Jessica Anne Schindler Clinical Makeup #1 8/12/2011

Osteoarthritis
1) Name of assigned disorder and missed clinical date: Osteoarthritis, 7/26/2011

2) Pathophysiology of osteoarthritis:

Osteoarthritis (sometimes called degenerative joint disease) is the degeneration of articular cartilage and hypertrophy of underlying bone. In normal anatomy and physiology, the cartilage makes the surface smooth so that the weight shifts from one bone to another, so that they do not shatter. With osteoarthritis, the articular cartilage is so deteriorated that the shock absorbing properties the cartilage once provided are gone, leaving bone against bone. This stimulates new bone growth, which is caused by exposed bone surface areas and creates bone spurs to develop. Because it generally affects the joints, especially those of the fingers, spine, knees, and shoulders people who are obese or have poor posture or experience occupation stress are at greatest risk. It can be classified as either primary or secondary. With primary osteoarthritis, the cause is unknown why chemicals in the body are released to break down joint cartilage. Secondary osteoarthritis may be associated with trauma, infection, deformities from birth, or the use of corticosteroid therapy.

3) Predisposing factors and related factors: Obesity- from excessive weight on the joints People with poor posture People who experience occupational stress from excessive overuse of a joint (factory workers, laborers, etc.)

4) Preventive measures: One of the most important measures a person can take to prevent osteoarthritis is to maintain a normal weight. This helps by limiting the amount of stress placed on the joints. Exercise is another good way to prevent osteoarthritis because it helps to strengthen the muscles around the joints, and helps prevent the breakdown of cartilage. Exercise should be alternated (ex. Weight training one day, and cardio the next day) because repetitive motions can wear down the cartilage. Another key point to remember is to rest when you have joint pain, and not to ignore it. Pain after activities is an indication that you have overused your joints. A good thing to remember when starting any exercise program is to start slow, and build up the intensity gradually. In other words, dont try to overwork yourself because your body will tire more quickly and because your joints arent used to the amount of activity, you are putting your self at risk for an injury. 5) Signs and symptoms: Pain that is associated with activity, but is diminished with rest Stiffness in the joints Limitation of movement Tenderness around the area of the joint Swelling around the area of the joint Deformity or enlargement of the joint

6) Diagnostic procedures: Diagnostic procedures for osteoarthritis are generally based on the health history and radiographic studies. In the early stages of the disease, the patient may not have any symptoms, even though radiograph tests reveal joint changes. Based on radiographic evidence, 68% of women older than age 65 have osteoarthritis. Men have a slightly lower incidence rate. Radiographs do not always reveal cartilage abnormalities. Other methods used to diagnose osteoarthritis are arthroscopy, MRI, scintigraphy, and ultrasound. ESR blood test results are usually negative, as well as the RF assay, and aspirated synovial fluid. Few or no leukocytes are expected because osteoarthritis is generally classified as noninflammatory, except in the later stages when significant inflammation is present. Obviously, if there is no inflammation there wont be any/or very few leukocytes, because leukocytes are only present with infection and inflammation. However, it is normal for a healthy older person to have a slightly elevated ESR. This is probably due to normal aging, and does not necessarily mean the person has an infection.

7) Treatments: There is no cure for osteoarthritis, but there are several palliative treatments that can control the symptoms. The main goals are to reduce pain to a level that is manageable for the patient, maintain mobility as much as possible, and to decrease disability. Physical Measures Physical therapy is used to improve range of motion and to maintain muscle mass and strength. When muscle mass is maintained, it reduces the load or work for the cartilage. This is most beneficial for patients with mild osteoarthritis. Isotonic exercises are not recommended because isotonic exercises increase the amount of strain on the joints. Exercise should be followed by rest periods, give the joints a period for rest. Using a cane to walk can also reduce joint strain by shifting body weight to the cane when ambulating, which takes the weight off of the joint. Moist heat and occasionally cold can be used to treat pain. Using heat is a good way to prepare the muscles for exercise, but it may be contraindicated in people whove had arthroplasty or prostheses made with metal because it can lead to deep burns. Use of a TENS machine can also be useful in treating back pain, because it soothes irritated nerves. Drug therapy Pain can usually be controlled with nonopioid analgesics such as acetaminophen and NSAIDS. NSAIDS are the most effective drugs to use when the patient shows signs of inflammation, because they decrease the inflammatory response, which is caused by prostaglandins (a natural chemical in the body that causes inflammation, redness, fever, and aids in the blood clotting function of platelets). However, the side effects from NSAIDS can be dangerous because regular use can cause stomach ulcers and bleeding. Other drugs that may be used are salicylates, which are inexpensive but a risk of toxicity exists, especially in older adults because their body takes a longer period of time to metabolize drugs. Although gluccorticoids are not indicated for treatment, intraarticular injections can be beneficial because it decreases inflammation. Some people find relief from localized pain with topical applications of capsaicin (which is derived from chili peppers) because it has a warming effect on the skin. Surgery Surgery is usually a last resort and is only used for patients who have persistent pain that interferes with their daily living. Some of the surgical

procedures that are used include arthroscopy (irrigation and removal of cartilage debris) and total hip or knee replacement. These procedures restore function and relieve pain to the joints. Medications: Acetaminophen: Dose: 325-650mg q 4-6 hrs Route: PO Nursing Considerations: Assess onset, type, and location of pain. Effect of medication is reduced if full pain response recurs prior to next dose. Assess for clinical improvement of relief of pain. Side Effects: Hypersensitivity Ibuprofen: Dose: 1,200-3,200 mg/day in 3-4 divided doses Route: PO Nursing Considerations: Assess onset, type, location and duration of pain, and inflammation. Inspect appearance of affected joints for immobility, deformities, and skin condition. Side Effects: Nausea (with or without vomiting), dyspepsia, dizziness, and rash. Acetylsalicylic Acid: Dose: Initially, 2.4-3.6 g/day in divided doses, then 3.6-5.4 g/day Route: PO Nursing Considerations: Do not give to children or teenagers who have flu or chickenpox symptoms (increases risk of Reyes syndrome). Assess type, location, duration of pain, and inflammation. Inspect appearance of affected joints for immobility, deformities, and skin condition. Side Effects: Abdominal distention, cramping, heartburn, mild nausea; pruritus, urticaria, bronchospasm (indicative of allergic reaction).

Nursing Interventions: Interventions when caring for the patient with osteoarthritis are focused on relieving pain. Administer analgesics and anti-inflammatory drugs as prescribed. In addition, instruct the patient on the use of heat or cold treatments as ordered. Modification of daily activities and joint protection measures can help maintain function and prevent further deterioration. Stress to the patient the need to balance rest and activity to avoid becoming overly tired. Suggest to the patient to wear

clothes with elastics waists or Velcro closures instead of buttons, and shoes with Velcro instead of laces to make it easier to get dressed if the hands are affected.

Dietary Requirements: Add extra fiber to your diet such as fresh fruits, vegetables and whole grains and drink more water. This will decrease constipation that can be a side effect of opioid pain medications (if you are taking them to control pain) Fish or fish oil to help reduce inflammation (research has shown that consuming oily fish, which are high in omega-3 fatty acids, reduces inflammation in the body)

Physical and Occupational Therapy: Recommend regular exercise to maintain muscle mass. Aerobic, muscle strengthening and water-based exercises are appropriate. For the patient who is over weight, weight loss will help relive stress on joints Bathroom grab bars, a shower seat, and a raised toilet seat will promote independence and safety for patients who have decreased mobility.

Short and Long Term Goals: Weight loss for over weight patients to relieve stress on joints Improved functional mobility Pain relief

Patient Teaching and Discharge Planning: Maintain proper posture and body alignment Push or slide heavy objects rather than pulling Know the side effects of your medications and notify your doctor if they occur Use higher chairs instead of sofas Avoid stairs whenever possible Wear shoes with low heels Sit rather than stand When rising from a chair, inch to the edge of the seat and use the armrests to push yourself up Wear splints or support devices that rest or relieve painful joints

Emotional/Psychosocial: Opportunities should be given to the patient to discuss concerns about osteoarthritis and management. Give practical suggestions for managing the disease to help the patient feel more independent with a sense of control and confidence.

Follow Up Care: For the patient with joint replacement surgery, it is necessary for the patient to be aware of the follow up care that will be needed following the operation. The patient should learn about wound care, and signs of possible infection (fever, swelling, pain, foul smelling drainage). You can insure understanding by having the patient repeat the information back to you. Make sure the patient is able to come back to the office for check ups to see how healing is progressing and to remove any staples or sutures.

Community Resources: A useful resource for a patient who lives alone and has difficulty ambulating might consider purchasing a Life Alert system to wear around their neck. If they fall, and have difficulty getting up, they can press the button around their neck and someone will immediately come to their aid. They also might want to consider getting a care giver that comes to the house a few times a week for a few hours to assist with ADLs, driving to appointments, and grocery shopping.

What I learned from this assignment: While researching information for this project, I felt I was able to better understand the pathophysiology of the disorder. I had originally thought that because it was arthritis it was an inflammatory condition, until I learned that inflammation of the joints doesnt occur until the later stages of the disorder. I also didnt know it was possible to have no symptoms of pain in the early stages, because when I thought about the word arthritis I always associated it with constant pain.

Bibliography: Introduction to Medical-Surgical Nursing, 5th Edition, Adrianne Dill Linton, Elsevier & Saunders, 2012 How to Prevent Osteoarthritis, http://www.stjohnprovidence.org/HealthInfoLib/swArticle.aspx?1,1411, St. John Providence Health Care System, St. John Health Care System, 2011 The Best Diet for Osteoarthritis, http://www.everydayhealth.com/osteoarthritis/osteoarthritis-diet.aspx, Chris Iliades, M.D Osteoarthritis Center-EverydayHealth.com