Osteoporosis, Arthritis & Total Joint Arthroplasty

What are the key concerns for Osteoporosis, Arthritis & Total Joint Arthroplasty?

• Osteoporosis → fracture

• Arthritis → pain, deformity, imparied mobility, psychosocial concerns

• Total Joint Arthroplasty → pain, VTE, dislocation, infection

What is Osteoporosis?

• Chronic disease characterized by bone loss, decreased bone density, and possible fracture (#1 risk, increased risk, specifically hip fractures)

• Osteoclastic activity (breaks down and reabsorbs old/damaged tissue) > osteoblastic activity (build, form and reshape bone tissue) → thin, fragile bones at risk for fracture

What are nonmodifiable risk factors for osteoporosis?

• Older age in both genders and all races

• Parental history of osteoporosis, especially mother

• History of low-trauma (fragile, minor impact) fracture after age 50

What are modifiable risk factors for osteoporosis?

• low body weight, thin build

• chronic low calcium and/or vitamin D intake

• estrogen and androgen deficiency

• current smoking (active or passive)

• high alcohol intake (three or more drinks a day)

• lack of physical exercise or prolonger immobility

What are a few symtpoms or things you may see with osteoporosis?

• May be asymptomatic

• Back pain with lifting or bending

• Fractures

• Kyphosis

How do you diagnosis and treat osteoporosis?

• Screening and diagnosis: Dual X-ray Absorptiometry (DXA scan- bone density test)

• Pharmacologic treatment:

  • Calcium and D3: intake of these supplements alone is not sufficient, but it is an important part of promoting bone health

  • Biphosphonates- slow bone reabsorption (ex’s: alendronate (Fosamax), ibandronate (Boniva)

What should you implement with osteoporosis?

• Pt teaching to prevent falls

• Lifestyle practice to prevent additional bone loss: daily sun exposure, adherence to medication regimen, encourage exercise

• Nutrition therapy: promotion of a single nutrient will not prevent or treat as many are needed for bone health

  • emphasize fruits/vegetables, low-fat dairy and protein sources, increased fiber, and moderation in alcohol/caffeiene intake

How can you try to prevent osteoporosis at an early age?

• Patient teaching is epspecially important before age 30!

  • Adequte dietary calcium and vitamin D intake

  • Smoking cessation and weight loss (if needed)

  • Limit carbonated beverages to <40oz. per day

  • Weight bearing exercise

What are key sources of calcium?

• Dairy

• Leafy greens

• Beans

• Foritifed foods (orange juice and cereal)

• Fortified nondairy milk (soy, almond)

What are key sources of vitamin D?

• Fatty fish (cod, salmon)

• Fortified diary (cheese and milk)

• Eggs

• Fortified foods

What does arthritis/rheumatic diseases affect?

• Rheumatic diseases affect joints, tendons, ligaments, bones and muscles

What is osteoarthritis?

• Progressive loss of bone and cartilage in one or more joints

• Decreased water, chondroitin (cushions joints), and cartilage between joints → narrowing of joint space and formation of bone spurs → joint pain

• Secondary inflammation can occur when damage is severe

• Also known as “Degenerative Joint Disease” (DJD)

What is rhematoid arthritis?

• Chronic, progressive systemic inflammatory autoimmune condition, affecting primarily synovial joints

• Autoantibodies attack synovium and cartilage, fluid accumulates in joint, and secondary osteoporosis occurs

• Other body systems affected

What is the age of onset, sex, risk factors/cause, disease pattern, physical assessment, and lab findings for osteoarthritis?

• Age on onset: >65

• Sex: female

• Risk factors/cause: genetic, aging, obesity, trauama or occupation

• Disease pattern: May affect only one joint, weight bearing joints (spine and hands), not systemic

• Physical assessment: crepitus, one ore more joints affected, progressive joint stiffness/pain, eventual joint deformity

• Lab findings: normal or slightly elevated ESR (anti-inflammatory marker)

What is the age of onset, sex, risk factors/cause, disease pattern, physical assessment, and lab findings for rheumatoid arthritis?

• Age on onset: 35-45

• Sex: female

• Risk factors/cause: genetic, autoimmune, emotional stress (triggers exacerbation)

• Disease pattern: Bilateral, symmetric, affects upper extremities first, systemic

• Physical assessment: Early sx’s- systemic sx’s (fever, fatigue, weakness) and Late sx’s- systemic sx’s (fatigue, osteoporosis, kidney disease), progressive joint stiffness/pain, eventual joint deformity

• Lab findings: Elevated rheumatoid factor, antinuclear antibody, and ESR (anti-inflammatory marker)

With arthritis, how can you promote mobility?

• OT & PT → stop moving = makes it worse/progresses

• Mobility aids

• Encourage independence

• Interventions to address fatigue

With arthritis, how can you encourage self-management?

• Participate in physical activity

• Don’t skip exercises on ‘bad’ days

• Don’t substitute household chores/activites in place of exercise

• Protect joints by adjusting habits of movement (use two hands instead of one, carry objects with large joints instead of small)

With arthritis, how can you address psychosocial concerns?

• Concerns: disfigurement, fear of pain, decreased quality of life, loss of independence

• Therapeutic communication

• Discuss goals to improve self-esteem

• Emphasize strengths

• Help identify previous effective coping strategies

• Consult with mental health professionals or spiritual leaders

How do you manage pain for osteoarthritis?

• Pharmacologic: Acetaminophen (1st choice), topical lidocaine patches, NSAIDs (only if tolerated)

• Non-pharamcologic: Application of heat/cold, weight loss for obesity, complementary treatments

• Additional Non-pharamacologic: rest balanced with exercise, functional position of joints, proper psoture and lifting, physical therapy

How do you manage pain for rheumatoid arthritis?

• Pharamcologic: NSAIDs, disease modifying anti-rheumatic drugs (DMARDs, biological response modifiers, glucocorticoids)

• Non-pharmacologic: application of cold to inflamed joints, heat to stiff joints, plasmapheresis

• Additional non-pharmacologic: rest balanced with exercise, functional position of joints, proper posture and lifting, physical therapy

What are the main teaching contents for osteoarthritis vs. rheumatoid arthritis?

• Osteoarthritis

  • May cause joint deformity

  • Acetaminophen priortized for pain

  • Application of heat to stiff or painful joints

  • Surgical treatment includes joint replacement

• Rheumatoid Arthritis

  • Systemic autoimmune disease

  • May cause joint deformity

  • Application of heat to stiff or painful joints (NOT for inflamed joints)

  • Treatment may include corticosteroids

  • May impact renal function

  • Surgical treatment includes joint replacement

What is the surgical procedure for osteoarthritis and/or rheumatoid arthritis?

• Total Joint Arthroplasty (TJA)

What are the reasons to get a TJA?

• Failure of conservative treatments

• Severe compromise of client’s functional ability

• Significant pain

What are the three big complications of a TJA?

• Dislocation (hip)- can happen to other parts of body but hip is most likely

• Infection

• Venous thromboembolism (VTE)

How can you prevent dislocation (hip) from a TJA?

• Position correctly

• Keep legs slightly abducted (for posterior surgical approach)

• Prevent hip flexion beyond 90 degrees (for posterior surgical approach)

• Prevent hip hyperextension (for anterior surgical approach)

• Assess for acute pain, rotation, and extremity shortening

• Perform frequent neurovascular assessments, at least every 4 hrs for the first 24hrs or per agency protocol

• Report dislocation immediately to the surgeon!

How can you prevent an infection from a TJA?

• Use aseptic technique for wound care and emptying of drains

• Wash hands thoroughly when caring for patient

• Culture drainage fluid, if change

• Monitor temperature

• Report excessive inflammation or drainage to surgeon

How can you prevent a venous thromboembolism from a TJA?

• Have pt wear elastic stockings and/or sequential compression device per agency protocol

• Teach leg exercises to pt

• Encourage fluid intake

• Observe for signs of DVT (redness, swelling, or pain)

• Observe pt for changes in mental status

• Administer anticoagulant as prescribed

• Do not massage legs

• Do not flex knees for a prolonged period of time

• Ambulation TID!

What is the difference between an anterior and posterior approach for a TJA hip replacement?

• Anterior: Often allows for a quicker early recovery, less initial pain, and typically requires no strict hip precautions (such as avoiding bending past 90 degrees)

  • muscke sparing technique

• Posterior: Provides an exceptional, wide view of the hip joint for the surgeon, but usually requires standard hip precautions for about 6 weeks post-surgery to prevent dislocation while tissues heal (more risk for dislocation)

  • requires splitting or detaching muscles/tendons

What interventions are for someone who had a posterior total hip arthroplasty to prevent dislocation?

• Abductor pillow (goes between knees/lower legs)

• Hip flexion: when standing up the angle shouldn’t bend your hip past 90 degrees

What interventions are for someone who had a total knee arthroplasty?

• No pillow under operative knee!

• Crytherapy

• Continuous Pasive Motion (CPM) machine

What TJA is this?

• Recovery: assisting with safe transfers and mobility is crucial, using techinqiues to prevent dislocation and injury during movement

• Nursing assessments: monitoring for leg shortening, external rotation, and neurovascular status to detect complications early

• Nursing interventions: requires strict movement restrictions to prevent dislocation, especially avoiding flexion over 90 degrees

• Patient education: effective pain control and patient education on movement limitations help prevent complications and support recovery

Posterior Hip Arthroplasty

What TJA is this?

• Recovery: Monitor surgical incision for infection and manage pain effectively to support recovery, encourage early ambulation. Some of these patients go home same day as surgery!

• Nursing assessments: Regular neurovascular checks post-surgery

• Nursing interventions: Routine post op VS, pain control

• Patient education: Teaching safe movements and positions prevents strain on the surgical site and supports healing

Anterior Hip Arthroplasty

What TJA is this?

• Recovery: Monitor surgal incision for infection and manage pain effectively to support recovery, encourage early ambulaiton

• Nursing assessments: Monitor for DVT signs, assess pain levels, and perform neurovascular checks regularly

• Nursing interventions: Use continuous passive motion machine (depends on program), apply ice, elevate limb, and encourage assisted ambulation

• Patient education: Educate pt on importance of movement to prevent complications and promote recovery. No pillow under the operative site!

Total Knee Arthroplasty

What TJA is this?

• Recovery: Goal is regaining limb function while avoiding movements that risk recovery

• Nursing assessments: Monitor swelling, bleeding, and perform neurovascular check to ensure proper healing

• Nursing interventions: Use sling for immobilization, avoid internal rotation and adduction, and provide range of motion exercises

• Patient education: Manage pain effectively and educate patient on activity restrictions and sling care

Total Shoulder Arthroplasty

What is ESR?

• Erythrocute Sedimentation Rate

• Why ordered: detects/nonspecefically monitors inflammation, ex: suspected infection or inflammatory disease

• Symptoms/history to prompt it: unexplained fever, joint pain/swelling, fatigue, symptoms suggesting infection or inflammatory/autoimmune disease

• How/what does it see? Blood test measuring how quickly RBC’s settle in a tube, faster settling = more inflammation

• Precautions/considerations: simple blood draw, ESR is non-specific → it indicates inflammation but does not identify the cause

• Normal/abnormal: varies by age, sex, lab, abnormal/elevated = possible inflammation/infection