Care of Patients with Arthritis and Other Connective Tissue Diseases

1
Chapter 20

• Care of Patients with Arthritis and Other
  Connective Tissue Diseases

2
Rheumatology

• Connective tissue disease (CTD) is a major focus
  of rheumatology.
• Rheumatic disease is any disease or condition
  involving the musculoskeletal system.
• Arthritis means inflammation of one or more
  joints.

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Rheumatology (Contd)

• Noninflammatory arthritis (osteoarthritis) is
  not systemic. OA is not an autoimmune disease.
• Inflammatory arthritis
• Rheumatoid arthritis
• Systemic lupus erythematosus
• Autoimmune disease
• Connective tissue disease that is inflammatory

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Osteoarthritis

• Most common type of arthritis
• Joint pain and loss of function characterized by
  progressive deterioration and loss of cartilage
  in the joints
• Osteophytes
• Synovitis
• Subluxation

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Joint Changes in Degenerative Joint Disease
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Collaborative Management

• History
• Physical assessment and clinical manifestations
• Joint involvement
• Heberden's nodes
• Bouchards nodes
• Joint effusions
• Atrophy of skeletal muscle

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Heberdens Nodes
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Ballottement
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Assessments

• Psychosocial
• Laboratory assessment of erythrocyte
  sedimentation rate and C-reactive protein (may be
  slightly elevated)
• Radiographic assessment
• Other diagnostic assessments
• MR imaging
• CT studies

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Chronic Pain Nonsurgical Management

• Analgesics
• Rest
• Positioning
• Thermal modalities
• Weight control
• Integrative therapies

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Chronic Pain Surgical Management

• Total joint arthroplasty (TJA)
• Total joint replacement (TJR)
• Arthroscopy
• Osteotomy

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Total Hip Arthroplasty

• Preoperative care
• Operative procedures
• Postoperative care
• Prevention of dislocation, infection, and
  thromboembolic complications
• Assessment of bleeding
• Management of anemia

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Hip Flexion After Total Hip Replacement
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Prevention of Complications

• Assessment for neurovascular compromise
• Management of pain
• Progression of activity
• Promotion of self-care

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Total Knee Arthroplasty

• Preoperative care
• Operative procedures
• Postoperative care
• Continuous passive motion machine
• Hot/ice device
• Pain management
• Neurovascular assessment

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Continuous Passive Motion Machine
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Rheumatoid Arthritis

• One of the most common connective tissue diseases
  and the most destructive to the joints
• Chronic, progressive, systemic inflammatory
  autoimmune disease affecting primarily the
  synovial joints
• Autoantibodies (rheumatoid factors) formed that
  attack healthy tissue, especially synovium,
  causing inflammation
• Affects synovial tissue of any organ or body
  system

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RA Pathology
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RACollaborative Management

• Assessment
• Physical assessment and clinical manifestations
• Early disease manifestationsjoint stiffness,
  swelling, pain, fatigue, and generalized weakness
  and morning stiffness
• Late disease manifestationsas the disease
  worsens, the joints become progressively inflamed
  and quite painful

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RA Joint Involvement
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RA Systemic Complications

• Weight loss, fever, and extreme fatigue
• Exacerbations
• Subcutaneous nodules
• Pulmonary complications
• Vasculitis
• Periungual lesions
• Paresthesias
• Cardiac complications

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RAAssessments

• Psychosocial assessment
• Laboratory assessmentrheumatoid factor,
  antinuclear antibody titer, erythrocyte
  sedimentation rate, serum complement, serum
  protein electrophoresis, serum immunoglobulins
• Other diagnostic assessmentsx-ray, CT,
  arthrocentesis, bone scan

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RADrug Therapy

• Disease-modifying antirheumatic drugs
• NSAIDs
• Biologic response modifiers
• Other drugs
• Glucocorticoids
• Immunosuppressive agents
• Gold therapy
• Analgesic drugs

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RANonpharmacologic Interventions

• Adequate rest
• Proper positioning
• Ice and heat applications
• Plasmapheresis
• Gene therapy
• Complementary and alternative therapies
• Promotion of self-care

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RANonpharmacologic Interventions (Contd)

• Management of fatigue
• Enhancement of body image
• Community-based care
• Home care management
• Health teaching
• Health care resources

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Lupus Erythematosus

• Chronic, progressive, inflammatory connective
  tissue disorder that can cause major body organs
  and systems to fail.
• Characterized by spontaneous remissions and
  exacerbations.
• Autoimmune process.
• Autoimmune complexes tend to be attracted to the
  glomeruli of the kidneys.
• Many patients with SLE have some degree of kidney
  involvement.

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Lupus ErythematosusClinical Manifestations

• Skin involvement
• Polyarthritis
• Osteonecrosis
• Muscle atrophy
• Fever and fatigue

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Characteristic Butterfly Rash of Systemic Lupus
Erythematosus
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LEClinical Manifestations

• Renal involvement
• Pleural effusions
• Pericarditis
• Raynauds phenomenon
• Neurologic manifestation
• Serositis

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Assessments for Lupus

• Psychosocial results can be devastating.
• Laboratory
• Skin biopsy (only significant test to confirm
  diagnosis)
• Immunologic-based laboratory tests
• Complete blood count
• Body system function assessment

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SLEDrug Therapy

• Topical drugs
• Plaquenil
• Tylenol or NSAIDs
• Chronic steroid therapy
• Immunosuppressive agents

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Scleroderma (Systemic Sclerosis)

• Chronic, inflammatory, autoimmune connective
  tissue disease
• Not always progressive
• Hardening of the skin

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Scleroderma
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CREST Syndrome

• Ccalcinosis
• RRaynauds phenomenon
• Eesophageal dysmotility
• Ssclerodactyly
• Ttelangiectasia

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SclerodermaClinical Manifestations

• Arthralgia
• GI tract
• Cardiovascular system
• Pulmonary system
• Renal system

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SclerodermaInterventions

• Drug therapy
• Identify early organ involvement
• Skin protective measures
• Comfort
• GI manifestation
• Mobility

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Gout

• Also called gouty arthritis, a systemic disease
  in which urate crystals deposit in the joints and
  other body tissues, causing inflammation
• Primary gout
• Secondary gouthyperuricemia

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GoutInterventions

• Drug therapy
• Nutritional therapy

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Other Connective Tissue Diseases

• Polymyositis
• Systemic necrotizing vasculitis
• Polymyalgia rheumatica and temporal arteritis
• Ankylosing spondylitis
• Reiters syndrome
• Marfan syndrome
• Infectious arthritis

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Lyme Disease

• Reportable systemic infectious disease caused by
  the spirochete Borrelia burgdorferi, resulting
  from the bite of an infected deer tick.
• Stages I and II.
• If not diagnosed and treated in early stages,
  chronic complications such as arthralgias,
  fatigue, and memory and thinking problems can
  result.
• For some patients, the first and only sign of
  Lyme disease is arthritis.

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Lyme Disease Rash
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Fibromyalgia Syndrome

• Chronic pain syndrome, not an inflammatory disease

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Chronic Fatigue Syndromes

• Chronic illness in which patients have severe
  fatigue for 6 months or longer, usually following
  flu-like symptoms
• Sore throat substantial impairment in short-term
  memory or concentration tender lymph nodes
  muscle pain multiple joint pain with redness or
  swelling headaches of a new type, pattern, or
  severity unrefreshing sleep and postexertional
  malaise lasting more than 24 hours

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Chapter 22

• Care of Patients with Immune Function Excess
  Hypersensitivity (Allergy) and Autoimmunity

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Hypersensitivities/Allergies

• Increased or excessive response to the presence
  of an antigen to which the patient has been
  exposed
• Degree of reaction ranging from uncomfortable to
  life threatening

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Type I Rapid Hypersensitivity Reactions

• Also called atopic allergy, this is the most
  common type of hypersensitivity.
• Some reactions occur just in the areas exposed to
  the antigen.

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Type I Rapid Hypersensitivity Reactions (Contd)

• Allergens can be contacted in these ways
• Inhaled (plant pollens, fungal spores, animal
  dander, house dust, grass, ragweed)
• Ingested (foods, food additives, drugs)
• Injected (bee venom, drugs, biologic substances)

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Type I Rapid Hypersensitivity Reactions (Contd)

• Contacted (pollens, foods, environmental
  proteins)
• Other reactions may involve all blood vessels and
  bronchiolar smooth muscle, causing widespread
  blood vessel dilation, decreased cardiac output,
  and bronchoconstriction, which is known as
  anaphylaxis

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Allergic Rhinitis
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Patient-Centered Collaborative Care

• History
• Laboratory assessmentincreased eosinophils,
  immunoglobulin E (IgE), RAST
• Allergy testing
• Patient preparation
• Procedure
• Follow-up care
• Oral food challenges

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Interventions

• Avoidance therapy
• Environmental changes
• Air-conditioning and air-cleaning units
• Cloth drapes
• Upholstered furniture
• Carpeting
• Pet-induced allergies

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Drug Therapy

• Decongestants
• Antihistamines
• Corticosteroids
• Mast cell stabilizers
• Leukotriene antagonists
• Complementary and alternative therapy
• Desensitization therapy

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Anaphylaxis

• First feelings of uneasiness, apprehension,
  weakness, and impending doom.
• Pruritus and urticaria.
• Erythema and sometimes angioedema of the eyes,
  lips, or tongue.

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Anaphylaxis (Contd)

• Histamine causes capillary leak,
  bronchoconstriction, mucosal edema, and excess
  mucus secretion.
• Congestion, rhinorrhea, dyspnea, and increasing
  respiratory distress with audible wheezing
  result.
• Anaphylaxis can be fatal.

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Interventions

• First assess respiratory function an airway must
  be established.
• CPR may be needed.
• Epinephrine (11000) 0.3 to 0.5 mL subcutaneous
  is given as soon as symptoms appear.
• Antihistamines treat angioedema and urticaria.
• Oxygen.
• Treat bronchospasm.
• IV fluids.

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Type II Cytotoxic Reactions

• The body makes special autoantibodies directed
  against self cells that have some form of foreign
  protein attached to them.
• Clinical examples include hemolytic anemias,
  thrombocytopenic purpura, hemolytic transfusion
  reactions, Goodpastures syndrome, and
  drug-induced hemolytic anemia.

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Antibody-Antigen Complexes
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Type III Immune Complex Reactions

• Excess antigens cause immune complexes to form in
  the blood. These circulating complexes usually
  lodge in small blood vessels.
• Usual sites include the kidneys, skin, joints,
  and small blood vessels.

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Type III Immune Complex Reactions (Contd)

• Deposited complexes trigger inflammation,
  resulting in tissue or vessel damage.
• Rheumatoid arthritis, systemic lupus
  erythematosus, and serum sickness occur.

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Immune Complex in a Type III Hypersensitivity
Reaction
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Type IV Delayed Hypersensitivity Reactions

• In a type IV reaction, the reactive cell is the
  T-lymphocyte (T-cell).
• Antibodies and complement are not involved.
• Local collection of lymphocytes and macrophages
  causes edema, induration, ischemia, and tissue
  damage at the site.

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Type IV Delayed Hypersensitivity Reactions
(Contd)

• Other examples include positive purified protein
  derivative, contact dermatitis, poison ivy skin
  rashes, insect stings, tissue transplant
  rejection, and sarcoidosis.

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Type V Stimulatory Reaction

• Excess stimulation of a normal cell surface
  receptor by an autoantibody, resulting in a
  continuous turned-on state for the cell.
• Graves disease.

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Autoimmunity

• Autoimmunity is the process whereby a person
  develops an inappropriate immune response.
• Antibodies and/or lymphocytes are directed
  against healthy normal cells and tissues.
• For unknown reasons, the immune system fails to
  recognize certain body cells or tissues as self
  and triggers immune reactions.

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Sjögrens Syndrome

• Group of problems that often appear with other
  autoimmune disorders
• Dry eyes, dry mucous membranes of the nose and
  mouth (xerostomia), and vaginal dryness
• Insufficient tears causing inflammation and
  ulceration of the cornea
• No cure intensity and progression can be slowed
  by suppressing immune and inflammatory responses

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Goodpastures Syndrome

• Autoimmune disorder in which autoantibodies are
  made against the glomerular basement membrane and
  neutrophils
• Lungs and kidneys
• Shortness of breath, hemoptysis, decreased urine
  output, weight gain, edema, hypertension, and
  tachycardia
• Treatmenthigh-dose corticosteroids