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PAGET’S DISEASE
PRESENTED BY
OM VERMA
ASSISTANT
PROFESSOR
RELIANCE INSTITUTE OF NURSING DHAMTARI
(C.G)
PAGET’S DISEASE:-
Introduction :-
Paget's disease is a chronic bone condition characterized by disorder of
the normal bone remodeling process. Normal bone has a synchronized
relationship of mechanisms that act to lay down new bone and take up
old bone. This relationship (referred to as remodeling) is essential for
maintaining the normal calcium levels in our blood. In bone affected by
Paget's disease, the bone remodeling is disturbed and not synchronized.
As a result, the bone that is formed is abnormal, enlarged, not as dense,
brittle, and prone to breakage (fracture). Paget's disease affects older
bone of adults. It's estimated that 1% of adults in the U.S. have Paget's
disease. There is an extremely rare form of Paget's disease in children,
referred to as juvenile Paget's disease. Paget's disease is also known as
osteitis deformans
DEFINITION :-
Paget’s disease of the bone is a skeletal disorder resulting from
excessive orthoclastic activity, affecting long bones, pelvis, lumbar
vertebrae & skull..
Paget's disease of bone is a chronic disease of the skeleton. In healthy
bone, a process called remodeling removes old pieces of bone and
replaces them with new, fresh bone. Paget's disease causes this process
to shift out of balance, resulting in new bone that is abnormally shaped,
weak, and brittle.
A chronic bone disorder that typically results in enlarged, deformed
bones due to excessive breakdown and formation of bone tissue that
can cause bones to weaken and may result in bone pain, arthritis,
deformities or fractures.
CAUSES :-
 It is not known what causes Paget's disease.
 Recently, certain genes have been associated with Paget's disease,
including the Sequestrosome 1 gene on chromosome 5.
 Virus infection may be necessary to trigger Paget's disease in
people who have inherited the genetic tendency to develop the
condition.
CAUSES
The cause of Paget's disease of bone is unknown. Scientists suspect a
combination of environmental and genetic factors contribute to the disease.
Several genes appear to be linked to getting the disease.
Some scientists believe Paget's disease of bone is related to a viral
infection in your bone cells, but this theory is controversial.
RISK FACTORS
Factors that can increase your risk of Paget's disease of bone include:
 Age. People older than 40 are most likely to develop Paget's disease
of bone.
 Sex. Men are more commonly affected than are women.
 National origin. Paget's disease of bone is more common in
England, Scotland, central Europe and Greece — as well as countries
settled by European immigrants. It's uncommon in Scandinavia and
Asia.
 Family history. If you have a relative who has Paget's disease of
bone, you're more likely to develop the condition.
SYMPTOMS :-
 Bone pain, deformity, fracture, and arthritis. The bone pain of
Paget's disease is located in the affected bone. The most common
bones affected by Paget's disease include the spine, the thigh bone
(femur), the pelvis, the skull, the collar bone (clavicle), and the
upper arm bone (humerus).
 The symptoms of Paget's disease depend on the bones affected and
the severity of the disease.
Enlarged bones can pinch adjacent nerves, causing tingling and
numbness. Bowing of the legs can occur. Hip or knee involvement
can lead to limping, as well as pain and stiffness of the hip or knee.
Headache, loss of vision, and hearing loss can occur when bones of
the skull are affected. With very widespread Paget's disease, it is
possible to develop congestive heart failure due to an increased
workload on the heart.
SYMPTOMS
Most people who have Paget's disease of bone have no symptoms. When
symptoms occur, the most common complaint is bone pain.
Because this disease causes your body to generate new bone faster than
normal, the rapid remodeling produces bone that's softer and weaker than
normal bone, which can lead to bone pain, deformities and fractures.
The disease might affect only one or two areas of your body or might be
widespread. Your signs and symptoms, if any, will depend on the affected
part of your body.
 Pelvis. Paget's disease of bone in the pelvis can cause hip pain.
 Skull. An overgrowth of bone in the skull can cause hearing loss or
headaches.
 Spine. If your spine is affected, nerve roots can become compressed.
This can cause pain, tingling and numbness in an arm or leg.
 Leg. As the bones weaken, they may bend — causing you to become
bowlegged. Enlarged and misshapen bones in your legs can put extra
stress on nearby joints, which may cause osteoarthritis in your knee or
hip.
ASSESSMENT & DIAGNOSTIC
FINDINGS:-
Therefore treatment is designed to control the symptoms and change the
rate of bone growth. Establishing the correct diagnosis is important
because something can be done to manage most forms of arthritis and
most therapies work best when started early in the disease.
 History and a physical examination.
 x-rays,
 Bone scans
 Bone biopsy.
 Blood and urine tests.
Methods used to diagnose Paget’s disease
Three tests – an x-ray, blood test, and bone scan – are commonly used to
discover Paget’s disease. Sometimes the disease is found by accident when
one of these tests is done for another reason. X-rays are used to make the
final diagnosis.
X-rays. In x-ray images, bones affected by Paget’s disease have a particular
appearance that is different from other bones. Accordingly, a doctor will use x-
rays, alone or with a blood test or bone scan, to confirm whether or not a
person has Paget’s disease of bone.
Blood test (measurement of serum alkaline phosphatase). Sometimes
blood test results are what first alert doctors to the possibility that a person
has Paget’s disease. When blood contains a higher-than-usual level of a
chemical substance called serum alkaline phosphatase (SAP), it is a sign that
the disease may be present. SAP is a type of enzyme made by bone cells that
is overproduced by pagetic bone.
A mild increase in SAP, up to twice the usual level, may indicate Paget’s
disease or another condition, such as liver disease or a bone fracture that is in
the process of healing. However, a SAP level greater than twice the usual
level strongly suggests Paget’s disease, especially if the person’s serum
calcium level, phosphorus level, and kidney function are normal.
Bone scan. A bone scan is a test that helps identify which bones have been
affected by Paget’s disease. The procedure is also a useful way to determine
the extent and activity of the disease. In a bone scan, a safe amount of a
radioactive substance is injected into the person’s vein. The substance
circulates through the bloodstream and "highlights" places in the skeleton
where Paget’s disease may be present. If the scan suggests that the person
has the disease, the affected areas usually are x-rayed to confirm the
diagnosis.
Bone biopsy. In rare cases, a biopsy (a small sample of tissue removed for
analysis) is taken from bone that is suspected of having Paget’s disease.
Bone biopsies are done when x-ray images do not confirm the presence or
absence of the disease.
Urine test. Although urine tests are not used to detect or diagnose Paget’s
disease, they may be used to monitor a person’s response to treatment for the
disease. In this test, a sample of the person’s urine is analyzed for the
presence of substances called bone markers. These substances provide
information about bone resorption – the process of breaking down and taking
up of bone by the body. One such substance is N-telopeptide.
MANAGEMENT :-
.Medicine
 Bisphosphonates These are Didronel, Fosamax and Actonel.
 Calcitonin If severe pain and bone loss prescribed a medication
called calcitonin, which is given by injection. Calcitonin is a
hormone that occurs naturally within the body. It helps increase
bone density by affecting the levels of calcium in the blood. It
reduces bone destruction and reduces the formation of new bone as
well. It can also relieve pain. Often calcitonin from eel or salmon is
used, as it is many times stronger than the human form.
 Acetaminophen For mild to moderate pain from Paget’s disease
Acetaminophen is a pain reliever, but has no anti-inflammatory
properties, so it does not actually reduce the swelling and pressure
that may be causing the pain. Because it is not an anti-
inflammatory it can usually be safely taken along with most
prescription medications. However, there are daily limits of
acetaminophen that can be taken, so caution should be exercised,
particularly if other medications that contain acetaminophen (for
example, it’s found in many cold remedies) are being used. A
serious overdose of acetaminophen can cause liver damage.
Diet
 proper intake of calcium. advise to drink about two litres (six to
eight glasses) of fluid daily to prevent other complications arising
from excess calcium in your body.
Calcium can be obtained by eating a well-balanced diet that includes
foods that are good sources of calcium – for example, milk and milk
products, dark-green leafy vegetables (such as mustard greens and kale),
and canned fish with soft bones (such as sardines and salmon). Dietary
supplements of calcium may be another source.
In general, apatient with Paget's disease should receive 1000-1500 mg
of calcium, adequate sunshine, and at least 400 units of vitamin D daily.
This is especially important if treated with bisphosphonates. If history of
kidney stones (calcium deposits in the kidneys) discuss calcium and
vitamin D intake with physician.
Exercise
Exercise may relieve stiffness and help you maintain flexibility. Always
consult doctor before beginning an exercise program. Depending on the
severity of symptoms doctor may advise against certain exercises. He or
she might refer to a therapist, who can show the exercises that may be
helpful and those that could be harmful.
Heat/Cold
Heat or cold application can provide temporary relief of pain. Heat
helps to reduce pain and stiffness by relaxing aching muscles and
increasing circulation to the area. There is some concern that heat may
worsen the symptoms in an already inflamed joint. Cold helps numb
the area by constricting the blood vessels and blocking nerve impulses in
the joint. Applying ice or cold packs appears to decrease inflammation
and therefore is the method of choice when joints are inflamed.
Protect Your Joints
Protecting your joints means using them in ways that avoid excess
stress. Benefits include less pain and greater ease in doing tasks. Three
main techniques to protect your joints are:
Pacing, by alternating heavy or repeated tasks with easier tasks or
breaks, reduces the stress on painful joints and allows weakened muscles
to rest.
Positioning joints wisely helps you use them in ways that avoid extra
stress. Use larger, stronger joints to carry loads. For example, use a
shoulder bag instead of a hand-held one. Also, avoid keeping the same
position for a long period of time.
Using helpful devices, such as canes, luggage carts, grocery carts and
reaching aids, can help make daily tasks easier. Small appliances such
as microwaves, food processors and bread makers can be useful in the
kitchen. Using grab bars and shower seats in the bathroom can help you
to conserve energy and avoid falls.
Staying at your recommended weight can lessen pain by reducing stress
on the bones. If you plan to lose weight, discuss the best program for
you with your doctor and a dietician.
Relaxation
Developing good relaxation and coping skills can give you a greater
feeling of control over your arthritis and a more positive outlook.
Surgery
Some people with severe, advanced Paget’s disease may require surgery,
though this is rare. Benefits include less pain and better movement and
function.
Some kinds of surgery can repair bone deformity or rebuild part of a
joint. With other kinds of surgery joints such as hips and knees can be
replaced with artificial joints.
Surgery could also be required for badly fractured bones.
Tips for Living Well
Along with the physical symptoms of arthritis, many people experience
feelings of helplessness and depression. Learning daily living strategies
to manage your arthritis gives you a greater feeling of control and a
more positive outlook. To get the best results, people affected by
arthritis need to form close ties with their doctors and therapists, and
become full partners in their treatment. From our perspective, it's all part
of 'living well with arthritis.' There are several resources you can use in
finding out how best to manage your own arthritis. Here are a few:
 The Arthritis Self-Management Program (ASMP) is a
unique self-help program offered by The Arthritis Society to
help you better control and manage your arthritis.
 The Open Forum within this Web site is an opportunity to
discuss and share information with other visitors - people who,
through their own experiences, may be able to offer some useful
insights.
Of course, there are many other valuable resources for people with
arthritis. If you're unclear about where to look for help, be sure to call
The Arthritis Society at 1-800-321-1433.
Nursing process:-
Assessment :-
 Assess pain & functional abilities.
 Observe for bowing (legs) or complaint that has feel tight.
 Assess for cardiovascular complication.
 Assess for auditory symptom- tinnitus, vertigo & hearing loss.
Nursing diagnosis:-
 Chronic pain related to pathophysiological process.
Goal :- to reduce pain.
Intervention Rationale
 Adviced patient to take
rest in bed by giving side
lying position or supine
position.
 Adviced patient to sleep
in firm mattress.
 Provide local heat
compression & back
massage.
 Instruct the patient to
move the trunk not to
twist & giving good
posture & teaches body
mechanics.
To relief back pain.
To provide comfort.
To promote muscle relaxation.
To provide comfort & reduces
risk of injury.
Evaluation :- pain is reduced.
 Risk for injury related to fall.
Goal :- to prevent injury.
Intervention Rationale
 Teach safe transferring, &
make sure patient can alert &
call nurses for help.
 Assist patient with activities as
necessary.
 Provide function & mobility
aids such as heel lifts, walking
aids as needed.
To prevent from falling.
To provide safety.
To provide comfort & make
independent.
Evaluation :- Risk for injury is reduced.
Deficient knowledge about the diseased condition & treatment regimen.
Goal :-
 To provide knowledge to patient.
Intervention Rationale
 Taught the patient about
disease condition like
development of paget’s
disease, intervention to
arrest or slow the process &
measure to relieve symptom
 Advise to patient regarding
dietry or supplemental
intake of calcium & vit. D,
regular weight bearing
exercise, & modification of
life style.
 Patient teaching related to
medication therapy its
important & side-effect.
 Teach patient to drink
adequate fluids.
To reduce anxiety.
To provide knowledge.
To provide knowledge.
To reduce risk of renal caliculi.
Evaluation :- Acquires knowledge about osteoporosis & treatment
regimen
COMPLICATIONS
In most cases, Paget's disease of bone progresses slowly. The disease
can be managed effectively in nearly all people. Possible complications
include:
 Fractures and deformities. Affected bones break more easily. Extra
blood vessels in these deformed bones cause them to bleed more
during repair surgeries. Leg bones can bow, which can affect your
ability to walk.
 Osteoarthritis. Misshapen bones can increase the amount of stress
on nearby joints, which can cause osteoarthritis.
 Neurologic problems. When Paget's disease of bone occurs in an
area where nerves pass through the bone, such as the spine and
skull, the overgrowth of bone can compress and damage the nerve,
causing pain, weakness or tingling in an arm or leg or hearing loss.
 Heart failure. Extensive Paget's disease of bone may force your heart
to work harder to pump blood to the affected areas of your body.
Sometimes, this increased workload can lead to heart failure.
 Bone cancer. Bone cancer occurs in about 1 percent of people with
Paget's disease of bone.
ARTHRITI
S
Definition :-
Arthritis is a joint disorder featuring inflammation. A joint is an area of
the body where two different bones meet. A joint functions to move the
body parts connected by its bones. Arthritis literally means inflammation
of one or more joints.
Arthritis is frequently accompanied by joint pain. Joint pain is referred
to as arthralgia.
Arthritis is the swelling and tenderness of one or more of your joints. The
main symptoms of arthritis are joint pain and stiffness, which typically
worsen with age. The most common types of arthritis are osteoarthritis
and rheumatoid arthritis.Jul 19, 2019
Includes Diseases: Osteoarthritis; Rheumatoid arthritis;...
Causes:-
 Injury (leading to osteoarthritis),
 metabolic abnormalities (such as gout and pseudogout),
 hereditary factors,
 the direct and indirect effect of infections (bacterial and viral), and a
 misdirected immune system with autoimmunity (such as in rheumatoid arthritis and
systemic lupus erythematosus).
CAUSES
The two main types of arthritis — osteoarthritis and rheumatoid arthritis —
damage joints in different ways.
Osteoarthritis
The most common type of arthritis, osteoarthritis involves wear-and-tear
damage to your joint's cartilage — the hard, slick coating on the ends of
bones where they form a joint. Cartilage cushions the ends of the bones
and allows nearly frictionless joint motion, but enough damage can result in
bone grinding directly on bone, which causes pain and restricted
movement. This wear and tear can occur over many years, or it can be
hastened by a joint injury or infection.
Osteoarthritis also affects the entire joint. It causes changes in the bones
and deterioration of the connective tissues that attach muscle to bone and
hold the joint together. It also causes inflammation of the joint lining.
Rheumatoid arthritis
In rheumatoid arthritis, the body's immune system attacks the lining of the
joint capsule, a tough membrane that encloses all the joint parts. This lining
(synovial membrane) becomes inflamed and swollen. The disease process
can eventually destroy cartilage and bone within the joint.
Risk factors
Risk factors for arthritis include:
 Family history. Some types of arthritis run in families, so you may be
more likely to develop arthritis if your parents or siblings have the
disorder. Your genes can make you more susceptible to
environmental factors that may trigger arthritis.
 Age. The risk of many types of arthritis — including osteoarthritis,
rheumatoid arthritis and gout — increases with age.
 Your sex. Women are more likely than men to develop rheumatoid
arthritis, while most of the people who have gout, another type of
arthritis, are men.
 Previous joint injury. People who have injured a joint, perhaps while
playing a sport, are more likely to eventually develop arthritis in that
joint.
 Obesity. Carrying excess pounds puts stress on joints, particularly
your knees, hips and spine. People with obesity have a higher risk of
developing arthriti
Classification
Primary forms of arthritis:
 Osteoarthritis
 Rheumatoid arthritis
 lupous
 Gout and pseudo-gout
Osteoarthritis
Osteoarthritis is the most common form of arthritis.[3] It can
affect both the larger and the smaller joints of the body,
including the hands, feet, back, hip or knee. The disease is
essentially one acquired from daily wear and tear of the joint,
however, osteoarthritis can also occur as a result of injury.
Osteoarthritis begins in the cartilage and eventually leads to the
two opposing bones eroding into each other. Initially, the
condition starts with minor pain while walking but soon the pain
can be continuous and even occur at night. The pain can be
debilitating and prevent one from doing some activities.
Osteoarthritis typically affects the weight bearing joints such as
the back, spine, and pelvis. Unlike rheumatoid arthritis,
osteoarthritis is most commonly a disease of the elderly. More
than 30 percent of females have some degree of osteoarthritisby
age 65. Risk factors for osteoarthritis include: prior joint trauma,
obesity, sedentary lifestyle.
Osteoarthritis, like rheumatoid arthritis, cannot be cured but one
can prevent the condition from worsening. Weight loss is the
key to improving symptoms and preventing progression.
Physical therapy to strengthen muscles and joints is very helpful.
Pain medications are widely required by individuals with
osteoarthritis. When the disease is far advanced and the pain is
continuous, surgery may be an option. Unlike rheumatoid
arthritis, joint replacement does help many individuals with
osteoarthritis.
Rheumatoid arthritis
Rheumatoid arthritis is a disorder in which, for some unknown
reason, the body's own immune system starts to attack body
tissues. The attack is not only directed at the joint but to many
other parts of the body. In rheumatoid arthritis, most damage
occurs to the joint lining and cartilage which eventually results
in erosion of two opposing bones. Rheumatoid arthritis affects
joints in the fingers, wrists, knees and elbows. The disease is
symmetrical and can lead to severe deformity in a few years if
not treated. Rheumatoid arthritis occurs mostly in people aged
20 and above. In children, the disorder can present with a skin
rash, fever, pain, disability, and limitations in daily activities. No
one knows why rheumatoid arthritis occurs and all treatments
are focused on easing the symptoms. With earlier diagnosis and
aggressive treatment, many individuals can lead a decent quality
of life. The drugs to treat rheumatoid arthritis range from
corticosteroids to monoclonal antibodies given intravenously.
The latest drugs like Remicade can significantly improve quality
of life in the short term. In rare cases, surgery may be required
to replace joints but there is no cure for the illness.
Lupus
This is a common collagen vascular disorder that can be present
with severe arthritis. Other features of lupus include a skin rash,
extreme photosensitivity, hair loss, kidney problems, emotional
lability, lung fibrosis and constant joint pain.
Gout
Gout is caused by deposition of uric acid crystals in the joint,
causing inflammation. There is also an uncommon form of
gouty arthritis caused by the formation of rhomboid crystals of
calcium pyrophosphate known as pseudogout. In the early
stages, the gouty arthritis usually occur in one joint, but with
time, it can occur in many joints and be quite crippling. The
joints in gout can often become swollen and lose function.[7]
Other
Infectious arthritis is another severe form of arthritis. It presents
with sudden onset of chills, fever and joint pain. The condition
is caused by bacteria elsewhere in the body. Infectious arthritis
must be rapidly diagnosed and treated promptly to prevent
irreversible and permanent joint damage.[8]
Psoriasis is another type of arthritis. With psoriasis, most
individuals develop the skin problem first and then the arthritis.
The typical features are of continuous joint pains, stiffness and
swelling. The disease does recur with periods of remission but
there is no cure for the disorder. A small percentage develop a
severe painful and destructive form of arthritis which destroys
the small joints in the hands and can lead to permanent disability
and loss of hand function. [9]
Signs and symptoms
Regardless of the type of arthritis, the common symptoms for all arthritis
disorders include varied levels of pain, swelling, joint stiffness and
sometimes a constant ache around the joint(s). Arthritic disorders like
lupus and rheumatoid can also affect other organs in the body with a
variety of symptoms.[10]
 Inability to use the hand or walk
 Malaise and a feeling of tiredness
 Fever
 Weight loss
 Poor sleep
 Muscle aches and pains
 Tenderness
 Difficulty moving the joint
It is common in advanced arthritis for significant secondary changes to
occur. For example, in someone who has limited their physical activity:
 Muscle weakness
 Loss of flexibility
 Decreased aerobic fitness
Assessment & diagnostic findings:-
 History and a physical examination.
 x-rays,
 Bone scans
 Bone biopsy.
 Blood and urine tests.
Medications:-
 NSAIDS(nonsteroidal anti-inflammatory drugs)
 COX-2 Inhibitors
 Pain Medication (analgesics)
 Corticosteroids
 DMARDs (disease-modifying anti-rheumatic drugs)
 Biologic Response Modifiers (i.e. biologics)
 Injections Into a Joint
 There are several types of injections which can be given locally into
the joint. Viscosupplementation is a procedure that involves the
injection of gel-like substances (hyaluronates) into a joint (currently
approved for knee) to supplement the viscous properties of synovial
fluid. The five types are:-
 Synvisc
 Orthovisc
 Supartz
 Euflexxa
 Hyalgan
 Local steroid injections can be used for a specific, painful joint. Three
steroid injections per year into a joint is the maximum allowed by
most doctors. Steroid injections were used long before
viscosupplementation became a treatment option.
Natural treatment
Treatment :-
 physical therapy, splinting, cold-pack application, paraffin wax
dips, anti-inflammatory medications, immune-altering
medications, and surgical operations.
Treatment Goals:-
The goals of arthritis treatment are to:
 Decrease arthritis symptoms
 Slow progression of the disease
 Prevent or minimize joint damage and deformities
 Maintain joint function
 Preserve mobility and range-of-motion
People with early symptoms of arthritis are often inclined to
self-treat with over-the-counter medications, topical creams, or
conservative measures such as ice and heat. The Arthritis
Foundation recommends seeing a doctor if you have joint pain,
stiffness, or swelling which persists for two or more weeks,
whether or not your symptoms began suddenly or gradually.
Only a doctor can diagnose arthritis. An accurate diagnosis is
needed so treatment can begin.
A rheumatologist (arthritis specialist) will help you understand
all of your treatment options and also help you steer clear of
unproven remedies. Discuss the potential benefits and risks of
each treatment option with your doctor.
Natural Treatments
Some people are more interested in natural treatments than
traditional medications
Be aware.
 Acupuncture / Acupressure
 Biofeedback
 Chiropractic
 Magnets
 Massage
 Meditation
 Tai Chi
 Yoga
 Supplements such as fish oil, glucosamine.
Complementary Medicine
The terms complementary medicine and alternative medicine are
sometimes used interchangeably. The difference is that
complementary treatments are used together with your usual
treatment regimen. Alternative treatments imply that they are
used instead of your usual treatment.
 Regular exercise is strongly recommended for arthritis
patients. Exercise can reduce pain and improve physical
function, muscle strength, and quality of life for people with
arthritis.
 Exercise: Essential Treatment for Arthritis
 Over One-Third of Arthritis Patients Get No Exercise
 Eating a nutritious diet is important for maintaining ideal
weight and for bone health too. There is no known diet
which can cure arthritis, but eating well is important.
 Fruits and Vegetables May Cut Arthritis Risk
 Stress management may also be useful as a complementary
treatment. Reducing stress helps to reduce pain and stiffness
associated with arthritis.
Surgical management:-
Joint surgery is usually considered a last resort treatment option.
Joint surgery is typically considered if other more conservative
treatment measures are unsatisfactory or have stopped working.
When joint damage is severe and when pain interferes with daily
activities, joint surgery may be an option with the goal of
decreasing pain and restoring function.
 Arthrodesis (fusion)
 Arthroplasty
 Osteotomy
 Joint replacement
 Revision joint replacement
 Resection
 Synovectomy
 Partial knee replacement
Nursing process:-
Assessment:-
 Assess pain & functional abilities.
 Observe for bowing (legs) or complaint that has feel
tight.
 Assess for cardiovascular complication.
 Assess for auditory symptom- tinnitus, vertigo & hearing
loss.
Nursing diagnosis:-
 Chronic pain related to pathophysiological process.
Goal :- to reduce pain.
Intervention Rationale
 Adviced patient to take
rest in bed by giving
side lying position or
supine position.
 Adviced patient to
sleep in firm mattress.
 Provide local heat
compression & back
massage.
 Instruct the patient to
move the trunk not to
twist & giving good
posture & teaches body
mechanics.
To relief back pain.
To provide comfort.
To promote muscle
relaxation.
To provide comfort &
reduces risk of injury.
Evaluation :- pain is reduced.
 Impaired physical mobility related to pain, use of
immobilization device & weight bearing limitation.
Goal :- improved physical mobility within
therapeutic limitation.
Intervention Rationale
 Treatmenr regimen
restrict activity.
 Encourage to take
rest.
 Encourage the patient
to participate in
activity of daily
living with in
physical limitation.
 Demonstrate safe use
of immobilizing &
assistive devices.
The bone is weakened
by the infective process
& must be procted by
immobilization devices
& by avoidance of stress
on the bone.
To reduce physical
mobility.
To promote general well
being.
To reduce risk of injury.
Evaluation :- physical mobility is improved.




 Deficient knowledge about the diseased condition &
treatment regimen.
Goal :-
 To provide knowledge to patient.
Intervention Rationale
 Taught the patient about
disease condition like
development of paget’s
disease, intervention to
arrest or slow the process &
measure to relieve symptom
 Advise to patient regarding
dietry or supplemental
intake of calcium & vit. D,
regular weight bearing
exercise, & modification of
life style.
 Patient teaching related to
medication therapy its
important & side-effect.
 Teach patient to drink
adequate fluids.
To reduce anxiety.
To provide knowledge.
To provide knowledge.
To reduce risk of renal caliculi.
Evaluation :- Acquires knowledge about osteoporosis &
treatment regimen
POTT’S SPINE:-
Definition :- Pott's disease is named after Percival Pott (1714-
1788), who was a surgeon in London. Pott's disease is
tuberculosis of the spinal column .
Pott's Disease is a combination of osteomyelitis and arthritis which involves
multiple vertebrae. The typical site of involvement is the anterior aspect of
the vertebral body adjacent to the subchondral plate and occurs most
frequently in the lower thoracic vertebrae.
Risk factors
 Endemic tuberculosis.
 Poor socio-economic conditions.
 HIV infection.
Sign & symptom:-
 The onset is gradual.
 Back pain is localised.
 Fever, night sweats, anorexia and weight loss.
 Signs may include kyphosis (common) and/or a
paravertebral swelling.
 Affected patients tend to assume a protective upright, stiff
position.
 If there is neural involvement there will be neurological
signs.
 A psoas abscess may present as a lump in the groin and
resemble a hernia:
o A psoas abscess most often originates from a
tuberculous abscess of the lumbar vertebra that tracks
from the spine inside the sheath of the psoas muscle.
o Other causes include extension of renal sepsis and
posterior perforation of the bowel.
o There is a tender swelling below the inguinal ligament
and they are usually apyrexial.
o The condition may be confused with a femoral hernia
or enlarged inguinal lymph nodes.
Assessment & diagnostic findings:-
 Elevated ESR.
 Strongly positive Mantoux skin test.
 Spinal X-ray may be normal in early disease as 50% of the
bone mass must be lost for changes to be visible on X-ray.
Plain X-ray can show vertebral destruction and narrowed
disc space.
 MRI scanning may demonstrate the extent of spinal
compression and can show changes at an early stage. Bone
elements visible within the swelling, or abscesses, are
strongly suggestive of Pott's disease rather than
malignancy. CT scans and nuclear bone scans can also be
used but MRI is best to assess risk to the spinal cord.
 A needle biopsy of bone or synovial tissue is usual. If it
shows tubercle bacilli this is diagnostic but usually culture
is required.
Management
 Immobilisation of the spine is usually for 2 or 3 months.
 Drug treatment: this is covered in the article on the Management
of Tuberculosis. Therapy may need to exceed 6 months.
Prevention
 As for all tuberculosis, BCG vaccination.
 Improvement of socio-economic conditions.
 Prevention of HIV and AIDS
Complication
 Vertebral collapse and kyphosis.
 Abscess can occur if the infection extends to adjacent
ligaments and soft tissues. Abscesses in the lumbar region
may descend down the sheath of the psoas to the femoral
trigone region and eventually erode into the skin and form
sinuses.

Om verma

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Om verma

  • 1. Topic PAGET’S DISEASE PRESENTED BY OM VERMA ASSISTANT PROFESSOR RELIANCE INSTITUTE OF NURSING DHAMTARI (C.G)
  • 2. PAGET’S DISEASE:- Introduction :- Paget's disease is a chronic bone condition characterized by disorder of the normal bone remodeling process. Normal bone has a synchronized relationship of mechanisms that act to lay down new bone and take up old bone. This relationship (referred to as remodeling) is essential for maintaining the normal calcium levels in our blood. In bone affected by Paget's disease, the bone remodeling is disturbed and not synchronized. As a result, the bone that is formed is abnormal, enlarged, not as dense, brittle, and prone to breakage (fracture). Paget's disease affects older bone of adults. It's estimated that 1% of adults in the U.S. have Paget's disease. There is an extremely rare form of Paget's disease in children, referred to as juvenile Paget's disease. Paget's disease is also known as osteitis deformans DEFINITION :- Paget’s disease of the bone is a skeletal disorder resulting from excessive orthoclastic activity, affecting long bones, pelvis, lumbar vertebrae & skull.. Paget's disease of bone is a chronic disease of the skeleton. In healthy bone, a process called remodeling removes old pieces of bone and replaces them with new, fresh bone. Paget's disease causes this process to shift out of balance, resulting in new bone that is abnormally shaped, weak, and brittle. A chronic bone disorder that typically results in enlarged, deformed bones due to excessive breakdown and formation of bone tissue that can cause bones to weaken and may result in bone pain, arthritis, deformities or fractures.
  • 3. CAUSES :-  It is not known what causes Paget's disease.  Recently, certain genes have been associated with Paget's disease, including the Sequestrosome 1 gene on chromosome 5.  Virus infection may be necessary to trigger Paget's disease in people who have inherited the genetic tendency to develop the condition. CAUSES The cause of Paget's disease of bone is unknown. Scientists suspect a combination of environmental and genetic factors contribute to the disease. Several genes appear to be linked to getting the disease. Some scientists believe Paget's disease of bone is related to a viral infection in your bone cells, but this theory is controversial. RISK FACTORS Factors that can increase your risk of Paget's disease of bone include:  Age. People older than 40 are most likely to develop Paget's disease of bone.  Sex. Men are more commonly affected than are women.  National origin. Paget's disease of bone is more common in England, Scotland, central Europe and Greece — as well as countries settled by European immigrants. It's uncommon in Scandinavia and Asia.  Family history. If you have a relative who has Paget's disease of bone, you're more likely to develop the condition.
  • 4. SYMPTOMS :-  Bone pain, deformity, fracture, and arthritis. The bone pain of Paget's disease is located in the affected bone. The most common bones affected by Paget's disease include the spine, the thigh bone (femur), the pelvis, the skull, the collar bone (clavicle), and the upper arm bone (humerus).  The symptoms of Paget's disease depend on the bones affected and the severity of the disease. Enlarged bones can pinch adjacent nerves, causing tingling and numbness. Bowing of the legs can occur. Hip or knee involvement can lead to limping, as well as pain and stiffness of the hip or knee. Headache, loss of vision, and hearing loss can occur when bones of the skull are affected. With very widespread Paget's disease, it is possible to develop congestive heart failure due to an increased workload on the heart. SYMPTOMS Most people who have Paget's disease of bone have no symptoms. When symptoms occur, the most common complaint is bone pain. Because this disease causes your body to generate new bone faster than normal, the rapid remodeling produces bone that's softer and weaker than normal bone, which can lead to bone pain, deformities and fractures. The disease might affect only one or two areas of your body or might be widespread. Your signs and symptoms, if any, will depend on the affected part of your body.
  • 5.  Pelvis. Paget's disease of bone in the pelvis can cause hip pain.  Skull. An overgrowth of bone in the skull can cause hearing loss or headaches.  Spine. If your spine is affected, nerve roots can become compressed. This can cause pain, tingling and numbness in an arm or leg.  Leg. As the bones weaken, they may bend — causing you to become bowlegged. Enlarged and misshapen bones in your legs can put extra stress on nearby joints, which may cause osteoarthritis in your knee or hip. ASSESSMENT & DIAGNOSTIC FINDINGS:- Therefore treatment is designed to control the symptoms and change the rate of bone growth. Establishing the correct diagnosis is important because something can be done to manage most forms of arthritis and most therapies work best when started early in the disease.  History and a physical examination.  x-rays,  Bone scans  Bone biopsy.  Blood and urine tests. Methods used to diagnose Paget’s disease Three tests – an x-ray, blood test, and bone scan – are commonly used to discover Paget’s disease. Sometimes the disease is found by accident when one of these tests is done for another reason. X-rays are used to make the final diagnosis. X-rays. In x-ray images, bones affected by Paget’s disease have a particular appearance that is different from other bones. Accordingly, a doctor will use x- rays, alone or with a blood test or bone scan, to confirm whether or not a person has Paget’s disease of bone.
  • 6. Blood test (measurement of serum alkaline phosphatase). Sometimes blood test results are what first alert doctors to the possibility that a person has Paget’s disease. When blood contains a higher-than-usual level of a chemical substance called serum alkaline phosphatase (SAP), it is a sign that the disease may be present. SAP is a type of enzyme made by bone cells that is overproduced by pagetic bone. A mild increase in SAP, up to twice the usual level, may indicate Paget’s disease or another condition, such as liver disease or a bone fracture that is in the process of healing. However, a SAP level greater than twice the usual level strongly suggests Paget’s disease, especially if the person’s serum calcium level, phosphorus level, and kidney function are normal. Bone scan. A bone scan is a test that helps identify which bones have been affected by Paget’s disease. The procedure is also a useful way to determine the extent and activity of the disease. In a bone scan, a safe amount of a radioactive substance is injected into the person’s vein. The substance circulates through the bloodstream and "highlights" places in the skeleton where Paget’s disease may be present. If the scan suggests that the person has the disease, the affected areas usually are x-rayed to confirm the diagnosis. Bone biopsy. In rare cases, a biopsy (a small sample of tissue removed for analysis) is taken from bone that is suspected of having Paget’s disease. Bone biopsies are done when x-ray images do not confirm the presence or absence of the disease. Urine test. Although urine tests are not used to detect or diagnose Paget’s disease, they may be used to monitor a person’s response to treatment for the disease. In this test, a sample of the person’s urine is analyzed for the presence of substances called bone markers. These substances provide information about bone resorption – the process of breaking down and taking up of bone by the body. One such substance is N-telopeptide.
  • 7. MANAGEMENT :- .Medicine  Bisphosphonates These are Didronel, Fosamax and Actonel.  Calcitonin If severe pain and bone loss prescribed a medication called calcitonin, which is given by injection. Calcitonin is a hormone that occurs naturally within the body. It helps increase bone density by affecting the levels of calcium in the blood. It reduces bone destruction and reduces the formation of new bone as well. It can also relieve pain. Often calcitonin from eel or salmon is used, as it is many times stronger than the human form.  Acetaminophen For mild to moderate pain from Paget’s disease Acetaminophen is a pain reliever, but has no anti-inflammatory properties, so it does not actually reduce the swelling and pressure that may be causing the pain. Because it is not an anti- inflammatory it can usually be safely taken along with most prescription medications. However, there are daily limits of acetaminophen that can be taken, so caution should be exercised, particularly if other medications that contain acetaminophen (for example, it’s found in many cold remedies) are being used. A serious overdose of acetaminophen can cause liver damage. Diet  proper intake of calcium. advise to drink about two litres (six to eight glasses) of fluid daily to prevent other complications arising from excess calcium in your body. Calcium can be obtained by eating a well-balanced diet that includes foods that are good sources of calcium – for example, milk and milk products, dark-green leafy vegetables (such as mustard greens and kale), and canned fish with soft bones (such as sardines and salmon). Dietary supplements of calcium may be another source.
  • 8. In general, apatient with Paget's disease should receive 1000-1500 mg of calcium, adequate sunshine, and at least 400 units of vitamin D daily. This is especially important if treated with bisphosphonates. If history of kidney stones (calcium deposits in the kidneys) discuss calcium and vitamin D intake with physician. Exercise Exercise may relieve stiffness and help you maintain flexibility. Always consult doctor before beginning an exercise program. Depending on the severity of symptoms doctor may advise against certain exercises. He or she might refer to a therapist, who can show the exercises that may be helpful and those that could be harmful. Heat/Cold Heat or cold application can provide temporary relief of pain. Heat helps to reduce pain and stiffness by relaxing aching muscles and increasing circulation to the area. There is some concern that heat may worsen the symptoms in an already inflamed joint. Cold helps numb the area by constricting the blood vessels and blocking nerve impulses in the joint. Applying ice or cold packs appears to decrease inflammation and therefore is the method of choice when joints are inflamed. Protect Your Joints Protecting your joints means using them in ways that avoid excess stress. Benefits include less pain and greater ease in doing tasks. Three main techniques to protect your joints are: Pacing, by alternating heavy or repeated tasks with easier tasks or breaks, reduces the stress on painful joints and allows weakened muscles to rest. Positioning joints wisely helps you use them in ways that avoid extra stress. Use larger, stronger joints to carry loads. For example, use a
  • 9. shoulder bag instead of a hand-held one. Also, avoid keeping the same position for a long period of time. Using helpful devices, such as canes, luggage carts, grocery carts and reaching aids, can help make daily tasks easier. Small appliances such as microwaves, food processors and bread makers can be useful in the kitchen. Using grab bars and shower seats in the bathroom can help you to conserve energy and avoid falls. Staying at your recommended weight can lessen pain by reducing stress on the bones. If you plan to lose weight, discuss the best program for you with your doctor and a dietician. Relaxation Developing good relaxation and coping skills can give you a greater feeling of control over your arthritis and a more positive outlook. Surgery Some people with severe, advanced Paget’s disease may require surgery, though this is rare. Benefits include less pain and better movement and function. Some kinds of surgery can repair bone deformity or rebuild part of a joint. With other kinds of surgery joints such as hips and knees can be replaced with artificial joints. Surgery could also be required for badly fractured bones. Tips for Living Well Along with the physical symptoms of arthritis, many people experience feelings of helplessness and depression. Learning daily living strategies to manage your arthritis gives you a greater feeling of control and a more positive outlook. To get the best results, people affected by
  • 10. arthritis need to form close ties with their doctors and therapists, and become full partners in their treatment. From our perspective, it's all part of 'living well with arthritis.' There are several resources you can use in finding out how best to manage your own arthritis. Here are a few:  The Arthritis Self-Management Program (ASMP) is a unique self-help program offered by The Arthritis Society to help you better control and manage your arthritis.  The Open Forum within this Web site is an opportunity to discuss and share information with other visitors - people who, through their own experiences, may be able to offer some useful insights. Of course, there are many other valuable resources for people with arthritis. If you're unclear about where to look for help, be sure to call The Arthritis Society at 1-800-321-1433.
  • 11. Nursing process:- Assessment :-  Assess pain & functional abilities.  Observe for bowing (legs) or complaint that has feel tight.  Assess for cardiovascular complication.  Assess for auditory symptom- tinnitus, vertigo & hearing loss. Nursing diagnosis:-  Chronic pain related to pathophysiological process. Goal :- to reduce pain. Intervention Rationale  Adviced patient to take rest in bed by giving side lying position or supine position.  Adviced patient to sleep in firm mattress.  Provide local heat compression & back massage.  Instruct the patient to move the trunk not to twist & giving good posture & teaches body mechanics. To relief back pain. To provide comfort. To promote muscle relaxation. To provide comfort & reduces risk of injury. Evaluation :- pain is reduced.
  • 12.  Risk for injury related to fall. Goal :- to prevent injury. Intervention Rationale  Teach safe transferring, & make sure patient can alert & call nurses for help.  Assist patient with activities as necessary.  Provide function & mobility aids such as heel lifts, walking aids as needed. To prevent from falling. To provide safety. To provide comfort & make independent. Evaluation :- Risk for injury is reduced.
  • 13. Deficient knowledge about the diseased condition & treatment regimen. Goal :-  To provide knowledge to patient. Intervention Rationale  Taught the patient about disease condition like development of paget’s disease, intervention to arrest or slow the process & measure to relieve symptom  Advise to patient regarding dietry or supplemental intake of calcium & vit. D, regular weight bearing exercise, & modification of life style.  Patient teaching related to medication therapy its important & side-effect.  Teach patient to drink adequate fluids. To reduce anxiety. To provide knowledge. To provide knowledge. To reduce risk of renal caliculi. Evaluation :- Acquires knowledge about osteoporosis & treatment regimen
  • 14. COMPLICATIONS In most cases, Paget's disease of bone progresses slowly. The disease can be managed effectively in nearly all people. Possible complications include:  Fractures and deformities. Affected bones break more easily. Extra blood vessels in these deformed bones cause them to bleed more during repair surgeries. Leg bones can bow, which can affect your ability to walk.  Osteoarthritis. Misshapen bones can increase the amount of stress on nearby joints, which can cause osteoarthritis.  Neurologic problems. When Paget's disease of bone occurs in an area where nerves pass through the bone, such as the spine and skull, the overgrowth of bone can compress and damage the nerve, causing pain, weakness or tingling in an arm or leg or hearing loss.  Heart failure. Extensive Paget's disease of bone may force your heart to work harder to pump blood to the affected areas of your body. Sometimes, this increased workload can lead to heart failure.  Bone cancer. Bone cancer occurs in about 1 percent of people with Paget's disease of bone.
  • 15. ARTHRITI S Definition :- Arthritis is a joint disorder featuring inflammation. A joint is an area of the body where two different bones meet. A joint functions to move the body parts connected by its bones. Arthritis literally means inflammation of one or more joints. Arthritis is frequently accompanied by joint pain. Joint pain is referred to as arthralgia. Arthritis is the swelling and tenderness of one or more of your joints. The main symptoms of arthritis are joint pain and stiffness, which typically worsen with age. The most common types of arthritis are osteoarthritis and rheumatoid arthritis.Jul 19, 2019 Includes Diseases: Osteoarthritis; Rheumatoid arthritis;... Causes:-  Injury (leading to osteoarthritis),  metabolic abnormalities (such as gout and pseudogout),  hereditary factors,  the direct and indirect effect of infections (bacterial and viral), and a  misdirected immune system with autoimmunity (such as in rheumatoid arthritis and systemic lupus erythematosus).
  • 16. CAUSES The two main types of arthritis — osteoarthritis and rheumatoid arthritis — damage joints in different ways. Osteoarthritis The most common type of arthritis, osteoarthritis involves wear-and-tear damage to your joint's cartilage — the hard, slick coating on the ends of bones where they form a joint. Cartilage cushions the ends of the bones and allows nearly frictionless joint motion, but enough damage can result in bone grinding directly on bone, which causes pain and restricted movement. This wear and tear can occur over many years, or it can be hastened by a joint injury or infection. Osteoarthritis also affects the entire joint. It causes changes in the bones and deterioration of the connective tissues that attach muscle to bone and hold the joint together. It also causes inflammation of the joint lining. Rheumatoid arthritis In rheumatoid arthritis, the body's immune system attacks the lining of the joint capsule, a tough membrane that encloses all the joint parts. This lining (synovial membrane) becomes inflamed and swollen. The disease process can eventually destroy cartilage and bone within the joint. Risk factors
  • 17. Risk factors for arthritis include:  Family history. Some types of arthritis run in families, so you may be more likely to develop arthritis if your parents or siblings have the disorder. Your genes can make you more susceptible to environmental factors that may trigger arthritis.  Age. The risk of many types of arthritis — including osteoarthritis, rheumatoid arthritis and gout — increases with age.  Your sex. Women are more likely than men to develop rheumatoid arthritis, while most of the people who have gout, another type of arthritis, are men.  Previous joint injury. People who have injured a joint, perhaps while playing a sport, are more likely to eventually develop arthritis in that joint.  Obesity. Carrying excess pounds puts stress on joints, particularly your knees, hips and spine. People with obesity have a higher risk of developing arthriti
  • 18. Classification Primary forms of arthritis:  Osteoarthritis  Rheumatoid arthritis  lupous  Gout and pseudo-gout Osteoarthritis Osteoarthritis is the most common form of arthritis.[3] It can affect both the larger and the smaller joints of the body, including the hands, feet, back, hip or knee. The disease is essentially one acquired from daily wear and tear of the joint, however, osteoarthritis can also occur as a result of injury. Osteoarthritis begins in the cartilage and eventually leads to the two opposing bones eroding into each other. Initially, the condition starts with minor pain while walking but soon the pain can be continuous and even occur at night. The pain can be debilitating and prevent one from doing some activities. Osteoarthritis typically affects the weight bearing joints such as the back, spine, and pelvis. Unlike rheumatoid arthritis, osteoarthritis is most commonly a disease of the elderly. More than 30 percent of females have some degree of osteoarthritisby age 65. Risk factors for osteoarthritis include: prior joint trauma, obesity, sedentary lifestyle. Osteoarthritis, like rheumatoid arthritis, cannot be cured but one can prevent the condition from worsening. Weight loss is the key to improving symptoms and preventing progression. Physical therapy to strengthen muscles and joints is very helpful.
  • 19. Pain medications are widely required by individuals with osteoarthritis. When the disease is far advanced and the pain is continuous, surgery may be an option. Unlike rheumatoid arthritis, joint replacement does help many individuals with osteoarthritis. Rheumatoid arthritis Rheumatoid arthritis is a disorder in which, for some unknown reason, the body's own immune system starts to attack body tissues. The attack is not only directed at the joint but to many other parts of the body. In rheumatoid arthritis, most damage occurs to the joint lining and cartilage which eventually results in erosion of two opposing bones. Rheumatoid arthritis affects joints in the fingers, wrists, knees and elbows. The disease is symmetrical and can lead to severe deformity in a few years if not treated. Rheumatoid arthritis occurs mostly in people aged 20 and above. In children, the disorder can present with a skin rash, fever, pain, disability, and limitations in daily activities. No one knows why rheumatoid arthritis occurs and all treatments are focused on easing the symptoms. With earlier diagnosis and
  • 20. aggressive treatment, many individuals can lead a decent quality of life. The drugs to treat rheumatoid arthritis range from corticosteroids to monoclonal antibodies given intravenously. The latest drugs like Remicade can significantly improve quality of life in the short term. In rare cases, surgery may be required to replace joints but there is no cure for the illness. Lupus This is a common collagen vascular disorder that can be present with severe arthritis. Other features of lupus include a skin rash, extreme photosensitivity, hair loss, kidney problems, emotional lability, lung fibrosis and constant joint pain.
  • 21. Gout Gout is caused by deposition of uric acid crystals in the joint, causing inflammation. There is also an uncommon form of gouty arthritis caused by the formation of rhomboid crystals of calcium pyrophosphate known as pseudogout. In the early stages, the gouty arthritis usually occur in one joint, but with time, it can occur in many joints and be quite crippling. The joints in gout can often become swollen and lose function.[7] Other Infectious arthritis is another severe form of arthritis. It presents with sudden onset of chills, fever and joint pain. The condition is caused by bacteria elsewhere in the body. Infectious arthritis must be rapidly diagnosed and treated promptly to prevent irreversible and permanent joint damage.[8] Psoriasis is another type of arthritis. With psoriasis, most individuals develop the skin problem first and then the arthritis. The typical features are of continuous joint pains, stiffness and swelling. The disease does recur with periods of remission but there is no cure for the disorder. A small percentage develop a severe painful and destructive form of arthritis which destroys the small joints in the hands and can lead to permanent disability and loss of hand function. [9]
  • 22. Signs and symptoms Regardless of the type of arthritis, the common symptoms for all arthritis disorders include varied levels of pain, swelling, joint stiffness and sometimes a constant ache around the joint(s). Arthritic disorders like lupus and rheumatoid can also affect other organs in the body with a variety of symptoms.[10]  Inability to use the hand or walk  Malaise and a feeling of tiredness  Fever  Weight loss  Poor sleep  Muscle aches and pains  Tenderness  Difficulty moving the joint It is common in advanced arthritis for significant secondary changes to occur. For example, in someone who has limited their physical activity:  Muscle weakness  Loss of flexibility  Decreased aerobic fitness Assessment & diagnostic findings:-  History and a physical examination.  x-rays,  Bone scans  Bone biopsy.  Blood and urine tests. Medications:-  NSAIDS(nonsteroidal anti-inflammatory drugs)  COX-2 Inhibitors
  • 23.  Pain Medication (analgesics)  Corticosteroids  DMARDs (disease-modifying anti-rheumatic drugs)  Biologic Response Modifiers (i.e. biologics)  Injections Into a Joint  There are several types of injections which can be given locally into the joint. Viscosupplementation is a procedure that involves the injection of gel-like substances (hyaluronates) into a joint (currently approved for knee) to supplement the viscous properties of synovial fluid. The five types are:-  Synvisc  Orthovisc  Supartz  Euflexxa  Hyalgan  Local steroid injections can be used for a specific, painful joint. Three steroid injections per year into a joint is the maximum allowed by most doctors. Steroid injections were used long before viscosupplementation became a treatment option. Natural treatment Treatment :-  physical therapy, splinting, cold-pack application, paraffin wax dips, anti-inflammatory medications, immune-altering medications, and surgical operations. Treatment Goals:- The goals of arthritis treatment are to:  Decrease arthritis symptoms  Slow progression of the disease  Prevent or minimize joint damage and deformities  Maintain joint function
  • 24.  Preserve mobility and range-of-motion People with early symptoms of arthritis are often inclined to self-treat with over-the-counter medications, topical creams, or conservative measures such as ice and heat. The Arthritis Foundation recommends seeing a doctor if you have joint pain, stiffness, or swelling which persists for two or more weeks, whether or not your symptoms began suddenly or gradually. Only a doctor can diagnose arthritis. An accurate diagnosis is needed so treatment can begin. A rheumatologist (arthritis specialist) will help you understand all of your treatment options and also help you steer clear of unproven remedies. Discuss the potential benefits and risks of each treatment option with your doctor. Natural Treatments Some people are more interested in natural treatments than traditional medications Be aware.  Acupuncture / Acupressure  Biofeedback  Chiropractic  Magnets  Massage  Meditation  Tai Chi  Yoga  Supplements such as fish oil, glucosamine.
  • 25. Complementary Medicine The terms complementary medicine and alternative medicine are sometimes used interchangeably. The difference is that complementary treatments are used together with your usual treatment regimen. Alternative treatments imply that they are used instead of your usual treatment.  Regular exercise is strongly recommended for arthritis patients. Exercise can reduce pain and improve physical function, muscle strength, and quality of life for people with arthritis.  Exercise: Essential Treatment for Arthritis  Over One-Third of Arthritis Patients Get No Exercise  Eating a nutritious diet is important for maintaining ideal weight and for bone health too. There is no known diet which can cure arthritis, but eating well is important.  Fruits and Vegetables May Cut Arthritis Risk  Stress management may also be useful as a complementary treatment. Reducing stress helps to reduce pain and stiffness associated with arthritis. Surgical management:- Joint surgery is usually considered a last resort treatment option. Joint surgery is typically considered if other more conservative treatment measures are unsatisfactory or have stopped working. When joint damage is severe and when pain interferes with daily activities, joint surgery may be an option with the goal of decreasing pain and restoring function.
  • 26.  Arthrodesis (fusion)  Arthroplasty  Osteotomy  Joint replacement  Revision joint replacement  Resection  Synovectomy  Partial knee replacement Nursing process:- Assessment:-  Assess pain & functional abilities.  Observe for bowing (legs) or complaint that has feel tight.  Assess for cardiovascular complication.  Assess for auditory symptom- tinnitus, vertigo & hearing loss.
  • 27. Nursing diagnosis:-  Chronic pain related to pathophysiological process. Goal :- to reduce pain. Intervention Rationale  Adviced patient to take rest in bed by giving side lying position or supine position.  Adviced patient to sleep in firm mattress.  Provide local heat compression & back massage.  Instruct the patient to move the trunk not to twist & giving good posture & teaches body mechanics. To relief back pain. To provide comfort. To promote muscle relaxation. To provide comfort & reduces risk of injury. Evaluation :- pain is reduced.
  • 28.  Impaired physical mobility related to pain, use of immobilization device & weight bearing limitation. Goal :- improved physical mobility within therapeutic limitation. Intervention Rationale  Treatmenr regimen restrict activity.  Encourage to take rest.  Encourage the patient to participate in activity of daily living with in physical limitation.  Demonstrate safe use of immobilizing & assistive devices. The bone is weakened by the infective process & must be procted by immobilization devices & by avoidance of stress on the bone. To reduce physical mobility. To promote general well being. To reduce risk of injury. Evaluation :- physical mobility is improved.    
  • 29.  Deficient knowledge about the diseased condition & treatment regimen. Goal :-  To provide knowledge to patient. Intervention Rationale  Taught the patient about disease condition like development of paget’s disease, intervention to arrest or slow the process & measure to relieve symptom  Advise to patient regarding dietry or supplemental intake of calcium & vit. D, regular weight bearing exercise, & modification of life style.  Patient teaching related to medication therapy its important & side-effect.  Teach patient to drink adequate fluids. To reduce anxiety. To provide knowledge. To provide knowledge. To reduce risk of renal caliculi. Evaluation :- Acquires knowledge about osteoporosis & treatment regimen
  • 30. POTT’S SPINE:- Definition :- Pott's disease is named after Percival Pott (1714- 1788), who was a surgeon in London. Pott's disease is tuberculosis of the spinal column . Pott's Disease is a combination of osteomyelitis and arthritis which involves multiple vertebrae. The typical site of involvement is the anterior aspect of the vertebral body adjacent to the subchondral plate and occurs most frequently in the lower thoracic vertebrae. Risk factors  Endemic tuberculosis.  Poor socio-economic conditions.  HIV infection. Sign & symptom:-  The onset is gradual.  Back pain is localised.  Fever, night sweats, anorexia and weight loss.  Signs may include kyphosis (common) and/or a paravertebral swelling.  Affected patients tend to assume a protective upright, stiff position.
  • 31.  If there is neural involvement there will be neurological signs.  A psoas abscess may present as a lump in the groin and resemble a hernia: o A psoas abscess most often originates from a tuberculous abscess of the lumbar vertebra that tracks from the spine inside the sheath of the psoas muscle. o Other causes include extension of renal sepsis and posterior perforation of the bowel. o There is a tender swelling below the inguinal ligament and they are usually apyrexial. o The condition may be confused with a femoral hernia or enlarged inguinal lymph nodes. Assessment & diagnostic findings:-  Elevated ESR.  Strongly positive Mantoux skin test.  Spinal X-ray may be normal in early disease as 50% of the bone mass must be lost for changes to be visible on X-ray. Plain X-ray can show vertebral destruction and narrowed disc space.  MRI scanning may demonstrate the extent of spinal compression and can show changes at an early stage. Bone elements visible within the swelling, or abscesses, are strongly suggestive of Pott's disease rather than malignancy. CT scans and nuclear bone scans can also be used but MRI is best to assess risk to the spinal cord.  A needle biopsy of bone or synovial tissue is usual. If it shows tubercle bacilli this is diagnostic but usually culture is required.
  • 32. Management  Immobilisation of the spine is usually for 2 or 3 months.  Drug treatment: this is covered in the article on the Management of Tuberculosis. Therapy may need to exceed 6 months. Prevention  As for all tuberculosis, BCG vaccination.  Improvement of socio-economic conditions.  Prevention of HIV and AIDS Complication  Vertebral collapse and kyphosis.  Abscess can occur if the infection extends to adjacent ligaments and soft tissues. Abscesses in the lumbar region may descend down the sheath of the psoas to the femoral trigone region and eventually erode into the skin and form sinuses. 