1. Arthritis Osteoarthritis (OA)
Most common form of joint (articular) disease
Previously called degenerative joint disease
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

2. 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

3. 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

5. Osteoarthritis Etiology & Pathophysiology

7. 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

8. Osteoarthritis Most Involved Joints

9. 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

10. 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

11. Osteoarthritis Diagnostic Studies
Bone Scan CT
MRI
General x-ray
Radiologic changes do not correlate with the degree of disease

12. Osteoarthritis Treatment Goals
No cure
Focus:
Managing pain
Preventing disability
Maintaining and improving joint function

13. 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

14. 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

15. Osteoarthritis Treatment Goals
Surgical Treatment
Joint Replacement
Hip, Knee, Shoulder
Spinal Surgery –
Diskectomy /spinal fusion

18. Spine Surgery for Arthritis
The Spine
Spine Surgery for Arthritis

19. Degenerative Disc Disease

20. Lumbar Spinal Stenosis

21. 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

22. 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

23. Rheumatoid Arthritis (RA)
Chronic, systemic disease
Inflammation of connective tissue in the diarthrodial (synovial) joint
Periods of remissions & exacerbation
Extraarticular manifestations

24. Rheumatoid Arthritis (RA) Etiology & Pathophysiology
Cause – unknown
Autoimmune – most widely accepted theory
Antigen/abnormal Immunoglobulin G (IgG)
Presence of autoantibodies –
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

25. Rheumatoid Arthritis

26. Osteoarthritis Rheumatoid Arthritis

28. 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

29. 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

30. 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

31. Rheumatoid Arthritis Clinical Manifestations

32. 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

33. 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

34. 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

35. 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

37. 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

38. 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