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Chapter 20

Nur 216/Care of Pts with Arthritis and Other Connective Tissue Diseases

Rheumatoid arthritis (RA) Chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints.
Pannus Vascular granulation tissue composed of inflammatory cells; erodes articular cartilage and eventually destroys bone.
RA- Early Manifestations Joint- inflammation; Systemic- low-grade fever, fatigue, weakness, anorexia, paresthesias
RA- Late Manifestations Joint-deformities, moderate-severe pain & morning stiffness. Systemic-osteoprosis, severe fatigue, anemia, weight loss, subcutaneous nodules, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung disease, Sjogren's/Felty's syndrome, renal disease
RA- key characteristics Bilateral & symmetric. Single hot, swollen joints are considered infected until proven otherwise and require immediate long-term antibiotic treatment.
Effusions Joint swelling with fluid, especially the knees.
Gel phenomenon Morning stiffness, which lasts for 45 min to several hrs after awakening.
Baker's cysts Enlarged popliteal bursae behind the knee.
Periungual lesions Ischemic skin lesions that appear in groups as small, brownish spots, most commonly around the nail bed.
Sjogren's Syndrome triad Dry eyes, dry mouth (xerostomia), and dry vagina.
Felty's Syndrome Characterized by RA, hepatosplenomegaly (enlarged liver and spleen) and leukopenia.
Caplan's Syndrome Characterized by the presence of rheumatoid nodules in the lungs and pneumoconiosis, which is noted primarily in coal miners and asbestos removal workers.
Rheumatoid factor (RF) Measures the presence of unusual antibodies of the immunoglobulins G (IgG) and M (IgM) types that develop in a number of connective tissue diseases.
Antinuclear Antibody (ANA) Test measures the titer of unusual antibodies that destroy the nuclei of cells and cause tissue death in pts with autoimmune disease.
Erythrocyte Sedimentation Rate (ESR) Can confirm inflammation or infection anywhere in the body. An elevated ESR helps confirm a Dx of an unspecified inflammatory disease. Most useful during the course of the disease.
High-intensity C-reactive protein (hsCRP) Another useful test to measure inflammation and may be done with or instead of the ESR.
Rheumatoid Factor Positive or elevation indicative of possible RA or other CTD; may also be elevated in leukemia, liver disease, and renal disease.
ANA (total) Elevations common in SLE, SSc, RA, and other inflammatory CTDs.
Serum complement Normal range- Total: 75-160 units/mL (C3: 55-120 mg/dL; C4: 20-50 mg/dL). Decreased values indicative of active autoimmune disease such as SLE & other problems- anemia, infection, & malnutrition.
Erythrocyte sedimentation rate (ESR) Normal- Male: up to 15 mm/hr; Female: up to 20 mm/hr. Increased in inflammatory diseases- RA, SLE, PMR, temporal arteritis, also in bacterial infections or severe anemias.
SPEP Total: 6.4-8.3 g/dL. Decreased level occurs with chronic inflammation or infection also decreased in malnutrition and advanced cirrhosis.
Albumin Normal- 3.5-5.0 g/dL. Decreased level occurs with chronic inflammation or infection also decreased in malnutrition and advanced cirrhosis.
Globulin Alpha1 globulin- 0.1-0.3 g/dL; Alpha2 globulin- 0.6-1.0 g/dL; Beta globulin- 0.7-1.1 g/dL; Gamma globulin- 0.8-1.6 g/dL (increased- CTD-inflammatory type). Increased level possible in RA.
HLA testing (HLA-B27) Presence indicative of Reiter's syndrome or ankylosing spondylitis.
Arthrocentesis Invasive procedure that may be used for pts with joint swelling caused by excess synovial fluid (effusion).
After arthrocentesis Teach pt to use ice and rest the affected joint for 24 hrs after. Acetaminophen PRN for pain. Notify HCP if there is any increase pain, swelling, bleeding or leakage of synovial fluid.
Synovectomy Removal of inflamed synovium may be needed for joints like the knee or elbow.
Most serious complication of hydroxychloroquine (Plaquenil) Retinal damage- teach pts to report blurred visionor headache. Remind them to have an eye exam every 6 mths to detect changes in the cornea, lens, or retina. Notify the HCP and the drug will be discontinued.
Energy conservation for the pt with arthritis Balance activity with rest, pace yourself, set priorities, delegate responsibilities, plan ahead, learn activity tolerance and do not exceed.
Systemic Lupus Erythematosus Chronic, progressive inflammatory connective tissue disorder that can cause major body organs and systems to fail. Characterized by remissions and exacerbations. May be acute or slow onset.
Key Features of SLE- Skin Inflamed red rash and discoid lesions (coinlike- scarring lesionsof discoid lupus).
Key Features of SLE- Renal Nephritis
Key Features of SLE- Cardio Pericarditis, Raynaud's phenomenon
Key Features of SLE- Pulmonary Pleural effusions
Key Features of SLE- Neuro CNS Lupus
Key Features of SLE- GI Abdominal pain
Key Features of SLE- Other Fever, fatigue, anorexia, vasculitis, joint inflammation and myositis.
Key Features of Systemic Sclerosis (SSc)- Skin Inflamed, fibrotic, sclerotic, edematous
Key Features of Systemic Sclerosis (SSc)- Renal Renal failure
Key Features of Systemic Sclerosis (SSc)- Cardio Myocardial fibrosis, and Raynaud's phenomenon
Key Features of Systemic Sclerosis (SSc)- Pulmonary Interstitial fibrosis and pulmonary hypertension.
Key Features of Systemic Sclerosis (SSc)- Neuro Not common
Key Features of Systemic Sclerosis (SSc)- GI Esophagitis and ulcers
Key Features of Systemic Sclerosis (SSc)- Musculoskeletal Joint inflammation and myositis
Key Features of Systemic Sclerosis (SSc)- Other Fever, fatigue, anorexia, vasculitis
Only significant test for Discoid Lupus Erythematosus (DLE) Skin Biopsy.
Skin Protection in pts with Lupus Erythematosus Clean with mild soap, dry skin thoroughly by patting, apply lotion liberally, avoid powder, use cosmetics with moisturizers, avoid direct sunlight, cover skin & wear large-brimmed hat while in sun, wear sunblock at least SPF 30, and inspect skin daily.
Diffuse cutaneous SSc Skin thickening on the trunk, face, and proximal and distal extremities (over most of the body).
Limited cutaneous SSc Thickened skin limited to sites distal to the face, neck, and distal extremities.
CREST syndrome Pts have with the limited form. Calcinosis (calcium deposits), Raynaud's phenomenon (first symptom that occurs), Esophageal dysmotility, Sclerodactyly (scleroderma of the digits), Telangiectasia (spider-like hemangiomas).
Arthralgia Joint pain
Autoamputation of the distal digits The tips of the digits fall off spontaneously.
For pts with Systemic Sclerosis and Esophagitis Put HOB 60 degrees for meals & 1 hr after. Give small, frequent meals & small amounts each bite. Teach pt to chew thoroughly. Give semisoft foods. Collaborate with dietician. Avoid foods that increase gastric secretion. Give antacids/antihistamines PRN.
Polymyositis A diffuse inflammatory disease of the skeletal (striated) muscle that causes symmetric weakness and atrophy.
Dermatomyositis When a rash accompanies polymyositis.
Polyarthralgia Aching around multiple joints.
Necrotizing vasculitis Term for a group of diseases whose primary manifestation is arteritis, which causes ischemia in the tissues usually supplied by the involved vessels.
Arteritis Inflammation of arterial walls.
Polymyalgia rheumatica (PMR) Clinical syndrome characterized by stiffness, weakness, and aching of the proximal musculature.
Giant cell arteritis (GCA) Systemic vasculitis that affects large and midsize arteries. Clinical manifestations may be classified as systemic, myalgic, and arteritic.
Key Features of Giant cell (temporal) arteritis- Systemic Fatigue, malaise, fever, weight loss, and night sweats.
Key Features of Giant cell (temporal) arteritis- Myalgic manifestaions if pt has PMR Proximal, symmetric muscle pain and stiffness.
Key Features of Giant cell (temporal) arteritis- Arteritic manifestations Erythema, pain (especially localized temporal headache), swelling, tenderness (especially scalp), amaurosis fugax (temp vision loss in one eye) and diplopia or any vision change (requires urgent management).
Ankylosing spondylitis (AS) or Marie-Strumpell Disease or Rheumatoid spondylitis Disease affects the vertebral column and causes spinal deformities.
Reiter's Syndrome Associated with the HLA-B27 antigen. A triad of arthritis, conjunctivitis, and urethritis resulting from exposure to sexually transmitted disease, such as Chlamydia or intestinal infection, such as Shigella or Salmonella.
Balanitis Circinata Possible complication of Reiter's Syndrome. Ringlike inflammation of the glans penis.
Marfan Syndrome Autosomal dominant connective tissue disease in which abnormalities of the skeletal, ocular, cardiopulmonary, and CNS result from a basic defect in the extracellular microfibrils.
Microfibrils Very small fibers within cells.
Lyme Disease Reportable systemic infectious disease caused by the spirochete Borrelia burgdorferi and results from the bite of an infected deer tick.
Localized Stage I Pt appears with flu-like symptoms, erythema migrans (round or oval, flat or slightly raised rash), and pain and stiffness in the muscles and joints.
Bull's-eye lesion Most pts in the US tend to only have one lesion.
Stage II (early disseminated stage) Occurs 2-12 wks after the tick bite. Pt may develop carditis with dysrhythmias, dyspnea, dizziness, or palpitations, meningitis, Bell's palsy and peripheral neuritis.
Stage III (chronic persistent stage) Occurs mths to years after the tick bite. Sometimes the first and only sign is arthritis.
Pseudogout Disease that mimics the clinical manifestations of gout, however, the crystals deposited in the joints are calcium pyrophosphate, not sodium urate.
Psoriatic arthritis (PsA) Skin condition characterized by a scaly, itchy rash, usually on the elbows, knees, and scalp. Fingernail and toenail lifting and pitting may also occur. Joint pain associated with stiffness, usually in the morning. Neck and back pain is common.
Fibromyalgia Chronic pain syndrome, with no inflammation. Increased muscle tenderness may be caused by inability to tolerate pain, may be a dysfunction in the brain (thalamus & hypothalamus).
Fibromyalgia characteristics Pain, stiffness and tenderness are located at specific sites in the back of the neck, upper chest, trunk, low back and extremities. Pain is usually described as burning and gnawing.
Chronic fatigue syndrome (CFS) Chronic illness in which pts have severe fatigue for 6 mths or longer usually following flu-like symptoms.
Characteristics of Dx for CFS (4 or more are required) Sore throat, substantial impairment in short-term memory/concentration, tender lymph nodes, muscle pain, multiple joint pain with redness/swelling, headaches of new type (pattern or severity), unrefreshing sleep, & postexertional malaise lasting >24 hrs
Created by: STorrez2