Rheumatoid arthritis, Osteoarthritis, Gouty Arthritis, Systemic Lupus Erythematosus , Lupus Erythematosus, Osteopenia, Osteoporosis, Osteomyelitis, Osteosarcoma, Paget's Disease

Rheumatoid Arthritis

• chronic systemic inflammatory disease

• destruction of connective tissue and synovial membrane within the joints

• weakens and leads to dislocation of the joint and permanent deformity

• Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing numerous WBC and inflammatory proteins

Rheumatoid Arthritis Risk Factors

• exposure to infectious agents

• fatigue

• stress

Rheumatoid Arthritis Signs and Symptoms

• Morning stiffness

• Fatigue

• Weight loss

• Joints are warm, tender, and swollen

• Swan neck deformity - late

Rheumatoid Arthritis Diagnostic Studies

• X-ray

• Elevated WBC, CRP, ESR*, positive RF, ANA

Rheumatoid Arthritis Treatment

No cure

Rheumatoid Arthritis Pharmacotherapy

1. Aspirin- mainstay of treatment, has both analgesic and anti-inflammatory effects

2. Nonsteroidal anti-inflammatory drugs (NSAIDs):

   • Indomethacin (Indocin)

   • Phenylbutazone (Butazoldin)

   • Ibuprofen (Motrin) • Fenoprofen (Nalfon)

   • Naproxen (Naprosyn)

   • Sulindac (Clinoril)

   • COX 2 inhibitors (Celecoxib, Arcoxia)

3. Immunosuppressives: Methotrexate

   • Gold Standard for RA treatment

   • Teratogenic

4. Gold compounds

5. Injectable form: sodium thiomalate, aurothioglucose; given IM once a week; takes 3-6 months to become effective

6. Oral form: auranofin- smaller doses are effective; diarrhea is a common side effect

7. Corticosteroids

8. Intra-articular injections

Rheumatoid Arthritis Surgical Treatment

• synovectomy

• arthrotomy

• arthrodesis

• arthroplasty

Rheumatoid Arthritis Nursing Management

• Advised bed rest during acute pain

• Passive ROM exercise of joints

• Splint painful joints

• Heat & Cold application

• Advised warm bath in the morning

• Protect from infection

• Advised well-balanced diet

Rheumatoid Arthritis Diet

• Regular diet with caloric restrictions because steroids may increase appetite

• Supplements of vitamins, iron and PROTEIN

How to Increase Mobility and Prevent Deformity in Rheumatoid Arthritis?

• Lie FLAT on a firm mattress

• Lie PRONE several times to prevent HIP FLEXION contracture

• Use one pillow under the head because of risk of dorsal kyphosis

• NO Pillow under the joints because this promotes flexion contractures

Osteoarthritis (Degenerative Joint Disease)

• Progressive degeneration of the joints as a result of wear and tear

• affects weight-bearing joints and joints that receive the greatest stress, such as the knees, toes, and lower spine.

Osteoarthritis Risk Factors

• aging (>50 yr)

• rheumatoid arthritis

• arteriosclerosis

• obesity

• trauma

• family history

Osteoarthritis Signs and Symptoms

• Dull, aching pain,* tender joints

• fatigability, malaise

• crepitus

• cold intolerance*

• joint enlargement

• presence of Heberden’s nodes or Bouchard’s nodes

• weight loss

Osteoarthritis Medications

1. Aspirin

2. Ibuprofen

3. Indomethacin

Aspirin

• inhibits cyclooxygenase enzyme, diminishes the formation of prostaglandins

• anti-inflammatory, analgesic, antipyretic action

• inhibit platelet aggregation in cardiac disorders

Aspirin Adverse effects

• Epigastric distress, nausea, and vomiting

• In toxic doses, can cause respiratory depression

• Hypersensitivity

• Reye’s syndrome

Ibuprofen

• use for chronic treatment of rheumatoid and osteoarthritis

• less GI effects than aspirin

Ibuprofen Adverse effects

• dyspepsia to bleeding

• headache, tinnitus and dizziness

Indomethacin

• inhibits cyclooxygenase enzyme

• more potent than aspirin as an anti-inflammatory agent

Indomethacin Adverse effects:

• nausea, vomiting, anorexia, diarrhea

• headache, dizziness, vertigo, lightheadedness, and mental confusion

• Hypersensitivity reaction

Osteoarthritis Nursing Intervention

• Promote comfort: reduce pain, spasms, inflammation, swelling

  • Heat to reduce muscle spasm

  • Cold to reduce swelling and pain

• Prevent contractures: exercise, bed rest on firm mattress, splints to maintain proper alignment

• Weight reduction

• Isometric and postural exercises

Osteoarthritis Nursing Diagnosis

• Pain related to friction of bones in joints

• Risk for injury related to fatigue

• Impaired physical mobility related to stiff, limited movement

Gouty Arthritis

• Metabolic disorder that develops as a result of prolonged hyperuricemia

• Caused by problems in synthesizing purines or by poor renal excretion of uric acid.

• Acute onset, typically nocturnal and usually monoarticular, often involving the first metatarsophalangeal joint

Gouty Arthritis Risk Factors

• Men

• Age >50 years

• Genetic/Familial tendency

Gouty Arthritis Causes

1. Primary gout-disorder of Purine metabolism

• Poor dieting technique

  • e.g. Elimination of CHO in the diet

• Increase purine in the diet

  • e.g. Organ meat, soya, etc.

2. Secondary gout excessive uric acid in the blood like leukemia

Gouty Arthritis Signs and Symptoms

• extreme pain

• swelling

• erythema of the involved joints

• fever

• Tophi

  • yellowish-whitish, irregular deposits in the skin that break open and reveal a gritty appearance

• PODAGRA-big toe

Gouty Arthritis Laboratory Findings

• elevated serum uric acid (>7.0 mg/dl)*

• urinary uric acid

• elevated ESR and WBC

• crystals of sodium urate aspirated from a tophus confirms the diagnosis*

Gouty Arthritis Treatment

1. Allopurinol (take it with foods)

2. Colchicine

3. Probenecid/Sulfinpyrazone

Allopurinol

• a purine analog

• reduces the production of uric acid by competitively inhibiting uric acid biosynthesis which are catalyzed by xanthine oxidase.

• Effective in the treatment of primary hyperuricemia of gout and hyperuricemia secondary to other conditions (malignancies).

Allopurinol Adverse effects

• hypersensitivity reactions

• nausea and diarrhea

Colchicine

• Effective for acute attacks

• Anti-inflammatory activity alleviating pain within 12 hours

Colchicine Adverse effects:

• nausea

• vomiting

• abdominal pain

• diarrhea

• agranulocytosis

• aplastic anemia

• alopecia

Probenecid/Sulfinpyrazone

• uricosuric agents

• increases the renal excretion of uric acid

• Sulfinpyrazone used as a preventive agent.

Probenecid/Sulfinpyrazone Adverse effects

• nausea

• rash

• constipation

Gouty Arthritis Nursing Implementation

• Maintain a fluid intake of at least 2000 to 3000 ml a day to avoid kidney stone.

• Avoid foods high in purine such as wine, alcohol, organ meats, sardines, salmon, anchovies, shellfish and gravy.

• Take medication with food.

• Have a yearly eye examination because visual changes can occur from prolonged use of allopurinol

• Caution client not to take aspirin with these medication because it may trigger a gout attack and may cause an elevated uric acid levels.

• Encourage rest and immobilize the inflamed joints during acute attacks • Avoid excessive alcohol intake

• Notify physician if rash, sore throat, fever or bleeding develops.

Systemic Lupus Erythematosus

• Chronic, progressive, inflammatory connective tissue disorder can cause major body organs and systems to fail.

• Many clients with this have some degree of kidney involvement.

• F>M (child bearing years)

SLE is present if client has four or more of these findings:

1. arthritis: characterized by swelling, tenderness and effusion; involving two or more peripheral joints

2. malar rash: characteristic butterfly rash over cheeks and nose

3. discoid lupus skin lesions

4. photosensitivity

5. oral ulcers

Lupus Erythematosus Signs and Symptoms

• Shows up in childbearing years

• Medication related

• Any body system

• Rash, lesions

• Exacerbations

• Pericarditis

• Renal > HTN

• CNS

• Fever, fatigue, weight loss, arthritis, hematuria onset

Assessments for Lupus

• Psychosocial results can be devastating.

• Laboratory

  • Skin biopsy (only significant test to confirm diagnosis)

  • Complete blood count

  • Body system functions

Collaborative Management of SLE

• Physical assessment and clinical manifestations

  • Skin involvement

  • Musculoskeletal changes

  • Systemic manifestations including pleural effusions or pneumonia and Raynaud’s phenomenon

Osteopenia

Reduced Bone Mass Density slightly elevated risk of fracture

Osteoporosis

• Severe Bone Mass Density reduction very high risk of fracture (hip, wrist, spine, ribs)

• reduction of total bone mass

• change in bone structure, which increases susceptibility to fracture

• bone becomes porous, brittle, and fragile

• 10 million suffer from this

• women lose 0.5-1% of their bone mass each year until age 50 or menopause

• after menopause rate of bone loss increases (as high as 6.5%)

• Metabolic disease, in which bone demineralization results in decreased density and subsequent fractures

• Osteopenia (low bone mass), which occurs when there is a disruption in the bone remodeling process

• Occurs mostly in white non-hispanic

Do you get shorter with age?

• Osteoporosis compromises structural integrity of vertebrae • weakened trabecular bone

  • vertebrae are “crushed”

    • actually lose height

    • more weight anterior to spine so the compressive load on spine creates wedge-shaped vertebrae

    • create a kyphotic curve known as Dowager’s Hump

  • for some reason men’s vertebrae increase in diameter so these effects are minimized

• Young woman: normal gait/posture

• Elderly woman: wedged upper vertebrae and crushed lower vertebrae

Classification of Osteoporosis

• Generalized osteoporosis occurs most commonly in postmenopausal women and men in their 60s and 70s.

• Secondary osteoporosis results from an associated medical condition such as hyperparathyroidism, long-term drug therapy, long-term immobility.

• Regional osteoporosis occurs when a limb is immobilized.

Osteoporosis Health Promotion/Illness Prevention

• Ensure adequate calcium intake.

• Avoid sedentary life style.

• Continue program of weight-bearing exercises.

Osteoporosis Non-modifiable risk factors

• female

• gender

• older age

• small or thin body size

• Caucasian and Asian ethnicity

• family history of fractures

• menopause

• coexisting medical conditions

  • hyperparathyroidism

  • hyperthyroidism

Osteoporosis Modifiable risk factors

• diet low in calcium and vitamin D

• use of certain medications

• inactive lifestyle or extended bed rest

• cigarette smoking

• excessive alcohol consumption

• long term corticosteroid therapy

• high caffeine intake

• • insufficient calcium intake or absorption

Osteoporosis Clinical Findings

• loss of height

• fractures of the wrist, vertebral column and hip

• lower back pain

• kyphosis

• Respiratory impairment

Osteoporosis Diagnostic Findings

• X-rays

• Dual-energy x-ray absorptiometry (DEXA)

• Serum calcium

• Serum phosphatase

• Urine calcium excretion

Preventing Osteoporosis

• Lifestyle Choices

  • proper diet

    • sufficient calcium, vitamin D

    • dietary protein and phosphorous (too much?)

    • tobacco, alcohol, and caffeine

  • EXERCISE, EXERCISE, EXERCISE

    • 47% incidence of osteoporosis in sedentary population compared to 23% in hard physical labor occupations (Brewer et al., 1983)

Osteoporosis Assessment

• Physical assessment

• Psychosocial assessment

• Laboratory assessment

• Radiographic assessment

Osteoporosis Drug Therapy

• Hormone replacement therapy

• Alendronate (Fosamax)

• Parathyroid hormone

• Calcium and vitamin D

• Bisphosphonates

• Calcitonin

  • ↓ plasma levels of Ca, ↑ deposition of Ca in the bone

Osteoporosis Diet Therapy

• Protein

• Magnesium

• Vitamin K

• Calcium and vitamin D

• Avoid alcohol and caffeine

Osteoporosis Fall Prevention

• Hazard-free environment

• High-risk assessment through programs such as Falling Star protocol

• Hip protectors that prevent hip fracture in case of a fall

• Exercise

• Pain management

• Orthotic devices

Fall Contributors

• Outdoors

  • Uneven surfaces No Handrails Bad lighting Slick Surfaces

• Health Conditions

  • Medications

  • Chronic Health Conditions

  • HTN

  • Cardiac Arrhythmias peripheral neuropathies

• Indoors

  • Poor Lighting

  • Clutter

  • Extension Cords

  • Unstable Handrails

  • Scatter rugs Pets

Osteoporosis Exercises

• Lateral Raises with TheraBand

• tension is increased by shortening the band to comfort level

Osteoporosis Nursing Management

• Prevention

• Adequate dietary or supplemental calcium

• Regular weight bearing exercise

• Modification of lifestyle

• Calcium with vitamin D supplements

• Administer HRT, as prescribed

• Relieving pain

• Improving bowel elimination

• Preventing injury

• Nursing Activities

• Encourage use of assistive devices when gait is unstable

• Protect from injury (side rails, walker)

• Encourage active/passive ROM

• Promote pain relief

• Encourage good posture and body mechanics

Osteomyelitis

• Infection of the bone

• Staphylococcus aureus is the most common pathogen.

• Other organisms include Proteus, Pseudomonas and E. Coli

Osteomyelitis Risk Factors

• poorly nourished, elderly or obese

• impaired immune systems

• chronic illnesses

• long term corticosteroid therapy

Osteomyelitis Common Cause

• Infection of bone with rich vascular supply from bacteremia

• UTI

• long term IV catheter

• Salmonella from GI

• poor dental hygiene

Osteomyelitis Clinical Manifestation

• area appears warm, swollen and extremely painful

• systemic manifestations (fever, chills, tachycardia)

Osteomyelitis Diagnostic Studies

• X-ray

• Bone Scan

• Blood and wound culture

Osteomyelitis Nursing Management

• Promote comfort

  • Immobilized affected bone by maintaining splinting.

  • Elevate affected leg

  • Administer analgesics as needed.

• Control infectious process

  • Apply warm, wet soaks 20 min. several times a day.

  • Administer antibiotics as prescribed.

  • Use aseptic technique when dressing the wound.

• Encourage participation in ADL within the physical limitations of the patient.

Osteosarcoma (Bone Tumors)

• Most common primary bone tumor

• Occurs between 10-25 years of age, with Paget's disease and exposure to radiation

• Exhibits a moth-eaten pattern of bone destruction.

• Most common sites: metaphysis of long bones especially the distal femur, proximal tibia and proximal humerus

Osteosarcoma Clinical Manifestation

• local signs

  • pain (dull, aching and intermittent in nature)

  • swelling

  • limitation of motion

• palpable mass near the end of a long bone

• systemic symptoms: malaise, anorexia, and weight loss

Osteosarcoma Diagnostic Findings

• Biopsy - confirms the diagnosis

• X-ray

• MRI

• Bone Scan

• Increase alkaline phosphatase

Osteosarcoma Medical Management

• Radiation

• Chemotherapy

• Surgical management

• amputation

• limb salvage procedures

Prognosis: poor prognosis (rapid growth rate)

Osteosarcoma Nursing Management

• Promote understanding of the disease process and treatment regimen

• Promote pain relief

• Prevent pathologic fracture

• Assess for potential complications (infection, complications of immobility).

• Encourage exercise as soon as possible (1st or 2nd post-op day)

Paget’s Disease

• Metabolic disorder of bone remodeling in which bone deposits are weak, enlarged and disorganized.

• 2nd most common bone disease in elderly.

• Cause unknown but may be latent viral appearing > 80 yrs.

• 80% asymptomatic; affects bone in skull, vertebrae, long bones, hip joint etc.

• Treatment

  • symptomatic for pain - NSAIDS, calcitonin, Fosamax