Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for osteoarthritis
- Describe the diagnostics and laboratory values of osteoarthritis
- Apply nursing concepts and plan associated nursing care for patients with osteoarthritis
- Evaluate the efficacy of nursing care for patients with osteoarthritis
- Describe the medical therapies that apply to the care of osteoarthritis
The most common form of arthritis, osteoarthritis (OA), is a degenerative joint disorder that involves the wearing down of joint cartilage and tissue over time. OA currently affects over 32.5 million Americans (Arthritis Foundation, n.d.). The joints most often affected include those in the hands, knees, spine, neck, and hips (Figure 13.6). Though joint damage cannot be reversed or cured, symptoms can usually be managed effectively with a combination of pharmacological and lifestyle interventions. In more severe cases, surgical intervention may be required. OA can be diagnosed at any age, but it is more common in individuals over the age of 50.
Pathophysiology
The pathophysiology of OA is somewhat unknown, but it appears to involve inflammation that results in the breakdown of joint cartilage over time. OA causes the cartilage to gradually become thinner, and as the cartilage layer wears down, more pressure is placed on the bones. The joint responds by increasing production of the synovial fluid for more lubrication, but this can cause swelling of the joint cavity. The bone tissue underlying the damaged articular cartilage also responds by thickening and causing the articulating surface of the bone to become rough or bumpy. As a result, joint movement results in pain and inflammation. Certain factors have been linked to an increased risk of developing OA, including
- advanced age,
- family history of OA,
- female sex,
- history of joint injury,
- obesity,
- overuse of joints (e.g., from sports or repetitive motions), and
- sedentary lifestyle.
Clinical Manifestations
The main clinical manifestation of OA is joint pain, which is often more apparent during activity or at the end of the day. Other common clinical manifestations of OA include
- joint stiffness, most often occurring first thing in the morning or after long periods of immobility;
- limited joint range of motion or flexibility;
- muscle weakness;
- joint instability (e.g., knee “giving out”);
- “grating” sensation with joint movement, which may be accompanied by a “popping” or “clicking” sound;
- a bony projection that develops along bone edges, known as a bone spur (Figure 13.7); and
- joint swelling.
Assessment and Diagnostics
The first step of diagnosing OA is to conduct a thorough physical examination. It is important to obtain a subjective report from the patient about their symptoms. Specifically, the nurse should ask about any joint pain or stiffness, as this may indicate the presence of OA. The nurse will also perform passive range of motion exercises and assess for pain, limited movement, and abnormal popping or clicking sounds. If symptoms of OA are present, other diagnostic tests may be indicated. Certain imaging tests such as x-ray or magnetic resonance imaging (MRI) can be used to visualize the joint space and determine the presence of cartilage breakdown and changes in the bone associated with OA. Joint aspiration, also known as arthrocentesis, is another diagnostic test that may be indicated in some cases. This procedure involves the insertion of a needle into the joint space to remove fluid, which is then tested for infection or crystals. Arthrocentesis may assist in ruling out other conditions such as gout, rheumatoid arthritis, or lupus (Figure 13.8).
Diagnostics and Laboratory Values
Because OA is an inflammatory condition, laboratory values indicating the presence of general inflammation can be used to assist in the diagnosis. Specifically, there is usually an elevation in both C-reactive protein and erythrocyte sedimentation rate (ESR). These laboratory tests cannot determine specifically where the inflammation is occurring, but they do confirm that inflammation is occurring somewhere in the body.
Nursing Care of the Patient with Osteoarthritis
Most of the nursing care for patients with OA centers around providing pain control and ensuring patient comfort. This includes administering analgesics as ordered by the provider and implementing comfort measures such as heat or cold application, position changes, and range of motion (ROM) exercises. ROM exercises can be classified as active or passive; active movements are achieved voluntarily by patients, without assistance, while passive movements are performed by the nurse or other practitioners because patients are unable or not permitted to move the body parts themselves.
Recognizing Cues and Analyzing Cues
When caring for a patient with OA, the nurse will monitor closely for symptoms indicating that the condition is becoming more severe or requires more intensive treatment. In addition to patient-reported joint pain, the nurse should regularly assess for joint swelling or tenderness. OA can occur in any joints, but swelling is usually most obvious in the hands (Figure 13.9).
Prioritizing Hypotheses, Generating Solutions, and Taking Action
In addition to medication administration and implementation of comfort measures, the nurse also provides emotional support for the patient with OA. Living with OA can be difficult and may negatively affect many aspects of life, including the patient’s ability to perform their own ADLs. This results in diminished independence and a need for assistance, something that may be hard for the patient to come to terms with. The nurse should help the patient create a plan of care that emphasizes independence and allows for the patient to perform as many personal care activities and ADLs as possible to increase their quality of life. The nurse could consult occupational therapy for adaptive devices to help the patient perform their ADLs.
Evaluation of Nursing Care for the Patient with Osteoarthritis
It is important for the nurse to follow-up with the patient to ensure their plan of care and treatments are effective. In some cases, medications or comfort measures may not be adequately providing pain relief, indicating the need for more invasive interventions such as surgical joint replacements.
Evaluating Outcomes
The nurse should evaluate patient outcomes to determine whether the current plan of care is appropriate. Outcomes indicating that the plan of care is appropriate and the patient is improving include
- pain relief,
- decreased joint swelling,
- increased ROM of affected joint,
- increased muscle strength, and
- patient usage of effective coping strategies.
Medical Therapies and Related Care
Treatment for OA involves a combination of pharmacological and nonpharmacological lifestyle interventions (Table 13.2).
| Medication | Rationale |
|---|---|
| Acetaminophen (e.g., Tylenol) | Assists with mild to moderate pain associated with OA |
| Nonsteroidal anti-inflammatory drugs (NSAIDs) | Assists with mild to moderate pain associated with OA and has anti-inflammatory effects |
| Duloxetine (e.g., Cymbalta) | Shown to improve chronic pain associated with OA |
| Glucocorticoid joint injections | thought to improve joint inflammation, though the benefits of chronic, long-term use are controversial |
Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety
Definition: Minimize risk of harm to patients and providers through both system effectiveness and individual performance.
Skill: Demonstrate effective use of strategies to reduce risk of harm to self or others. The nurse will
- provide education to patients with OA about the use of NSAIDs, as overuse of NSAIDs has been linked to an increased risk of GI bleeding, especially in OA patients; and
- provide education to patients to mitigate the risk of this adverse effect.
(QSEN Institute, n.d.)
Certain nonpharmacological lifestyle changes are also indicated in the treatment of OA. These include
- weight loss,
- regular physical activity and exercise,
- ROM exercises,
- use of assistive devices (e.g., braces, shoe inserts),
- use of adaptive devices (e.g., elevated toilet seats, hygiene devices),
- physical and occupational therapy, and
- relaxation and stress-reduction techniques.
If lifestyle and pharmacological interventions are not effective, surgery may be indicated. Specifically, joint replacement surgery has been shown to be effective for the treatment of OA. Hip and knee joint replacements are the most-performed surgical procedures for OA.