Care of Patients with Arthritis and Total Joint Arthroplasty

Concepts in Arthritis and Total Joint Arthroplasty

  • Priority Concepts:

  • Mobility: The ability to move freely and easily, which can be significantly impaired in individuals with arthritis.

  • Immunity: Understanding the role of immune responses in joint inflammation and potential infections associated with joint diseases.

  • Interrelated Concepts:

  • Pain: Chronic pain is a key symptom of arthritis, affecting quality of life.

  • Clotting: Increased risks of thromboembolic events in patients with limited mobility.

  • Infection: Potential complications following joint surgeries such as Total Joint Arthroplasty (TJA).

  • Inflammation: Central to the pathology of arthritis, particularly in autoimmune forms.

Mobility Concept Exemplar: Osteoarthritis

  • Definition:

  • Osteoarthritis (OA) is the most prevalent form of arthritis, characterized by the progressive degeneration of cartilage, resulting in bone-on-bone contact in one or more joints, ultimately leading to decreased mobility.

  • Pathophysiology:

  • The condition is driven by a complex interplay of mechanical stress and biological factors, where the enzymatic breakdown of the articular matrix leads to the formation of osteophytes (bone spurs).

  • Inflammatory cytokines like Interleukin-1 (IL-1) exacerbate the breakdown process of cartilage.

  • The disintegration of cartilage can lead to bone fragments floating in the joint, creating a pathological condition characterized by crepitus, or a grating sound during movement.

    • results in joint pain and stiffness can lead to decreased mobility and muscle atophy

Etiology of Osteoarthritis

  • Primary OA:

  • Often associated with aging and genetic predisposition.

  • Particularly prevalent in weight-bearing joints (such as hips and knees), shoulders, vertebral column, and hands are most commonly affected, because they are used most often or bear the mechanical stress of the body weight and many years of use

  • Secondary OA:

    • joint injury and obesity

    • repetitive stress to joints increases risk; heavy manual occupations like carpet laying, construction, and farming)

      • football players, runners, gymnasts, amateur athletes

    • metabolic disease (diabetes mellitus, Paget disease)

    • blood disorders (hemophilia, sickle cell disease)

  • Prevalence:

  • Affects a significant population, most notably those over 60 years of age, with an increased incidence in women, particularly after menopause.

  • It is recognized as the 5th most common cause of disability globally, impacting daily functioning and quality of life.

Osteoarthritis Health Promotion and Wellness

  • Nutrition: Emphasize a balanced diet along with adequate vitamins and minerals which can help maintain joint health and reduce inflammation. Foods rich in omega-3 fatty acids, antioxidants, and anti-inflammatory properties should be prioritized.

  • Injury Prevention: Encourage protective measures during activities or sports to prevent joint injuries.

  • Activity Management: Incorporate regular rest periods and ergonomic modifications at work to minimize strain on affected joints.

  • Physical Activity: Advocate for low-impact exercises, such as swimming or cycling, which can enhance mobility without exacerbating joint pain.

Joint Changes in Degenerative Joint Disease

  • Bone Hypertrophy: The presence of bone spurs that develop due to abnormal growth and repair processes in response to cartilage degradation.

  • Cartilage Loss: Progressive deterioration of cartilage in affected joints is a hallmark of OA.

  • Cartilage Debris: Identification of cartilage particles within joints can lead to increased inflammation and further joint dysfunction.

Interprofessional Collaborative Care

  • History Taking:

    • age (typical onset 60yrs), weight, injury, occupation, sports, family history

  • physical assessment/clinical manifestations

    • joint pain and stiffness

    • similar to RA in early disease

    • mostly seen in middle-aged or older woman

  • Clinical Manifestations:

  • Key symptoms include persistent joint pain and stiffness that typically lessen with rest but worsen with physical activity, particularly after periods of inactivity.

    • later pain may occur with slight motion or even when at rest

  • pt may report joint stiffness that usually lasts less than 30 mins after a period of inactivity

  • crepitus (a coarse grating sound caused by loosened bone and cartilage) may be felt or heard as the joint goes through a range of motion.

  • Heberden’s nodes (distal interphalangeal, DIP):

  • bouchard’s nodes (proximal interphalangeal, PIP)

  • joint effusions: excess joint fluid is common when the knees are inflamed

  • atrophy of skeletal muscle: the disease can discourage movement of the painful joints, which may result in contractures, muscle atrophy, and further pain

Assessment Methods

  • Psychosocial Assessment:

    • Recognizing that chronic pain can lead to psychological challenges, increasing risks for depression and anxiety, is essential for holistic care.

  • Laboratory Tests:

    • Blood tests like (ESR) and high-sensitivity C-reactive protein (hsCRP) as well as joint fluid aspiration can provide crucial diagnostic insights.

  • Imaging Techniques:

    • Use of X-rays can help visualize changes in bone structure, while MRI and CT studies provide more detailed images of soft tissue and cartilage degeneration.

Analysis of Osteoarthritis

  • Priority Problems:

  • Continuous chronic pain attributed to inflammation and joint degeneration leading to significant discomfort and lifestyle limitations.

  • There is a potential for decreased mobility due to joint-associated pain, stiffness, and resultant muscle atrophy over time.

Managing Chronic Pain

  • Nonsurgical Management:

  • Drug Therapy:

    • Acetaminophen (Tylenol) is typically the first-line treatment for pain management.

      • standard ceiling dose is 4000 mg each day

      • pt are at risk for liver damage if taking more than 3000 mg daily, have alcoholism or liver diseases

      • older pt are at risk because of normal changes of aging such as slowed excretion of drug metabolites

    • topical

      • lidocaine 5% (lidoderm), buspirone hCL (Buspar), otc preparation

        • teach pt to apply the patch on clean, intact skin for 12 hrs each day (up to 3 patches can be applied to a painful joint), but watch for skin irritation.

        • lidocaine patch is contraindicated in pt taking class 1 antidysrhythmics

    • NSAID

      • Cox-2 nonselective (celecoxib)

        • before beginning drug therapy get baseline lab (CBC, CMP,)

        • don’t give to pt with hypertension, kidney disease, or cardiovascular disease (can cause MI, and hypertension)

        • GI side effects, bleeding, acute kidney injury with long-term use.

        • tkae with food

        • adverse reactions: dark, tarry stools; SOB, edema, frequent dyspepsia, hematemesis (bloody vomitus) and changes in urine output.

    • Hyaluronic Acid (lubricating synthetic joint fluid)

      • contraindicated in obesity, severe OA, over 65, previous injection

    • cyclobenzaprine HCL (flexeril)

  • Other pain management approaches:

  • Balancing periods of rest and exercise to prevent worsening of symptoms, utilizing thermal modalities (heat/cold therapy), maintaining weight (encourage weightloss)

  • positioning: when pt is in a supine position (recumbent), use of small pillow under the head or neck but avoid the use of other pillows.

    • integrative therapies (these supplements are not recommended)

      • glucosamine may decrease inflammation

      • chondroitin plays a role in strengthening cartilage

  • Surgical Management:

    • Total Joint Arthroplasty (TJA) or TJR is a common procedure employed when conservative measures fail.

      • surgical creation of a functional synovial joint using implants.

      • most often to manage the pain of OA and improve mobility, RA, congenital anomalies, trauma, and osteonecrosis.

  • Contraindications for TJA:

    • active infection

    • advanced osteoporosis

    • progressive inflammation

    • diabetes/hypertension

  • preoperative TJA/TJR

    • patient education

    • multidisciplinary care

    • equipment

    • avoid procedure

    • lab testing

    • medication reconciliation

    • blood needs (cell saver, continuous reinfusion)

    • antiseptic bath

  • postoperative care: hip arthroplasty

    • prevention complications

      • hip dislocation-abduction devices with straps; be sure to loosen the straps every 2 hrs and check pt’s skin for irritation or breakdown

      • knee-positioning : operative leg needs to be fully supported with pillows to prevent slipping of the leg into adducted position which can lead to dislocation

    • VTE( DVT/PE)

      • older pt have increased risk for VTE because of age and decreased circulation before surgery. obese pt, pt who currently smokes, and those with history of VTE.

      • P (pharmacology), A (ambulation), C (compression)

        • anticoagulants: heparin, LMWH (enoxaparin, dalteparin), factor Xa inhibitors( SC fondaparinux, PO rivaroxaban)

    • infection (surgical incisions and vital signs-—increased redness, excessive/foul-smelling drainage, temp) s/s can be seen has early has 2 to 3 days after surgery

      • VS should be monitored every 4 hrs for first 24 hours and every 8-12 hrs

      • older pt may experience altered mental state, especially delirium

    • Anemia

      • dressings (excessive bleeding)

      • monitor labs (H&H)

    • neurovascular compromise

    • manage pain

      • short-term PCA or IV push morphine or hydromorphone, oral oxycodone

      • NSAIDS (ketorolac, celecoxib)

      • NMDA receptor antagonists( ketamine)

      • Gabapentinoids (gabapentin, pregabalin)

      • continuous peripheral nerve block (bupivacaine, ropivacaine)

Improving mobility

  • pt with OA often requires interprofessional efforts

    • physical therapy to teach weigh-bearing restrictions

    • occupational therapy

    • ambulatory aids may be needed for assistance with ADLs (walkers, crutches, cane)

care coordination and transition management

  • home care management: arranging to live on one floor with accessibility to all rooms is often the best solution. lowering counters, getting rid of throw rugs etc

  • self-management education: learning how to protect joints most importantly, weight reduction, eating well-balanced meals.

  • home care resources: providing patient safety information to prevent falls

Evaluation: reflecting

  • evaluate the care of the pt with OA on the basis of the identified priority problems. the expected outcome is that he or she

    • achieves pain control to a pain intensity level of 2 to 3 on a scale of 0 to 10 or at a level that is acceptable to the patient

    • does not experience complications associated with total joint arthroplasty ( if performed)

    • moves and functions in his or her own environment independently with or without assistive devices

Rheumatoid Arthritis (RA)

  • chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints.

    • systemic means this disease can affect any or all parts of the body while affecting many joints

  • transformed autoantibodies (rheumatoid factors) that attack healthy tissues, especially synovium, are formed, causing inflammation

  • synovium thickens and becomes hyperemic, fluid accumulates in the joint space and the pannus forms

    • pannus is a vascular granulation tissue composed of inflammatory cells; it erodes articular cartilage and eventually destroys bone.

  • RA is characterized by natural remission and exacerbations (flare-ups)

  • inflammation outside the joints( blood vessels vasculitis)

etiology and genetic risks

  • combination of environmental and genetic factors

  • females reproductive hormones influence the development of RA (young to middle-age women)

  • infectious organism like Epstein-Barr virus

  • physical and emotional stress linked to exacerbations

interprofessional collaborative care: RA

  • assessment

    • acute/severe

    • slow/progressive onset

    • more common in winter months

  • Physical assessment/clinical manifestation

    • early-joint inflammation, swelling, pain, fatigue, generalized weakness

      • anorexia (weight loss about 2-3 lbs or 1 kg)

      • persistent low-grade fever

      • paresthesias

      • joints may be slightly reddened, warm, stiff, swollen, and tender or painful, particularly on palpation (caused by synovitis)

      • bilateral and symmetric (both wrists)

    • Late

      • joints become progressively inflamed and quite painful

      • frequent morning stiffness

      • palpation the joints feel soft and look puffy because of synovitis and effusions

      • muscle atrophy

      • decreased ROM

RA late systemic complications

  • weight loss, fever, and extreme fatigue which are common in late disease exacerbations

  • exacerbations

  • subcutaneous nodules: soft, round, moveable, ulnar surface of the arm.

  • respiratory (pleurisy, pneumonitis, diffuse interstitial fibrosis, and pulmonary hypertension), cardiac complications (myocarditis, pericarditis)

  • vasculitis is inflammation of the blood vessels

  • periungual lesions- ischemic skin lesions that appear in groups as small, brownish spots (nail beds)

  • paresthesias caused by peripheral neuropathy usually in older ppl

  • associated syndromes

    • sjogren’s syndrome most common

      • dry eyes (keratoconjunctivitis sicca (KCS)

      • dry mouth (xerostomia)

      • dry vagina (in some cases)

    • felty’s syndrome

    • caplan’s syndrome

  • psychosocial assessment

    • body image changes

  • Laboratory

    • RF is not diagnostic for RA but there they will have a positive titer (greater than 1:80)

    • ESR greater than 20mm/hr

    • serum complement (C3 and C4)

    • serum immunoglobulins

    • HsCRP

  • Diagnostic

    • x-ray to visualize the joint changes and deformities

    • CT scans help determine the presence and degree of cervical spine involvement

    • arthrocentesis is an invasive diagnostic procedure used for pt with joint swelling caused by excess synovial fluid (effusion)

    • bone scan

planning and implementation: responding

  • managing chronic inflammation and pain

    • drug therapy

      • DMARD: given to slow the progression of the disease, for best results they should be started early in the disease process

        • hydroxychloroquine antimalarial drug. ( watch for retinal damage)

      • NSAIDs given with H2 blocker (famotidine) if no change in 6-8 wks it may be discontinued

      • BRMs: help reduce signals for the immune system to cause inflammation. prevents further deterioration

        • recommended every 3 to 6 months

        • pt is at high risk for developing impaired immunity and subsequent infection

        • don’t give to pt with a serious infection, TB, or MS because it can exacerbate their health problems

        • don’t take any live vaccines and avoid large crowds and ppl with respiratory infections

      • other

        • glucocorticoids: prednisone

          • given for fast-acting anti-inflammatory and immunosuppressive effects

            • chronic use can cause: DM, impaired or decreased immunity, fluid and electrolyte imbalances, hypertension, osteoporosis, glaucoma

        • Methotrexate (MTX): immunosuppressive agent, low once-in-a-week dose, slow-acting drug taking 4 to 6 wks to begin control joint inflammation

          • adverse effects: decreasing WBCs and platelets ( bone marrow suppression), elevation in liver enzyme or serum creatinine

            • risk for infection (avoid crowds and ill ppl)

            • folic acid and B vitamins is recommended

            • NO PREGNANCY, strict birth control

      • nonpharmacologic interventions

        • Adequate rest

        • proper positioning

        • ice and heat application

        • plasmapheresis (not common)

        • complementary and integrative therapies

        • Promotion of self-management

        • Management of fatigue

        • enhance body image

  • promoting mobility

    • promote independence

      • adaptive devices

    • combat fatigue

      • physical therapy

      • energy conservation, taking 1 to 2 naps each day.

        • pacing activities

        • allowing rest periods

        • setting priorities’

        • obtaining assistance when needed

  • enhancing self-esteem

    • communicating acceptance of the pt

    • promote coping strategies

    • avoid using the term “arthritis personality” because it represents a negative label

  • Management

    • home care management

      • doors must be wide enough to accommodate a wheelchair or walker

      • ramps needed, ADL on one floor, Handrails available in bathroom and halls

      • elevated chairs, toilet seats ( needed for older ppl with arthritis.

    • self-management education

      • assess coping strategies

      • discuss with HCP before getting any OTC home remedies

      • assess self-esteem

      • assess how RA affects their work life.