Med-Surg: Chapter 20: Connective Tissue Disorder: Osteoarthritis

Question 1

Epidemiology

Answer 1

• most common form of arthritis in the US
• leading cause of chronic disability in the country
• not a part of aging; but aging is a risk factor

Question 2

What does Osteoarthritis Involve?

Answer 2

• it involves weight bearing joints such as the knees, hips, feet, and lumbar spine
• also affects cervical spine, proximal interphalangeal joints, and distal interphalangeal joints of the hands
• osteoarthritic involvement of the shoulders and elbows usually occurs after trauma, inflammation, or overuse

Question 3

Risk factors for Osteoarthritis

Answer 3

• age
• female sex
• obesity
• occupations that involve repetitive motions
• sports activities
• previous injury
• muscle weakness
• genetics
• history of inflammatory arthritis
• other bone and joint disorders

Question 4

What is the single most modifiable risk factor contributing to Osteoarthritis?

Answer 4

Obesity

• correlates to development of knee osteoarthritis
• shown to correlate with the development of hand osteoarthritis, indicating that obesity itself, not only increased stress on weight-bearing joints and decreases exercise, may contribute to osteoarthritis

Question 5

Occupations that involve repetitive motions

Answer 5

• individuals whose jobs entail repetitive knee bending are prone to develop knee osteoarthritis
• individuals who perform physical labor are at an increased risk for developing hand and hip osteoarthritis

Question 6

Pathophysiology

Answer 6

osteoarthritis is a disease that affects the joint as a whole b/c of biological, chemical, and viscoelastic changes within the joint

• Tendons and Ligaments are viscoelastic (they lengthen while under tension but return to normal shape at rest)
• cartilage, synovium, subchondral bone, synovial fluid, ligaments, periarticular muscle, and sensory nerves are altered by osteoarthritis
• when the cartilage is damaged from major trauma or repetitive microtrauma, osteophytes are formed by the body in an attempt to repair the damage; cartilage loss is a clinical feature of osteoarthritis, causing the bone to be unprotected, which leads to the deterioration of the joint function
• in osteoarthritis the synovial membrane may become thickened and overproduce synovial fluid, causing more pain and even greater restriction on joint movement; chronic effusions, an overproduction of synovial fluid, may cause collateral ligaments to stretch, leading to joint laxity,or looseness, and mechanical instability, compounding joint damage
• muscles around the joints tend to atrophy as a consequence of decreased use of the joint

Question 7

Cartilage

Answer 7

a material made of water, collagen, proteoglycans, and elastin
-serves to provide joint protection by providing a smooth surface on which bones glide and disperse loads across the joint

Question 8

Osteophytes

Answer 8

projections of new cartilage and bone growth that form along joint lines, contributing to pain in the joint and decreased range of motion
>osteophyte formations on the proximal interphalangeal joints and distal interphalangeal joints are referred to as Bouchard’s nodes and Heberden’s nodes
-some of the new bone growth may break off as bone spurs and contribute to further cartilage loss

Question 9

Synovium

Answer 9

membrane that lines the non-cartilaginous surfaces of highly mobile joints
-produces synovial fluid, to lubricate joints

Question 10

Chronic Effusions

Answer 10

An overproduction of synovial fluid

• may cause collateral ligaments to stretch, leading to joint laxity, or looseness, and mechanical instability, compounding joint damage
• muscles around the joints tend to atrophy as a consequence of decreased use of the joint

Question 11

What happens to the Synovial Membrane in Osteoarthritis

Answer 11

may become thickened and overproduce synovial fluid, causing more pain and greater restriction of joint movement

Question 12

Viscoelastic

Answer 12

lengthen while under tension but return to normal shape at rest
-tendons and ligaments are viscoelastic

Question 13

Clinical Manifestations

Answer 13

• progressive pain over time
• decreased range of motion
• tenderness to touch over the joint line or around the joint
• bony swelling
• soft tissue swelling
• deformity
• instability
• Crepitus (crackling, grating sound or feeling due to air or gas under the skin); due to cartilage breakdown in the joint
• pain with activity; improves with rest

Question 14

Diagnosis

Answer 14

-based on clinical manifestations without laboratory testing or radiographs when pt is 45 or older and presents with persistent usage-related pain in several joints and morning stiffness that lasts less than 30 minutes

Question 15

Laboratory testing

Answer 15

• may be performed to rule out other diagnoses (such as Rheumatoid arthritis)
• laboratory testing should be a part of the medical management of osteoarthritis to monitor for side effects r/t medication use

Question 16

Radiographs

Answer 16

plain radiographs of the affected joints, such as the hands, hips, knees, and spine, along with a history and physical examination can be used to confirm the diagnosis of osteoarthritis
>Evidence includes:
-joint-space narrowing
-subchondral sclerosis or cysts
-presence of osteophytes

Question 17

Treatment Plan

Answer 17

• pharmacological or nonpharmacological
• no therapy available to stop the progression
• goal: decreasing pain and improving or maintaining joint mobility while avoiding the toxic effects of pharmacological therapy

Question 18

Nonpharmacological Therapies

Answer 18

• weight loss
• heat and cold compress applications
• aerobic exercise
• physical therapy; range of motion and muscle-strengthening exercises
• use of ambulatory assistive devices
• appropriate footwear; lateral-wedged insoles
• occupational therapy
• joint protection
• energy conservation
• assistive devices for activities of daily living
• patient education about self-management and social support

Question 19

Pharmacological Therapy

Answer 19

> Acetaminophen (Tylenol)

• mild to moderate pain
• safe to use in doses not exceeding 4 g daily; ask pt about liver disease

> NSAIDs

• mild to moderate pain unresponsive to acetaminophen
• severe pain

> Intra-articular Corticosteroids

• use in conjunction with oral medications
• side effect: local discomfort, temporary increase in blood glucose levels

> Intra-articular Hyaluronans

• use in conjunction with oral medications
• side effects: local discomfort, temporary increase in synovitis

> Opioid analgesics

• are an option but used sparingly b/c can be habit forming
• bind to opioid receptors in the central and peripheral nervous systems decreasing pain perception
• treats moderate to severe pain
• side effects: nausea, constipation, confusion. drowsiness, respiratory depression, and addiction

Question 20

Acetaminophen (Tylenol)

Answer 20

• for mild to moderate pain
• Side effects: hepatic toxicity (especially in those who use alcohol regularly) and potentiation of warfarin
• works by inhibiting prostaglandin synthesis, a modulator of the inflammatory response, and blocking the generation of pain impulses

Question 21

NSAID

Answer 21

• for severe pain
• for mild to moderate pain unresponsive to acetaminophen
• works by non-selectively inhibit cyclooxygenase, an isoenzyme responsible for the production of prostaglandins; nonselective means inhibition of prostaglandins role in inflammation and pain but also inhibition of the gastrointestinal (GI) protective function of prostaglandin, hence the adverse effect of GI bleeding and ulceration with NSAID use

Question 22

NSAID warning

Answer 22

may cause increased risk of serous cardiovascular thrombotic events, myocardial infarction, stroke, renal insufficiency (especially in a “stressed” kidney, e.g. patient with pre-existing risk factors such as dehydration or a patient with a already compromised renal function), and serious GI adverse events, including bleeding, ulceration, and perforation of the stomach
-contraindicated for perioperative pain in setting of coronary artery bypass graft and in renal failure

Question 23

Intra-articular Injections of corticosteroids or hyaluronans

Answer 23

• strategically place the steroid into the joint space; the steroid inhibits the inflammatory process by suppressing the migration of polymorphonuclear leukocytes
• Hyaluronans work inside the joint to provide lubrication to the articular surfaces

Question 24

Is it acceptable and safe to use acetaminophen, NSAIDs, and intra-articular medications in conjunction with each other?

Answer 24

yes
-however, patients should not use more than one NSAID concomitantly b/c of increased risk of bleeding, development of gastric ulcers, and risk of renal damage

Question 25

Complications of Osteoarthritis

Answer 25

• chronic pain
• decreased function
• toxic effects of medication
• negatively affect comorbid conditions such as diabetes and HF r/t a decreased ability to exercise

Question 26

Surgical Intervention

Answer 26

• may be necessary for pts suffering from disability and severe pain r/t osteoarthritis
• arthroscopic irrigation and/or debridement
• arthroscopic synovectomy
• surgical fusion
• total joint replacement

Question 27

Arthroscopic Irrigation and/or Debridement

Answer 27

procedure in which the jointis irrigated and expanded in order to visualize the joint and remove debris that could be promoting joint inflammation

Question 28

Synovectomy

Answer 28

surgical procedure used to remove excessive growth of the synovial membrane in order to reduce joint inflammation

Question 29

Surgical Fusion

Answer 29

procedure performed to fuse together the joint surfaces to eliminate any movement of the joint

Question 30

Total Joint Replacement

Answer 30

surgically replacing the joint surface with a prosthesis

Question 31

Nursing Management: Assessment and Analysis

Answer 31

clinical manifestations are r/t pain and decreased function of the affected joints

• unsteady gait
• bony enlargement or swelling of affected joints
• fatigue
• painful range of motion of affected joints
• elevated serum creatinine secondary to NSAID use
• elevated liver enzymes r/t multiple medication use
• constipation secondary to decreased physical activity and/or use of narcotic analgesics

Question 32

Nursing Interventions: Assessments

Answer 32

> Vital Signs
-hypertension may occur r/t chronic NSAID therapy that alters renal function, reducing sodium excretion and enhancing fluid retention

> Weight
-the use of NSAIDs may alter renal function, leading to weight gain

> Skin Integrity
-skin breakdown may occur in bony prominences b/c of decreased physical mobility

> Serum Creatinine
-use of NSAIDs may lead to renal impairment by inadvertently blocking essential prostaglandins, which maintain blood flow to the kidneys, resulting in an increase in serum creatinine, while blocking the targeted prostaglandin, which are necessary for pain control

Question 33

Nursing Actions

Answer 33

> Administer analgesic and anti-inflammatory medications as ordered
-acetaminophen and NSAIDs reduce pain by inhibiting prostaglandin production, thus blocking the generation of pain impulses and inhibiting the inflammatory response; opioids alter the perception of pain

> Provide cold packs for painful joints
-cold reduces inflammation

> Provide a heat pad for painful muscles
-heat relaxes muscles and causes vasodilation, which improves blood flow and promotes healing

Question 34

Teaching

Answer 34

> Take medications only as prescribed
-misuse or overuse of analgesics and anti-inflammatories may lead to side effects and can be dangerous; NSAID therapy may increase risk of myocardial infarction (MI), GI bleeding, stomach ulcers, renal insufficiency, and abnormal platelet function

> Report chest pain, abdominal pain, abnormal bleeding, and blood in stool or emesis
-signs of NSAID toxicity or MI

> Participate in regular physical activity

• promotes good health, weight management, joint mobility, muscle strength, cardiac health, and self-efficacy
• can reduce stress, anxiety, and depression

> Assist with referring the patient to occupational and physical activities
-fitting for assistive devices, splints, and other assistive devices should be done by physical and occupational therapists
-physical and occupational therapies should be
utilized to improve or maintain joint function

> Assist with referring the patient to orthopedic surgery when necessary
-surgery may be necessary for end-stage osteoarthritis once other treatment have failed

> Assist with home healthcare referral
-home care may be utilized; assessing patient’s homes for safety hazards and teaching patients and their families about the management of osteoarthritis

Question 35

Evaluating Care Outcomes

Answer 35

-important to maintain function
>well-managed patient: has pain under control and has good, unrestricted movement
-achieved by pharmacological and nonpharmacological management