Joint disorders are a leading cause of pain and disability in adults. Nursing questions focus on telling the major types apart, because their causes, patterns, and care differ sharply.

Gout mechanism. Urate is the end product of purine breakdown. High production (purine-rich diet, alcohol, cell turnover) or low renal excretion (CKD, thiazide and loop diuretics, low-dose aspirin) raises serum urate. Crystals trigger intense neutrophil inflammation. Flares are provoked by alcohol, large meals, dehydration, surgery, trauma, and starting or changing urate-lowering therapy.

Other joint conditions to know

• Ankylosing spondylitis (axial spondyloarthritis): inflammatory disease of the sacroiliac joints and spine, usually beginning before age 45. Hallmark is inflammatory back pain: morning stiffness that improves with exercise and worsens with rest. Fatigue and low-grade fever can occur; anterior uveitis is a common extra-articular feature. Late disease fuses the spine into a forward-flexed posture.
• Septic arthritis: bacterial infection of a joint (often Staphylococcus aureus); a hot, swollen, very painful joint with fever is an emergency until proven otherwise.
• Joint involvement in lupus is covered in Topic 74; spinal stenosis (pain relieved by bending forward) is also covered there.

Subjective

• Pain pattern: mechanical (OA — worse with activity, late in the day) vs. inflammatory (RA, spondyloarthritis — worse after rest, morning stiffness)
• Duration of morning stiffness, fatigue, sleep disturbance
• Functional limits: dressing, grooming, walking, stairs, opening jars
• Gout: sudden onset, exquisite tenderness (even bedsheets hurt), triggers such as alcohol or a large meat or seafood meal

Objective

• Joint inspection: swelling, warmth, redness, deformity, nodules
• Range of motion, crepitus (OA), gait, muscle strength
• RA: symmetric soft, boggy swelling of small joints; rheumatoid nodules over pressure points
• Gout: red, shiny, hot, swollen joint; tophi in chronic disease
• Screen for extra-articular features: dry eyes and mouth, eye redness, shortness of breath, pericarditis signs

Osteoarthritis

• Core therapy: exercise (strengthening, especially quadriceps; low-impact aerobic activity) and weight loss if overweight
• Topical NSAIDs for knee and hand OA (fewer systemic effects), then oral NSAIDs at the lowest effective dose for the shortest time
• Intra-articular corticosteroid injections for flares (limited number per year)
• Acetaminophen has only small benefit; limit total daily dose (commonly no more than 3 g/day in older adults or with liver risk)
• Assistive devices (cane, knee brace); joint replacement for end-stage disease (Topic 76)

Rheumatoid arthritis

• Early DMARD therapy to prevent erosions; aim for remission or low disease activity
• Methotrexate is the first-line conventional DMARD. Weekly dosing (never daily); give folic acid. Monitor CBC, liver enzymes, and creatinine. Contraindicated in pregnancy (teratogenic) — reliable contraception required; avoid alcohol. Watch for mouth ulcers, cytopenias, liver toxicity, pneumonitis (new cough or dyspnea). Avoid trimethoprim-sulfamethoxazole (severe marrow suppression)
• Others: hydroxychloroquine (baseline and periodic eye exams for retinal toxicity), sulfasalazine, leflunomide (teratogenic; persists for up to 2 years, so a cholestyramine washout is required before pregnancy)
• Biologics (e.g., TNF inhibitors) and JAK inhibitors: serious infection risk; screen for latent TB and hepatitis B first; no live vaccines during therapy; JAK inhibitors carry boxed warnings for serious infection, death, major cardiovascular events, thrombosis, and malignancy
• Glucocorticoids only as a short bridge at the lowest dose; long-term use causes osteoporosis, hyperglycemia, infection, and cataracts
• NSAIDs for symptoms: GI bleeding, kidney injury, fluid retention, raised blood pressure; avoid from 20 weeks of pregnancy onward (fetal kidney injury and low amniotic fluid; premature ductus arteriosus closure in the third trimester)

Gout — acute flare (start within 24 hours of onset)

• NSAIDs (e.g., naproxen, indomethacin), colchicine (low-dose regimen; diarrhea is common; reduce dose or avoid in severe kidney or liver disease and with strong CYP3A4/P-gp inhibitors such as clarithromycin), or corticosteroids (oral or intra-articular)
• Rest and elevate the joint, apply ice; do not stop urate-lowering therapy that is already established

Gout — long-term urate-lowering therapy (ULT)

• Indicated for frequent flares (2 or more per year), tophi, or radiographic damage
• Allopurinol first-line: start low (100 mg/day or less, lower in CKD) and titrate to a serum urate below 6 mg/dL (treat-to-target); EULAR uses a lower target, below 5 mg/dL (about 300 µmol/L), for severe or tophaceous gout
• HLA-B*58:01 testing before allopurinol is advised for people of Southeast Asian descent (e.g., Han Chinese, Korean, Thai) and African American people, who have a higher risk of severe skin reactions (Stevens–Johnson syndrome/toxic epidermal necrolysis). Stop the drug at the first sign of rash
• Febuxostat: alternative; boxed warning for cardiovascular death — avoid in established cardiovascular disease if possible
• Probenecid (uricosuric): needs good kidney function and high fluid intake; avoid with kidney stones
• Prophylaxis (low-dose colchicine or NSAID) for at least 3–6 months when starting ULT, because flares are common early

Listed in priority order.

1. Recognize emergencies first
   • A single hot, swollen joint with fever may be septic arthritis — report immediately; joint aspiration and antibiotics are urgent
   • Clients on biologics, JAK inhibitors, or methotrexate: treat fever or new infection signs as urgent
2. Pain management
   • Give prescribed analgesics and anti-inflammatories on schedule during flares; reassess pain and function
   • Heat (warm shower, warm packs) relieves stiffness in RA and OA; cold for acutely inflamed, hot joints and gout flares. Protect skin — limit applications to about 20 minutes
   • Gout flare: rest and elevate the joint, use a bed cradle to keep linens off the foot
3. Mobility and joint protection
   • Daily range-of-motion and muscle-strengthening exercise; avoid long bed rest, which causes stiffness and weakness
   • RA flare: rest inflamed joints, use resting splints in functional position; resume gentle ROM as inflammation settles
   • Morning stiffness: a warm shower and gentle ROM before activity — do not stay immobile
4. Medication safety
   • Verify methotrexate is weekly; check labs before each dose change
   • NSAIDs: give with food; monitor for black stools, rising creatinine, edema, blood pressure
   • Allopurinol: encourage fluids; report any rash immediately
5. Fall prevention for clients with deformity, pain, or assistive devices
6. Psychosocial support: chronic pain, body image changes, fatigue, and loss of roles; refer to occupational and physical therapy

Joint protection (RA and OA)

• Use larger, stronger joints instead of small finger joints: carry bags on the forearm or shoulder, lift with the palms of both hands, push doors open with the palm or body
• Avoid tight gripping, twisting (wringing cloths), and prolonged pinching; use built-up handles, jar openers, and lever faucets
• Spread heavy loads into several light trips; balance activity with rest; change position often
• Maintain good posture; avoid prolonged positions that stress one joint

Osteoarthritis

• Weight loss reduces load on knees and hips and lessens pain
• Regular low-impact exercise (walking, cycling, water exercise) plus quadriceps strengthening
• Use a cane in the hand opposite the painful knee or hip

Gout

• Limit organ meats, some seafood (anchovies, sardines, shellfish), red meat, alcohol (especially beer and spirits), and sugar-sweetened drinks and high-fructose corn syrup
• Low-fat dairy, vegetables, and whole grains are encouraged; drink plenty of fluids unless restricted
• Diet alone rarely controls gout — take urate-lowering medication daily, even without symptoms; flares during the first months do not mean the drug is failing
• Keep the flare-treatment plan at home and start it at the first twinge
• Low-dose aspirin prescribed for heart protection should not be stopped without talking to the prescriber

Ankylosing spondylitis

• Daily stretching and extension exercises, deep breathing, swimming; sleep flat on a firm mattress with a thin pillow; stop smoking

• OA: degenerative, asymmetric, pain worse with activity, stiffness under 30 minutes, Heberden and Bouchard nodes
• RA: autoimmune, symmetric small joints, morning stiffness over 1 hour, systemic symptoms, swan-neck deformity
• Joint protection = use large joints and palms, avoid gripping and twisting with the fingers
• OA core care: quadriceps strengthening, low-impact exercise, weight loss; topical NSAIDs
• Methotrexate is weekly, teratogenic, requires CBC and liver monitoring and folic acid
• Screen for latent TB and hepatitis B before biologics; no live vaccines on biologics
• Gout diagnosis: needle-shaped negatively birefringent crystals in joint fluid
• Acute gout: NSAID, colchicine, or corticosteroid; these do not lower urate
• Long-term gout: allopurinol, treat to serum urate below 6 mg/dL, start low, prophylaxis for 3–6 months
• HLA-B*58:01 testing before allopurinol in higher-risk Asian and African American clients
• Ankylosing spondylitis: back pain and stiffness that improve with exercise, worsen with rest
• A hot swollen joint with fever is septic arthritis until proven otherwise