OSTEOATHRITIS

• Derived from the Greek word “osteo”, which means bone; “arthro” means joint
and “itis” means inflammation.

• It is the most common of the various kinds of arthritis.

• A chronic, slowly progressing disorder that causes deterioration of articular

cartilage.

• It affects weight-bearing joints (hip and knees) as well as joints of the distal
interphalangeal and proximal interphalangeal joints of the fingers.

• It is also known as Degenerative Joints Disease, characterized by the

inflammation of the joints between the bones.

Incidences

By the numbers, 1 in 4 U.S adults has been diagnosed with some form of arthritis,
while an additional 17% may have the disease without even knowing it. According to
the Arthritis Foundation, Osteoarthritis affects an estimated 20.7 million Americans,
80 % of these are women.

Risk / Predisposing Factors

1. Aging

2. Long term mechanical stress-athletics, ballet, dancing or repetitive physical tasks

3. Congenital or acquired skeletal deformities

4. Anatomic abnormality

5. Inflammation in joint structures

6. Joint Instability from damage to supporting structures

7. Neurologic disorders (diabetic neuropathy, Charcot neuropathic joint)

8. Hematologic or endocrine disorders ( hemophilia, hyperthyroidism)

9. Obesity
 10. Systemic Diseases

11. Genetic Factors

12. Drugs

13. Other form of arthritis

Manifestations

1. Pain and Swelling

2. Stiffness

3. Enlargement of Joint

4. Crepitus

5. Discomfort in the joint before or during a change in the weather

6. Limited range of motion

7. Hypermobility and subluxation of joints

8. Knee Alignment ( vagus or varus )

Classification of Osteoarthritis

• Classification by the joint involved

o Monoarticular, oligoarticular, or polyarticular (generalized)

o Chief joint site 9index joint site) and localization within the joint

 Hip ( superior pole, medial pole and concentric)

 Knee ( medial, lateral, patellofemoral compartments)

 Hand ( interphalangeal joint and or thumb base)

 Spine (apophyseal joints or intervertebral disk disease)

• Classification into Primary and Secondary forms of OA

o Primary (idiopathic)
o Secondary

 Indicates that a likely cause can be identified

 Metabolic causes

• Ochronosis

• Acromegaly

• Hemochromatosis

• Calcium crystal deposition

• Anatomic causes

• Slipped femoral epiphysis

• Epiphyseal dysplasia

• Blount disease

• Perthes disease

• Congenital dislocation of the hip

• Leg length inequality

• Hypermobility syndromes

• Traumatic Causes

• Major joint trauma

• Fracture through a joint or osteonecrosis

• Joint surgery (meniscectomy)

• Chronic injury (occupational arthropathies)

• Inflammatory causes

• Any inflammatory arthropathy

• Septic arthritis
 • Classification by the presence of specific features

o Inflammatory OA

o Erosive OA

o Atrophic or destructive OA

o OA with chondrocalcinosis

Pathophysiology

1. Changes in articular cartilage occur first; later, secondary soft tissue changes
may occur.

2. Progressive wear and tear on cartilage leads to thinning of point surface and
ulceration into bone.

3. Leads to inflammation of the joint and increased flow and hypertrophy of

subchondral bone.

4. New cartilage and bone formation at joint margins results in osteophytosis

(bone spurs), altering the size and shape of bone.

Diagnostic study

1. No specific laboratory examination.

2. CT Scan

3. Arthroscopy

4. X-rays of affected joints show joint space narrowing, osteophytes, and sclerosis.

5. Radionuclide imaging (bone scan)-shows increased uptake in affected bones.

6. Analysis of synovial fluid differentiates OA from RA

7. Aspiration of synovial fluid to rule out infection or crystal deposition

8. Erythrocyte Sedimentation Rate is useful if systemic manifestations are present.

9. Magnetic Resonance Imaging may be ordered to rule out meniscal injury.

Management

• Medical Management
B. Include PT and OT to maintain function while preserving the joints

C. SAM-e (S-adenosylmethionine), occurs naturally in all living cells

contributes to the production of proteoglycans for cartilage repair.

D. Pain management using non-narcotic analgesics, such as

acetaminophen;COX-2 inhibitors and NSAIDs, mostly for analgesic
affects; and possibly, such oploids as oxycodone, codeine, or
hydrocordone (these may be used in combination with non-narcotic
analgesics).

• Celecoxib (Celebrex) and meloxicam (Mobic) are COX-2 inhibitors.

They mainly block the prostaglandins involved in inflammation. ( In
2003 the New England Journal of Medicine published the result of
clinical trial showing that Celebrex, a long used drug for treating the
pain of degrading cartilage, doees not protect the patients against
bleeing ulcers ( a common side effects of arthritis medications) as
well as previously believed. On he other hand, a different study
found Celebrex may help combat heart disease by improving blood-
vessel flexibility and lessening inflammation.)

• They can be used in patients taking anticoagulants because

bleeding time and platelet aggregation are not affected by these
agents.

• They can cause renal impairment; monitor renal function with long-
term use.

• Celocoxib is contraindicated in people with known allergies to

sulfonamides and history of asthma, atucaria, or allergic reaction to
aspirin and other NSAIDs.

E. Hyaluronate (Hyalgan) and hylan G-F 20 ( synvisc), agents known as

viscosupplements, have been approved by the food and drug
administration. These drugs are administered overtime through intra-
articular injections into the knee.

• They relieve pain and are most effective for people with mild to
moderate knee Osteoathritis.

• After the injection, patient is instructed to avoid prolonged weight-

bearing activities for 48 hours.
 • Contraindicated for patients with joint infections and for those with
allergies to hyaluronate preparations, avian proteins, and bird
feathers or eggs.

F. Weight loss, if necessary, to relieve stress on joints. Losing weight may

reduce pressure on those painful joints.

G. Proper nutrition and adequate sleep.

H. For older patients, a new study has shown that receiving care for
depression can significantly lessen the impact of pain associated with
osteoarthritis of the knee.

I. Hydrotherapy (exercising in swimming pool) improves mobility about as

much as exercising in a gym, but with much greater reduction in joint pain,
according to the study of both hip and knee patients.

J. Movement therapies such as Tai Chi may be suggested as a low-impact

alternative to increase fitness and flexibility within the client’s own limit.

K. Use of cane in the contralateral hand can decrease joint stress during
episodes of of severe hip or knee pain.

L. Elastic brace or neoprene, may reduce pain and stabilize the joint in a
functional position.

M. Heat applications help with stiffness by increasing collagen elasticity and

flexibility.

N. Cold applications are used less frequently than heat but may be beneficial
during episodes of acute inflammation immediately after exercise or for
relief of muscle exercise.

O. Ionized wrist bracelet are commonly advertised for pain relief, however
research suggest that this form of therapy provides no better relief pain
than in placebo.

P. Capsaicin cream application to affected joints, it is effective for OA of the

knees and hand.

Q. Over-the-counter (OTC) supplements glucosamine and chondroitin sulfate

are common alternative remedies that have potential cartilage-rebuilding
effects, but clinical trials in humans have been scant up to this point.

Surgical Intervention
 Surgical intervention is considered when the pain becomes intolerable to patient
and mobility is severely compromised. Options include osteotomy, debridement, joint
fusion, arthroscopy, and arthroplasty

• Osteotomy is the cut across bone with resection of a bone fragment either
to correct deformity or to alter stresses on joint.

• Arthrodesis or joint fusion procedure, the articular joint surfaces, which

hold the bone ends together, are removed so that the bone edges unite
like a fracture.

• Arthroplasty is performed to restore joint motion by replacing arthritic bone

with metal and plastic components.

Nursing Diagnosis

1. Deficient Knowledge regarding procedures, outcomes and self-care needs

2. Acute or Chronic Pain Related to joint degeneration and muscle spasm

3. Impaired physical mobility related to pain and limited joint motion

4. Bathing, hygiene, feeding and toileting self-care deficits related to pain

and limited joint movement.

5. Disturbed body Image / Ineffective role performance may be related to

change in body structure

Nursing Responsibilities

Education

is the key to successful treatment of the disease. Important areas in the client
education include:

• Pain management

• Rest-activity balance

• Nutrition and weight loss

• Self-care strategies
 • Medications

Relieving pain

1. Advice patient to take prescribed NSAIDs or OTC analgesics as directed to

relieve inflammation and pain. May alternate with oploid analgesic, if prescribed.

2. Provide rest for involved joints- excessive use aggravates the symptoms and
accelerates degeneration.

a. Use splints, braces, cervical collars traction, lumbosacral corsets as

necessary.

b. Have prescribed rest periods in recumbent position.

3. Advise patient to avoid activities that precipitate pain.

4. Apply heat as prescribed- relieves muscle spasm and stiffness; avoid prolonged
application of heat-may cause increased swelling and flare symptoms.

5. Teach correct posture and body mechanics- postural alterations leads to chronic
muscle tension and pain

6. Advise sleeping with a rolled terry cloth towel under the neck- for relief of cervical
OA.

7. Provide crutches, braces, or cane when indicated- to reduce weight-bearing

stress on hips and knees.

8. Teach use of cane in hand on side opposite involved hip/knee.

9. Advise wearing corrective shoes and metatarsal supports for foot disorder- also
helps in the treatment of arthritis of the knee.

10. Encourage the weight loss to decrease stress on weight-bearing joints.

11. Support patient undergoing orthopedic surgery for unremitting pain and disabling
arthritis of joints.

Increasing Physical Mobility

1. Encourage activity as much as possible without causing pain.

 2. Teach ROM exercise to maintain joint mobility and muscle tone for joint support,
to prevent capsular and tendon tightening, and to prevent deformities. Avoid
flexion and adduction deformities.

3. Teach isometric exercises and graded exercises to improve muscle strength

around the involved joint.

4. Advise putting joints through ROM after periods of inactivity (eg, automobile ride)

Promoting self-care

1. Suggest performing important activities in morning, after stiffness has been

abated and before fatigue and pain become a problem.

2. Advise on modification, such as wearing looser clothing without buttons, placing

bench in tub or shower for bathing, sitting a table or counter in kitchen to prepare
meals.

3. Help with obtaining assistive devices, such as padded handles for utensils and
grooming aids, to promote independence.

4. Refer to OT for additional assistance.

Illustrations
 References


Lippincott
Manual of Nursing Practice Eight Edition

 A to Z Health Guide, by the Editors of TIME pp.15-17

 Understanding Pathophysiology by Huether; 3rd ed., p.1091-1095

 Medical Surgical Nursing by Black, 8th ed., p. 471-473

 Nurse’s Pocket Guide by Doenges, 11th ed., p.798

 Microsoft Encarta 2006

 www.medical-look.com

 www.mdconsult.com