THE ADULT CLIENT WITH MUSCULOSKELETAL

DISORDERS

ARTHRITIS: OSTEOARTHRITIS,
RHEUMATOID ARTHRITIS, AND
GOUTY ARTHRITIS

By Group 2 (De Gracia - Gesta)

BSN 3 - C6
LEARNING OUTCOMES
Upon Completion of this Lesson, the Nursing Students Can:

1
Identify the types of
patients with Arthritis
2
The pathophysiologic
responses to different types
3
Implement safe and
quality nursing
4
Institute preventive
actions to minimize
of Arthritis interventions to the Client harm
WHAT IS A JOINT?

A STRUCTURE IN ANATOMY THAT CONNECTS TWO OR

MORE NEIGHBORING SKELETAL PARTS. SUCH
SEPARATED PIECES MAY OR MAY NOT MOVE ON ONE
ANOTHER DEPENDING ON THE TYPE OF JOINT.
ANATOMY OF A JOINT
OSTHEOARTHRITIS
 OSTEOARTHRITIS

It is also knwon as degenerative joint disease or

ostheoarthrosis (even though inflammation may
be presented), is the most common and most
frequently disabling of the joint disorder. OA
occurs most often in weight-bearing joints
(hips, knees, cervical and lumbar spine), and
may also involve the proximal and distal finger
joints.
 OSTEOARTHRITIS

Classifications Risk Factors

Primary (idiopathic) • Increased age
• With no prior event or disease related to the OA. • Between 50 to 60 years of age
Secondary • Genetic
• Resulting from previous joint injury or • Previous joint damage
inflammatory disease. • Congenital and developmental disorders of the hip:
congenital subluxation-dislocation of the hip, acetabular
dysplasia, Legg-Calvé-Perthes disease, and slipped
capital femoral epiphysis
• Obesity
• Repetitive use (occupational or recreational)
SLIPPED CAPITAL FEMORAL EPIPHYSIS
OSTEOARTHRITIS
Clinical Manifestation Assessment and Diagnostic Findings

• Primary manifestations: pain, stiffness, and functional • Tender and enlarged joints
impairment • X-ray- progressive loss of the joint cartilage
Pain - caused by an inflamed synovium, stretching of the joint
capsule or ligaments, irritation of nerve endings in the
periosteum over osteophytes (bone spurs), trabecular
microfracture, intraosseous hypertension, bursitis, tendinitis,
and muscle spasm.
Stiffness - most commonly experienced in the morning or after
awakening, usually lasts less than 30 minutes and decreases
with movement.
Functional impairment - results from pain on movement and
limited motion caused by structural changes in the joints.
• Painful bony nodes when inflamed
 1 2 3
Medical Management Surgical Management Nursing Management
• Weight reduction
• Prevention of injuries • Osteotomy Pain management and optimal functional ability are
• Perinatal screening for congenital hip disease major goals of nursing intervention.
• Use of heat, joint rest and avoidance of joint overuse, orthotic • Arthroplasty • Advise the patient to reduce weight and to exercise
devices (splints, braces)
• Isometric and postural exercises, and aerobic exercise (walking).
• Massage, yoga, or music therapy
• Pulsed electromagnetic fields, or Transcutaneous electrical
• Refer the patient for physical therapy or to an
nerve stimulation (TENS) exercise program.
• Occupational and physical therapy
• Herbal and dietary supplements
• Encourage the patient to use canes or other
• Acupuncture, acupressure, wearing copper bracelets or assistive devices for ambulation.
magnets, and participation in Tai chi
• Pharmacologic Therapy
• Provide adequate pain management.
• Initial analgesic therapy: Acetaminophen
• Other analgesics: NSAIDs, COX-2 enzyme blockers, Opioids,
Intra-articular corticosteroids, Topical analgesic agents such as
Capsaicin (Capsin, Zostrix), or Methylsalicylate
• Glucosamine and Chondroitin - modify cartilage structure
• Intra-articular Viscosupplementation (hyaluronates) -
supplements the viscous properties of synovial fluid
RHEUMATOID ARTHTRITIS
Rheumatoid arthritis is a chronic inflammatory disorder that can affect more than just your
joints. In some people, the condition can damage a wide variety of body systems, including
the skin, eyes, lungs, heart and blood vessels.

An autoimmune disorder, rheumatoid arthritis occurs when your immune system mistakenly
attacks your own body's tissues. RA mainly attacks the joints, usually many joints at once.
RA commonly affects joints in the hands, wrists, and knees. In a joint with RA, the lining of
the joint becomes inflamed, causing damage to joint tissue. This tissue damage can cause
long-lasting or chronic pain, unsteadiness (lack of balance), and deformity (misshapenness).
RA can also affect other tissues throughout the body and cause problems in organs such as
the lungs, heart, and eyes.
 PATHOPHYSIOLOGY
Autoimmune Response Formation of Rheumatoid Nodules

Inflammation Systemic Effects

Synovial Brain Involvement Chronic Nature

Cartilage and Bone Damage Joint Stiffness

Rheumatoid Nodules
Unlike the wear-and-tear damage of osteoarthritis, rheumatoid arthritis affects the lining
of your joints, causing a painful swelling that can eventually result in bone erosion and
joint deformity.
Risk Factors:
• Sex (more common in women)
• Genetics/inherited traits.
• Age (people in their 60's)
• Smoking.
• History of live births.
• Early Life Exposures.
• Obesity.
Unlike the risk factors above which
may increase risk of developing RA,
at least one characteristic may
decrease risk of developing RA.
• Breastfeeding. Women who have
breastfed their infants have a
decreased risk of developing RA.
The cause of RA is unknown.
SIGNS AND SYMPTOMS:
• pain
• stiffness
• tenderness
• swelling or redness in one or more
joints, usually in a symmetrical
pattern
LABORATORY TEST IMAGING
TEST
• Rheumatoid factor (RF) • X RAYS
• Anti-cyclic citrullinated • Magnetic Resonance
peptide antibody Imaging
• Complete blood count
• Erythrocyte sedimentation
rate
• C-reactive protein
MEDICAL INTERVENTIONS:
 1. DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS):
METHOTREXATE, HYDROXYCHLOROQUINE, AND BIOLOGICS LIKE
ETANERCEPT CAN SLOW DISEASE PROGRESSION.

2. NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDS):

PROVIDE PAIN RELIEF AND REDUCE INFLAMMATION.

3. CORTICOSTEROIDS:
OFFERED FOR SHORT-TERM RELIEF DURING FLARE-UPS.
4. PHYSICAL THERAPY:
EXERCISES TO IMPROVE JOINT FUNCTION AND MOBILITY.
5. OCCUPATIONAL THERAPY:
TECHNIQUES FOR ADAPTING DAILY ACTIVITIES TO REDUCE JOINT STRESS.
Surgical Management
 Synovectomy
REMOVAL OF THE INFLAMED SYNOVIUM
TO ALLEVIATE PAIN AND SLOW JOINT
DAMAGE.
JOINT REPLACEMENT
(ARTHROPLASTY)

Total joint replacement surgery,

especially for severely affected
joints like hips or knees.
 TENDON REPAIR
Repair or reconstruction of damaged tendons.
 OSTEOTOMY

Osteotomy involves reshaping the bones

to correct deformities and improve joint
alignment. This procedure is often
considered in the early stages of joint
damage.
 JOINT FUSION (ARTHRODESIS)
Arthrodesis involves fusing the bones on either side of a joint to eliminate
movement. This procedure can be effective in reducing pain but results in the loss
of joint mobility.
 Nursing
Responsibilities
• Pain Management
•Mobility Assistance
•Education
•Emotional Support
•Monitoring for Complications
 GOUTY
ARTHRITIS
Gout is a heterogeneous group of
inflammatory conditions related to a
genetic defect of purine metabolism and
resulting in hyperuricemia.

Adult male: 4.0-8.5 mg/dL

Adult female: 2.7-7.3 mg/dL
RISK FACTORS

1 2
Primary Hyperuricemia Secondary Hyperuricemia

• Severe dieting or Starvation • Increase in cell turnover (leukemias, multiple

• Excessive intake of foods high in purines. myeloma, psoriasis, some anemias)
- Internal organs (Liver or Kidneys) • Increase in cell breakdown
- Red meats • Certain pharmacologic agents (diuretics such as
- Seafood (Shellfish, Sardines, Scallops, thiazides or furosemide)
Tuna)
- Alcohol (Especially beer)
• Heredity
PATHOPHYSIOLOGY

01 Hyperuricemia (serum concentration greater than 7 mg/dL) can, but does not always
cause urate crystal deposition.

02 When the urate crystals precipitate within a joint, an inflammatory response occurs, and an
attack of gout begins.

With repeated attacks, accumulations of sodium urate crystals, called tophi, are deposited in

03 peripheral areas of the body, such as the great toe, the hands, and the ear.
TOPHI
STAGES OF GOUT PROGRESSION
ASYMPTOMATIC HYPERURECIMIA

01 Results of abnormally high serum urate level, without the

arthritis.Hyperurecimia defined as greater than 7.0 mg/dL (3.4 - 7.0 mg/dL)
gouty

ACUTE GOUT

02
It is characterized by the sudden onset of pain, erythema, limited range of motion and
swelling of the involved joint. The peak incidence of acute gout occurs between 30 and 50
years of age. First appear in the metatarsophalangeal joint.

INTERCRITICAL GOUT

03
After your first gout attack, you'll probably experience a time without symptoms until another
attack occurs, which could be months or even years. The stage during which attacks come at
intervals — short or long — is known as “intercritical” gout.

CHRONIC TOPHACEOUS GOUT

04
Associated with more frequent and severe inflammatory episodes and also related with more extensive tophus
formation thus can cause joint enlargement which may cause loss of joint motion.
Acute Gout. Note erythrema and swelling in
the metatarsophalangeal joint.
Chronic Tophaceous Gout. Most commonly
occur in the synovium, olecranon bursa,
subchondral bone, infrapatellar and Achilles
tendons, and subcutaenous tissue on the
extensor surface of the forearms and
overlying joints.
CLINICAL MANIFESTATION
• Early: Acute Gout Arthritis (Metatarsophalangeal joint of the big toe
is the most commonly affected joint)
At Night: Severe pain, redness, swelling, and warmth of the affected joint.
2. Tophi Formation - crystalline deposits accumulating in the articular
tissue, osseous tissue, soft tissue, and cartilage.

<--- Crystalline Formation

 COMPLICATIONS
• RENAL URATE LITHIASIS (URIC ACID
URINARY CALCULI / STONES )

It is the formation of a stone when you have a high The normal range for urine pH is
level of uric acid in your urine (hyperuricemia). 4.5 to 8.

2. KIDNEY DAMAGE / GOUTY NEPHROPATHY

(RENAL IMPAIRMENT)

It is a common comorbidity of gout and as kidney

function declines, uric acid excretion through the urine
is reduced, leading to hyperuricemia
URIC ACID STONE
 ASSESSMENT AND DIAGNOSTIC FINDINGS
• POLARIZED LIGHT MICROSCOPY OF THE
SYNOVIAL FLUID (ARTHROCENTESIS)

A needle is used to take fluid from a joint to see

if it has uric acid crystals.

2. ELEVATED SERUM URIC ACID

A uric acid blood test, also known as a serum uric acid

measurement, determines how much uric acid is
present in your blood.
POLARIZED LIGHT MICROSCOPY OF THE SYNOVIAL FLUID
POLARIZED LIGHT MICROSCOPY OF THE SYNOVIAL FLUID
 NURSING DIAGNOSIS
• Acute pain related to joint inflammation
• Impaired physical mobility related to
pain
• Activity intolerance related to pain
• Bathing
• Self-care deficit related to
musculoskeletal impairment
MEDICAL MANAGEMENT
1.Acute attacks:
Colchicine (oral or parenteral), NSAIDS (indomethacin), or a Corticosteroid
2. Uricosuric agents: Probenecid (Benemid)
Medication of choice; correct hyperuricemia and dissolve deposited urate.
3. Allopurinol
Interrupts the breakdown of purine before uric acid is formed.
4. Febuxostat (Uloric)
Treatment of gout that does not respond to usual treatment.
 NURSING MANAGEMENT
• Encourage the patient to restrict the consumption of foods high in
purines.
2. Encourage the patient to increase fluid intake.

3. Advise the patient to maintain normal body weight.

4. in an acute episode: administer analgesics and instruct the patient to avoid

factors that increase pain and inflammation, such as trauma, stress and
alcohol.