INTRODUCTION

Arthritis means inflammation in one or more joints .It often leads to swelling ,pain and
stiffness of the joints and is a cause of disability for many people .With an acute arthritis the
joints becomes hot and swollen ,often with intense pain and difficulty with movement .The
most prevalent types of arthritis are osteoarthritis, rheumatoid arthritis, and gout.

DEFINITION
Arthritis is an inflammation of one or more joints, causing pain and stiffness that
can worsen with age.

INCIDENCE
About 54 million adults doctor have been diagnosed with arthritis .In india, it is
estimated that 8%-9% of adults population has some form of rheumatic disease and 5%-6%
has joint or related diseases. Among these, osteoarthritis being the commonest -1% -1.5% .

TYPES
The most common types of arthritis are:

1)osteoarthritis arthritis- It is the commonest type of arthritis.In osteoarthritis , the disease

moves slowly and slowly from one joint to the other and progresses slowly .It involves
common weight bearing joints, i.e hips and knees

2) Rheumatoid arthritis –Rheumatoid arthritis is a chronic inflammatory multisystem disease

involving articular and extraarticular tissue ,the cause of which is still uncertain .It is
characterised by persistent bilateral Symmetric arthritis involving the peripheralSmall joints
resulting in cartilage destruction and bony erosion

3) Psoriatic arthritis- Psoriatic arthritis is a chronic seronegative inflammatory arthritis that

affects 5 to 40% of people with psoriasis

4) Gout-Gout is an abnormality of uric acid metabolism that causes hyperuricaemia and

deposition of monosodium urate crystals in joint , soft tissue and renal tubules .The
prevalence rate is approximately 0.2%.

RELATED ANATOMY AND PHYSIOLOGY

A joint is formed , where two or more bones come (articulate) together .There may or may
not be movement between them .

CLASSIFICATION OF JOINTS

The joints can be classified according to the tissues that unite the bone ends. There are
three types of joints .

Fibrous joints

Cartilaginous joints

Synovial joints

FIBROUS JOINTS
In this type , the articulating surfaces of bones are connected by fibrous tissue .There
are three types of fibrous joints.

SUTURES OR SUTURAL JOINTS

 Sutures occur only in the skull , e.g coronal suture between the frontal and parietal .The
sutures form wide areas of fibrous tissue called fontanelles.

SYNDESMOSIS: In this type, the bones are united by a sheet of fibrous tissue . It may be a

ligament or a fibrous membrane , e.g an interosseous membrane connects the radius and ulna
.

GOMPHOSIS : This is a special type of fibrous joints ,between a tooth and its socket .The
fibrous Tissue of the periodontal ligament firmly holds the tooth in its socket .

CARTILAGINOUS JOINTS

Bones are united either by hyaline cartilage or by fibro cartilage. Depending on this, the
cartilaginous joints are classified into primary and secondary cartilaginous joints .

PRIMARY CARTILAGINOUS JOINTS : The bones are united by hyaline cartilage ,which
permits slight movement during early life .This type of joint is temporary ,as in the
development of a long bone.

SECONDARY CARTILAGINOUS JOINTS : The surfaces of the articulating bones are

covered with hyaline cartilage and the bones are united by strong fibrous tissue or
fibrocartilage .These joints usually occur in the middle of the body, e.g symphysis pubis .

SYNOVIAL JOINTS

They are the most common and important joints in the body .They normally provide free

movement .They are called synovial joints because they lined with a synovial membrane and
contain a lubricating fluid called synovial fluid .

TYPES OF SYNOVIAL JOINTS

BALL AND SOCKET JOINT: In this type ,one of the articular surfaces is spherical and ball
–like the other articular surface presents a cup like concavity, e.g shoulder joint .

HINGE JOINT: Movements take place in one plane only it is usually a uni axial joint , e.g
elbow joint .

PIVOT JOINT: These joints allow rotation movement .In these joints ,a rounded process of
bone rotate within a ring ,e.g radioulnar joint .

CONDYLOID JOINT OR ELLIPSOID JOINT : In this type , one of the articular ends is
convex and the others is reciprocally concave .It is a bi-axial joints where movements can
occur in 2 axes .

SADDLE JOINT OR SELLAR JOINT : In this type ,the articular surfaces are reciprocally
concavoconvex (saddle shape) and movement can occur in all plane ,e.g the carpometacarpal
joint of the thumb .
PLANE JOINT: In this type , the articular surfaces are flat and the movement restricted to
slight gliding, tilting and rotation ,e.g joint between the articular processes of the thoracic
vertebrae.

OSTEOARTHRITIS
It is a slowly progressive degenerative and non inflammatory disorder of the synovial joints
involving the articulating cartilage of weight bearing joints ,characterised by degeneration
and destruction of cartilage .

INCIDENCE
The prevalence of osteoarthritis in india is high, ranging from 22% -39% in different parts

of the country. Approximately 45% of women over the age of 65 have osteoarthritis .

RISK FACTORS
1) Age – after the age of 30 years

2) Gender- Men are most affected than women before the age of 50 years. Women
are affected twice as often as men after the age of 50 years.
 3) Joints injuries

4) Obesity

5) Family history

6) Ethnicity

7) Certain diseases

8) Some medications

9) Occupation

PATHOPHYSIOLOGY

The exact cause is unknown

Degenerative processes

Decrease inhibitors of matrix and increase cartilage Decrease inhibitors of

metalloproteinase enzyme and increase metalloproteinase production by chondrocytes

Deficiency of IGF-I and TGF-β and increased degradation

Imbalance result osteoarthritis

Fig: Pathophysiology of osteoarthritis

CAUSES OF OSTEOARTHRITIS
The exact cause is unknown. However there are some contributing factors that

causes osteoarthritis
 1) Trauma

2) Mechanical stress

3) Inflammation

4) Joint instability

5) Neurological disorders

6) Skeletal deformities

7) Hematologic/endocrine disorders

8) Use of selected drugs

CLINICAL MANIFESTATION
1) Fatigue

2) Fever

3) Joints pain

4) Stiffness of the joints

5) Swelling

6) Tenderness

7) Loss of flexibility

8) Grating sensation

9) Bone spurs

DIAGNOSTIC EVALUATION
1) History and physical examination

2) Joint aspiration

3) Computed tomography

4) Magnetic resonance imaging

5) X-ray
 6) Blood investigation

MANGEMENT
The aims of management of osteoarthritis is focus on managing the pain and
inflammation ,preventing disability, maintaining and improving joint function

1.Medical management -

a) NSAIDs – e.g Ibuprofen , Diclofenac

b) Salicylates

c) Antibiotic –e.g Doxycycline , minocycline

d) Topical analgesics – e.g capsaicin cream

2. Surgical management –

a) Arthroplasty : arthroplasty is an orthopaedic surgical procedure where the articular surface

of a musculoskeletal joint is replaced ,remodelled and realigned .

b) Osteotomy :It is a surgical procedure whereby a bone is cut to shorten or lengthen it or to

change its alignment.

3. Collaborative management :

a) Lifestyle changes

b) Physiotherapy

c) Rest and joint protection-the osteoarthritis patients must understand the importance of a
balance of rest and activity. The affected joint should be rested during any periods of acute
inflammation and maintained in a functional position with splints or braces if necessary .

d) Heat and cold application –application of heat and cold may help reduce complaints of
pain and stiffness. Heat therapy is especially helpful for stiffness , including hot packs.

e) Nutritional therapy –if the patient is overweight, a weight reduction program is a critical
part of the total treatment

NURSING MANAGEMENT
A) History collection

B) Nursing assessment –the nurses should carefully assess and document the type,
location ,severity ,frequency ,and the duration of the patients joint pain and stiffness .

C) NURSING DIAGNOSIS-

1) Acute/ chronic pain related to join degeneration as evidence by patient having joint pain .

2) Impaired physical mobility related to joint deformities as evidence by patient weakness

3) Self care deficit related to decrease in muscle strength as evidence by patient pain when
moving

4) Risk for injury related to by stiffness of the joint

D) NURSING INTERVENTION

1- a) Assess pain note the location , intensity, duration,frequency

b) Provide comfort

c) Provide comfortable position and change the position frequently

d) Provide divertional therapy

e) Evaluate with patient health care team about the effectiveness of pain control measure

f) Teach non pharmacological techniques e.g relaxation

g) Provide analgesics as prescribed by the physician

2- a) Assist the patient in physical activity

b) Maintain bed rest

c) Assist the client in range of motion

d) Help the patient in achieve mobility

e) Apply hot and cold compress

f) Determine limitation of joints

 g) Explain to patient and family members abo the purpose and plan of joint exercise

3- a) Assist the patient in physical activity

b) Supervise the patient for each activity until the patient is fit to do by himself herself

c) Provide comfortable device

d) Implement measures to promote independence

e) Allow the patient to feed himself / herself as tolerated

4 – a) Assess the patient ability to walk

b) Provide belt while mobilise the patient

c) Provide attendance to stay with the patient

d) Provide side railing to prevent from injury

COMPLICATION

1. Chondrolysis
2. Osteonecrosis

RHEUMATOID ARTHRITIS
Rheumatoid arthritis is a chronic inflammatory disease that affects joints and other organ
systems. It is an autoimmune disease
INCIDENCE

Rheumatoid arthritis affects 0.5% to 1% of the population worldwide and sex ratio of
women vs men is 3:1.

RISK FACTOR
1. Genetic factor : Family studies suggest a genetic predisposition. Rheumatoid arthritis
is four time common in the first degree relatives of an individual with the disease .
2. Environmental factors : It has been suggested that rheumatoid arthritis might be
response to an infectious agent in a genetically predisposed host .
3. Autoimmune factors : Both B and T cell autoimmunity play a role in progression of
rheumatoid arthritis .

STAGES OF RHEUMATOID ARTHRITIS

Stage I : Early

No destructive changes on x-ray ,possible x-ray evidence of osteoporosis

Stage II: Moderate

 X-ray evidence of osteoporosis, with or without slight bone and cartilage
destruction ,no joints deformities ,adjacent muscle trophy ,possible presence of extra-articular
soft tissue lesions

Stage III: Severe

X-ray evidence of cartilage and bone destruction in addition to osteoporosis , joint

deformity such as subluxation , ulnar deviation ,without fibrous or bony ankylosis ,extensive
muscle trophy , possible presence of extra-articular soft tissue lesion

Stage IV : Terminal

Fibrous or bony ankylosis

PATHOPHYSIOLOGY

The exact cause is unknown

In the first stage , the synovium shows signs of chronic inflammation and by lymphocytes
plasma cells and macrophages infiltration

Proliferates and grows out over the surfaces of cartilage, producing a tumour like mass called
pannus.

In second stage , articular cartilage covers the ends of articular surfaces of the bone

Pannus forms at the junction of synovial tissue and cartilage and invades the subchondrial
bone and supporting soft tissue structure and destroy them

Leading to joint pain

Destruction of the supporting tissue structure result in subluxation and dislocation

In third stage ,pannus is replaced by fibrous connective tissue wchich occludes the joint space
resulting in fibrous ankylosis

Limitation of joint movement and deformity of joint

In fourth stage, bony ankylosis results due to calcification to total joint immobility

Fig Pathophysiology of Rheumatoid arthritis

CAUSES
1) The exact cause is unknown

2) Immunological processes result in inflammation of synovium , producing antigens and

inflammatory by products that lead to destruction of articular cartilage, edema ,and

production of a granular tissue called pannus

3) Granulation tissue forms adhesions that lead to decreased joint mobility

4) Similar adhesion can occur in supporting structure, such as ligaments and

tendons ,and cause contractures and ruptures that further affect joint structure and mobility

5) Infection

CLINICAL MANIFESTATION
1. Nervous system –
a) Carpal tunnel syndrome
b) Atlan foaxial subluxation
c) Sensory polyneuropathy

2.Musculoskeletal system-

a) Joint pain

b) Swelling and tenderness of joints

c) Joints immobility
 d) Muscle wasting

3. Skin

a) Rheumatoid nodules- elbow , occiput ,sacrum

b) Vasculitic changes

4. Cardiovascular system

a) Acute pericarditis

b) Conduction defects

c) valvular insufficiency

d) Coronary arteritis

5. Pulmonary manifestations

a) Asymptomatic pulmonary disease

b) Pleural effusion

c) Laryngeal obstruction caused by involvement of the cricoarytenoid joint

e) Pulmonary nodules

Some common clinical manifestation are –

a) Weakness
b) Fatigue
c) Anorexia
d) Low grade fever
e) Anaemia

DIAGNOSTIC EVALUATION
According to American Rheumatoid Association criteria for diagnosis of rheumatoid
arthritis are as followed:

a) Monitoring stiffness

b) Poly arthritis

c) Arthritis of hand joints and wrist

d) Symmetric small joints arthritis

f) Nodules
g) A positive serum rheumatoid factor

h) Radiological changes

OTHERS INVESTIGATION :

a) Blood investigation
b) Synovial fluid examination-
c) X-ray –The x-ray changes of rheumatoid show loss of articular cartilage and
bone erosion that has the appearance of mouse bite on the surface of affected
joint. Erosion are best seen in x-ray of hand and feet .
d) Other imaging techniques – CT scan and MRI scan
e) Echocardiography
f) Arthroscopy- It is helpful in obtain synovial fluid for histopathological
examination as well as to know the erosion and rupture of cruciate ligaments in
the knee joint.
g) Bone scan

MANAGEMENT
Goal of therapy are
(i)Control of pain and inflammation
(ii) To protect articular structure
(iii) To maintain joints function
(iv) To control systematic manifestations.

1.MEDICAL MANAGEMENT-
a) NSAIDs- tablet Paracetamol 500 mg with or without dextropropoxyphene
hydrochloride 65 mg three time aday .

b) Disease modifying antirheumatoid drugs (DMARDs)-

Synthetic DMARDs :These drugs are capable of altering the course of rheumatoid
arthritis for at least one year by causing cytokine inhibition leading to improvement in
joint function.It is divided into mono – therapy and poly- therapy.

Monotherapy drugs include

:Hydroxychloroquine 200mg twice daily for 3months then once daily
 :Sulfasalazine 2-3 g twice daily
:methotrexate 7.5 -20 mg
:tablet cyclosporine 2.5-5mg/kg/day

Polytherapy drugs include

:Allopurinol 300mg once daily or in a divided dose

:Probenecid with a starting dose of 250mg twice daily

Biological DMARDs: The commonly used drugs are

: Etanercept 25mg s.c twice a week or 50mg/week
:Infliximab 3-10 mg /kg i.v
:Adalimumab 40mg every other week

Combination of DMARDs

C) Corticosteroids therapy :Systematic glucocorticosteroid therapy can provide

effective symptomatic relief in rheumatoid arthritis Prednisolone <7.5mg/day
methylprednisolone

f)Bone marrow (stem cell )transplantation and gene transfer

2.SURGICAL MANAGEMENT :

a) Arthroplasty
b)Total joint replacement
c) Synovectomy –it is done in the persistent mono arthritis
d) Osteotomy –it is done to correct varus or valgus deformity

3.COLLABORATIVE MANAGEMENT

a)Physiotherapy
b)Exercise
c)Diet
e) Rest
d)Splint
e)Assistive device
f) Supportive device
g) Nutrition

4.NURSING MANAGEMENT
 A)History collection

B) Asessment

C) Nursing diagnosis

a) Chronic pain related to joint inflammation as evidenced by limited joint function

b) Impaired physical mobility related to joint pain as evidenced by limitation of joint motion
and strength

c) Disturbed body image related to deformities as evidenced by patient altered self concept

e) Ineffective therapeutic regimen management related to sense of powerlessness as

evidenced by patient ability to perform activities only for short periods

d) Self care deficit related to disease progression as evidenced by patient inability to perform
activities

D) Nursing intervention

1- a) Assess pain note the location , intensity, duration,frequency

b) Provide comfort

c) Provide comfortable position and change the position frequently

d) Provide divertional therapy

e) Evaluate with patient health care team about the effectiveness of pain control measure

f) Teach non pharmacological techniques e.g relaxation

g) Provide analgesics as prescribed by the physician

2- a) Assist the patient in physical activity

b) Maintain bed rest

c) Assist the client in range of motion

d) Help the patient in achieve mobility

e) Apply hot and cold compress

f) Determine limitation of joints

g) Explain to patient and family members about the purpose and plan of joint exercise
 .
3 a) Identify effects of patients culture ,religion, race, sex and age in terms of body
image to determine extent of problem and plan appropriate interventions.

b) Encourage the patient to discuss any changes

c) Provide information about the prognosis of the disease

4.a) Determine patients usual method of problem solving problem to identify the
appropriate intervention

b) Provide information on realistic expectation related patient behaviour to ensure

understanding of disease management

c) Include family and others to increase their sense of control and to increase patient sense
of support

5. a) Assist the patient in physical activity

b) Supervise the patient for each activity until the patient is fit to do by himself /
herself

c) Provide comfortable device

d) Implement measures to promote independence

e) Allow the patient to feed himself / herself as tolerated

COMPLICATION
 The joint damage rheumatoid arthritis causes disfigure and damage the ends of bones ,
making it nearly impossible to complete activities of daily living .It may be harder to
do even the simplest activities
 Since rheumatoid arthritis is an autoimmune disease ,it causes problems with the skin
,eyes ,lungs ,heart , and other organs
 The medications used for treatment can cause side effects and living with a chronic
condition such as rheumatoid arthritis can cause depression and anxiety
 Rashes , ulcers ,vision loss , leisions and lack of tears
PROGNOSIS
Rheumatoid arthritis vary from patient to patient are at increased risk of a shorter life
expectancy .Some common prognosis possibilities for rheumatoid arthritis patient include
continued joint inflammation that persist over time .Progressive joint deterioration affecting
multiple joints. The prognosis of the patient with osteoarthritis depends on which joints is
affected ,some patients are unaffected by osteoarthritis while others can be severely
disabled .Joint replacement surgery for some result is the best long term outcome.

PREVENTION
a) Avoid trauma to joints

b) Maintain healthy weight

c) Exercise regularly ,including strength

d) Use of assisted device

e)Avoids position to joints deviation

f) Change position frequently

g) Determine limitation of joints

h) Explain to patient and family members about

i)the purpose and plan of joint exercise

CONCLUSION
Arthritis refers to the inflammation of joints while rheumatoid arthritis involve the
bone ,muscle and joints. The most prevalent types of arthritis is osteoarthritis , rheumatoid
arthritis and gout . The outcome is good if treated at the earlier.

BIBLIOGRAPHY
 G Deepa , PR Ashalatha. A textbook of anatomy and physiology for
nurses ,third edition- 2011.New Delhi : Jaypee Bother’s medical
publisher’s .pvt.ltd
 Chintamani ,Lewis’s ,Medical –surgical nursing .New Delhi:Reed Elsevier
India Pvt Ltd ,2013
 Black .M.Joyce,Hawk Jane .Medical surgical nursing .Eight edition.New
Delhi :Reed Elsevier India Pvt Ltd ;2012
 Sharma Suresh .K .Lippincott Manual of Medical –surgical nursing ,second
edition ,2017 .Haryana : Wolters Kluwer (India) Pvt Ltd
 http://www.rheumatoidarthritis
 http://www.webmd.com
 http://www.mayoclinic.org
 www.arthritis.org
 https://www.rheumatoidarthritis.org