Musculoskeletal: Autoimmune; Inflammatory; Metabolic; Infectious Disorders Rheumatoid Arthritis; SLE; Paget’s Disease; Gout; Osteomyelitis Carolyn Morse Jacobs, RN, MSN, ONC 10/ 24/ 04
Musculoskeletal: Autoimmune; Inflammatory; Metabolic; Infectious DisordersRheumatoid Arthritis; SLE; Pagets Disease; Gout; OsteomyelitisCarolyn Morse Jacobs, RN, MSN, ONC 10/ 24/ 04
Autoimmune and Inflammatory Disorders:Rheumatoid Arthritis
Chronic systemic, inflammatory disease characterized by recurrent inflammation of connective tissue, primarily of joints (diarthroidal) and related structures.
Pathophysiology Rheumatoid Arthritis
Normal antibodies (immunoglobulins) become autoantibodies and attack host tissues (RF)Neutrophils, T cells synovial fluid cells acitavted;Cystokines, interleukin-1 and TNR (tumor necrosing factor) alpha; chrondroytes attack cartilage;Synovium digests cartilage; inflammatory molecules released containing interleukin-1 and TNF alpha
Pathophysiology: Rheumatoid Arthritis
Pathophysiology
IgG/RF (HLA)= antigen-antibody complexPrecipitates in synovial fluidInflammatory responseCartilage connective tissue primarily affected!
Rheumatoid arthritis: assessment: manifestations and complicationsFatigue, weakness, painJoint deformityRheumatic nodulesMultisystem involvement
How does Rheumatoid Arthritis Compare to Osteoarthritis?Definition: *wear and tear, progressive, non-systemic, Degenerative Joint Disease (DJD)
Pathophysiology
Identify which joints are primarily affected with osteoarthritis.What factors contribute to the development of osteoarthritis?Osteoarthritis (top slide only)Ankylosing spondylitis (what type of arthritis is this?)
Structural changes with OsteoarthritisEarly Cartilage softens, pits, fraysProgressiveCartilage thinner, bone ends hypertrophy, bone spurs develop and fissures formAdvancedSecondary inflammation of synovial membrane; tissue and cartilage destruction; late ankylosis
Normal Knee structureModerately advanced osteoarthritisAdvanced osteoarthritisWhat signs and symptoms does the person with osteoarthritis experience?
What symptoms/assessment for the patient with osteoarthritis? Onset of pain is insidious, individual is healthy!Pain is aching in nature; relieved by rest!.Local signs and symptoms: swelling, crepitation of joint and joint instability, asymmetrical joint involvement
Deformities with OsteoarthritisGenuvarusHerberdens nodesCarpometacarpocarpal joint of thumb with subluxation of the first MCP
Osteoarthritis (review only)Diagnostic TestsNone specificLate joint changes, boney sclerosis, spur formationSynovial fluid inc., minimal inflammationGait analysisNursing diagnosisInterventions determined by complicationsSupportive devicesMedications (no systemic treatment with steroids)Dietary to dec. wt.Surgical Intervention (joint replacement)Teaching
Comparison of RA and OA
RACause unknown; auto-immune factorOnset suddenRemissions*Body parts affected, systemic, small joints, symmetricalCauses redness, warmth, swelling of jointsFemales, age 20-30; 3-1 ratioOACause wear and tear, develops slowly Non-systemic, weight bearing jointsMiddle-aged and elderly, males 2-1 affectedDoes not cause malaiseBegins after 40
Manifestations of RASystemically illHematologicPulmonary/CVNeurologicOcular symptoms (Sjorgens)SkinMusculoskeletal deformity, painPain!Pain!Pain
Joints changes with RA Early PannusGranulation, inflammation at synovial membrane, invades joint, softens and destroys cartilage
Mod advanced Pannusjoint cartilage disappears, underlying bone destroyed, joint surfaces collapse
Fibrous AnkylosisFibrous connective tissue replaces pannus; loss of joint otion
Bony AnkylosisEventual tissue and joint calcificationRA
Joint Changes RABilateral, symmetrical, PIPs, MCPsThumb instabilitySwan neck, boutonniere deformityTensynovitisMultans deformitySubcutaneous nodulesGenu valgumPes plano valgusProminent metatarsal headsHammer toes
Assessment RADeformities that may occur with RASynotenovitisUlnar driftSwan neck deformityBoutonniere deformity
Mutlans deformity (rapidly progressing RA)Hitch-hiker thumbGenu valgus
Subcutaneous nodules (disappear and appear without warning)
Hammer toes
Diagnostic Tests RAESR elevated
+ RA, ^ RA titer
Sed rate increased
CBC
C-reactive protein
Dec. serum complement
Synovial fluid inflammation
Joint and bone
Swelling,inflammation
Interventions RANursing DiagnosisComfortPhysical mobilitySelf imageGoalsTeam ApproachPain managementExerciseSurgeryTeaching
Medications RAASA & NSAIDSCorticosteroids; low doseDMARDs (diverse group) of remitting agents: including antimalarial (hydroxychloroquine:plaquenil) *eye effects; Penicillamine (empty stomach); Gold (Auranofin) *dermatitis, blood dyscrasia; and Immunosuppressive agents as methotrexate and cyclosporineBiologic response modifiers Adalimumab (Humira)Infliximab (Remicade)
Joint Protection: Dos and Donts
Case Presentation; Mrs. Michaels with Rheumatoid Arthritis(PDS: Adult Health: Musculoskeletal Health: Mrs. Michaels)Comparison to usual courseDiagnostic testsNursing diagnosisTherapiesMedications usedExerciseJoint ProtectionResources on the Web
Systemic Lupus Erythematous (SLE)Chronic multisystem disease involving vascular and connective tissueLupus Foundation
Etiology and Pathophysiology SLEExact etiology unknown: genes (HLA), hormones, environment involvedFormation auto-antibodies; immune complexes depositedInflammatory response triggered by deposition of immune complexes (kidney, brain)Drug induced syndrome similar to SLE (Procan-SR, hydralazine, isonaiazid)Pneumonia, infections, *renal, CNS involvement!; Course of disease variesMildEpisodicRapidly fatal
Manifestations/Complications of SLETypes: Discoid, SLEIncidence: 1:2000Women 1-9, child-bearing age, african americans Periods remission and exacerbationStress Environmental factors AssessmentLow grade feverIntegumentary MS involvementCVRespiratoryUrinary Renal failureNeurologic CNSGI HematologicEndocrineReproductive
Characteristic butterfly rash associated with SLE, especially discoid lupus erythematousBarrys lupus
SLE characterized by periods of remission and exacerbation. Stimulated by sunlight, stress, pregnancy, infections like strep and some drugs. Some drugs like apresoline, pronestyl, dilantin, tetracycline, phenobarbital may cause a lupus-like reaction which disappears when drug is stopped.
Diagnostic TestsLE cellAnt-DNAANA, titerAnti-DNAComplement fixation decreasedESROther (and CBC, UA)Kidney biopsyCriteria to Dx.malar, discoid rashphotosensitivityarthritisrenal disorderimmunological disorderDNA, ANA
Therapeutic Interventions/Management SLENursing diagnosisSee RAImpaired skin integrityIneffective protectionImpaired health maintenance
Goal: control inflammation
Emotional support
Life Planning
Required ReviewMedicationsNSAIDS(Disease modifying agents) Antimalarial drugsCorticosteroidsImmunsuppressive therapy
Antineoplastic drugs such as Imuran, cytoxan, cyclosporine
Avoid UV Reduce stressMonitor/manage to prevent complications
Case StudyClinical Background:
18 year old patient admitted with recent onset (3 months earlier) of malar rash and constitutional symptoms (weakness and malaise), now symptoms of renal failure. She reported having a 5-year history of Raynaud's phenomenon and arthralgia. Abnormal results of laboratory studies included the presence of ANA, anti-nDNA, anti-SS-A autoantibodies and a proteinuria of approximately 10 g/d. Renal biopsy revealed a Class IV lupus glomerulonephritis.
What assessment data is priority: what additional date should you collect?
What are the priority nursing problems? What are the priority interventions?What medications are typically used and why?
Scleroderma (Systemic sclerosis)Definition: progressive sclerosis of skin and connective tissue; fibrous and vascular changes in skin, blood vessels, muscles, synovium, internal organs. become hide boundImmune-mediated disorder; genetic component
Scleroderma (Systemic sclerosis)Abnormal amounts of fibrous connective tissue deposited in skin, blood vissels, lungs, kidneys, other organsCan be systemic or localized (CREST) syndrome
CREST SyndromeCalcinosisRaynauds phenomenaEsophageal hypomotilitySclerodactyl (skin changes of fingers)Telangiectasia (macula-like angioma of skin)More on CREST
Crest Syndrome
CREST Syndrome & sclerodermaSclerodactyl (localized scleroderma of fingers)Raynauds disease with ischemia
Typical hide-bound face of person with sclerodermaTissue hardens; claw-like fingers; fibrosis
Manifestations & Complications (systemic)Female 4:1Pain, stiffness, polyartheritisNausea, vomitingCoughHypertensionRaynaulds syndrome Skin atrophy, hyperpigmented
Scleroderma cont.Esophageal hypomotility leads to frequent refluxGI complaints commonLung-pleural thickening and pulmonary fibrosisRenal disease...leading cause of death!
Diagnosis/Treatment SclerodermaR/O autoimmune diseaseRadiological: pulmonary fibrosis, bone resorption, subcutaneous calcification, distal esophageal hypomotilityESR elevatedCBC anemiaGammaglobulin lelels elevaed; RA presentSkin biopsy to confirmWhat are the KEY components of care for the individual with Scleroderma?
Scleroderma: Patient CareDosAvoid coldProvide small, frequent feedingsProtect fingersSit upright post mealsNo fingersticksDaily oral hygieneResources
Scleroderma: Patient CareMedications: based upon symptoms:Immunosuppressive agents & steroids & remitting agentsCa channels blockers & alpha-adrenergic blockersH2 receptor blockersACE inhibitorsBroad spectrum antibiotics
Ankylosing SpondylitisDefinitions: chronic inflammatory polyarteritis of spineAffects mostly young men Associated with HLA-B27 antiget positive antigen (90%)Pathophysiology & ManifestationsLike arthritis have inflammatory changes; erosion of cartilage, ossification of joint margins; scar tissue replacesMorning backache, flexion of spine, decreased chest expansionDiagnosisESR elevationPositive HLA-B27 antigenVertebral changes
Ankylosing SpondylitisInsidious onsetMorning backacheInflammation of spine; later spine ossification
Oh my back hurts!
Comparison of changes with ospeoporosis and Ankylosing spondylitisIdentify a PRIORITY nursing concern related to ankylosing spondylitis
Management Ankylosing Spondilitis
DosMaintain spine mobilityPain managementProper positioningMeds for pain, inflammation
Other Collagen DiseasesReiters SyndromeReactive arthritis associated with enteric disease
Lyme Disease (mimics rheumatoid disease)Caused by spirochete, borrelia burgdorferi (tick)Inflammatory disorder3 stagesInitial rash (target)Disseminated (arthitic like symptoms)Late (neurologic symptoms)DiagnosisCulture (difficult)Antibody detection
Treatment: antibiotics (amoxicillin, vibramycin, tetracycline, etc); NSAID)Prevention
Other Collagen DiseasesPolymyositis
Systemic connective tissue disorder characterized by inflamation of connective tissue and muscle fibersAutoimmune; affecting women 2:1If muscle fiber inflammation is accompanied by skin lesion disease known as dermatomyositisManifestations & complicationsMuscle pain, tenderness, rash; arthralgias; fatigue; fever and weight loss;Skeletal muscle weakness most prominentDusky red rash over faceRaynauds phenomenonMalignancy with dermatomyositisDiagnosisNone specificElevated CK
Other Collagen Diseases contReiters syndromeSelf-limited disease of reactive arthritis such as shingles, venereal diseas, associated with HLAB27 antigen
Polyarteritis NodosaCollegan; diffuse inflammation and necrosis of wall of small to medium sized arteries especially in muscles , kidneys, heart liver, GI and peripheral nerves like SLEJuvenile Rheumatoid Arthritis