Summary
Akal College of Nursing
Medical Surgical Nursing-I
Topic: Arthritis ()
Introduction
ARTHRITIS is primary reason for work related disabilities and is leading cause of disability among
people 65 years of age or older.
There are over 100 forms of arthritis.
Most common form is osteoarthritis.
DEFINITION
ARTHRITIS is an inflammation of joint characterized by pain , swelling and limitation of joint
movement.
TYPES
Rheumatoid arthritis
Osteoarthritis
Spondyloarthropathies
Gout arthritis
Septic arthritis
Still’s disease.
GOUTY ARTHRITIS
It is a disease in which purine metabolism is altered and the byproduct uric acid accumulates in the
body evidenced by increased uric acid in blood stream.
Uric acid form crystals which are deposited in connective tissue and trigger an inflammatory
response.
Cause - hereditary
Symptoms- Join pain
Swollen joints
Redness.
Gouty nephropathy
Urinary calculi
Treatment-Anti inflammatory drugs
-Allopurinol and probenicid
-Ample fluid to promote excretion of uric acid
RHEUMATOID ARTHRITIS
It is a chronic systemic progressive inflammatory disease affecting connective tissues of the body.
It is characterized by inflammation in lining of synovial joints with severe involvement of joint
structure.
Affects women more than men.
Etiology
 Cause is still unknown
 Autoimmunity
 Genetic predisposition- certain histo compatibility markers
Agents- Mycoplasma
Clostridium
Epstein barr virus
Parvovirus
Clinical manifestations
It is a systemic disease, however joints are generally affected first.
Joints tend to be affected symmetrically.
Wrist joint, PIP (proximal inter pharyngeal) and MCP( meta carpo phalangeal) joints are involved
first.
Joint swelling is more apparent in the morning.
CRITERIA FOR DIAGNOSIS OF RA
 Morning stiffness lasting at least 1 hr.






Swelling of three or more joints
Swelling of wrist, PIP or MCP joints
Symmetrical joint swelling
Rheumatoid nodules
Positive results on test for RF
Changes on X ray typical for RF: A definitive requires that 4 of these seven features be
present at the same time
Articular manifestations- Synovitis
-Muscle spasm and weakness
-Hand deformity (ulnar drift, Boutonniere deformity, Swan neck deformity)
-Rheumatoid nodules
Extra articular manifestations- Skin changes
- Pulmonary disease
- Cardiac disease
- Ocular symptoms
- Neurological disease
- Felty’s syndrome
- Vasculitis
Other symptoms
 Fatigue
 Weakness
 Low grade fever
 Anorexia
 Weight loss
 Generalized aching
DIAGNOSTIC TEST
 Radiography
 Blood test- elevated ESR
- elevated serum globulins
- positive test for C reactive protein
- anemia
- RF( rheumatoid factor) positive with
in 3 months after onset of symptoms
- ANA( anti nuclear antibodies) positive
 Synovial fluid examination- arthrocentesis
- Shows synovial fluid is cloudy, milky or dark yellow
- Contains numerous inflammatory components
- Reduced viscosity
- WBC count is as high as 50,000/mm3
Medical management
Early RA
- NSAIDS (therapeutic doses)
- Methotrexate (standard treatment for RA)
- Analgesics
- Balance of rest and exercise
Non pharmacological measures- Relaxation techniques
- Heat and cold application
2) Moderate erosive RAIn this stage occupational and physical therapy is prescribed to educate patient about
- joint protection
- pacing activities
- work simplification
- range of motion
- muscle strengthening exercise
Cyclosporin can be given
3) Persistent erosive RAcorticosteroids( local injection may be given)
4) Advanced RARequires high dose of methotrexate, cyclophosphamide, and azathioprine (DMARDS)
Through all stages of RA low dose of antidepressants can be given
Surgical management
 Synovectomy- excision of synovial membrane
 TENORRHAPHY- suturing of tendon
 Arthrodesis –surgical fusion of joints
 Arthroplasty- replacement of joints
Nursing care
PHYSICAL MOBILITY-Preserve joint function
- Provide ROM to maintain joint motion and muscle strengthening
- Balance rest and activity
- Splints may be used during acute
-inflammation to prevent deformity
- Prevent flexion contractures
- Apply heat and cold therapy
-Apply paraffin baths and massage as prescribed.
-Encourage consistency with exercise program
-Instruct client to stop exercise if pain increases
- Exercise only to the point of pain
- Avoid weight on the inflammed joint
- Assess need for assistive devices
- Assess client’s reaction to the body change
Osteoarthritis
It is degenerative joint disease characterized by degeneration and loss of articular cartilage in synovial
joint resulting in deterioration of underlying bone.
Types
Primary
It occurs mainly in weight bearing areas with no prior event and is idiopathic.
Secondary
Resulting from previous injury or inflammatory disease.
Etiology Joint injury- repetitive sprain and strain
- joint dislocation
- fracture
- neurological disease. It may involve spine. Mostly occur in weight bearing joints of lower
exremities
Risk factors
 Increasing age
 Genetic predisposition
 Gender and hormonal factors
 Obesity and overweight
 Mechanical factors
 Congenital and developmental disorder of hips
 Previous inflammatory disease
Clinical manifestations
Pain--- Client experiences pain that diminishes after rest and intensify after activity early in disease
- As the disease progresses, pain occurs even with slight motion or even at rest
-Symptoms are aggravated by temperature change and climate humidity.
-Joint Stiffness, swelling, crepitus, and limited ROM
-Difficulty getting up after prolonged sitting.
-Skeletal muscle disuse atrophy.
Functional impairment
Heberden’s node--These are hard or bony swellings that can develop in the DIP joints,they are caused by
formation of osteophytes of articular cartilage in response to repeated trauma to the joints
Osteophytes are also known as bone spurs are bony projections that form along the joints
Bouchard’s node—osteophytes on PIP JOINTS
Diagnostic test
 X ray
 On physical examination reveals tender and enlarged joints.
Medical management
 Drug therapy- Aspirin
- NSAIDS
 Relieve patient’s apprehension about disease and treatment
 Rest
 Good nutrition
 Maintenance of general health
 Physical therapy- Heat application
- Weight reduction
- Joint rest
- Avoidance of joint overuse
- Orthotic devices(splints , braces)
- Isometric exercises
- Aerobic exercises
- Massage ,TENS
- Musical therapy
-Isometric exercises
Surgical management
 Viscosupplementation( Hyaluronic acid injection )
 Tidal irrigation
 Arthroscopic debridement With or without arthroscopic lavage.
 Arthroplasty
 Arthrotomy.
Septic arthritis: Septic arthritis is invasion of synovial membrane by pathogens
Causes- staphylococcus ,
- gonococcus
- Meningococcus
- streptococcus
Mode of infection
Organism can reach the synovium by one of following routes:
 Hematogenous
 Spread
 inoculation
 infection
 Previous trauma to joints, joint replacement, co existing arthritis, diminished host resistance
also contribute.
Risk factors
 Advanced age
 DM
 RA
 Pre existing joint disease
 Joint replacement
 Long term corticosteroids
Pathophysiology
 Invasion of micro-organism into the joint
 Synovial membrane swells
 Become infiltrated with neutrophils
 Neutrophils release lysosomal enzymes
 Destroy articular cartilage, subchondral bone and joint capsule
 Septic arthritis
Clinical manifestations
 Warm painful and swollen joint
 Decreased range of motion
 Fever,chills ,rapid pulse
 Leucocytosis
Diagnostic test
 Aspiration, examination and culture of synovial fluid.
 CT and MRI.
 Radioisotope scanning – localizes infectious process
Medical management
 Broad spectrum i/v antibiotics.
 Synovial fluid monitored for sterility and decrease in WBC.
 Aspiration of synovial fluid may be done to remove excessive joint fluid , exudate and debris
 Support by splint.
 Analgesics
 NSAIDS
 Good nutrition and fluid status
 Progressive range of motion
Spondyloarthropathies: It is the another category of systemic inflammatory disorder of skeleton
system. It includes:
 Ankylosing sponylitis
 Reactive arthritis or Rieter’s syndrome
 Psoriatic arthritis.
Ankylosing spondilitisI: t is a chronic progressive inflammatory disease of the spine and sacro-iliac
joint which leads to extensive bony ankylosis or scaring within the joint.
 It affects men more than women.
 Begins in adolescence or early adulthood.
 Results in poker like spine.
 Common symptoms are pain and stiffness in the back.
 Treatment- anti inflammatory drugs.
Reactive arthritis
 The disease process is called reactive because arthritis occurs after the infection.
 It mostly affects the young adult males and is characterized primarily by urethritis, arthritis
and conjunctivitis.
 Dermatitis, and ulceration of the mouth & penis may also be present.
 Low back pain is common.
Psoriatic arthritis
 It is characterized by synovitis, polyarthritis and spondilytis.
 The prevalence of arthritis in patient with psoriasis is 15-25%.
 Prevalence of psoriasis in patient with arthritis is 2.6 – 7%.
Medical management
 Focus is on treating pain and suppressing inflammation and maintains mobility.
 Maintain ROM with regular exercises.
 NSAIDS & corticosteroids are helpful.
 Methotrexate may help with peripheral disease.
 Surgical management includes total joint replacement.
Still’s disease
 It may refer to:
 Juvenile idiopathic arthritis
 Adult onset still’s disease.
 AOSD is systemic inflammatory disease characterized by triad of fever, joint pain and rash.
 Serum ferritin is elevated. , RF & ANA are negative.
 Treatment: steroids e.g. prednisolone
 Juvenile arthritis have onset before 16 years
 Limping and flu like symptoms are common manifestations.
 Persistent swelling of affected joints.
 Pain with morning stiffness.
Submitted by:
Komal Rana
CI
ACN