Ch. 43 Arthritis &Total Joint Arthroplasty

most common type of arthritis

osteo

osteoarthritis

• progressive deterioration of cartilage particles

• generally 1 joint affected

etiology & risk for OA (primary & secondary)

• primary: family history, elderly

• secondary: old injuries from sports

• obesity, genetics

prevalence of OA in men

more men than women younger than 55 have OA caused by athletic or traumatic injuries

prevalance of OA in women

• after 55 prevalence in women is higher

• could be due to increased obesity or after having children and broader hips

OA prevalence in military

• most OA occurs from combat injuries

• occurs twice as often in military members younger than 40 than gen population

• associated with comorbidities r/t CV health like obesity, diabetes, HTN

• those w mental health issues, PTSD, depression, anxiety at higher risk for OA likely due to mental health disorders making infrequent exercise and weight gain bc lack of energy

what to assess military pt’s for

• joint pain

• previous traumatic events

• comorbidities both mental and physical

healthy people 2030 objectives

• reduce # of adults w arthritis causing moderate to severe joint pain

• reduce # of adults whose arthritis limits work or activities

• increases # w arthritis who get counseling for physical activity

key concepts OA
onset, gender, risks, process, pattern, labs, & drug tx

• onset: older than 60

• gender: females 2:1

• risks: aging, genetics, obesity, trauma, occupation

• disease process: degenerative w secondary inflammation

• disease pattern: unilateral single joint, affects weight bearing joints and hands, spine, metocarpophalangeal joints spared, nonsystemic

• lab findings: normal or slightly elevated ESR, high sensitivity c reactive protein

• drug tx: nsaids (short term), acetaminophen, other analgesics

key concepts RA
onset, gender, risks, process, pattern, labs, & drug tx

• onset: 35-45

• gender affected: female

• risks: autoimmune (genetic), emotional stress, environmental fx

• disease process: inflammatory

• disease pattern: bilateral, symmetric, multiple joint, usually affects upper extremities first, distal interphalangeal joints of hands spared first, systemic

• lab findings: elevated rheumatoid fx, antinuclear body, and esr

• drug tx: nsaids (short term), methotrexate, biological response modifiers

family & pt education for exercises r/t OA

• Follow the exercise instructions that have been prescribed specifically for you. There are no universal exercises; your exercises have been specifically tailored to your needs.

• Do your exercises on both "good" and "bad" days. Consistency is important.

• Respect pain. Reduce the number of repetitions when the inflammation is severe and you have more pain.

• Use active rather than active-assist or passive exercise whenever possible.

• Do not substitute your normal activities or household tasks for the prescribed exercises.

• Avoid resistive exercises when your joints are severely inflamed.

RA and genetics

HLA-DR alleles (DR4, DRB1)

highest risk for RA

• african americans, esp those w education level less than high school and low family income

herberden nodes are _____, bouchard nodes are ______

which arthritis?

distal
proximal
osteoarthritis - ½ involve hand movement

common & early s/s of RA

• joint inflammation

• low grade fever

• fatigue

• weakness

• anorexia

• paresthesia

common late s/s RA

• joint deformaties (swan neck, ulnar deviation)

• moderate to severe pain and morning stiffness

• osteoporosis

• severe fatigue

• anemia

• weight loss

• muscle atrophy

• subcutaneous nodules

• peripheral neuropathy

• vasculitis (blood vessel infammation)

• pericarditis

• fibrotic lung diseae

• sjorgen syndrome (dry eyes, mouth, and vagina)

• kidney disease

CRITICAL RESCUE! cervical RA

• may result in subluxation esp in first and second vertebrae

• deadly bc branches or phrenic nerve that supply diaphragm are restricted and resp fx is compromised

• pt can become qudriparetic or quadriplegic

• if cervical pain (can be down one arm) or loss of rom present in cervical spine, keep neck straight in a neutral position to prevent permanent damage to spinal cord or nerves

• notify rapid response and pcp immediately

can labs diagnose RA

no, dx made from s/s, drawing fluid from joints (arthrocentesis), xray or ct scans, mri, initial presentation, hx

lab tests involved w RA

• **no single test or group of tests can confirm it

• rheumatoid fx (RF) measures presence of IgG and IgM that develop in a number of connective tissue diseases

• anti-ccp (new) detects anti-cyclic citrullinated peptide, very specific in detecting early RA and aggressive and erosive late stages

• ANA: measures the titer of a group of antibodies that destroy the nuclei of cells and cause tissue death in patients with autoimmune disease.

• ESR >20 can confirm inflammation or infection

• hsCRP to measure inflammation

planning and implementation for RA cycle

• diagnose early

• alleviate pain

• preserve fx

• control disease activity

• maximize qol

• slow progression and rate of joint damage

What are the overall goals with treating RA?

 to manage pain and inflammation, prevent further joint damage, promote mobility and independence, and enhance self esteem

promoting mobility with RA

Promote rest for energy conservation. Proper positioning. Thermal therapy. Safety measures. Teach PT how to use larger joints instead of smaller ones. 

drug used to treat RA

• DMARDS: hydroxychloroquine, methotrexate

• BRMS

• steroids

• NSAIDs

complications of steroids

• DM

• decreased immunity

• f and e imbalance

• HTN

• osteoporosis

• glaucoma

when a pt is taking NSAIDs, check what before they start therapy

CBC & CMP
complete blood count & comprehensive metabolic panel

key features DMARDs

• ordered 1st

• slow progression

• most cause birth defects and miscarriage, need to be on birth control

• methotrexate

• hydroxychloroquine

DRUG ALERT! methotrexate

• do NOT take if pregnant

• increased risk for infection

• avoid crows and ill people

• avoid alcohol to prevent liver toxicity

• report side effects like mouth sores, acute dyspnea from pneumonitis and lymphoma

• take folic acid and vit b to decrease some side effects of drug

• hard on liver and kidneys, check enzymes

• can cause bone marrow suppression

DRUG ALERT! hydroxychloroquine

• can cause retinal damage

• report blurred vision or h/a

• have eye exam before tx and every 6o after to detect changes in cornea, lens, and retina

• d/c if this occurs

• do not use in pt’s w known cardiac disease or dysrhythmias

BRMs key features

• biological response modifiers

• block effect of TNF which stops inflammatory process

• more expensive

• higher risk for impaired immunity

• can get flare ups/exacerbations of TB & MS

• give tb ppd skin test and dont start drug until negative result**

• keep refrigerated except for infliximab

• do NOT give live vaccines

imaging for OA

• xrays

• MRI

drug therapy for OA

• tylenol

• NSAIDs (primary choice - multimodal)

• celeoxib (COX-2 - works really well if eligible)

standard ceiling dose acetaminophen____ …BUT

4000mg

• risk for liver damage if more than 3000mg daily if they have alcoholism or liver disease, older adults

pt teaching for acetaminophen

• read labels in otc meds

• liver enzymes may be monitored while taking this drug

nonpharmacologic interventions for OA

• rest

• immobilization

• positioning

• menthol oils and rubs

• hydrotherapy, mineral baths, hot tubs, thermal modalities

• weight control

• Complementary and integrative health (acupuncture/pressure, PT)

complementary drug/diet interventions for OA

• glucosamine

• chondroitin

• both reduce pain and improve function mobility

contraindications for glucosamine and chondriotin

• do not give if HTN

• pregnant or breastfeeding

DRUG ALERT! celecoxib (COX2)

Thought to cause cv disease like MI and HTN due to vasoconstriction and increases platelet aggregation (clumping). All NSAIDs can cause GI side effects, bleeding, and acute kidney injury if used long-term. Therefore, they are prescribed at the lowest effective dose. Remind patients to take celecoxib with food to decrease GI distress. Teach your patient about potential adverse effects and the need to report them to the primary health care provider. Examples include having dark, tarry stools; shortness of breath; edema; frequent dyspepsia; hematemesis (bloody vomitus); and changes in urinary output.

teaching COX2

• take w food to decrease gi distress

• report adverse effects to pcp

• report dark tarry stool, sob, edema, frequent dyspepsia, hematemesis, changes in urinary output

when is surgical management for arthritis necessary

when other conservative measures are no longer working

minimal invasive joint replacement surgery is contraindicated when

the pt is obese or has osteoporosis

when to stop taking anticoagulants before surgery

5-10 days

what is prehab

• preop rehab

• prevents fx decline after surgery to provide a quicker recovery

• learn joint postop exercises

• transfer and positioning techniques

• ambulation w walker or crutches

pt THA preop nutrition assessment

• stress the need for preop assessment for clinical malnuturtion which is associated w prolonged postop rehab and surgical comp

• collab w RD for nutritional assessment

pt teaching THA preop pain assessment and management

• asses for use of opiods for persistent pain before surgery

• teach pt and joint coach ab multimodal pain management options

pt teaching THA about postop

- need for anticoagulants starting 24 hrs after surgery and continue for 14 days after surgery
- need for frequent mobilization postop: prevent constipation
- need for compression stockings or scds during hospital stay

pt teaching tha preop infection prevention

• expect to recieive iv antibiotics before surgery and up to 24hrs after

• importance of screening nares for staph 2-4 wks before surgery and nasal mupirocin 1 wk before surgery

• bathe w CHG solution the night before and morning of surgery

• sleep on clean linen and don’t use powder or lotion after CHG baths, no pets in bed

s/s hip dioslocation

• sudden difficulty bearing weight on surgical leg

• leg shortening or rotation

• feeling a pop w immediate intense pain

pt teaching THA postop pain management

• report increased hip or anterior thigh pain to surgeon

• take oral analgesics as prescribed

• do not overexert yourself, take frequent rest

• use ice as needed to prevent swelling and decrease pain

pt teaching THA post op incisional care

• follow instructions for dressing changes

• inspect hip everyday for redness/hyperpigmentation, heat, or drainage, call surgeon if present

• do not bathe the incision or apply anything directly to incision

• shower according to instructions

pt teaching THA postop other care

• continue walking and performing leg exercises

• do not decrease amt of activity unless instructed

• do not cross legs, helps prevent blood clots

• call 911 for acute chest pain or sob (PE)

• follow bleeding precautions to prevent bleeding

• follow up w outpt pt for exericse and ambulation program to rebuild strength, mobility, and endurace

• follow up w surgeon visits as instructed

bleeding precautions

• avoid using straight razor

• avoid injuries

• report bleeding or excessive bruising

contraindications for THA

• must no have infection anywhere in body

• dental work

key things to remember for older adults w tha postop

• use abduction pillow or splint to keep legs apart and prevent adduction

• keep heels off bed to prevent pressure ulcers

• do not rely on fever as a sign of infection (watch for decreasing mental status or increased wbc as indicator)

• move pt slowly when getting out of bed

• encourage deep breathing and incentive spirometer q2h to prevent pneumonia

• on surgical day, get pt out of bed to a recliner chair to prevent comp or decreased mobilty

ACTION ALERT! postop THA (monitor)

• monitor neurovascular assessments frequently for compromise in circulation to affected distal extremity

• check color, temp, distal pulses, cap rf, movement, and sensation

• compare to nonop leg

• perform this assessment at the same time vitals are performed

• early detection can prevent permanent tissue damage

ACTION ALERT! pt’s getting out of bed first time postop THA

• assist first time to prevent falls and observe dizziness

• put gait belt on, stand on same side of bed as the affected leg

• after pt is sitting on side of bed remind them to stand on the unaffected leg and pivot to the chair w guidance

• do not lift the pt!

most common reason to be readmitted after THA

thromboembolic problems/throwing a clot (DVT, stroke, SSI, and systemic infections like pneumonia and sepsis). Men of advanced age and those with comorbidities, such as heart failure and diabetes, are at the highest risk for hospital readmission after a THA

comp of THA

• hip dislocation

• infection

• vte

• dvt

• pe

• hypotension

• bleeding

ACTION ALERT! positioning after tha

• teach pts to maintain correct position of hip joint and leg at all times

• place them in supine after returning from pacu w head slightly elevated

• 1 or 2 pillows used to remind pts to keep legs abducted if had lateral surgical approach

• if abduction device w straps is used to prevent dislocation, loosen straps q2h and check for skin breakdown

• place and support leg in neutral rotation

• turning the pt to the side provides splinting but may be too painful

• if pt turned on nonoperative side, bad leg needs to be fully supported w pillow to prevent the leg slipping into an adducted position

• crossing the legs can cause the hip to pop right back out. 

why is there an increased demand for tka

osteoarthritis and obesity

CRITICAL RESCUE! continuous femoral nerve blockade

• perform and document neurovascular assessment q2-4h

• make sure pts can perform dorsiflexion and plantar flexion of affected food w out pain in lower leg

• monitor for s/s that indicate absorption of local anesthetic into pts system (report to surgeon, crna, or rapid response immediately)

s/s that indicate absorption of local anesthetic into pt’s system

• metallic taste

• tinnitus

• nervousness

• slurred speech

• bradycardia

• hypotension

• decreased resp

• seizures

what is a CPM machience

• helps regain flexion

• continuous passive motion

• keep prosthetic knee in motion and prevent scar tissue

how long does total recovery from tka take

6+ weeks

instruction for joint protection in arthritis pt’s

• use large joints instead of small ones (use purse strap over ur shoulder instead of grasping purse with hand)

• do not turn a doorknob clockwise to avoid twisting arm an promoting ulnar deviation (esp w RA) - counterclockwise

• use two hands instead of 1 to hold objects

• sit in a chair that has a high straight back

• when getting out of bed, do not push off w ur fingers, use entire palm of both hands

• do not bend at your waist, bend knees while keeping back straight instead

• use long handled devices like a hairbrush w an extended handle

• use assistive and adaptive devices like velcro

• do not use pillows in bed except a small one under ur head

• avoid twisting or wringing hands, use device or ribber grip to open jars or bottles

energy conservation for arthritis pt

• balance activity w rest

• take 1-2 naps per day

• pace yourself, do not plan too much for one day

• set priorities, determines most important activities and do them first

• delegate responsibilities and tasks to family and friends

• plan ahead to prevent last min rushing and stress

• learn your own activity tolerance and do not exceed it

what is gout

the body’s inflammatory response to a large amount of uric acid (a result of purine metabolism) in the blood (hyperuricemia) and other body fluids.

phase 1 gout

• asymptomatic hyperuricemia

• increased uric acid but don’t know

• some PTs never progress past this phase

phase 2 gout

• acute attack usually in one single joint (often big toe)

• excruciatingly painful that can last hours to days

• aka gouty arthritis

phase 3 gout

• tophaceous gout (feels like clumps of sand)

• few pt’s progress to this stage bc of new drugs

• may progress to get kidney stones or disease. Again, many people don’t get to this phase.

drug therapy for gout

acute gout: NSAID, steroid, or colchicine. Probenecid to excrete excess uric acid.

*For chronic gout, allopurinol (prevent them from forming too much uric acid) or febuxostat.

gout triggers to avoid

• red meat

• liver

• shellfish

• shrimp

• alcohol

• beer

• thiazide diuretics

what can you inject into a joint to help w pain

• steroids

• hyaluronic acid

Plasmapheresis

plasma enhance - pulls out antibodies that cause RA (can produce remission)