OsteoarthritisIn Partial Fulfillment of the Requirements in

Nursing Care Management 104

Related Learning Experience

A Compilation Presented to the STI College of Nursing

Presented by:

GROUP BENEFICENCE

Group Leader:

Rubio, Reshiel

Members:

Afante, Booz

Andres, Jessica

Arcena. Katrine Ann

Atienza, Angielique

Barron, Edgar Allan

Cabutihan, Precious Diane

Delos Santos, Rosella

De Luna, Leny

Macabasco, Queenie

Chapter I

INTRODUCTION

Osteoarthritis is a type of arthritis that is caused by the

breakdown and eventual loss of the cartilage of one or more joints.

Cartilage is a protein substance that serves as a "cushion" between the

bones of the joints. Osteoarthritis is also known as degenerative

arthritis or degenerative joint disease, is a group of mechanical

abnormalities involving degradation of joints, including articular

cartilage and subchondral bone.

Also known as the wear and tear disease, it is characterized by

areas of destruction of articular cartilage, sclerosis of the underlying

bone, and hypertrophy of soft tissues. This type of arthritis affects

more people than any other type. Patients usually know this disease

best as old-age arthritis. Patients with OA may have joint pain on only

one side of the body and it primarily affects the knees, hands, hips,

feet, and spine.

In the Philippines, the point prevalence of osteoarthritis is 4.1

percent of an urban population (mean age=34). Manila, its capital city,

with a population of 11 million, therefore has approximately half a

million sufferers of OA. Considering population growth in the next 25

years as projected in the Summary of Philippine Demographic Data

2000, the number of individuals with OA will more than double by

2025.6 Recently, the Food and Nutrition Research Institute in the

National Nutrition Health Survey (NNHES) of 2003 noted a 0.5 percent

prevalence of OA among individuals 40 years of age and above, a

lower figure compared to the first study, perhaps an effect of the

methods employed in this national survey. This figure reflects not only

urban but also rural Philippines. In an 80 million strong population, this

will easily be about 3.2 million plus Filipinos with the disease.

A. Background of the Study

Our patient is a 75-year-old male with Osteoarthritis (OA);

he is suffering with this disease for almost 20 years, starting

when he was 55 years old. He is former cook in a fishing vessel.

B. Rationale for Choosing the Case

We chose this case osteoarthritis of Mr. Beneficence

because majority of the diseases encountered in the community

were already tackled and discussed in previous case

presentations like cough and colds, fever and hypertension. This

is the only case which was not presented in the previous case

presentations and it captures our attention. So far this was the

interesting case we encountered in the community. All of us

know that everyone will commence on the stage of aging, this

could also be of great help to all of us so as we can further

understand its development, clinical manifestation and the

various means on how to manage it.

C. Significance of the Study

To the patient. This study aims to be of help to our

patient by rendering the best care that we could possibly

give to him.

To the care givers or significant others. To aid and

supplement them with information for the better

management of his condition.

To the community. To educate the public with knowledge

about the disease as well as its management.

To the student. To be of reference to our fellow students

who will handle the same case in the future.

D. Scope and limitation

This study covers and focuses on the following:

A brief discussion of the disease, its causes, manifestations

and proper treatment.

Assessment of the patient.

Drug study of the medications given and other treatments

done to the patient.

Formulation of nursing care plans appropriate for the

patient.

Preparation of discharge plan for the patient.

Chapter II

CLINICAL SUMMARY

A. Biological Data

Name: Mr. Beneficence

Address: Sta. Cruz, Laguna

Age: 75 years old

Sex: Male

Marital Status: Married

Date of Birth: ???????????????????????????????????????????????

Nationality: Filipino

Religion: Roman Catholic

Occupation: former cook

Diagnosis: Osteoarthritis- knee

Allergies: No known allergy

Past Medical History:?????????????????????????????

Past History of Illness:????????????????????????????

Attending Physician: Dr. Tan

Source of information: wife and himself

B. Physical Assessment

Cephalocaudal Assessment

BODY PART FINDINGS

Head Normocephalic, symmetrical

Absence of masses, lesions or nodules

No tenderness, No dandruff

Hair White hair; oily; thin

Face Wrinkled skin

Eyes

Eyelids

Sclera

Iris

Pupils

Eye movement

Lids close symmetrically, bilateral blinking.

No edema or tenderness over lacrimal gland

Appears reddish with visible microvessels

With presence of cataract on OU

PERRLA

OU coordinated, move in unison with parallel

alignment

Ears Color same as facial skin; symmetrical;

auricle aligned with outer canthus of eye.

Dry, grayish-tan cerumen.

Nose Symmetric and straight, air moves freely as

the client breathes through the nares

Mucosa pink, cilia present

Septum was intact and in midline

Mouth

Lips

Teeth

Tongue

Palates

Uniform pink in color, free from discharge,

ability to purse lips

Smooth, intact, no bad breath

Pink color, moist, no lesions, moves freely, no

tenderness

Light pink, smooth (soft palate)

Lighter pink, irregular texture (hard palate)

Neck Muscles equal in size; head centered

Free from lumps, masses and lesions; no

tenderness

Thorax Symmetrical, chest wall intact, no tenderness

No adventitious breath sounds

Abdomen Unblemished skin, uniform color,

symmetrical; no tenderness, lesions and

masses

Extremities Skin uniform in color, no lesions, no nodules,

with usual number of fingers.

Upper extremities: Smooth coordinated

movements, can extend arms without

difficulty.

Lower extremities: With presence of

inflammation on both knees, prominently on

the left; with pain upon movement

Capillary refill = 2secs

C. System Assessment

The major system involved in the case study is the

musculoskeletal system. Both knees are the joints most affected to Mr.

Beneficience. Symptoms felt include stiffness of both knees mostly

during every early in the morning and during cold weather. Both knees

are swollen, prominently on the left and pain felt upon movement

which makes him find hard to walk, get in and out of chairs and do

other activities.

Vital Signs

Date Temperatur

e (°C)

Pulse

rate

(bpm)

Respiratory

rate (cpm)

Blood

Pressure

(mmHg)

July 27,

2010

36.9 70 22 120/90

August 2,

2010

36.7 67 23 120/80

August 3,

2010

36.3 66 20 120/80

August 9, 36.7 68 22 120/80

2010

Height and Weight

Height: 5’8’’

Weight: 70 kg

D. Course in the Community

July 27, 2010

????????????????????????????????????????????????????????????????

Maam, ung course in the community po n kay miss delos santos po..

Chapter III

Clinical Discussion

A. Anatomy and Physiology

Joints

Also called articulations

It is placed where two bones come together

It is usually considered movable but not all the time, many joints

have limited movements while others are almost completely or

completely immovable.

The 3 major structural classes of joints are:

o Fibrous joints- little movement

- joined by fibrous connective tissue

o Cartilaginous joints- slight movement

- joined by cartilage

o Synovial joints- freely movable joints

- not directly joined

There are 3 classifications of joints based on the degree of

motions:

o Synoarthrosis- non-movable joints

- permits little or no mobility. Most

synarthrosis joints are fibrous joints (e.g., skull sutures).

o Amphiarthrosis- slightly movable joints

- permits slight mobility. Most

amphiarthrosis joints are cartilaginous joints (e.g.,

vertebrae).

o Diarthrosis - freely movable joints

- permits a variety of movements. All

diarthrosis joints are synovial joints (e.g., shoulder, hip,

elbow, knee).

The Synovial Joints

It contains synovial fluid in a cavity surrounding the end of

articulating bones.

The articular cartilage is a thin layer of cartilage that covers the

surface of the bone within the synovial joint that provides a

smooth surface where the bones meet.

The joint cavity is filled with a fluid called synovial fluid that is

enclosed by a joint capsule that helps hold the bone together

and allows movement. Portion of the joint capsule maybe

thickened to form ligaments and tendons outside the joint

capsule that helps in strengthening of the joint.

The synovial membrane lines the joint cavity everywhere except

over the articular cartilage. This membrane is responsible for the

production of synovial fluid. The synovial fluid is a complex

mixture of polysaccharides, protein, fats and cells. It also for a

thin lubricating film that covers the surface of the joint. In certain

synovial joint the synovial fluid extends up to a pocket called

bursa.

Bursa or bursae are pocket located between the structures that

rub together. They are also responsible for the reduction of

friction, that damages the structure involve.

Tendon sheaths serves as the extension along with some

tendons associated with the joints.

Types of Synovial Joints

1. Ball and socket  2. Condyloid (ellipsoid)  3. Saddle 

4. Hinge 5. Pivot

Plane or gliding joints

o consist of 2 opposed flat surface that glides over each

other.

o Articular surface between vertebrae.

Saddle joint

o Consist of 2 saddle shaped articulating surface oriented at

right angles to each other.

o Movements in these joints can occur in 2 planes.

o Joints between the metatarsals and carpals, thumb

Hinge joints

o Permits movement in 1 plane only

o They consist of convex cylinder of bone

o Elbow, knee and finger joints

Pivot joints

o Restrict movements to rotation around a single axis

o Each of these joint is consist of cylindrical bony process

that rotates within a ring composed partly of ligaments.

Ball-and-socket joints

o It consists of the ball or the head at the end of 1 bone and

a socket in an adjacent bone into which portion of the ball

fits.

o It allows a wide range of movements in almost any

directions

o Shoulder and hip joints

Ellipsoid or Condyloid joints

o Are elongated ball-and-socket joint

o The shape of the joint limit the range of movement nearly

to a hinge motion but in 2 planes

o The joint between the occipital condyles of the skull and

the atlas of the vertebral column

Bone tissue is removed by osteoclasts, and then new bone tissue is formed by osteoblasts. Both

processes utilize cytokine (TGF-β, IGF) signalling.

Bone remodeling (or bone metabolism) is a life-long process where

mature bone tissue is removed from the skeleton (a process called bone

resorption) and new bone tissue is formed (a process

called ossification or new bone formation). These processes also control the

reshaping or replacement of bone during growth and following injuries

like fractures but also micro-damage, which occurs during normal activity.

Remodeling responds also to functional demands of the mechanical loading.

As a result, bone is added where needed and removed where it is not

required.

In the first year of life, almost 100% of the skeleton is replaced. In

adults, remodeling proceeds at about 10% per year.[1]

An imbalance in the regulation of bone remodeling's two sub-processes, bone

resorption and bone formation, results in many metabolic bone diseases,

such as osteoporosis.

Bone RepairStages of Healing

normal bone ---------- ----- --------- ----- ---------- -----------healed fracture

Clot formation Callus formation Callus ossification Bone remodeling

1. Clot formation. When a bone is broken, a clot forms

in the damaged area.

2. Callus formation. Blood vessels and cells invade

the clot and produce a fibrous network and cartilage between the

broken bones, called a callus.

3. Callus ossification. Osteoblasts enter the callus

and form cancellous bone.

4. Bone remodeling. The cancellous bone is slowly

remodeled to form compact bone and the repair is complete.

Please include also how bone remodeling & repair occur??? It

was written in your anaphys book coz this will be included in your

pathophysio. It usually happens when damage occur but if it

does not work that is the time surgery or stem cell or growth

hormone injection will advisable to be done.

B. Pathophysiology

Predisposing Factors Precipitating Factors

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Age, Diet, Obesity, Nature of work

Advancing Loss of

Formation of Osteocytes

Decrease in synovial fluid

Pinch/crowd

Pain

Narrowing of joint spaces

Obliteration of joint space

Pressure between joint

Formation of subchondral cysts

Hardening of the underlying bone

Repair and remodelling

If not remodeled Surgery, GH & stem cell injection

Pain

Difficulty of movement

Degeneration of cartilage

Continuous use of joint

Disappearing of full thickness of articular

Wear and tear of articular cartilage

Inflammatory response

Release of chemical mediators

Acts on pain receptors

Increase vascular permeablity

Increase blood

Pain

edemaRedness, increase WBC

Immobilization

Osteoarthritis

Seen in x-ray

!-------------------------------!-------------------------------!------------------------ --------------------- !--------------------------------------------

------- !

C. Drug Study

Chapter IV

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

“Nahihirapan

akong kumilos

sa umaga,”

as verbalized by

the patient.

Objective:

Limited

ability to

perform

skills

Felt stiffness

every early

morning or

during cold

weather

Limited

Impaired

physical

mobility related

to loss of

integrity of

bone structure

as evidenced by

client’s

verbalization

and slowed

movement.

After series of

nursing

intervention the

client will be

able to

maintain/

increase

strength and

function of the

affected and/or

compensatory

body part.

Support the

affected

body

parts/joints

by using

pillow or

rolls, foot

support or

shoes, air

mattress.

Schedule

activities

with

adequate

rest periods

during the

day.

Provide for

To maintain

position of

function and

reduced risk

of pressure

ulcers.

To reduce

fatigue.

To prevent

fall.

After series of

nursing

intervention the

client was able

to maintain

strength and

function of the

affected body

part as

evidenced by

the client can

now perform

simple exercise

such as walking

for at least 15-

30minutes

everyday and

drink glass of

range of

motion

Slowed

movement

Joint swelling

Decreased

walking

speed

safety

measures as

indicated by

individual

situation

including

environment

al

management

.

Encourage

adequate

intake of

fluids or

nutritious

foods

particularly

foods that

are rich in

calcium.

Encourage to

take

To promote

well being,

strengthen

bone density

and

maximize

energy

production.

To permit

maximal

effort or

involvement

in activity.

To improve

the blood

milk every

morning.

medications

prior to

activity as

needed for

pain relief.

Encourage to

do simple

exercise

such as

walking for

at least 15

minutes.

Teach weight

loss diet, if

appropriate.

Teach the

importance

and

appropriate

use of

circulation in

the joints.

To reduce

weight that

would

reduce the

pressure in

the joints.

To aid in

walking and

minimize

injuries.

To minimize

the use of

body energy.

devices such

as walker,

canes and

crutches.

Advised

client to rest

between

each

activities.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

“Masakit ang

tuhod ko,” as

Acute pain

related to loss

of integrity of

After series of

nursing

intervention the

Assessed for

referred

pain.

To help

determine

possibility of

After series of

nursing

intervention the

verbalized by

the client.

Objective:

Pain scale of

6/10

With

guarded

behavior

With facial

grimace

Immobility

Swollen

joints

P= cold

weather/

analgesic

Q=pressing

R=thigh &

lower leg

S= 6/10

bone structure

as evidenced by

client’s verbal

reports, facial

grimace,

immobility &

swollen joints.

client’s pain

scale of 6/10

will decrease to

2/10.

Note client’s

attitude

towards pain

medication.

Determine

factors of

client’s

lifestyle.

Monitor vital

signs and

skin color.

Provide

comfort

underlying

conditions

requiring

treatment.

To determine

the

effectiveness

of relieving

pain.

To determine

the effect

response to

analgesic or

choice of

intervention

for pain

management

.

This usually

alters when

pain occurs.

To promote

client’s pain

was lessened

from 6/10 to

3/10 and

demonstrated

ways on how to

provide relief as

evidenced by;

The client

follow

pharmacolog

ical regimen

as

prescribed.

Took glasses

of milk

everyday.

Walk for 15-

30minutes

as a means

of exercise.

T= measure

such as use

of hot

compress

and

encourage

the use of

diversional

activities like

watching tv,

listening to

music and

socialization

with others.

Encourage

adequate

rest periods.

Instruct the

client to

follow

medication

regimen as

non-

pharmacolog

ical pain

management

and avoid

being

dependant to

pain

relievers.

To prevent

fatigue and

conserve

energy.

To help

reduce the

pain

sensation.

prescribed

by the

physician.

Instructed

the client to

eat nutritious

foods

especially

food that are

rich in

calcium,

protein and

carbohydrate

.

To

strengthen

the bone

density and

reduce

inflammatory

response.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

“Bakit po kaya

lagi paring

sumasakit ang

tuhod ko tuwing

umaga at kapag

Deficient

knowledge

related to lack

of information

and

unfamiliarity

After 8 hours of

nursing

intervention the

client will

verbalized

understanding

Determine

the client’s

ability or

readiness

and barriers

to learning.

Individual

may not be

physically,

emotionally

or mentally

capable at

After 8 hours of

nursing

intervention the

client was able

to verbalized

and

malamig ang

panahon.” As

verbalized by

the client

Objective:

Does not

know how to

manage the

present

condition

particularly

as to what

type of

action to be

done and

diet to be

followed.

Always

asking

questions as

related to

with information

resource.

of situation and

treatment

regimen and

safety

measures.

Be alert in

the signs of

avoidance.

Assess the

level of

client’s

capabilities

and the

possibilities

of the

situation.

Provide

information

relevant only

to the

situation

such as

definition of

this time.

Client may

need to

suffer

consequence

of lack of

knowledge

before he is

ready to

accept

information.

May need

the help of

SO or

caregivers to

learn.

Can improve

understandin

g about the

disease

condition

demonstrated

understanding

of situation and

individual

treatment

regimen and

safety

measures AEB

client followed

safety

measures &

treatment

regimen such

as: does simple

exercise every

morning for 15-

30min., drinks

milk every

morning, takes

analgesic as

prescribed.

the

condition.

osteoarthritis

, causes,

signs and

symptoms,

treatment

and

management

.

Provide feed

back.

Begin the

information

the client

already

knows and

more to what

the client

does not

know,

progressing

from simple

thereby

acquiring

clients

cooperation

on disease

management

.

Can

encourage

continuation

of efforts.

Can arouse

interest or

limit sense of

being

overwhelme

d.

to complex.

Advised the

client the

importance

of having a

regular

check up to

the physician

or RHU.

To monitor

the

progression

of the

disease and

effectiveness

of therapy.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

“ Kadalasan

hindi agad ako

makakilos o

makagalaw lalo

na tuwing

umaga” as

verbalized by

the patient.

Objective:

Limited

range of

motion

Slow ed

movement

Gait

Impaired

Physical

Mobility related

to loss of

integrity of

bone structure.

After series of

nursing

intervention the

patient will be

maintain or

increase

strength &

function of

affected and or

compensatory

body part.

Support

affected

body parts /

joints using

pillows /

rolls, foot

support /

shoes.

Encourage

adequate

intake of

fluids as well

as nutritious

foods.

Encourage

To maintain

position of

function and

reduce risk of

pressure ulcers.

To promotes

well being and

maximizes

energy

production.

To keep joints

Goal met

Stiffness

(early

morning

until about

an half hour

after rising

Muscle

spasms

Joint swelling

the patient

to increase

activity as

indicated.

Encourage

the patient

to ambulate

with

assistive

devices.

mobile and not

taxing the joint

too much

To reduces the

load on the joint

and promotes

safety.

Chapter V

Discharge Planning