Joints and connective tissue diseases

Osteoarthritis
Osteoarthritis (OA) or degenerative joint disease (DJD) is a
disorder characterized by progressive deterioration of the
articular cartilage.
Most common joint disease
It is a noninflammatory (unless localized), no systemic disease.

Cont.…
Minimal inflammatory component
Differentiated from inflammatory disease by:
Absence of synovial membrane inflammation
Lack of systemic signs and symptoms
Normal synovial fluid
Much of the pain and loss of mobility associated with aging.

Cont.…
As the cartilage wears away, the joint space decreases, so
that the bone surfaces are closer and rub together.
In an attempt to repair the damaged surface, new bone
develops in the form of bone spurs, bone cysts, or
osteophytes, which are extended margins of the joints.
The joint becomes deformed, and the client experiences
pain and limited joint movement.

Risk factors
Increasing age
Previous joint injury
Obesity
congenital and developmental disorders
Hereditary factors
Decreased bone density.

Classified
o Primary, when the etiology is unknown, or
o Secondary, when OAhas an underlying cause such as
injury or a congenital disorder.

SIGNS AND SYMPTOMS
 Stiff joints for short time in morning, usually 15 minutes or less due to
changes within joints
 Joint pain with movement or weight bearing due to joint remodeling
 Crepitus (grating feeling on palpation over joint during range of motion)
due to loss of articular cartilage and bony overgrowth in joint
 Pain relief when joints are rested because lack of movements will relieve
irritation in joint space
 Enlargement of joint due to bony overgrowth or remodeling
 Heberden’s nodes—swelling of the distal interphalangeal joints
 Bouchard's nodes;- swelling of proximal interphalangeal joints

Heberden’s nodes.

TEST RESULTS
X-ray shows narrowed joint spaces, bone divisions, or
osteophytes around joints.
Tests for inflammation will be normal

Medical Treatment
 Analgesics and anti-inflammatory drugs (NSAIDs)
 Injections of corticosteroids or sodium hyaluronate (to improve
lubrication)
 Intra-articular injections of corticosteroid up to 3 or 4 times in a year
 Range of motion exercises
 Surgical removal of bone divisions, and other
 Replacement of joint

Nursing Intervention
Instruct the client on proper body mechanics.
local rest of the affected joints, heat applied to the painful
part, weight loss.
Splints, braces, canes, or crutches may reduce discomfort,
relieve pain, and prevent further destruction of the affected
joints.

Rheumatoid Arthritis
 is a chronic, progressive inflammatory disease that can affect tissues
and organs but principally attacks the joints producing an
inflammatory synovitis.
 It involves joints bilaterally and symmetrically, and it typically
affects several joints at one time.
 RA typically affects upper joints first.

Cont.….
RA is an autoimmune disease that is precipitated by WBCs
attacking synovial tissue.
The WBCs cause the synovial tissue to become inflamed and
thickened.
The inflammation can extend to the cartilage, bone, tendons,
and ligaments that surround the joint.
Joint deformity and bone erosion may result from these
changes, decreasing the joint’s range of motion and function.

Rheumatoid arthritis of hands and joint

Cause
Idiopathic disease
Immune-mediated destruction of joints
Rheumatoid factors (IgM and IgG) target blood cells and
synovial membranes forming antigen-antibody complexes
Genetic predisposition
Possibly bacterial or viral infection (Epstein-Barr)

Clinical Manifestation
Chronic inflammation of synovial membrane
Cellular proliferation and damage to the microcirculation
Synovial membrane becomes irregular
Swelling, stiffness and pain
Cartilage and bone destruction
Ankylosis or fusing of joint
Ligaments and tendons also affected

Diagnosis
 Evaluation :
history
Physical examination
X-ray
Serologic tests for rheumatoid factor and circulating antigen-
antibody complexes, esp. antibodies against cyclic citrullinated
peptide (CCP)
 No cure

Treatment
 NSAIDs provide analgesic, antipyretic, and anti-inflammatory effects.
NSAIDs can cause considerable gastrointestinal (GI) distress.
Corticosteroids (prednisone) are strong anti-inflammatory medications
that may be given for acute exacerbations or advanced forms of the
disease.
They are not given for long-term therapy due to significant adverse
effects (osteoporosis, hyperglycemia, immunosuppression, cataracts).

Cont.…
Antimalarial agent – hydroxychloroquine
Methotrexate
Surgical
Synovectomy
Correction of deformities
Joint replacement
Joint fusion

Nursing Intervention
 Apply heat or cold to the affected areas as indicated based on client
response.
 Assist with and encourage physical activity to maintain joint
mobility (within the capabilities of the client).
 Administer medications and proper positioning as prescribed.
 Monitor for medication effectiveness (reduced pain, increased
mobility).
 Teach the client regarding signs/symptoms that need to be reported
immediately (fever, infection, pain upon inspiration, pain in the
substernal area of the chest).

Osteomyelitis
Osteomyelitis is an infection of the bone.
 In an adult, it is most commonly due to direct contamination of
the site during trauma, such as an open fracture.
 Bacteria that cause infections elsewhere in the body may also
enter the bloodstream and become deposited into the bone,
starting a secondary infection site there.
This is more common in children and adolescents.

Cont.….
Acute infection is associated with inflammatory changes in
the bone and may lead to necrosis.
Some patients will develop chronic osteomyelitis.

Causative organism
The causative organism is not always identified.
 More than three-quarters of the identified organisms are
Staphylococcus aureus/streptococus.

Clinical Manifestation
Typical signs and symptoms :
Acute osteomyelitis include:
• Fever that may be abrupt
• Irritability or lethargy in young children
• Pain in the area of the infection
• Swelling, warmth and redness over the area of the infection
Chronic osteomyelitis include:
• Pain or tenderness in the affected area
• Chronic fatigue
• Drainage from an open wound near the area of the infection
• Fever, sometimes

TEST RESULTS
 Elevated white blood count (WBC).
 X-ray osteolytic lesions (localized loss of bone density).
 Culture and sensitivity tests to determine the infecting organism and
antibiotic—may be difficult to determine infecting organism.
 Bone biopsy to identify organism.

Treatment
Debridement of the area to remove necrotic tissue.
Drain the infected site.
 Immobilize or stabilize the bone if necessary.
Administer antibiotics parenterally for 4 to 6 weeks or
orally for 6 to 8 weeks:
Vancomycin 1g iv bid for 4 to 6 weeks
Cloxacillin 500mg po QID for 6 to 8 weeks.

Cont.…
Administer analgesic to relieve discomfort as needed:
• ibuprofen, acetaminophen
If there is vascular insufficiency or gangrene, amputation
may be needed.

Nursing Intervention
 Monitor vital signs, changes in blood pressure, elevated pulse,
elevated temperature and respiratory rate.
 Monitor wound site for redness, drainage, and odor.
 Monitor IV access site for patency.
 Explain to the patient:
• When and how to take medications.
• Importance of completing antibiotic medication.
• How to flush venous access device.
• Signs of infiltration, clotting of venous access device.
• When to call for assistance with venous access.

Septic arthritis
• Refers to bacterial infection resulting inflammatory destruction of
joints.
• Is highly destructive to the joint and is considered a medical
emergency.
• It is commonly hematogenous in origin (80-90%), contiguous spread
(10-15%), and direct penetration of microorganisms secondary to
trauma, surgery or injection.
• It is more common in children. In adults old age, diabetes mellitus,
skin infection, alcoholism, intra-articular steroid injections are some of
the common risk factors.

Cause
• Staphylococcus aureus is the most common cause.
• Group B Streptococci and other gram positive are also
frequent causes.
• Gram-negative bacilli are found as causes in specific
situations such as trauma, immunosuppression and very
elderly.
• Gonococcal arthritis is an infectious arthritis which should
be considered in sexually active young adults with culture
negative arthritis.

Clinical features
Joint pain, Erythema ,swelling, warmth
Restricted movement
Chills and rigors are not usually present
High grade feverand malaise
Altered gait- if weight bearing jointsare involved
Restricted rangeof movements

Lab Investigations
Joint (synovial fluid) fluid aspiration
 Fluid should be aspirated before initiation of antibiotics.
 The diagnosis of septic arthritis needs synovial fluid analysis.
 Definitive diagnosis requires identification bacteria in the synovial fluid: gram
stain and/or culture.
 Synovial fluid WBC count is usually >50,000/mm3 with predominate
neutrophils but a cell count.
 Raised ESR, leukocytosis, positive blood or joint fluid cultures.
X-ray of the affected joint : to evaluate for possible associated
osteomyelitis

Treatment
Joint fluid drainage
 All patients with septic arthritis needs joint fluid drainage.
 The options are the following
 Needle aspiration (arthrocentesis):
 repeated aspirations until the effusion resolves
Arthroscopic drainage
 Arthrotomy (open surgical drainage)
 Indications for surgical drainage: hip joint involvement, failure to responds with
needle aspiration and antibiotics after 5-7 days
 Splintage/immobilization may be needed for pain relief; however early
mobilization is encouraged once there is improvement.

Cont.….
 Pharmacologic (Antibiotics)
 As septic arthritis is destructive, empiric intravenous antibiotics
should be started immediately after taking synovial fluid samples.
 The initial empiric antimicrobial choice should cover the most likely
pathogens. If the facility cannot carry a gram stain analysis the following
regimen is generally recommended.
 First line –
Vancomycin, 30mg/kg/day IV in two divided doses, not to exceed
2g per day PLUS - Ceftriaxone, 2gm, IV, once daily or cefotaxime 2
g IV TID
Alternatives - Cloxacillin, IV, 2g . QID for 4-6 weeks OR -
Ceftriaxone 2gm, IV, once daily or cefotaxime 2 g IV TID

Nursing intervention
Same with osteomyelitis

Gout arthritis
 is a metabolic disorder in which the body does not
properly metabolize purine-based proteins.
As a result, there is an increase in the amount of uric acid,
which is the end product of purine metabolism.
As a result of hyperuricemia, uric acid crystals accumulate
in joints, most commonly the big toe (podagra), causing
pain when the joint moves.

Cont.…
 Uric acid is cleared from the body through the kidneys.
 These patients may also develop kidney stones as the uric acid
crystallizes in the kidney.
 A person may also develop secondary gout.
 is due to another disease process or use of medication, such as
thiazide diuretics or some chemotherapeutic agents.

Signs and Symptoms
Acute onset of excruciating pain in joint due to accumulation
of uric acid within the joint
Redness due to inflammation around the joint
Nephrolithiasis (kidney stones) due to uric acid deposits in
the kidney.
Joint pain, swelling, warmth
Restricted rangeof movements

TEST RESULTS
Elevated erythrocyte sedimentation rate (ESR).
Elevated serum uric acid level—not seen in all patients
with gout. Typical of primary gout patients prior to
episode of acute joint pain.
Elevated urinary uric acid levels.
Arthrocentesis shows uric acid crystals within the joint
fluid.

Treatment
 Administer NSAID to decrease inflammation to aid in pain relief
 indomethacin, ibuprofen.
Not aspirin; regular dosing causes retention of uric acid.
 Administer uricosuric medications when the total body amount of
urate needs to be decreased.
 Low-fat, low-cholesterol diet—elevated uric acid levels accelerate
atherosclerosis.
 Immobilize the joint for comfort.

Nursing Intervention
 Have the patient drink 3 liters of fluid per day to avoid
crystallization of uric acid in the kidneys.
 Increased fluids help flush the uric acid through the kidneys.
 Monitor uric acid levels in serum.
 Assist with positioning for comfort.
 Avoid touching inflamed joint unnecessarily. May need to keep
clothing or bed linen away from area.
 Explain to patient:
 Which foods are high-purine proteins- organ meats,
sardines, bacon.
Avoid alcohol, which inhibits renal excretion of uric acid.

Osteoporosis
is a decrease in bone density, making bones more brittle and it
becomes thinner and weaker, and more prone to fractures.
The body continuously replaces older bone with new bone
through a balance between the osteoblastic and osteoclastic
activity.
A disease in which loss of bone exceeds rate of bone formation;
Usually increase in older women.

Cont.…
• WHO defines osteoporosis by bone density:
Normal bone > 833 mg/cm2
Osteopenia 833 to 648 mg/cm2
Osteoporosis < 648 mg/cm2

Risk factors
Increased age,
Lack of physical activity
Poor nutrition
Osteoporosis can also occur as a secondary disease, due to
another condition.
Use of medications such as corticosteroids or
Some anticonvulsants,
Hormonal disorders (Cushing's or thyroid), and
Prolonged immobilization.

Signs and Symptoms
 Asymptomatic
 Back pain due to compression fractures in vertebral bodies
 Loss of height
 (kyphosis) due to pathologic vertebral fractures; collapsing of the
anterior portion of the vertebral bodies in the thoracic area
 Fracture with minor trauma

TEST RESULTS
X-ray shows demineralization of the bone—not an early
sign.
Dual energy x-ray absorptiometry (DEXA) shows
decrease in bone mineral density in the hip and spine
compared to young normal patients, and compared to age-
matched, race-matched, sex-matched patients.

TREATMENT
 Administer calcitonin nasal spray to increase bone density, also has
analgesic effect on bone pain after 2 to 4 weeks.
 Administer selective estrogen receptor modulator for postmenopausal
women for prevention of osteoporosis:
Raloxifene
 Administer vitamin D, which enhances the absorption of calcium;
many patients with osteoporosis are also deficient in vitamin D
 Administer calcium, 1000 to 1500 mg per day in divided doses to
enhance absorption.
 Perform range-of-motion activities.
 Increase vitamins and calcium in diet.

Nursing Intervention
 Pain control if fracture occurs.
 Explain to the patient:
 How to properly take medications.
 Bisphosphonates must be taken first thing in the morning on an empty
stomach, with a full glass of water. The patient can’t lie down for 30 to
60 minutes after taking the medication; this is to reduce risk of
esophageal irritation.
 Monitor for side effects of medications—GI effects with
bisphosphonates.
 Encourage weight-bearing activity.
 Encourage appropriate nutrition.

Ankylosing Spondylitis
 Affects the cartilaginous joints of the spine and surrounding tissues.
 Occasionally, the large synovial joints, may be involved.
 Characteristics include spondylosis and fusion of the vertebrae
 Usually begins in early adulthood and mainly affects men than women.
 Back pain is the characteristic feature.
 As the disease progresses, ankylosis (stiffness) of the entire spine may
occur, leading to respiratory compromise and complications.

Medical Management
Focuses on treating pain and maintaining mobility by
suppressing inflammation.
Good body positioning and posture are essential, so that if
ankylosis (fixation) does occur, the patient is in the most
functional position.
Maintaining ROM with a regular exercise and muscle-
strengthening program is especially important.

Cont.…
NSAIDS such as indomethacin are usually prescribed for
relieving inflammation and pain.

Nursing Management of Spondylitis
⚫The nurse administers prescribed drugs
⚫Encourages the client to perform ADLs as much as
possible.
⚫Teaches the client to perform mild exercises that reduce
stiffness and pain.