Focus on Osteoarthritis (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.

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 Osteoarthritis involves the formation of new joint tissue in response to cartilage destruction. 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 Few patients experience symptoms until after age 50 or 60, but more than half of those older than 65 years of age have x-ray evidence of the disease in at least one joint. Women are affected more often than men, and they may have more severe OA. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 3

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 See Table 65-1 for more information. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 4

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. Anterior cruciate ligament injury, which is associated with quick stops and pivoting as in football and soccer, has been linked to increased risk of knee OA. Occupations that require frequent kneeling and stooping are also linked to higher risk of knee OA. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 5

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 use The body’s attempts at cartilage repair cannot keep up with the destruction that is occurring. Continued changes in the collagen structure of the cartilage lead to fissuring and erosion of the articular surfaces. As the central cartilage becomes thinner, cartilage and bony growth (osteophytes) increase at the joint margins. {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 6

Etiology and Pathophysiology A, Normal synovial joint. B, Early change in osteoarthritis is destruction of articular cartilage and narrowing of the joint space. Inflammation and thickening of the joint capsule and synovium are noted. C, With time, thickening of subarticular bone is caused by constant friction of the two bone surfaces. Osteophytes form around the periphery of the joint through irregular overgrowth 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. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 7

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. The pain of later disease results from contact between exposed bony joint surfaces after the articular cartilage has deteriorated completely. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 8

Clinical Manifestations Systemic 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]) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 9

Clinical Manifestations Joints 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 Joint pain is the predominant symptom of OA and the typical reason that the patient seeks medical attention. Pain may also become worse as the barometric pressure falls before inclement weather. As OA progresses, increasing pain can contribute significantly to disability and loss of function. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 10

Clinical Manifestations Joints 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. As OA develops in the intervertebral (apophyseal) joints of the spine, localized pain and stiffness are common. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 11

Clinical Manifestations Joints 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 12

Clinical Manifestations Joints 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 13

Clinical Manifestations Joints 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 {See next slide for figure.} Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 14

Clinical Manifestations Joints Fig. 65-2. Joints most frequently involved in osteoarthritis. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 15

Clinical Manifestations Deformity Specific to involved joint Can appear as early as age 40 Tends to be seen in family members For example, Heberden’s nodes occur on the DIP joints as an indication of osteophyte formation and loss of joint space. Bouchard’s nodes on the PIP joints indicate similar disease involvement. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 16

Clinical Manifestations Deformity 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 17

Clinical Manifestations Deformity 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 18

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 X-rays are helpful in confirming disease and staging the progression of joint damage. Changes seen on an x-ray do not always correlate with the degree of pain experienced by the patient. Despite significant radiologic indications of disease, the patient may be relatively free of symptoms. Conversely, another patient may have severe pain with only minimal x-ray changes. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 19

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Diagnostic Studies No laboratory abnormalities or biomarkers have been identified. Routine blood tests are useful in Screening for related conditions Establishing baselines from therapy The erythrocyte sedimentation rate (ESR) is normal except in instances of acute synovitis, when minimal elevations may be noted. Synovial fluid analysis allows differentiation between OA and other forms of inflammatory arthritis. In the presence of OA, the fluid remains clear yellow with little or no sign of inflammation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 20

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. See Table 65-2 for more information. Nonpharmacologic interventions should be maintained throughout the patient’s treatment period. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 21

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Symptoms of disease are often managed conservatively for many years, but the patient’s loss of joint function, unrelieved pain, and diminished ability to independently perform self-care may prompt a recommendation for surgery. Arthroscopic surgery for knee OA remains widely practiced, although recent randomized controlled trials showed no benefit in reducing patient pain and improving function. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 22

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. Immobilization should not exceed 1 week because of the risk of joint stiffness with inactivity. The patient may need to modify his or her usual activities to decrease stress on affected joints. For example, the patient with knee OA should avoid prolonged periods of standing, kneeling, or squatting. Using an assistive device such as a cane, walker, or crutches can help decrease stress on arthritic joints. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 23

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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 24

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. Aerobic conditioning, range-of-motion exercises, and specific programs for strengthening the quadriceps have been beneficial for many patients with knee OA. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 25

Collaborative Care Complementary /Alternative Therapies Acupuncture Yoga Massage Guided imagery Therapeutic touch Nutritional supplements (glucosamine, chondroitin sulfate) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 26

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) Zostrix blocks pain by locally interfering with substance P, which is responsible for the transmission of pain impulses. A concentrated product is available by prescription, but creams of 0.025% to 0.075% capsaicin are sold over the counter. Because effects of topical agents are not sustained, several applications may be needed daily. Synthetic and naturally occurring HA derivatives (Orthovisc, Synvisc, Supartz, Nuflexxa, Hyalgan) are administered in three weekly injections directly into the joint space. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 27

Collaborative Care Drug Therapy Based on severity of patient’s symptoms (cont’d) Moderate to severe joint pain Nonsteroidal antiinflammatory drug (NSAID) NSAID therapy typically is initiated in low-dose OTC strengths (ibuprofen [Motrin] 200 mg up to 4 times daily), with the dose increased as patient symptoms indicate. If the patient is at risk for or experiences gastrointestinal (GI) side effects with a conventional NSAID, supplemental treatment with a protective agent such as misoprostol (Cytotec) may be indicated. As an alternative to traditional NSAIDs, treatment with the COX-2 inhibitor celecoxib (Celebrex) may be considered in selected patients. Intraarticular injections of corticosteroids may be appropriate for the elderly patient with local inflammation and effusion. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 28

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Management Carefully assess and document patient’s joint pain and stiffness. Type Location Severity Frequency Duration Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 29

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Compare an involved joint with the contralateral joint if it is not affected. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 30

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Nursing Diagnoses Self-care deficits Joint deformity Pain with activity Imbalanced nutrition: less than body requirements Chronic low self-esteem Changing physical appearance Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Planning Overall goals Maintain or improve joint function through a balance of rest and activity. Use joint protection measures to improve activity tolerance. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 33

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Planning Overall goals (cont’d) Achieve independence in self-care and maintain optimal role function. Use pharmacologic and nonpharmacologic strategies to manage pain. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34

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 Congenital conditions, such as Legg-Calvé-Perthes disease, that are known to predispose a patient to the development of OA should be treated promptly. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 35

Nursing Implementation Acute 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 The older adult may believe that OA is an inevitable part of aging, and that nothing can be done to ease the discomfort and related disability. The patient with OA is often treated by an interdisciplinary team of health care providers that includes a rheumatologist, a nurse, an occupational therapist, and a physical therapist. The patient is usually hospitalized only if joint surgery is planned. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 36

Nursing Implementation Acute 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 37

Nursing Implementation Acute 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. Nonpharmacologic pain management strategies may include massage, the application of heat (thermal packs) or cold (ice packs), relaxation, and guided imagery. Splints may be prescribed to rest and stabilize painful or inflamed joints. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38

Nursing Implementation Acute 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 39

Nursing Implementation Acute 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. The patient can also gain support and understanding of the disease process through community resources such as the Arthritis Foundation’s Self-Help Course (www.arthritis.org). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 40

Nursing Implementation Ambulatory 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 41

Nursing Implementation Ambulatory 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 The nurse should urge the patient to continue all prescribed therapies at home and should be open to discussion of new approaches to symptom management. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 42

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 43

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Evaluation Expected outcomes (cont’d) Verbalize acceptance of OA as a chronic disease, collaborating with health care providers in disease management. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 44

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Audience Response Question The nurse determines that teaching about management of osteoarthritis of the feet and hands has been effective when the patient says, 1. “I will be careful to avoid crowds and people with infections.” 2. “I can use heat to relieve the stiffness when I wake up in the morning.” 3. “I should exercise my hands every day, especially if they are painful and inflamed.” 4. “I should avoid the use of glucosamine as it has been shown to have no therapeutic value.” Answer: 2 Rationale: Effective management of osteoarthritis includes the following: heat therapy for stiffness, including hot packs, whirlpool baths, ultrasound, and paraffin wax baths; the affected joint should be rested during any periods of acute inflammation and maintained in a functional position with splints or braces if necessary; cortisone injections have a local effect, and the patient will not develop immunosuppression; nutritional supplements such as glucosamine and chondroitin sulfate may be helpful in some patients for relieving moderate to severe arthritis pain in the knees and improving joint mobility. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 45 45

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 46

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 47

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 48

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 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. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 49

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions He asks you what he can take for pain relief over the next 3 months. What can you tell him? What alternative therapies may benefit him? He should begin by taking acetaminophen (Tylenol). He can also use capsaicin cream (Zostrix) and topical salicylates (e.g., Aspercreme). If pain persists, he may use ibuprofen 200 mg up to 4 times daily. Acupuncture has been found to relieve OA pain of the knee. He may also use yoga, massage, guided imagery, and therapeutic touch. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 50

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Discussion Questions What patient teaching should you perform with him? What type of physical activity is advisable for him? 3. Teach the nature and treatment of the disease, pain management, correct posture and body mechanics, correct use of assistive devices such as a cane or walker, principles of joint protection and energy conservation, nutritional choices, weight and stress management, and a therapeutic exercise program. 4. After resting the joint for 3 weeks, he may begin a therapeutic exercise program, such as Tai Chi or yoga. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 51