Osteoarthritis

Most common form of arthritis, 20% of population as a whole, 50% of those aged over 60

A disease of cartilage, erosion and progressive thinning

Possibly a common response to a variety of insults

Disease moves slowly from joint to joint and progresses in a joint slowly

Most marked on weight bearing joints

No systemic illness

No non joint features

Epidemiology

Throughout the world and human history

Women:Men 2:1

Aetiology

Mechanical insults

Biochemical changes in the cartilage

Age - more common after 50

Genetics - strong familial tendency

Obesity - associated with OA of the knees

Pathology

Condrocytes release destructive enzymes

Cartilage takes up water and splits

Synovial inflammation develops

Progressive cartilage loss

Attempts at repair lead to formation of osteophytes

Results in ossification of the joint

Symptoms

Pain - often in knees hips or hands, aggravated by use, relieved by rest, often worse in the evenings

Morning stiffness - usually for about 30 minutes, stiffness after sitting

Disability - depends on joints effected

Signs

Swelling - hard and bony possible effision

Crepitis - on movement

Limitations of movement - wasting of associated muscles and joint deformities

Management

Drugs

Entirely symptomatic

Analgesics

NSAIDs

No steroids

Physical

Local heat for pain relief

Exercise to maintain muscle condition, (especially quadriceps in knee disease)

Hydrotherapy, (good for hips)

Walking aids

Surgical

Joint replacement

99% chance of almost complete pain relief

Failure rate is about 1% per year

Problems - infection is rare but serious, cement loosening causing pain

Rheumatoid arthritis

Chronic systemic disease

Symmetrical inflammatory polyarthritis

Extra-articular involvement, eg lungs and other organs

Progressive joint damage causing severe disability in young people

Epidemiology

Effect 2% of world-wide population

Women:Men 3:1

Often starts from 30 - 40, (may be 10 - 70)

Family history (5-10%)

Aetiology

Unknown

Toxins produced in the inflammatory process damage cartilage

Autoimmune

Autoantibodies seen

Immune complexes in synovial fluid and blood

Possibly caused by chronic presence of an antigen

Pathology

A disease of the synovium

Inflammation ------ joint tender, swollen and warm

Thickened synovial membrane, (termed a pannis) overlies articular cartilage and erodes it ------ joint painful, swollen and immobile

Bone ends erode ------ joint obliterated, ankylosis and deformity

10% of patients - results in serious disability

40% of patients - significant disability

Symptoms

Joint pain - often worst in the morning and may improve with activity

Morning stiffness - often for several hours

General - fatigue, general malaise

Disability - depends on changes in individual joints

Signs

Swelling of joints

Warmth -

Tenderness - on pressure or movement

Limitation of movement - muscle wasting around joint

Deformities - in the later stages

Nodules - a non articular feature

Diagnosis - mostly clinical

Management

Depends on the stage the condition has reached

Early management

Information, explanation, support, reassurance

Exercise to maintain joint mobility and muscles - prevent future movement restrictions

Physical activity does not increase rate of joint deterioration

Later

Symptomatic management

NSAIDs and analgesics

Corticosteroids are only occasionally used

Intra-articular injections

Rest - splints may provide localised rest for a joint

Suppressive treatment with drugs, eg penicillamine, gold, azothioprine

Later treatments involve optimising the patients life-style with disability

Nursing Care in Rheumatoid Arthritis

Pain and inflammation of joints

Position in bed - well supported

Bed cradle - light bed covers

Analgesia/NSAIDs - as prescribed e.g.

- aspirin, ibroprofine, indomethazine

- monitor effects and limit side-effects, eg. drugs given after food

Splinting of affected joints

Gentle handling and movement

Discomfort due to pyrexia

Monitor vital signs

Tepid sponge if required

Change night attire/bed linen frequently

Provide fan, avoid direct fanning

Ventilate room/area

Give extra fluids 2 - 3 litres daily

Immobility

Provide call bell

Relief of pressure - assess risk on assessment tool

Pressure area care - pressure relieving devices, change positions

Assist with gentle exercise

Provide pain relief

Plan for gradual mobilisation with exercise regime when inflammation subsides

Lethargy/Fatigue

Provide for adequate rest/sleep

Monitor for signs of anaemia, eg. breathlessness/tachycardia

Give prescribed medication, eg. iron supplements

Difficulty in maintaining hygiene

Assisted bed bath

Mouth care

Encourage maintenance of body image

Difficulty in maintaining nutrition

Offer light, high-protein, easily-digested diet

Consider likes/dislikes

Give extra fluids, e.g. fruit juices

Special utensils/help with eating

Difficulty with elimination

Assist with toilet/commode

Provide comfort/privacy

Use of apperients for limited periods for specific indications

Given high fibre and fluid diet if tolerated

Anxiety/depression

Involve in personal care

Clear explanation of condition and possible outcome

Inform about progress

Give time to talk/listen

Involve social worker

Encourage family/friends to visit - involve in care

Provide diversional therapy - avoid boredom

- promote independence