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Musculoskeletal: Autoimmune; Inflammatory; Metabolic; Infectious Disorders


Rheumatoid Arthritis; SLE; Paget s Disease; Gout; Osteomyelitis Autoimmune and Inflammatory Disorders: Rheumatoid Arthritis Pathophysiology: Rheumatoid Arthritis ... – PowerPoint PPT presentation

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Title: Musculoskeletal: Autoimmune; Inflammatory; Metabolic; Infectious Disorders

Musculoskeletal Autoimmune Inflammatory
Metabolic Infectious Disorders
  • Rheumatoid Arthritis SLE Pagets Disease Gout

Autoimmune and Inflammatory DisordersRheumatoid
Chronic systemic, inflammatory disease
characterized by recurrent inflammation of
connective tissue, primarily of synovial joints
and related structures.
Pathophysiology Rheumatoid Arthritis Cause
unknown - Autoimmune Theory
  • Exposure to unidentified antigen
  • Triggers formation of an abnormal immunoglobulin
    G (IgG)
  • Autoantibodies called rheumatoid factor (RF)
    develop in response to IgG
  • ( Rheumatoid factor (RF) is diagnostic for RA)
  • IgG RF IgG/RF called immune complexes
  • Precipitates in synovial fluid on articular
  • Triggers Inflammatory response
  • Cartilage and connective tissue primarily

Pathophysiology Rheumatoid Arthritis
Inflammatory response
  • Immune complexes activate complement
  • Neutrophils release proteolytic enzymes damage
    or thickening of synovial lining and damaged
  • T helper CD4 cells stimulate release of cytokines
    such as interleukin-1 and TNR (tumor necrosis
    factor alpha) cause chondrocytes to attack
    cartilage. Primary drivers of immune response in
  • Chronic inflammation hypertrophy of synovial
    membranes, pannus formation, scarring, cartilage
    destruction, disrupts tendons, ligaments

Joints changes with RA
  • Early Pannus
  • Immune complexes enter joint
  • Granulation, inflammation at synovial membranes
  • Cartilage softens and begins process of
    destroying joint

Mod advanced Pannus joint cartilage disappears,
underlying bone destroyed, joint surfaces
collapse Fibrous Ankylosis Fibrous connective
tissue replaces pannus loss of joint
motion Bony Ankylosis Eventual tissue and
joint calcification
Rheumatoid arthritis assessment manifestations
and complications
  • Fatigue, weakness, pain
  • Joint deformity
  • Rheumatic nodules
  • Multi-system involvement

Joint Changes RA
  • Bilateral symmetrical
  • PIPs (hands)
  • MTPs (feet)
  • Thumb instability
  • Swan neck deformity
  • Boutonniere deformity
  • Tensynovitis
  • Subcutaneous nodules
  • Genu valgum (knock-knee)
  • Pes plano (flat foot)
  • Gneu valgus
  • Hallux valgus
  • Prominent metatarsal heads
  • Hammer toes

Assessment RA
Deformities that may occur with RA
Synotenovitis Ulnar drift Swan neck
deformity Boutonniere deformity
Mutlans deformity (rapidly progressing
RA) Hitch-hiker thumb Genu valgus Hallux valgus
Hammer toes
Subcutaneous nodules (disappear and appear
without warning)
Manifestations of RA
  • Systemically ill
  • Hematologic
  • Pulmonary/CV
  • Neurologic
  • Ocular symptoms (Sjogrens Felty)
  • Skin
  • Musculoskeletal deformity, pain

Extra-articular Manifestations
  • Can affect almost all systems
  • Sjogrens syndrome 10-15 of patients. Decreased
    lacrimal and salivary gland secretions
  • Felty Syndrome most common in pts with nodule
    forming type - Inflammatory eye disorders,
    splenomegaly, lymphadenopathy, pulmonary disease,
    blood dyscrasias

Diagnostic Tests RA
RF RF titer 80 ESR elevated
C-reactive protein general indicators of
inflammation CBC Synovial fluid WBCs
present bone scans early detection Swelling,in
flammation X-rays only useful in late stages
How does Rheumatoid Arthritis Compare to
  • Definition wear and tear, progressive,
    non-systemic, Degenerative Joint Disease (DJD)
  • Pathophysiology loss of cartilage, exposed
    bone, bone spurs, inflammation

Comparison of RA and OA
RA Cause unknown auto-immune factor,
genetic? Onset sudden with Remissions Body
parts affected systemic, small joints,
symmetrical Causes redness, warmth, swelling of
joints Females, begins at any age 2-31
ratio RF is positive, pain increases with
movement OA Cause wear and tear, develops
slowly Non-systemic, weight bearing
joints Middle-aged, elderly, males 2-1 affected,
Begins after 40 Does not cause malaise RF is
negative, pain decreases with movement
Osteoarthritis (top slide only)
Identify which joints are primarily affected with
osteoarthritis. What factors contribute to the
development of osteoarthritis?
Structural changes with Osteoarthritis Early
Cartilage softens, pits, frays Progressive C
artilage thinner, bone ends hypertrophy,
bone spurs develop and fissures
form Advanced Secondary inflammation of
synovial membrane tissue and cartilage
destruction late ankylosis
What signs and symptoms does the person with
osteoarthritis experience?
Normal Knee structure
Moderately advanced osteoarthritis
Advanced osteoarthritis
What symptoms/assessment for the patient with
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 Osteoarthritis
Carpometacarpocarpal joint of thumb with
subluxation of the first MCP
Genu varus
Herberdens nodes
Osteoarthritis (review only)
  • Nursing diagnosis
  • Interventions determined by complications
  • Supportive devices
  • Medications (no systemic treatment with steroids)
  • Dietary to dec. wt.
  • Surgical Intervention (joint replacement)
  • Teaching
  • Diagnostic Tests
  • None specific
  • Late joint changes, boney sclerosis, spur
  • Synovial fluid inc., minimal inflammation
  • Gait analysis

Interventions RA
  • Nursing Diagnosis
  • Comfort
  • Physical mobility
  • Self image
  • Goals
  • Team Approach
  • Pain management
  • Exercise
  • Surgery
  • Synovectomy
  • Joint fusion
  • Athrodesis
  • Joint replacement
  • Arthroplasty
  • Teaching

Medications RA
  • ASA NSAIDS, Cox-2 inhibitors
  • Corticosteroids low dose
  • DMARDs (diverse group) of remitting agents
    including antimalarial (hydroxychloroquine
    plaquenil) loss of vision Penicillamine (empty
    stomach) bone marrow/kidney issues
  • Gold (Auranofin) dermatitis, blood
    dyscrasias, renal toxicity
  • Immunosuppressive agents as methotrexate and
  • Biologic response modifiers
  • Adalimumab (Humira)- Sub-Q binds with tumor
    necrosis factor to decrease inflammatory process
    report infections STAT
  • Infliximab (Remicade)- IV similar to above

Joint Protection Dos and Donts
Case Presentation Mrs. Michaels with Rheumatoid
Arthritis(PDS Adult Health Musculoskeletal
Health Mrs. Michaels)
  • Comparison to usual course
  • Diagnostic tests
  • Nursing diagnosis
  • Therapies
  • Medications used
  • Exercise
  • Joint Protection
  • Resources on the Web

Systemic Lupus Erythematous (SLE)
  • Chronic multisystem disease involving vascular
    and connective tissue

Lupus Foundation
Etiology and Pathophysiology SLE
  • Exact etiology unknown genes (HLA), hormones,
    environment involved
  • Formation auto-antibodies to DNA immune
    complexes deposited
  • Inflammatory response triggered by deposition of
    immune complexes in skin kidney, heart, joints,
    brain, lung, spleen, GI
  • Drug induced syndrome similar to SLE (Procan-SR,
    Pronestal, (Apresoline) hydralazine, isonaiazid,
    siezure meds)
  • Course of disease varies
  • Mild
  • Episodic
  • Rapidly fatal

Manifestations and Complications
  • Dermatologic 50 have butterfly rash. Skin,
    nasal, oral lesions, hair loss.
  • Musculoskeletal polyarthralgia, arthritis,
    swelling, pain, deformity
  • Cardiopulmonary Tachypnea, cough, fibrosis of
    nodes arrhythmias, accelerates CAD
  • Renal 50 of patients within 1 year of onset.
    Protienurea to rapid glomerulonephritis
  • CNS focal seizures, peripheral neuropathy,
    organic brain syndrome
  • Hematologic antibodies form against blood cells
  • Infection major cause of death

Manifestations/Complications of SLE
  • Assessment
  • Low grade fever
  • Integumentary
  • MS involvement
  • CV
  • Respiratory
  • Urinary Renal failure
  • Neurologic CNS
  • GI
  • Hematologic
  • Endocrine
  • Reproductive
  • Incidence 12000
  • Women 91, child-bearing age, african american,
    native american, asian
  • Periods remission and exacerbation
  • Stress
  • Environmental factors

Characteristic butterfly rash associated with
SLE, especially discoid lupus erythematous
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
Diagnostic Tests
  • LE cell prep in other rheumatoid diseases
  • Anti-DNA- specific
  • Anti nuclear antibody, titer
  • Serum Complement levels decreased
  • ESR - elevated
  • CBC- leuko /lympho cytopenia, anemia
  • UA RBCs, protien
  • Kidney biopsy
  • Criteria to Dx.
  • malar, discoid rash oral ulcers
  • photosensitivity
  • arthritis
  • renal disorder
  • immunological disorder

Therapeutic Interventions/Management SLE
  • Medications
  • (Disease modifying agents) Antimalarial drugs
  • Corticosteroids
  • Immunsuppressive therapy
  • Antineoplastic drugs such as Imuran, cytoxan,
  • Avoid UV light
  • Reduce stress
  • Monitor/manage to prevent complications
  • Nursing diagnosis
  • See RA
  • Impaired skin integrity
  • Ineffective protection
  • Impaired health maintenance
  • Goal control inflammation
  • Emotional support
  • Life Planning
  • Required Review

Case Study
  • Clinical 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
  • 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 bound
  • Immune-mediated disorder genetic component

Scleroderma (Systemic sclerosis)
  • Abnormal amounts of fibrous connective tissue
    deposited in skin, blood vessels, lungs, kidneys,
    other organs
  • Can be systemic or localized (CREST) syndrome

CREST Syndrome
  • Calcinosis
  • Raynauds phenomena
  • Esophageal hypomotility
  • Sclerodactyl (skin changes of fingers)
  • Telangiectasia (macula-like angioma of skin)

More on CREST
CREST Syndrome scleroderma
Sclerodactyly (localized scleroderma of fingers)
Raynauds disease with ischemia
Typical hide-bound face of person with
scleroderma Tissue hardens claw-like fingers
Scleroderma Manifestations Complications
  • Female 41
  • Pain, stiffness, polyartheritis
  • Nausea, vomiting
  • Cough
  • Hypertension
  • Raynaulds syndrome
  • Skin atrophy, hyperpigmented

Scleroderma cont.
  • Esophageal hypomotility leads to frequent reflux
  • GI complaints common
  • Lung-pleural thickening and pulmonary fibrosis
  • Renal disease...leading cause of death!

Diagnosis/Treatment Scleroderma
  • R/O autoimmune disease
  • Radiological pulmonary fibrosis, bone
    resorption, subcutaneous calcification, distal
    esophageal hypomotility
  • ESR elevated
  • CBC anemia
  • Gammaglobulin levels elevated
  • RF in 30 SCL-70 in 35
  • Skin biopsy to confirm
  • What are the KEY components of care for the
    individual with Scleroderma?

Scleroderma Patient Care
  • Dos
  • Avoid cold
  • Provide small, frequent feedings
  • Protect fingers
  • Sit upright post meals
  • No fingersticks
  • Daily oral hygiene

Scleroderma Patient Care
  • Medications based upon symptoms
  • Immunosuppressive agents steroids remitting
  • Ca channels blockers alpha-adrenergic blockers
  • H2 receptor blockers
  • ACE inhibitors
  • Broad spectrum antibiotics
  • Capsaicin

Ankylosing Spondylitis
  • Pathophysiology Manifestations
  • Like arthritis have inflammatory changes erosion
    of cartilage, ossification of joint margins scar
    tissue replaces
  • Morning backache, flexion of spine, decreased
    chest expansion
  • Diagnosis
  • ESR elevation
  • Positive HLA-B27 antigen
  • Vertebral changes
  • Definitions chronic inflammatory polyarthritis
    of spine
  • Affects mostly young men
  • Associated with HLA-B27 antigen
  • positive antigen (90)

Ankylosing Spondylitis Insidious onset Morning
backache Inflammation of spine later spine
Oh my back hurts!
Ankylosing spondylitis
Identify a PRIORITY nursing concern related to
ankylosing spondylitis
Management Ankylosing Spondilitis
  • Dos
  • Maintain spine mobility
  • Pain management
  • Proper positioning
  • Meds for pain, inflammation

Other Collagen Diseases
  • Lyme Disease (mimics rheumatoid disease)
  • Caused by spirochete, borrelia burgdorferi (tick)
  • Inflammatory disorder
  • 3 stages
  • Initial rash (target)
  • Disseminated (arthritic like symptoms)
  • Late (neurologic symptoms)
  • Diagnosis
  • Culture (difficult)
  • Antibody detection

Treatment antibiotics (amoxicillin, vibramycin,
tetracycline, etc) NSAID) Prevention
Other Collagen Diseases
  • Polymyositis
  • Systemic connective tissue disorder characterized
    by inflammation of connective tissue and muscle
  • Autoimmune affecting women 21
  • If muscle fiber inflammation is accompanied by
    skin lesion disease known as dermatomyositis
  • Manifestations complications
  • Muscle pain, tenderness, rash arthralgias
    fatigue fever and weight loss
  • Skeletal muscle weakness most prominent
  • Dusky red rash over face
  • Raynauds phenomenon
  • Malignancy with dermatomyositis
  • Diagnosis
  • None specific
  • Elevated CK

Other Collagen Diseases cont
  • Reiters syndrome
  • Self-limited disease of reactive arthritis
  • Adult males infection of eyes and urethra
  • infections such as
  • Chlamydia
  • Shigella
  • Salmonella
  • Enterocolitis
  • associated with HLAB27 antigen

Antibiotics pain meds Joints of ankles, feet.
sacroiliac Persists and returns
Other Collagen Diseases cont.
  • Polyarteritis Nodosa
  • Collagen
  • diffuse inflammation and necrosis of wall of
    small to medium sized arteries
  • Especially in
  • Muscles
  • Kidneys
  • heart
  • liver,
  • GI and peripheral nerves like SLE
  • Juvenile Rheumatoid Arthritis