Understanding
blood sample. Normally, red blood cells
- 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.
Common types of Arthritis:
A. Osteoarthritis
- Defined as a form of arthritis with progressive
destruction of the cartilage in both the synovial
joints and vertebrae
 Laboratory and Diagnostic Tests
 X-ray Imaging – Cartilage doesn't show up on
X-ray images, but cartilage loss is revealed by
a narrowing of the space between the bones
in your joint. An X-ray can also show bone
spurs around a joint.
 Magnetic Resonance Imaging (MRI) – An MRI
uses radio waves and a strong magnetic field
to produce detailed images of bone and soft
tissues, including cartilage. An MRI isn't
commonly needed to diagnose osteoarthritis
but can help provide more information in
complex cases.
 Joint Fluid Analysis – Your doctor might use
a needle to draw fluid from an affected joint.
The fluid is then tested for inflammation and
to determine whether your pain is caused by
gout or an or an infection rather than
osteoarthritis.
B. Rheumatoid Arthritis
- Defined as a chronic, progressive, systemic,
autoimmune disease with inflammation of the
joints and deformity
 Laboratory and Diagnostic Tests
 Rheumatoid factor (RF) blood test –
Rheumatoid factor (RF) is a protein made by
your immune system that can attack healthy
tissue in your body. Healthy people don’t
make RF. So, the presence of RF in your blood
can indicate that you have an autoimmune
disease
 A rheumatoid factor (RF) blood test
measures the amount of the RF antibody
present in the blood. Normally, antibodies
are produced by the immune system to help
destroy and eliminate invading bacteria and
viruses that can cause disease. But the RF
antibody can attach to normal body tissue,
resulting in damage.
o Normal: 0-20 u/mL (units per
milliliter of blood)
o High: 20 u/mL or higher
 Anti-cyclic Citrullinated Peptide (anti-CCP) –
Anti-cyclic citrullinated peptide (anti-CCP) is
an antibody present in most rheumatoid
arthritis patients. A positive anti-CCP test
result can be used in conjunction with other
blood tests, imaging tests, and/or physical
examination findings to diagnose
rheumatoid arthritis.
o Normal: 20 u/mL or less
 Erythrocyte Sedimentation Rate (ESR) – is a
type of blood test that measures how
quickly erythrocytes (red blood cells) settle
at the bottom of a test tube that contains a
settle relatively slowly. A faster-than-
normal rate may indicate inflammation in
the body.
o Normal:
- Men younger than 50: 0-15 mm/h
- Men older than 50: 0-20 mm/h
- Women younger than 50: 0-20
mm/h
- Women older than 50: 0-30 mm/h
C. Gout
- Defined as a metabolic disease marked by
increased serum uric acid levels (hyperuricemia)
and joint inflammation
 Laboratory and Diagnostic Tests
 Joint Fluid Test – Your doctor may use a
needle to draw fluid from your affected joint.
Urate crystals may be visible when the fluid
is examined under a microscope.
 Blood Test – Your doctor may recommend a
blood test to measure the levels of uric acid
and creatinine in your blood. Blood test
results can be misleading, though. Some
people have high uric acid levels, but never
experience gout. And some people have signs
and symptoms of gout, but don't have
unusual levels of uric acid in their blood.
 X-ray Imaging – Joint X-rays can be helpful to
rule out other causes of joint inflammation.
 Ultrasound – Musculoskeletal ultrasound
can detect urate crystals in a joint or in a
tophus. This technique is more widely used
in Europe than in the United States.
 Dual Energy CT Scan – This type of imaging
can detect the presence of urate crystals in a
joint, even when it is not acutely inflamed.
This test is not used routinely in clinical
practice due to the expense and is not widely
available
Pathophysiology:
A. Osteoarthritis (OA)
 Underlying pathophysiology:
 Synovial joint cartilage deteriorates as a
result of damage to chondrocytes (cells
responsible for binding cartilage)
 Cartilage softens with age, narrowing
the joint space
 Mechanical injury also erodes articular
cartilage
 Bone underneath the cartilage is
unprotected and scleroses
 Cartilage flakes irritate the synovial
lining, which becomes fibrotic, limiting
joint movements
 Synovial fluid may be forced into bone
defects, causing cysts
 New bone (osteophyte, or bone spur)
forms at joint margins as the articular
cartilage erodes, causing gross
alteration of the bony contours and
enlargement of the joint
 Etiology:
a. Primary idiopathic (normal part of aging):
 - Metabolic factors (endocrine disorders
such as hyperthyroidism) and genetic
factors (decreased collagen synthesis)
- Chemical factors (drugs such as steroids
that stimulate the collagen-digesting
enzymes in synovial membrane)
- Mechanical factors (repeated stress on
joint)
b. Secondary disorder (follows an identifiable
predisposing event that leads to
degenerative changes)
- Trauma (most common cause)
- Congenital deformity
- Obesity
 Signs and Symptoms:
a. Dull, aching pain in the affected joint relieved
with rest
b. Numbness or tingling at night, associated
with disease progression secondary to nerve
damages
c. Crepitus with joint movement
d. Edema and stiffness in the affected joint
e. Decreased range of motion (ROM) and ability
to participate in activities of daily living
(ADLs)
f. Joint deformities: Heberden’s nodes
(formation if hard nodules in the DIP joints,
resulting in joint deformity) and Bouchard’s
nodes (formation of hard nodules in the PIP
joints resulting in joint deformity)
g. Symptoms may vary in severity and may
range from mild intermittent discomfort to
complete disability
 Complications:
a. Decreased joint ROM
b. Irreversible joint changes and node
formation
c. Loss of independence in activities of daily
living (ADLs)
d. Pain (debilitating in later stages)
e. Subluxation of the joint
 Nursing management:
a. Teach self-care skills to promote joint health
b. Assist with physical therapy, and encourage
the patient to perform gentle isometric ROM
exercises
c. If the patient needs surgery, provide
appropriate preoperative and postoperative
care
d. Provide emotional support and reassurance
to help the patient cope with limited mobility
e. Instruct on safety in home
i. Eliminate throw rugs in home
ii. Use good body mechanics when
performing ADLs and work/leisure
activities
iii. Use a shower chair and hand rails in
bathing
iv. Use cane and walker as directed to
decrease workload on hips and
knees
v. Use well-fitting, supportive shoes
when ambulating
B. Rheumatoid Arthritis (RA)
 Underlying pathophysiology
 Exposure to a viral pathogen may
initiate the inflammatory response;
immunoglobulin G (IgG) is formed in
response to the antigen, but for some
unknown reason the body begins to
produce autoantibodies (called
rheumatoid factors) against IgG
- The rheumatoid factors
combine with IgG to form
immune complexes
- The continued presence of the
immune complexes within the
joint cavity results in chronic
inflammation and destruction
of the articular cartilage as well
as surrounding joint structures
 The synovial membrane (located within
the joint capsule and responsible for
producing synovial fluid to lubricate
joint structures) hypertrophies and
thickens secondary to chronic
inflammation
- Blood supply to the area is
occluded and cellular necrosis
occurs
- These events lead to the
formation of pannus (vascular
granulation tissue that forms in
the synovial membrane of
clients with RA)
- Pannus gradually extends from
the synovial membrane and
surface of the articular
cartilage into the joint capsule
and subchondral bone causing
destruction of the bone
 Fibrous adhesions and bony ankylosis
(joint immobility or fixation secondary
to an underlying disease process occurs
as the involved bone is destroyed; the
inflammatory process extends to the
support structures of the bone, tendons
and ligaments, and joint instability and
deformities occur
 Etiology
a. Unknown etiology; however, evidence
supports that disease progression is related
to autoimmune processes in middle age
 Signs and Symptoms:
a. Initially may present with vague systemic
symptoms such as anorexia, weight loss,
fever and loss of energy
b. Early disease states will present with
inflammation, swelling, and decreased
movement of the joints in the hand (PIP and
MCP), feet (MTP), wrists, and elbows; as RA
progresses, joints of the knees, hips, and
cervical spine may also be involved
c. The American Rheumatism
d. Association has developed diagnostic
criteria for rheumatoid arthritis; evidence of
four out of seven criteria must be present to
confirm the diagnosis
 i. Morning stiffness lasting for at least
1 hour and persisting over at least 6
weeks
ii. Arthritis with swelling or effusion
of three or more joints persisting
for at least 6 weeks
iii. Arthritis of wrist, MCP, or PIP joints
persisting for at least 6 weeks
iv. Symmetric arthritis with
simultaneous involvement of
corresponding joints on both sides
of the body
v. Rheumatoid nodules
vi. Positive serum rheumatoid factor
vii. Characteristic radiologic changes of
rheumatoid arthritis notes in hands
and wrists
 Complications:
a. Risk to carpal tunnel syndrome
increases
b. Pain (debilitating in later stages)
c. If rheumatoid arthritis isn't treated
early or isn't well controlled, the
inflammation in the joints could lead to
significant and permanent damage.
 Nursing management:
a. Administration of medications like
NSAIDs, systemic corticosteroids, and
disease-modifying drugs (MDARDs)
b. Instruct on disease process and
treatment regimen
c. Refer to support groups including
Arthritis Foundation
d. Emphasize rest to decrease joint stress
i. Pace activities
ii. Perform activities while sitting
when possible
iii. Splints for hands and wrists
iv. Relaxation techniques
v. Guided imagery
e. Collaborate with physical therapy (PT)
regarding therapeutic exercises
program, isotonic exercises, passive
range of motion (PROM), and active
range of motion (AROM) to maintain
muscle strength and ROM
f. Collaborate with occupational therapist
(OT) regarding assistive devices for
ADLs, tips for joint protection and work
simplification
g. Teach action and side effects of
medications used for pain control
h. Implement and assess effectiveness of
pain relief measures
i. Medications
ii. Application of heat or cold,
depending on what works for
client
iii. Firm mattress for sleeping and
proper positioning in bed for
comfort
i. Instruct on home safety
j. Instruct on hazards of immobility if
bedridden and teach prevention
C. Gout Arthritis
 Underlying pathophysiology
 Uric acid becomes supersaturated in the
blood and body fluids
 Uric acid then crystallizes and forms a
precipitate of urate salts that
accumulates in connective tissue
throughout the body
 Crystal deposits (called tophi) trigger an
acute inflammatory response when
neutrophils begin to ingest them
 Neutrophils release lysosomes that
damage tissues and perpetuate the
inflammation
 With gout that produces no symptoms:
- Serum urate levels increase but
don’t crystallize
- Progression may cause
hypertension or urate renal
calculi
 Etiology
- Exact cause unknown
- Possible causes:
 Genetic defect in purine
metabolism causing
hyperuricemia
 Retention of uric acid
 Combination of the above
- Causes of secondary gout (develops
during the course of another disease)
 Alcoholism
 Diabetes mellitus
 Hypertension
 Obesity
 Renal disease
 Sickle cell anemia
 Signs and Symptoms:
a. Sudden onset of severe pain in one joint;
the great toe is most commonly affected;
however, it
b. may occur in the instep, wrist, tarsal
joints, knees, elbows, and ankles
c. Joint appears red or dusky, swollen,
edematous, and is extremely tender to
touch
d. Tophi: hard, movable, nodules with
irregular surfaces occur in synovium,
helix of ear, olecranon bursa, and
Achilles’ tendon (most common
locations); associated with chronic
untreated gout; can resolve with
treatment
 Complications:
a. Renal calculi
b. Atherosclerotic disease
c. Cardiovascular lesions
d. Stroke
e. Coronary thrombosis
 Nursing management:
a. Encourage bed rest, but use a foot cradle
to keep bed covers off extremely
sensitive, inflamed joints
b. Give pain medications as needed,
especially during acute attacks
 c. Apply hot or cold packs to inflamed Steroids decrease inflammation and reduce the activity
joints according to what the patient of the immune system. Inflammation is a process by
finds most effective which the body's white blood cells and chemicals
d. Urge the patient to drink plenty of fluids protect the body against infection and foreign
to prevent formation of renal calculi organisms such as bacteria and viruses.
e. Watch for gout attacks 24 to 96 hours Side effects: Blurred vision, difficulty sleeping, high
after surgery blood pressure, increased appetite, weight gain, easy
bruising, glaucoma
f. Before and after surgery, administer
colchicine, as ordered, to help prevent
E. Hyaluronan Injections – There are several versions of
attacks
hyaluronan injections, also called
g. Make sure the patient understands the
viscosupplementation, that are used to
importance of checking serum uric acid
treat osteoarthritis of the knee. They are injected
levels
directly into the joint. Some studies have shown some
h. periodically and avoiding high-purine
benefit for reducing pain for periods of up to six
foods
months, but others have shown more limited results.
i. Teach the patient to report any adverse
effects from medications immediately Side effects: Injection site reactions (pain, swelling,
Medications: warmth, stiffness, puffiness, or fluid buildup in or around the
knee), muscle pain, trouble walking, fever, chills, nausea
A. Analgesics (Acetaminophen) – Still considered first-
line therapy although more recent trials find NSAIDs
more effective, Acetaminophen is available without a
prescription and is a commonly used pain reliever for
people with arthritis.
Side effects: Usually no side effects, rare but very
serious allergic reaction, severe dizziness, trouble
breathing

B. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

- Aspirin (Bufferin, Bayer)
- Celecoxib (Celebrex)
- Diclofenac (Cataflam, Voltaren0
Nonsteroidal anti-inflammatory drugs or NSAIDs are
available both over-the-counter and by prescription.
Almost everyone with arthritis has taken or is taking
one of these drugs. Prescription doses can help curb
joint inflammation.

Side effects: Stomach pain and heartburn, stomach

ulcers, headache and dizziness, high blood pressure,
liver and kidney problems

C. Disease-Modifying Antirheumatic Drugs (DMARDs) –

These drugs are often able to alter the course of some
forms of inflammatory arthritis -- diseases such
as rheumatoid arthritis, psoriatic arthritis,
or ankylosing spondylitis – that can destroy the joints.
Often these drugs are the first ones used for these
diseases.
DMARDs work by interfering with or suppressing the
immune system that attacks the joints in people with
certain forms of inflammatory arthritis. Aggressive
treatment of arthritis often involves using one or more
DMARDs.
Although effective, DMARDs have a higher risk of
serious side effects. It also often takes weeks for you to
notice the benefits of taking a DMARD. Therefore, they
are often combined with a faster-working drug such as
an NSAID, another painkiller, or steroids to help relieve
some arthritis symptoms.
Side Effects: Stomach upset, Liver problems, Infection-
fighting white blood cells may also be decreased

D. Corticosteroids
- Hydrocortisone (Cortisol)
- Triamcinolone acetonide (Kenalog)
- Triamcinolone hexacetonide
(Aristospan)