1. Nursing Management: Osteoarthritis and Rheumatoid Arthritis
Today’s topic is nursing management for people diagnosed with osteoarthritis and rheumatoid arthritis

2. What is it? Arthritis Prevalence Disability
Over 100 different types
Prevalence
52.5 million adults, 1 in 5 (CDC)
Disability
Osteoarthritis and Rheumatoid Arthritis
Arthritis is inflammation of a joint. Rheumatic disease includes the joints, but may also involve many other parts of the body. There are over 100 different types of arthritis and rheumatic disease.
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According to the CDC, arthritis affects 52.5 million adults in the U.S. – which is approximately 1 in 5 adults.
In addition, the CDC reports that arthritis is the most commonly reported cause of disability in the U.S. Based on 2012 survey, an estimated 22.7 million adults have arthritis and arthritis-attributable activity limitation.
Of the many types of arthritis, osteoarthritis and rheumatoid arthritis are the most common, which will be the focus of this presentation.

3. Etiology Idiopathic Secondary Unknown Autoimmune (?) Osteoarthritis
Rheumatoid Arthritis
Idiopathic
Unknown
Secondary
Cartilage damage or joint instability
Unknown
Autoimmune (?)
Osteoarthritis and rheumatoid arthritis, which I will interchangeably refer to as “OA” or “RA,” have differing etiologies.
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The cause of osteoarthritis may be either idiopathic or secondary.
The underlying cause of idiopathic osteoarthritis is unknown, whereas with [click] secondary osteoarthritis, there is an identifiable event or condition that caused initial cartilage damage or joint instability. An example could be a repetitive use injury from participation in sports.
With rheumatoid arthritis, the exact cause is unknown, but is thought to be an [click] an autoimmune response.

4. This slide shows the pathologic changes that take place with osteoarthritis. This figure depicts a normal synovial joint
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Figure B shows early changes from osteoarthritis, including destruction of articular cartilage, narrowing of the joint space, and inflammation and thickening of the joint capsule and synovium.
This figure shows additional changes over time. Constant friction on the two bone surfaces from loss of cartilage cause thickening of the subchondral bone. Bony outgrowth begins to form at the periphery of the joint.
This last image shows Heberden’s nodes, found on the distal interphalangeal joints of the fingers, commonly noted in people with osteoarthritis.

5. Similar to the previous slide, this slide depicts the pathologic changes that take place with rheumatoid arthritis. This first shows early pathologic changes, including a thickened and inflamed synovium with lymphocyte infiltration.
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Over time, vascular granulation tissue grows along the surface of the cartilage, and the articular cartilage begins to breakdown at the periphery.
As the disease progresses, inflammation continues and leads to focal destruction of the bone, leading to joint deformities…
…as you can see in this last image.

6. Clinical Manifestations
Osteoarthritis
Rheumatoid Arthritis
Age at onset
Usually > 40
Young to middle
age
Gender
F to M ratio is
3:1
Before 50, M>F
After 50, F>M
Systemic (Y/N) No
Yes
Pain hr
AM stiffness
< 30 min, á
with use, â
with rest
AM stiffness > 1 ,
may
with use
The clinical manifestations of osteo- and rheumatoid arthritis are similar, but differ in several key areas, which we will look at in these next two slides.
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Osteoarthritis usually appears after age 40, whereas rheumatoid arthritis can begin at a very young age.
At all ages, females are more likely than males to have osteoarthritis, at a ratio of 3:1. With rheumatoid arthritis however, gender differences vary with age. Before age 50, it is more common in males but after age 50, it is more common in females.
Osteoarthritis only manifests with joint symptoms, whereas rheumatoid arthritis may also present with additional systemic symptoms.
Persons with osteoarthritis often experience joint pain on waking in the morning, but this stiffness typically goes away within 30 minutes. Joint pain may also increase with use, but will decrease following rest. Morning stiffness may also be present with rheumatoid arthritis, but typically takes much longer to resolve than with osteoarthritis. Also, in contrast to osteoarthritis, rheumatic joint pain may actually decrease with use.
Clinical Manifestations

7. Clinical Manifestations
Osteoarthritis
Rheumatoid Arthritis
Affected Joints
Often asymmetric, weight -
bearing
joints first
Usually
symmetrical, small
Deformity
Heberden’s
(DIP) and
Bouchard’s (PIP) nodes
Ulnar
drift, swan neck,
Boutonnière
, subluxation
Disease
Localized disease with
variable, progressive
course
Systemic disease with
exacerbations
and remission
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Osteoarthritis may affect joints asymmetrically, and typically affect weight-bearing joints first. Rheumatoid arthritis is usually symmetrical and affects small joints, such as those of the fingers, first.
Heberden’s and Bouchard’s nodes are often seen with osteoarthritis. Deformities such as: ulnar drift, swan neck, Boutonniere, and subluxation are common with rheumatoid arthritis.
Osteoarthritis is usually a localized disease that has a variable and progressive course. Rheumatoid arthritis, on the other hand, is usually a systemic disease with periods of exacerbation and remission.
Clinical Manifestations

8. Typical deformities of rheumatoid arthritis. A, Ulnar drift
Typical deformities of rheumatoid arthritis. A, Ulnar drift. B, Boutonnière deformity. C, Hallux valgus. D, Swan neck deformity.
This image shows the deformities that are often present with rheumatoid arthritis. Figure A shows ulnar drift of the hand. Figure B shows Boutonneire’s deformity. Figure C shows Hallux valgus, which is more commonly known as a bunion. And Figure D demonstrates the swan neck deformity.

9. Is it intra- or extra-articular? Is it acute or chronic?
Musculoskeletal Complaint
Use initial assessment to determine:
Is it intra- or extra-articular?
Is it acute or chronic?
Is inflammation present?
How many/which joints are involved?
Is involvement symmetric?
When someone presents with a musculoskeletal complaint, [click] the initial assessment should be used to help answer the following questions:
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Is the pain intra- or extra-articular?
Is the pain acute or chronic?
Is there any inflammation?
How many joints are involved, and which ones?
Is the involvement just on one side, or one both sides of the body?
Answering these questions can help identify whether the person is experiencing osteoarthritis, rheumatoid arthritis, or some other musculoskeletal disorder. Once the specific disorder is identified, an appropriate treatment plan can be developed.

10. Assessment: Subjective
History of present illness: Symptoms Past Medical History: Medical & Surgical Hx, trauma, medication hx, menopause Social History: Diet, exercise, repetitive physical activity (sports and/or occupation) Family History: Genetic factors (RA)
Both subjective and objective data are collected during the initial exam.
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Begin by inquiring about the presenting symptoms, and the reason that the person is seeking care. Be sure to include a discussion of when the symptoms began and any precipitating factors.
Past medical history should include a thorough investigation of prior medical and surgical problems, including trauma or injury to the joints, medication history, and timing of menopause – when applicable.
The social history should include an inquiry into diet and weight, amount and type of exercise, and participation in repetitive physical activity such as certain sports or occupations that require frequent kneeling.
A family history should be conducted to look into potential genetic factors, particularly related to rheumatoid arthritis, which may have significant hereditary influence for certain people.

11. Assessment: Objective
General: VS, appearance, demeanor, affect MSK: Symmetry, surrounding tissues, ROM, muscle strength, swelling, warmth, tenderness, redness Integument: Keratoconjunctivitis, subcutaneous rheumatoid nodules, skin ulcers Sjögren’s syndrome:  lacrimal and salivary secretion GI: Splenomegaly (Felty syndrome)
General objective data include vital signs, overall appearance, demeanor, and affect.
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A focused musculoskeletal assessment should be completed, paying attention to symmetry, the condition of surrounding tissues, range of motion of the affected joints, muscle strength and tone, and the presence of any swelling, warmth, tenderness, or redness.
Rheumatoid arthritis may also have integumentary manifestations including kerato-conjunctivitis, subcutaneous nodules, or ulcers related to swelling or deconditioning
Sjögren’s syndrome occurs in 10-15% of persons with rheumatoid arthritis, and may also occur by itself or with other autoimmune disorders. Decreased lacrimal and salivary secretion typically lead to dry mouth, burning/gritty/itchy eyes with decreased tearing, and photosensitivity.
Splenomegaly may be present in persons with Felty syndrome, which most commonly occurs in patients with severe, nodule-forming rheumatoid arthritis. Other manifestations of Felty syndrome include: inflammatory eye disorders, lymphadenopathy, pulmonary disease, and blood dyscrasias

12. Labs & Diagnostics Labs: Rheumatoid Factor, Anti-CCP, ESR, CRP
Imaging: X-ray, bone scan, CT, or MRI
Other tests: Synovial fluid analysis
By Bernd Brägelmann Braegel with Dr. Martin Steinhoff (Own work) [GFDL or CC BY 3.0], via Wikimedia Commons
Diagnosis of arthritis is often made based on a thorough history and physical, but certain laboratory tests may be used to confirm the diagnosis or to monitor progression of the disorder
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Serum labs may include rheumatoid factor, anti-CCP, ESR, or CRP – all of which may be present to varying degrees in persons with rheumatoid arthritis, but are typically within normal limits in persons with osteoarthritis.
Imaging studies often include a-rays of the affected joints, such as the image here showing deformities commonly seen in persons with rheumatoid arthritis. Other imaging studies may include a bone scan, CT, or MRI.
Synovial fluid analysis can be helpful for differentiating between types of arthritis. With osteoarthritis, the synovial fluid remains clear yellow, but with rheumatoid arthritis signs of inflammation are often present – such as an elevated white blood cell count.

13. Physiological: ABCD Acute or chronic pain Impaired physical mobility
Self-care deficit
Nursing management of the person with arthritis should be prioritized in order of physiologic need, according to the ABCDs of Airway, Breathing, Circulation, and Disability.
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Acute or chronic pain may be related to joint inflammation, misuse of joints, physical activity or inactivity, or ineffective pain self-management techniques
Impaired physical mobility is often related to weakness, stiffness, deformity, or pain
In addition, Self-care deficit can become a major concern also related to joint deformity, weakness, and/or pain

14. Psychological Chronic low self-esteem Disturbed body image
Psychological concerns may be a significant issue in persons with arthritis.
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Chronic low self-esteem may develop related to changing physical appearance and social and work roles.
Disturbed body image may also be a problem, related to deformities, progressive chronic deterioration, and/or inability to perform usual activities

15. Interventions Monitor: Pain, ROM, participation in ADLs Administer:
Medications: NSAIDS, DMARDS
Pain-relieving measures: therapeutic heat/cold, rest, relaxation techniques, biofeedback, TENS, splints, psychologic support
Nursing interventions should be prioritized according to physiologic and psychologic need.
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Pain, range of motion, and ability to participate in and carry out activities of daily living should be monitored.
Administration of certain medications may be indicated. With osteoarthritis, drug therapy is based on the severity of symptoms. Non-steroidal anti-inflammatory medications are typically used first. Hyaluronic acid, a type of viscosupplementation, may also be used for persons with mild to moderate knee osteoarthritis. Disease-modifying anti-rheumatic drugs, also called DMARDS, are now extensively used to treat rheumatoid arthritis. Many of these drugs are expensive, and the specific drug that is chosen will depend on the severity of the disease, functional limitations, and other lifestyle considerations. Examples of DMARDS include: hydroxychloroquine, sulfasalazine, leflunomide, anti-inflammatories such as methotrexate, and biologic or targeted therapies including etanercept and infliximab.
Non-pharmacologic pain-relieving measures are also very important to include in the treatment plan. These may include therapeutic heat or cold, rest, relaxation techniques, biofeedback, transcutaneous electrical nerve stimulation, splints, or psychologic support.

16. Interventions Support & Educate: Use of assistive devices
Joint protection and energy conservation
Therapeutic exercise
Nutrition and weight management
National Institute of Arthritis and Musculoskeletal and Skin Diseases, Public Domain
Additional nursing interventions include supporting and educating the patient and their family or caregivers.
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Teaching should be completed on proper use of assistive devices such as a cane or walker.
Maintenance of joint function can maximized through joint protective measures and energy conservation strategies. The nurse should ensure that the person understands the importance of balancing rest and activity and can identify methods to simplify and space out important tasks.
Therapeutic exercise should be encouraged in order to maintain strength, promote heart and lung health, and maximize range of motion.
If the person is overweight, a weight-reduction plan is often included in the plan of care. Maintenance of joint function is a priority and extra weight adds stress to the load-bearing joints.

17. Evaluation: Desired Outcomes
Maintenance or improvement in joint function
Effective use of joint protective measures
Management of pain through the use of both pharmacologic and non-pharmacologic strategies
The overall goal of care for a person with arthritis is to maximize function and manage pain.
Specific desired outcomes should be identified based on an individualized plan of care and may include:
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Maintenance or improvement in joint function
Effective use of joint protective measures
Management of pain through the use of both pharmacologic and non-pharmacologic strategies

18. Evaluation: Desired Outcomes
Achievement of maximal amount of independence with ADLs
Maintenance of a positive self-image
Achievement of maximal amount of independence with ADLs
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And maintenance of a positive self-image
This concludes the presentation on nursing management of the person with arthritis.