Osteoarthritis

Progressive degeneration of articulating cartiledge

Hyaluronidase- enzyme in synovial fld may digest proteoglycans via cracks

Excessive use of jt, age, congenital defects, metabolic (DM), repeated intraarticular hemorrhage, inflam & septic arthritis

Genetic- Heberden’s nodes

Osteoarthritis

S/S- pain r/t movement, relieved by rest, jt stiffness after rest, crepitation, deformity, subluxation, loss of function Heberden’s & Bouchard’s nodulesHip- pain buttock, groin, medial side of leg or kneeKnees- limited ROM, flexion deformityVertebral Column- herniation, spurs

Osteoarthritis

Dx- x-ray-> narrow jt space,spurs, subluxation

Tx- rest, heat, cold, exercise

Meds-acetaminophen 1 Gm qid, creams, low dose ibuprofen

Full dose NSAIDs, Cytotec + NSAID= Arthrotec, COX-2 inhibitor- Celebrex

Osteoarthritis

Corticosteroids- intraarticular injections

Knee intraarticular hydraluronic acid derivatives

Assistive devices

Orthopedic surgery- debridement, arthrodesis, arthroplasty, osteotomy, total joint replacement

Nursing Care

Assessment- jt pain, effect on ADL, meds, swelling, tenderness, ROM, crepitation

H. Promotion- teach body mechanics, good posture, wt reduction, occupational hazards, avoid stress on jts & painful activities, rest & pace activities, athletic & exercise programs teach ways to reduce stress on jts

Nursing Care

Pain- application of heat for muscle relaxation, cold to decr swelling, meds, rest & pace activities, guided imagery, distraction, PTProper body alignment, don’t rush pt, care when moving & positioning, use assistive devicesTeaching- meds

Rheumatoid Arthritis

Recurrent inflammation of diarthrodal jtsRemissions & exacerbationsMay also have rh nodules, arteritis, neuropathy, pericarditis, scleritis, enlarg spleen, lymphadenopathyEtiology- poss infection, autoimmune, genetic, nutrition, environmental, biochemical, occupation

Rh. Arthritis Progression

Joint inflammation or synovitisPannus at synovium & cartilage & spreads to jt capsule & boneFibrous tissue replaces pannus & occludes jt space-> decr jt motion, deformityFibrous tissue calcifies, bony ankylosis ->total jt immobilization

Clinical Manifestations

Fatigue, anorexia, wt loss, stiffnessArticular s/s- pain, stiff, limited ROM, inflammationJt s/s bilateral esp hands & feet, lg jts, cervical spineWrist tenosynovitis ->carpal tunnel syndDeformities & disabilityExtraarticular

Dx Rheumatoid Arthritis

History & physical

CBC, ESR hi, + titer serum rheumatoid factor, small % pts ANA & lupus cell test +

Synovial fld analysis- thick, hi WBC

X-rays-> demineralization, narrow jt space, erosion, subluxation

Collaborative Care

Meds & rest

Education- disease, meds, home management

PT & OT

Follow up care with MD, labs

Surgery- joint replacement

Drug Therapy

Disease-modifying drugs- Methotrexate,Plaquenil- mild disease, safestCorticosteroids- bridge therapy, burst therapy, intraarticular, pulse therapyRemission inducing therapy- gold therapy, Imuran, D-PenicillamineASA & NSAIDs, Cox-2 inhibitorsNew meds- Arava, Enbrel

Nursing Care

Assessment of physical, psychological & environmental needs

Rehab & education

Pain relief & adeq rest

Monitor labs, meds

Plan care around pts s/s, pace activities

Skin care, splints

Nursing Care

Good body alignment, exercise

At home, learn ways to put decr stress on jts

Rest during day, conserve energy

If flare up->ice, not more than 10-15 min

Heat- not to exceed 20 min, check temp

Eval family support, psychol support

Community resources

Psoriatic Arthritis

10-15% people with psoriasis have arthritis, usually mild

Severe erosive form-> asymmetrical, resoption at distal phalanges of hands feet, metatarsals

Hyperuricemia

Rx- splints, PT, gold, methotrexate

Septic Arthritis

Invasion of joint cavity with bacteria->bacteremiaTrauma, arthritis, leukemia, DM, meds- immunosuppressive or corticosteroidsJt red, swollen, pain, feverAspirate jt-> C&S synovial fld, bld C&SAseptic technique, antibiotics, resting splint, gentle ROM

Lyme Disease

Spirochete- Borrelia burgdorferi, tic biteS/S- Erythema migrans, fever, chills, jt pain, headache, stiff neckArthritis, AV conduction defects, myocarditis, neuro abnorm, Bell’s palsyDx- history, + B. burgdorferi antibodiesRx-early Amoxicillin, Doxycycline, later- 20-30 days rx, neuro s/s- Rochephin

Gout

High serum uric acid assoc with arthritis

S/S- arthritis in less than 4 jts, jt tender, dusky, inflam of great toe, lo fever

Chronic gout- tophi

Dx- monosodium urate monohydrate crystals in synovial fld, hi uric acid serum & 24 hr urine

Drug therapy

Colchicine- relief of s/s in 24-48hrs

Benemid- incr uric acid excretion –ASA inactivate this, use Acetaminophen

Need adeq urine output to prevent precipitation in renal tubules

Allopurinol- blocks production uric acid

Check uric acid, s/s- eval effectiveness

Nursing Care

BR, assess pain, inflammation & ROM

Be gentle when touching, moving

Bed cradle or foot board

Teach precipitating factors- over eating, alcohol, purines, ASA & diuretics, fasting, stress, surgery, major illness

Chronic prob- see MD, labs, take meds

Scleroderma

Systemic sclerosis- conn tissue fibrotic, inflammation of skin, changes bld vessels synovium, muscle, organsChief s/s- skin thickening & tighteningOverproduction of collagenCREST syndrome- benign form Can also rapidly affect organs-kidney, heart, lungs,GI

Clinical Manifestations

Raynaud’s PhenomenonSkin taut, shiny,thick- hands, fingers flexed, wrist tight, face expressionless, AM stiffness, tendon friction rubsGI- prob swallowing, reflux, constipation Lungs-pleural thickening, pul hypertenHeart-pericaditis, myocardial fibrosisRenal-hi BP, renal insufficiency & failure

Scleroderma

Dx- elev ESR, + ANA, nail bed capillary microscopy, x-rays->sub-q calcification, pul fibrosis, skin biopsy, u/a

RX- PT, vasodilators, calcium channel blockers, antihypertension meds

Nursing Care

Explain dx procedures, assess VS, I&O, wt, jt ROM, resp, renal, cardiac function

No FS blood testing, heat therapy, protect hands & feet from cold, treat cuts, no smoking, lotions for dry skin, wear gloves, padded utensils, assistive devices

Small freq. feedings, eat slow, chew food, antacids, sit up after eating, HOB elev

Nursing Care

See dentist, good oral hygiene

Psychol support, referral to support group

Sexual dysfunction, refer to counseling

Teach how to live with disease- eg job modification, changes in ADL

Fibromyalgia

Musculoskeletal chronic pain syndromeFatigue, stiffness, myalgia, arthralgia, headache, irritable bowel syndrome, sleep disturb, stress related component18 tender points, dx h/o widespread pain & 11 tender ptsRest, NSAIDs, Elavil, muscle relaxants, stress managemt, Zoloft, exercise, yoga, psychol counseling

Systemic Lupus Erythematosus

Chronic multisystem inflammatory diseaseAlterations in the immune system – autoimmune reactions against the cell nucleusEtiology is unknownGenetic, environmental, Infectious agents, drugs

SLE manifestations

Variable – mild to severe, affecting various organsSkin – cutaneous vascular lesions usually in sun exposed areas, butterfly rash over the cheeks and bridge of the nose, photosensitivity, oral and nasal lesions, alopeciaMusculoskeletal – arthitisCardiopulmonary – tachypnea and cough, pleurisy, arrhythmias, HTN, CADRenal – Lupus nephritis, Nervous system – seizures, peripheral neuropathy, organic brain syndromeHematologic – antibodies against blood cells > anemia, leukopenia, thrombocytopeniaInfection – increased susceptibility to infection. Major cause of death

SLE

Dx – pt hx, physical exam, laboratory tests see table 63-13

Rx – treat both active phases and effects of long term complications

NSAIDs, antimalarial agents, corticosteroids, methotrexate, folic acid,

SLE Nursing management

Good assessment

Health promotion

Treat exacerbations

Patient and family teaching

Psychological issues