Rheumatoid Diseases

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Rheumatoid Diseases

• Osteoarthritis
• Rheumatoid Arthritis
• Systemic Lupus Erythematosis
• Scleroderma

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Osteoarthritis

• Definition wear and tear, progressive,
  non-systemic, Degenerative Joint Disease (DJD)
• Pathophysiology

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Note top slide only
Identify which joints are primarily affected with
osteoarthritis. What factors contribute to the
development of osteoarthritis?
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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
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What signs and symptoms does the person with
osteoarthritis experience?
Normal Knee structure
Moderately advanced osteoarthritis
Advanced osteoarthritis
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Assessment
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
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Deformities with Osteoarthritis
Carpometacarpocarpal joint of thumb with
subluxation of the first MCP
Genuvarus
Herberdens nodes
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Osteoarthritis

• 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
  formation
• Synovial fluid inc., minimal inflammation
• Gait analysis

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Rheumatoid Arthritis
Chronic systemic, inflammatory disease
characterized by recurrent inflammation of
diarthroidal joints and related structures.
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Comparison of RA and OA
RA Cause unknown Remissions Body parts
affected, systemic, small joints,
symmetrical Females, age 20-30 3-1
ratio OA Cause wear and tear,
weight Non-systemic, weight bearing
joints Middle-aged and elderly, males 2-1
affected
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Manifestations of RA

• Systemically ill
• Hematologic
• Pulmonary/CV
• Neurologic
• Ocular (Sjorgens)
• Skin
• MS, deformity, pain

Pain!
Pain!
Pain
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Assessment

• Fatigue, weakness, pain
• Joint deformity
• Rheumatic nodules

• Pathophysiology
• IgG/RF (HLA) antigen-antibody complex
• Precipitates in synovial fluid
• Inflammatory response

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Joints changes with RA

• Early Pannus
• Granulation, inflammation at synovial membrane,
  invades joint, softens and destroys cartilage

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Diagnostic Tests

• ESR elevated
• RA, RA titer
• Dec. serum complement
• Synovial fluid inflammation
• Joint and bone swelling,inflammation

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Mod advanced Pannus joint cartilage disappears,
underlying bone destroyed, joint surfaces
collapse Fibrous Ankylosis Fibrous connective
tissue replaces pannus loss of joint otion Bony
Ankylosis Eventual tissue and joint
calcification
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Joint Changes

• Bilateral, symmetrical, PIPs, MCPs
• Thumb instability
• Swan neck, boutonniere deformity
• Tensynovitis
• Multans deformity

• Subcutaneous nodules
• Genu valgum
• Pes plano valgus
• Prominent metatarsal heads
• Hammer toes

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Assessment
Deformities that may occur with RA
Synotenovitis Ulnar drift Swan neck
deformity Boutonniere deformity
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Mutlans deformity (rapidly progressing
RA) Hitch-hiker thumb Genu valgus
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Hammer toes Subcutaneous nodules (disappear and
appear without warning)
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Interventions

• Nursing Diagnosis
• Comfort
• Physical mobility
• Self image
• Goals
• Team Approach

• Pain management
• Exercise
• Surgery
• Teaching

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Medications

• ASA cornerstone
• NAISD
• Steroids (burst therapy)
• Remitting agents
• antimalarial (plaquinal) eye effects
• Penicillamine
• gold dermatitis, blood dyscrasia
• Immunosuppressive agents

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Joint Protection Dos and Donts
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Case Presentation

• Comparison to usual course
• Diagnostic tests
• Nursing diagnosis
• Therapies
• Medications used
• Exercise
• Joint Protection

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Systemic Lupus Erythematous (SLE)

• Chronic multisystem disease involving vascular
  and connective tissue

Lupus help
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Characteristics of SLE

• Assessment
• Low grade fever
• Discoid erythema
• MS involvement
• Pericarditis
• Raynaulds
• RENAL
• CNS
• Digestive,anemia

• Types Discoid, SLE
• Incidence
• Periods remission and exacerbation
• Stress factor

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Characteristic butterfly rash associated with
SLE, especially discoid lupus erythematous
Barrys lupus
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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, phenobard may cause a lupus-like
reaction which disappears when drug is stopped.
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Diagnostic Tests

• Criteria to Dx.
• malar, discoid rash
• photosensitivity
• arthritis
• renal disorder
• immunological disorder
• DNA, ANA

• LE cell
• ANA, titer
• Anti-DNA
• Complement fixation
• ESR
• Other

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Management SLE

• Nursing diagnosis
• Goal to control inflammation
• Emotional support
• Life Planning

• Medications
• Avoid UV
• Reduce stress
• Monitor/manage to prevent complications

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Scleroderma

• Definition progressive sclerosis of skin and
  connective tissue fibrous and vascular changes
  in skin, blood vessels, muscles, synovium,
  internal organs. become hide bound
• CREST syndrome benign variant of disease

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Typical hide-bound face of person with
scleroderma Tissue hardens claw-like fingers
fibrosis
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Assessment of Scleroderma

• Female 41
• Pain, stiffness, polyartheritis
• Nausea, vomiting
• Cough
• Hypertension
• Raynaulds syndrome

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Scleroderma cont.

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

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CREST Syndrome

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

More on CREST
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Diagnosis/Treatment Scleroderma

• R/O autoimmune disease
• Radiological pulmonary fibrosis, bone
  resorption, subcutaneous calcification, distal
  esophageal hypomotility

• What are the KEY components of care for the
  individual with Scleroderma?

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Scleroderma Patient Care

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

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Ankylosing Spondylitis

• Signs and symptoms
• Morning backache, flexion of spine, decreased
  chest expansion
• Diagnosis
• Nursing Diagnosis

• Definitions polyarteritis of spine
• Affects mostly men
• Associated with HLA positive antigen

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Ankylosing Spondylitis Insidious onset Morning
backache Inflammation of spine later spine
ossification
Oh my back hurts!
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Comparison of changes with ospeoporosis and
Ankylosing spondylitis
Identify a PRIORITY nursing concern related to
ankylosing spondylitis
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Management Ankylosing Spondilitis

• Dos
• Maintain spine mobility
• Pain management
• Proper positioning
• Meds for pain, inflammation

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Other Collagen Diseases

• Polyarteritis Nodosa
• Inflammation, necrosis of walls small to medium
  sized arteries
• Like SLE
• Dermatomyositis
• Affects skin and voluntary muscles
• Sjogrens
• JRA

• Reiters Syndrome
• Reactive arthritis associated with enteric
  disease
• Lyme Disease
• Caused by spirochete, borrelia burgdorferi
• 3 stages
• Initial rash
• disseminated
• Late
• Antibiotics effective

Rheumatoid Review