2. Osteoarthritis
Osteoarthritis (OA) or degenerative joint disease (DJD) is a
disorder characterized by progressive deterioration of the
articular cartilage.
Most common joint disease
It is a noninflammatory (unless localized), no systemic disease.
3. Cont.…
Minimal inflammatory component
Differentiated from inflammatory disease by:
Absence of synovial membrane inflammation
Lack of systemic signs and symptoms
Normal synovial fluid
Much of the pain and loss of mobility associated with aging.
4. Cont.…
As the cartilage wears away, the joint space decreases, so
that the bone surfaces are closer and rub together.
In an attempt to repair the damaged surface, new bone
develops in the form of bone spurs, bone cysts, or
osteophytes, which are extended margins of the joints.
The joint becomes deformed, and the client experiences
pain and limited joint movement.
6. Classified
o Primary, when the etiology is unknown, or
o Secondary, when OAhas an underlying cause such as
injury or a congenital disorder.
7. SIGNS AND SYMPTOMS
Stiff joints for short time in morning, usually 15 minutes or less due to
changes within joints
Joint pain with movement or weight bearing due to joint remodeling
Crepitus (grating feeling on palpation over joint during range of motion)
due to loss of articular cartilage and bony overgrowth in joint
Pain relief when joints are rested because lack of movements will relieve
irritation in joint space
Enlargement of joint due to bony overgrowth or remodeling
Heberden’s nodes—swelling of the distal interphalangeal joints
Bouchard's nodes;- swelling of proximal interphalangeal joints
9. TEST RESULTS
X-ray shows narrowed joint spaces, bone divisions, or
osteophytes around joints.
Tests for inflammation will be normal
10. Medical Treatment
Analgesics and anti-inflammatory drugs (NSAIDs)
Injections of corticosteroids or sodium hyaluronate (to improve
lubrication)
Intra-articular injections of corticosteroid up to 3 or 4 times in a year
Range of motion exercises
Surgical removal of bone divisions, and other
Replacement of joint
11. Nursing Intervention
Instruct the client on proper body mechanics.
local rest of the affected joints, heat applied to the painful
part, weight loss.
Splints, braces, canes, or crutches may reduce discomfort,
relieve pain, and prevent further destruction of the affected
joints.
12. Rheumatoid Arthritis
is a chronic, progressive inflammatory disease that can affect tissues
and organs but principally attacks the joints producing an
inflammatory synovitis.
It involves joints bilaterally and symmetrically, and it typically
affects several joints at one time.
RA typically affects upper joints first.
13. Cont.….
RA is an autoimmune disease that is precipitated by WBCs
attacking synovial tissue.
The WBCs cause the synovial tissue to become inflamed and
thickened.
The inflammation can extend to the cartilage, bone, tendons,
and ligaments that surround the joint.
Joint deformity and bone erosion may result from these
changes, decreasing the joint’s range of motion and function.
15. Cause
Idiopathic disease
Immune-mediated destruction of joints
Rheumatoid factors (IgM and IgG) target blood cells and
synovial membranes forming antigen-antibody complexes
Genetic predisposition
Possibly bacterial or viral infection (Epstein-Barr)
16. Clinical Manifestation
Chronic inflammation of synovial membrane
Cellular proliferation and damage to the microcirculation
Synovial membrane becomes irregular
Swelling, stiffness and pain
Cartilage and bone destruction
Ankylosis or fusing of joint
Ligaments and tendons also affected
17. Diagnosis
Evaluation :
history
Physical examination
X-ray
Serologic tests for rheumatoid factor and circulating antigen-
antibody complexes, esp. antibodies against cyclic citrullinated
peptide (CCP)
No cure
18. Treatment
NSAIDs provide analgesic, antipyretic, and anti-inflammatory effects.
NSAIDs can cause considerable gastrointestinal (GI) distress.
Corticosteroids (prednisone) are strong anti-inflammatory medications
that may be given for acute exacerbations or advanced forms of the
disease.
They are not given for long-term therapy due to significant adverse
effects (osteoporosis, hyperglycemia, immunosuppression, cataracts).
20. Nursing Intervention
Apply heat or cold to the affected areas as indicated based on client
response.
Assist with and encourage physical activity to maintain joint
mobility (within the capabilities of the client).
Administer medications and proper positioning as prescribed.
Monitor for medication effectiveness (reduced pain, increased
mobility).
Teach the client regarding signs/symptoms that need to be reported
immediately (fever, infection, pain upon inspiration, pain in the
substernal area of the chest).
21. Osteomyelitis
Osteomyelitis is an infection of the bone.
In an adult, it is most commonly due to direct contamination of
the site during trauma, such as an open fracture.
Bacteria that cause infections elsewhere in the body may also
enter the bloodstream and become deposited into the bone,
starting a secondary infection site there.
This is more common in children and adolescents.
22. Cont.….
Acute infection is associated with inflammatory changes in
the bone and may lead to necrosis.
Some patients will develop chronic osteomyelitis.
23. Causative organism
The causative organism is not always identified.
More than three-quarters of the identified organisms are
Staphylococcus aureus/streptococus.
24. Clinical Manifestation
Typical signs and symptoms :
Acute osteomyelitis include:
• Fever that may be abrupt
• Irritability or lethargy in young children
• Pain in the area of the infection
• Swelling, warmth and redness over the area of the infection
Chronic osteomyelitis include:
• Pain or tenderness in the affected area
• Chronic fatigue
• Drainage from an open wound near the area of the infection
• Fever, sometimes
25. TEST RESULTS
Elevated white blood count (WBC).
X-ray osteolytic lesions (localized loss of bone density).
Culture and sensitivity tests to determine the infecting organism and
antibiotic—may be difficult to determine infecting organism.
Bone biopsy to identify organism.
26. Treatment
Debridement of the area to remove necrotic tissue.
Drain the infected site.
Immobilize or stabilize the bone if necessary.
Administer antibiotics parenterally for 4 to 6 weeks or
orally for 6 to 8 weeks:
Vancomycin 1g iv bid for 4 to 6 weeks
Cloxacillin 500mg po QID for 6 to 8 weeks.
27. Cont.…
Administer analgesic to relieve discomfort as needed:
• ibuprofen, acetaminophen
If there is vascular insufficiency or gangrene, amputation
may be needed.
28. Nursing Intervention
Monitor vital signs, changes in blood pressure, elevated pulse,
elevated temperature and respiratory rate.
Monitor wound site for redness, drainage, and odor.
Monitor IV access site for patency.
Explain to the patient:
• When and how to take medications.
• Importance of completing antibiotic medication.
• How to flush venous access device.
• Signs of infiltration, clotting of venous access device.
• When to call for assistance with venous access.
29. Septic arthritis
• Refers to bacterial infection resulting inflammatory destruction of
joints.
• Is highly destructive to the joint and is considered a medical
emergency.
• It is commonly hematogenous in origin (80-90%), contiguous spread
(10-15%), and direct penetration of microorganisms secondary to
trauma, surgery or injection.
• It is more common in children. In adults old age, diabetes mellitus,
skin infection, alcoholism, intra-articular steroid injections are some of
the common risk factors.
30. Cause
• Staphylococcus aureus is the most common cause.
• Group B Streptococci and other gram positive are also
frequent causes.
• Gram-negative bacilli are found as causes in specific
situations such as trauma, immunosuppression and very
elderly.
• Gonococcal arthritis is an infectious arthritis which should
be considered in sexually active young adults with culture
negative arthritis.
31. Clinical features
Joint pain, Erythema ,swelling, warmth
Restricted movement
Chills and rigors are not usually present
High grade feverand malaise
Altered gait- if weight bearing jointsare involved
Restricted rangeof movements
32. Lab Investigations
Joint (synovial fluid) fluid aspiration
Fluid should be aspirated before initiation of antibiotics.
The diagnosis of septic arthritis needs synovial fluid analysis.
Definitive diagnosis requires identification bacteria in the synovial fluid: gram
stain and/or culture.
Synovial fluid WBC count is usually >50,000/mm3 with predominate
neutrophils but a cell count.
Raised ESR, leukocytosis, positive blood or joint fluid cultures.
X-ray of the affected joint : to evaluate for possible associated
osteomyelitis
33. Treatment
Joint fluid drainage
All patients with septic arthritis needs joint fluid drainage.
The options are the following
Needle aspiration (arthrocentesis):
repeated aspirations until the effusion resolves
Arthroscopic drainage
Arthrotomy (open surgical drainage)
Indications for surgical drainage: hip joint involvement, failure to responds with
needle aspiration and antibiotics after 5-7 days
Splintage/immobilization may be needed for pain relief; however early
mobilization is encouraged once there is improvement.
34. Cont.….
Pharmacologic (Antibiotics)
As septic arthritis is destructive, empiric intravenous antibiotics
should be started immediately after taking synovial fluid samples.
The initial empiric antimicrobial choice should cover the most likely
pathogens. If the facility cannot carry a gram stain analysis the following
regimen is generally recommended.
First line –
Vancomycin, 30mg/kg/day IV in two divided doses, not to exceed
2g per day PLUS - Ceftriaxone, 2gm, IV, once daily or cefotaxime 2
g IV TID
Alternatives - Cloxacillin, IV, 2g . QID for 4-6 weeks OR -
Ceftriaxone 2gm, IV, once daily or cefotaxime 2 g IV TID
36. Gout arthritis
is a metabolic disorder in which the body does not
properly metabolize purine-based proteins.
As a result, there is an increase in the amount of uric acid,
which is the end product of purine metabolism.
As a result of hyperuricemia, uric acid crystals accumulate
in joints, most commonly the big toe (podagra), causing
pain when the joint moves.
37. Cont.…
Uric acid is cleared from the body through the kidneys.
These patients may also develop kidney stones as the uric acid
crystallizes in the kidney.
A person may also develop secondary gout.
is due to another disease process or use of medication, such as
thiazide diuretics or some chemotherapeutic agents.
38. Signs and Symptoms
Acute onset of excruciating pain in joint due to accumulation
of uric acid within the joint
Redness due to inflammation around the joint
Nephrolithiasis (kidney stones) due to uric acid deposits in
the kidney.
Joint pain, swelling, warmth
Restricted rangeof movements
39. TEST RESULTS
Elevated erythrocyte sedimentation rate (ESR).
Elevated serum uric acid level—not seen in all patients
with gout. Typical of primary gout patients prior to
episode of acute joint pain.
Elevated urinary uric acid levels.
Arthrocentesis shows uric acid crystals within the joint
fluid.
40. Treatment
Administer NSAID to decrease inflammation to aid in pain relief
indomethacin, ibuprofen.
Not aspirin; regular dosing causes retention of uric acid.
Administer uricosuric medications when the total body amount of
urate needs to be decreased.
Low-fat, low-cholesterol diet—elevated uric acid levels accelerate
atherosclerosis.
Immobilize the joint for comfort.
41. Nursing Intervention
Have the patient drink 3 liters of fluid per day to avoid
crystallization of uric acid in the kidneys.
Increased fluids help flush the uric acid through the kidneys.
Monitor uric acid levels in serum.
Assist with positioning for comfort.
Avoid touching inflamed joint unnecessarily. May need to keep
clothing or bed linen away from area.
Explain to patient:
Which foods are high-purine proteins- organ meats,
sardines, bacon.
Avoid alcohol, which inhibits renal excretion of uric acid.
42. Osteoporosis
is a decrease in bone density, making bones more brittle and it
becomes thinner and weaker, and more prone to fractures.
The body continuously replaces older bone with new bone
through a balance between the osteoblastic and osteoclastic
activity.
A disease in which loss of bone exceeds rate of bone formation;
Usually increase in older women.
43. Cont.…
• WHO defines osteoporosis by bone density:
Normal bone > 833 mg/cm2
Osteopenia 833 to 648 mg/cm2
Osteoporosis < 648 mg/cm2
44. Risk factors
Increased age,
Lack of physical activity
Poor nutrition
Osteoporosis can also occur as a secondary disease, due to
another condition.
Use of medications such as corticosteroids or
Some anticonvulsants,
Hormonal disorders (Cushing's or thyroid), and
Prolonged immobilization.
45. Signs and Symptoms
Asymptomatic
Back pain due to compression fractures in vertebral bodies
Loss of height
(kyphosis) due to pathologic vertebral fractures; collapsing of the
anterior portion of the vertebral bodies in the thoracic area
Fracture with minor trauma
46. TEST RESULTS
X-ray shows demineralization of the bone—not an early
sign.
Dual energy x-ray absorptiometry (DEXA) shows
decrease in bone mineral density in the hip and spine
compared to young normal patients, and compared to age-
matched, race-matched, sex-matched patients.
47. TREATMENT
Administer calcitonin nasal spray to increase bone density, also has
analgesic effect on bone pain after 2 to 4 weeks.
Administer selective estrogen receptor modulator for postmenopausal
women for prevention of osteoporosis:
Raloxifene
Administer vitamin D, which enhances the absorption of calcium;
many patients with osteoporosis are also deficient in vitamin D
Administer calcium, 1000 to 1500 mg per day in divided doses to
enhance absorption.
Perform range-of-motion activities.
Increase vitamins and calcium in diet.
48. Nursing Intervention
Pain control if fracture occurs.
Explain to the patient:
How to properly take medications.
Bisphosphonates must be taken first thing in the morning on an empty
stomach, with a full glass of water. The patient can’t lie down for 30 to
60 minutes after taking the medication; this is to reduce risk of
esophageal irritation.
Monitor for side effects of medications—GI effects with
bisphosphonates.
Encourage weight-bearing activity.
Encourage appropriate nutrition.
49. Ankylosing Spondylitis
Affects the cartilaginous joints of the spine and surrounding tissues.
Occasionally, the large synovial joints, may be involved.
Characteristics include spondylosis and fusion of the vertebrae
Usually begins in early adulthood and mainly affects men than women.
Back pain is the characteristic feature.
As the disease progresses, ankylosis (stiffness) of the entire spine may
occur, leading to respiratory compromise and complications.
50. Medical Management
Focuses on treating pain and maintaining mobility by
suppressing inflammation.
Good body positioning and posture are essential, so that if
ankylosis (fixation) does occur, the patient is in the most
functional position.
Maintaining ROM with a regular exercise and muscle-
strengthening program is especially important.
51. Cont.…
NSAIDS such as indomethacin are usually prescribed for
relieving inflammation and pain.
52. Nursing Management of Spondylitis
⚫The nurse administers prescribed drugs
⚫Encourages the client to perform ADLs as much as
possible.
⚫Teaches the client to perform mild exercises that reduce
stiffness and pain.
