Osteoarthritis Nursing Care and Management: Study Guide for Nurses

Osteoarthritis is the most common and most disabling of the joint disorders, and you will see it constantly in older patients. Your work is pain control, protecting joint function, and keeping the patient moving, because activity is both the goal and part of the treatment.

What is Osteoarthritis?

Osteoarthritis (OA), sometimes called osteoarthrosis, is a degenerative joint disease, though inflammation may be present. It is both overdiagnosed and trivialized, and it is frequently overtreated or undertreated. Its functional impact on quality of life, especially in elderly patients, is often ignored.

Classification

OA splits into two classes, though the line between them is not always clear. Primary or idiopathic OA has no prior event or disease behind it. Secondary OA follows a previous joint injury or inflammatory disease.

Pathophysiology

OA is the result of many factors that together predispose a patient to the disease. It starts with injury to the articular cartilage, subchondral bone, and synovium. Previous joint damage, genetic and hormonal factors, and others initiate a chondrocyte response, which releases cytokines. Proteolytic enzymes, metalloproteases, and collagenase are then stimulated and released. The resulting damage triggers the chondrocyte to respond again, driving further damage.

Statistics and Epidemiology

OA often begins in the third decade of life and peaks between the fifth and sixth decades. By 40 years of age, 90% of the population has degenerative joint changes in their weight-bearing joints. Prevalence in the elderly runs between 50% and 80%. Increasing age relates directly to the degenerative process in the joint.

Causes

Understanding has moved well past the old "wear and tear" of aging. With increased age, the articular cartilage loses its ability to resist microfracture under repetitive loads. Obesity wears out weight-bearing joints under the added load. Previous joint damage predisposes to secondary OA, and repetitive use from occupational or recreational activity also drives it.

Clinical Manifestations

Pain comes from inflamed synovium, stretching of the joint capsule or ligaments, irritation of nerve endings in the periosteum over osteophytes, trabecular microfracture, intraosseous hypertension, bursitis, tendinitis, and muscle spasm. Stiffness is worst in the morning or on awakening, usually lasts less than 30 minutes, and eases with movement. Functional impairment follows from pain on movement and the limited motion caused by structural joint changes.

Prevention

No treatment halts the degenerative process, but early measures can slow it. Weight reduction takes load off the joints. Preventing injury matters because previous joint damage is a risk factor, so protect the weight-bearing joints. Perinatal screening for congenital hip disease catches the developmental hip disorders known to predispose to hip OA.

Assessment and Diagnostic Findings

Diagnosis is complicated because only 30% of patients with changes on x-ray report symptoms. Physical assessment of the musculoskeletal system reveals tender, swollen joints. OA shows a progressive loss of joint cartilage, which appears on x-ray as a narrowing of the joint space.

Medical Management

Management is conservative, combining physical modalities and alternative therapies. Heat applied over the joints reduces pain. Weight reduction is strongly recommended for obese patients to limit cartilage damage. The patient should avoid joint overuse and rest the joints regularly. Splints and braces support inflamed joints. Initial analgesic therapy is acetaminophen; some patients respond to NSAIDs, COX-2 enzyme blockers, opioids, and intra-articular corticosteroids.

Surgical Management

In moderate to severe OA, when pain is severe or function is lost, surgery may be used. Osteotomy alters the distribution of weight within the joint. Arthroplasty replaces the diseased joint components.

Nursing Management

Nursing Assessment

Assessment centers on history and physical exam. The area over the affected joint may be tender and enlarged. Note any past joint injury, since it is a risk factor for OA.

Diagnosis

• Acute pain related to inflammation of the synovium and irritation of the nerve endings.
• Activity intolerance related to joint pain.
• Impaired physical mobility related to joint stiffness.

Nursing Care Planning and Goals

The patient should identify the negative factors affecting activity intolerance and reduce their effects where possible, use techniques that improve activity tolerance, report a measurable increase in activity, report pain relieved or controlled, follow the prescribed pharmacologic regimen, and participate in ADLs and desired activities.

Nursing Interventions

The major goals are pain management and optimal function. Weight loss is an important approach to reducing pain and disability. Canes and other ambulatory devices help with walking. Exercise such as walking should start moderately and build gradually, and adequate pain management is essential to the success of an exercise program. A referral to physical therapy can be very helpful.

Evaluation

Confirm success: the patient identified and reduced negative factors affecting activity tolerance, used techniques to improve it, reported a measurable increase in activity, reported pain relieved or controlled, followed the prescribed pharmacologic regimen, and participated in ADLs and desired activities.

Discharge and Home Care Guidelines

Management continues at home. Patients should plan daily exercise for when pain is least severe, or take a prescribed analgesic before exercising. They may use complementary or alternative therapies such as herbal and dietary supplements, special diets, acupuncture, acupressure, copper bracelets or magnets, and T'ai Chi. Prescribed medications, especially analgesics, should be taken as directed to avoid severe pain.

Documentation Guidelines

Document level of activity; causative or precipitating factors; client reports of difficulty or change; vital signs before, during, and after activity; the response to pain, expectations of pain management, and acceptable pain level; prior medication use; the plan of care and who was involved in planning; the teaching plan; responses to interventions, teaching, and actions performed; attainment or progress toward desired outcomes; modifications to the plan of care; and discharge and long-term needs.