Download Rheumatoid Arthritis

Arthritis
Osteoarthritis (OA)
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Osteoarthritis
 Most common form of joint (articular) disease
 Previously called degenerative joint disease
 Risk Factor: growing older
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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
Osteoarthritis (OA)
Etiology & Pathophysiology
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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
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Chronic illness such as diabetes, cancer or liver disease
Infections such as Lyme disease.
Risk Factor: Obesity
Osteoarthritis (OA)
Etiology & Pathophysiology
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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
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Inflammation is not a characteristic of OA
Osteoarthritis
Etiology & Pathophysiology
Osteoarthritis
Clinical Manifestations
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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”
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Resolved within 30 minutes after movement
Overuse – joint effusion
Crepitation – grating sensation caused by loose
particles – contributes to stiffness
Osteoarthritis
Most Involved Joints
Osteoarthritis
Etiology & Pathophysiology
Affects joints asymmetrically
 Most commonly involved joints:
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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
Osteoarthritis
Etiology & Pathophysiology
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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
Osteoarthritis
Diagnostic Studies
Bone Scan
 CT
 MRI
 General x-ray
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Radiologic changes do not correlate
with the degree of disease
Osteoarthritis
Treatment Goals
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No cure
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Focus:
Managing pain
Preventing disability
Maintaining and improving joint
function
Osteoarthritis
Treatment Goals
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Rest and Joint Protection
Balance of rest and activity
Assistive devices
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Heat and Cold Applications
Hot packs, whirlpools, ultrasound, paraffin wax
baths, pool therapy
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Nutritional Therapy & Exercise
Weight reduction – Goal: decrease load on the
joints & increase joint mobilization
Osteoarthritis - Tx Goals
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Drug Therapy
 Tylenol – up to 1000 mg q6h
 Aspirin
 Nonsteroidal anti-inflammatory drugs
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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
Osteoarthritis
Treatment Goals
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Surgical Treatment
Joint Replacement
 Hip,
Knee, Shoulder
Spinal Surgery –
 Diskectomy
/spinal fusion
Spine Surgery for Arthritis
Degenerative Disc Disease
Lumbar Spinal Stenosis
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
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Osteoarthritis
Nursing Management Goals
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Maintain or improve joint function through
balance of rest and activity
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Joint protection measures to improve activity
tolerance
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Maintain independence and self-care
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Use drug therapy safely to manage pain
without side effects
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REHABILITATION
Rheumatoid Arthritis (RA)
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Chronic, systemic disease
Inflammation of connective tissue in the
diarthrodial (synovial) joint
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Periods of remissions & exacerbation
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Extraarticular manifestations
Rheumatoid Arthritis (RA)
Etiology & Pathophysiology
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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
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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
Rheumatoid Arthritis
Osteoarthritis
Rheumatoid Arthritis
Rheumatoid Arthritis
Anatomic 4 Stages
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Stage 1 – Early
 No destructive changes on x-ray; possible osteoporosis
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Stage II – Moderate
 X-ray osteoporosis; no joint deformities; possible
presence f extraarticuloar soft tissue lesions
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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
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Stage IV – Terminal
 Fibrous or bony ankylosis; criteria of Stage III
Rheumatoid Arthritis
Clinical Manifestations
Insidious – fatigue, anorexia, weight loss,
generalized stiffness
 Joints
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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
Rheumatoid Arthritis
Clinical Manifestations
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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
Rheumatoid Arthritis
Clinical Manifestations
Rheumatoid Arthritis
Diagnostic Studies
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Lab Studies
Rheumatoid Factor – 80% of patients
ESR
C-Reactive Protein
WBC up to 25,000/ul
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Synovial biopsy – inflammation
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Bone Scan
Rheumatoid Arthritis
Treatment Goals
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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
 Nutrition
Therapy
– balanced diet
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
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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
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Rheumatoid Arthritis
Rest alternating with activity as
tolerated -- Energy conservation
 Joint protection
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Time-saving joint protective devices
Heat / Cold Therapy – relieve stiffness,
pain, and muscle spasm
 Exercise –individualized –Aquatic Therapy
 Psychological Therapy – individual &
family support system
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Arthritis
Gerontologic Considerations
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Sensitivity to medication
NSAIDs – GI Bleed
Corticosteroid therapy – osteopenia adds to
inactivity-related loss of bone density
 Pathological
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fractures
Challenges to Self-Care & Decisions
Autonomous
Assisted Living