequently involved in osteoarthritis.

Clinical ManifestationsDeformity Specific to involved joint Can appear as early as age

40 Tends to be seen in family

members


Clinical ManifestationsDeformity Heberden’s and Bouchard’s

nodes Red, swollen, and tender Visible disfigurement

Can cause patient to be distressed Does not cause significant loss

of function Osteophyte formation and loss

of joint space


Clinical ManifestationsDeformity Knee OA often leads to joint

malalignment. Result of cartilage loss in

medial compartment Bowlegged appearance Altered gait

Advanced hip OA may cause one leg to be shorter.


Diagnostic Studies In early OA tests

Detect joint changes Bone scan, computed tomography

(CT) scan, magnetic resonance imaging (MRI)

In progressed OA Detect joint space narrowing,

bony sclerosis, osteophyte formation X-rays


Diagnostic Studies No laboratory abnormalities or

biomarkers have been identified.

Routine blood tests are useful in Screening for related conditions Establishing baselines from

therapyCopyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Collaborative Care Focuses on

Managing pain and inflammation Preventing disability Maintaining and improving joint

function Foundation for OA management is

nonpharmacologic interventions. Drug therapy serves as an

adjunct.


Collaborative Care Arthroscopic surgery

Debridement is usually not recommended.

Effective in reducing pain and improving function when it is used to Repair ligament tears Remove bone bits or cartilage


Collaborative Care Rest and Joint Protection Patient must understand importance

of balancing rest and activity. During any periods of acute

inflammation, affected joint should be Rested Maintained in a functional position

With splints or braces if necessary Immobilization should not exceed 1

week.


Collaborative Care Heat and Cold Applications May help reduce pain and

stiffness Heat is used more often than ice.

Ice appropriate for acute inflammation

Heat therapy is especially helpful for stiffness. Hot packs, whirlpool baths,

ultrasound, paraffin wax baths


Collaborative Care Nutritional Therapy and Exercise Weight-reduction program is

critical for overweight patient. Exercise is a fundamental part

of OA management. Load on joints and degree of

joint mobilization are essential for preservation of articular cartilage integrity.


Collaborative Care Complementary /Alternative Therapies Acupuncture Yoga Massage Guided imagery Therapeutic touch Nutritional supplements

(glucosamine, chondroitin sulfate)


Collaborative Care Drug Therapy Based on severity of patient’s

symptoms Mild to moderate joint pain

Acetaminophen (1000 mg every 6 hours)

Topical agent (e.g., capsaicin cream [Zostrix])

Topical salicylates (e.g., Aspercreme)

Hyaluronic acid (HA)


Collaborative Care Drug Therapy Based on severity of

patient’s symptoms (cont’d) Moderate to severe joint pain

Nonsteroidal antiinflammatory drug (NSAID)


Nursing Management Carefully assess and

document patient’s joint pain and stiffness. Type Location Severity Frequency Duration


Nursing Management Question

Extent to which symptoms affect ability to perform activities of daily living

Duration and success of treatment for each intervention

Physical examination Tenderness, swelling, limitation

of movement, crepitation


Nursing Diagnoses Acute and chronic pain

Physical activity Lack of knowledge of pain

self-management techniques Insomnia Impaired physical mobility

Weakness, stiffness, or pain on ambulation


Nursing Diagnoses Self-care deficits

Joint deformity Pain with activity

Imbalanced nutrition: less than body requirements

Chronic low self-esteem Changing physical appearance


Planning Overall goals

Maintain or improve joint function through a balance of rest and activity.

Use joint protection measures to improve activity tolerance.


Planning Overall goals (cont’d)

Achieve independence in self-care and maintain optimal role function.

Use pharmacologic and nonpharmacologic strategies to manage pain.


Nursing Implementation Prevention is not possible. Community education should

focus on Alteration of modifiable risk

factors Weight loss Occupational and recreational

hazards Athletic instruction and physical

fitness program safety measures


Nursing ImplementationAcute Intervention Frequent complaints of OA

patients Pain Stiffness Limitation of function Frustration of coping with physical

difficulties on a daily basis Usually treated on an outpatient

basis


Nursing ImplementationAcute Intervention Health assessment

questionnaires used to pinpoint areas of difficulty

Questionnaires are updated regularly.

Treatment goals developed based on data from questionnaires and physical examination


Nursing ImplementationAcute Intervention Drugs administered for relief

of pain and inflammation After an acute flare, a physical

therapist can assist in planning an exercise program. Tai Chi

Emphasize importance of warming up.


Nursing ImplementationAcute Intervention Patient and family teaching is an

important foundation for successful management of OA.

Teach Information about nature and

treatment of disease and pain management

Correct posture and body mechanics Correct use of assistive devices


Nursing ImplementationAcute Intervention Teach (cont’d)

Principles of joint protection and energy conservation

Nutritional choices Weight and stress management Therapeutic exercise program

Assure patient deformity is not usual course of OA.


Nursing ImplementationAmbulatory and Home Care Primary concerns

Chronic pain Loss of function of affected joints

Home management goals must be individualized to meet patient’s needs. Family members or significant

others should be included in goal setting and teaching.


Nursing ImplementationAmbulatory and Home Care Home and work environments

should be modified to maximize safety. Remove scatter rugs. Provide railing at stairs and bathtub. Use night lights. Wear well-fitting support shoes. Use assistive devices.

Canes, walkers, elevated toilet seats, grab bars


Evaluation Expected outcomes

Experience adequate amounts of rest and activity.

Achieve satisfactory pain management.

Maintain joint flexibility and muscle strength through joint protection and therapeutic exercise.


Evaluation Expected outcomes (cont’d)

Verbalize acceptance of OA as a chronic disease, collaborating with health care providers in disease management.


The nurse determines that teaching about The nurse determines that teaching about management of osteoarthritis of the feet and hands management of osteoarthritis of the feet and hands has been effective when the patient says,has been effective when the patient says,

1. “I will be careful to avoid crowds and people with 1. “I will be careful to avoid crowds and people with infections.” infections.” 2. “I can use heat to relieve the stiffness when I 2. “I can use heat to relieve the stiffness when I wake up in the morning.” wake up in the morning.” 3. “I should exercise my hands every day, especially 3. “I should exercise my hands every day, especially if they are painful and inflamed.”if they are painful and inflamed.”4. “I should avoid the use of glucosamine as it has 4. “I should avoid the use of glucosamine as it has been shown to have no therapeutic value.”been shown to have no therapeutic value.”

Audience Response Question


Case Study


Case Study 47-year-old man presents to

a clinic complaining of pain in his right knee with activity.

Negative history for illnesses or trauma


Case Study He used to play soccer

regularly but has not played in 10 years.

He claims the pain prevents him from playing football with his teenage son.


Case Study No swelling of the knee is noted,

but crepitation is present.

MRI is ordered. It shows articulation of femur and

tibia.

His physician prescribes rest for his knee with a follow-up in 3 months.


Discussion Questions1.He asks you what he can

take for pain relief over the next 3 months. What can you tell him?

2.What alternative therapies may benefit him?


Discussion Questions3. What patient teaching

should you perform with him?

4. What type of physical activity is advisable for him?


Date post:	26-Dec-2015
Category:	Documents
Upload:	branden-holmes
View:	216 times
Download:	0 times

Focus on Osteoarthritis (Relates to Chapter 65, “Nursing Management: Arthritis and Connective...

Documents