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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.
connective tissue diseases.pptx

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  • 1. Joints and connective tissue diseases
  • 2. 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.
  • 3. 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.
  • 4. 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.
  • 5. Risk factors Increasing age Previous joint injury Obesity congenital and developmental disorders Hereditary factors Decreased bone density.
  • 6. Classified o Primary, when the etiology is unknown, or o Secondary, when OAhas an underlying cause such as injury or a congenital disorder.
  • 7. 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
  • 9. TEST RESULTS X-ray shows narrowed joint spaces, bone divisions, or osteophytes around joints. Tests for inflammation will be normal
  • 10. 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
  • 11. 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.
  • 12. 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.
  • 13. 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.
  • 14. Rheumatoid arthritis of hands and joint
  • 15. 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)
  • 16. 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
  • 17. 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
  • 18. 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).
  • 19. Cont.… Antimalarial agent – hydroxychloroquine Methotrexate Surgical Synovectomy Correction of deformities Joint replacement Joint fusion
  • 20. 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).
  • 21. 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.
  • 22. Cont.…. Acute infection is associated with inflammatory changes in the bone and may lead to necrosis. Some patients will develop chronic osteomyelitis.
  • 23. Causative organism The causative organism is not always identified.  More than three-quarters of the identified organisms are Staphylococcus aureus/streptococus.
  • 24. 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
  • 25. 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.
  • 26. 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.
  • 27. Cont.… Administer analgesic to relieve discomfort as needed: • ibuprofen, acetaminophen If there is vascular insufficiency or gangrene, amputation may be needed.
  • 28. 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.
  • 29. 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.
  • 30. 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.
  • 31. 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
  • 32. 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
  • 33. 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.
  • 34. 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
  • 36. 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.
  • 37. 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.
  • 38. 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
  • 39. 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.
  • 40. 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.
  • 41. 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.
  • 42. 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.
  • 43. Cont.… • WHO defines osteoporosis by bone density: Normal bone > 833 mg/cm2 Osteopenia 833 to 648 mg/cm2 Osteoporosis < 648 mg/cm2
  • 44. 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.
  • 45. 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
  • 46. 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.
  • 47. 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.
  • 48. 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.
  • 49. 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.
  • 50. 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.
  • 51. Cont.… NSAIDS such as indomethacin are usually prescribed for relieving inflammation and pain.
  • 52. 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.