Rheumatoid Diseases Osteoarthritis Rheumatoid Arthritis Systemic Lupus Erythematosis Scleroderma

Osteoarthritis n Definition: *wear and tear, progressive, non-systemic, Degenerative Joint Disease (DJD) n Pathophysiology

Identify which joints are primarily affected with osteoarthritis. What factors contribute to the development of osteoarthritis? Note top slide only

Structural changes with Osteoarthritis Early Cartilage softens, pits, frays Progressive Cartilage thinner, bone ends hypertrophy, bone spurs develop and fissures form Advanced Secondary inflammation of synovial membrane; tissue and cartilage destruction; late ankylosis

Normal Knee structure Moderately advanced osteoarthritis Advanced osteoarthritis What signs and symptoms does the person with osteoarthritis experience?

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

Deformities with Osteoarthritis Genuvarus Herberden’s nodes Carpometacarpocarpal joint of thumb with subluxation of the first MCP

Osteoarthritis n Diagnostic Tests –None specific –Late joint changes, boney sclerosis, spur formation –Synovial fluid inc., minimal inflammation –Gait analysis n Nursing diagnosis n Interventions determined by complications –Supportive devices –Medications (no systemic treatment with steroids) –Dietary to dec. wt. –Surgical Intervention (joint replacement) –Teaching

Rheumatoid Arthritis Chronic systemic, inflammatory disease characterized by recurrent inflammation of diarthroidal joints and related structures.

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

Manifestations of RA n Systemically ill n Hematologic n Pulmonary/CV n Neurologic n Ocular (Sjorgen’s) n Skin n MS, deformity, pain Pain! Pain

Assessment n Fatigue, weakness, pain n Joint deformity n Rheumatic nodules n Pathophysiology –IgG/RF (HLA)= antigen-antibody complex –Precipitates in synovial fluid –Inflammatory response

Joints changes with RA n Early Pannus Granulation, inflammation at synovial membrane, invades joint, softens and destroys cartilage

Diagnostic Tests n ESR elevated n + RA, ^ RA titer n Dec. serum complement n Synovial fluid inflammation n Joint and bone swelling,inflammation

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

Joint Changes n Bilateral, symmetrical, PIP’s, MCP’s n Thumb instability n Swan neck, boutonniere deformity n Tensynovitis n Multans deformity n Subcutaneous nodules n Genu valgum n Pes plano valgus n Prominent metatarsal heads n Hammer toes

Assessment Deformities that may occur with RA Synotenovitis Ulnar drift Swan neck deformity Boutonniere deformity

Mutlans deformity (rapidly progressing RA) Hitch-hiker thumb Genu valgus

Hammer toes Subcutaneous nodules ( disappear and appear without warning)

Interventions n Nursing Diagnosis –Comfort –Physical mobility –Self image n Goals n Team Approach n Pain management n Exercise n Surgery n Teaching

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

Joint Protection: Do’s and Don’t’s

Case Presentation n Comparison to ‘usual’ course n Diagnostic tests n Nursing diagnosis n Therapies –Medications used –Exercise –Joint Protection

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

Characteristics of SLE n Types: Discoid, SLE n Incidence n Periods remission and exacerbation n Stress factor n Assessment –Low grade fever –Discoid erythema –MS involvement –Pericarditis –Raynauld’s –RENAL –CNS –Digestive,anemia

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

Diagnostic Tests n LE cell n ANA, titer n Anti-DNA n Complement fixation n ESR n Other n Criteria to Dx. –malar, discoid rash –photosensitivity –arthritis –renal disorder –immunological disorder –DNA, ANA

Management SLE n Nursing diagnosis n Goal to control inflammation n Emotional support n Life Planning n Medications n Avoid UV n Reduce stress n Monitor/manage to prevent complications

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

Typical “hide- bound” face of person with scleroderma Tissue hardens; claw-like fingers; fibrosis

Assessment of Scleroderma n Female 4:1 n Pain, stiffness, polyartheritis n Nausea, vomiting n Cough n Hypertension n Raynauld’s syndrome

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

CREST Syndrome n Calcinosis n Raynaud’s phenomena n Esophageal hypomotility n Sclerodactyl (skin changes of fingers) n Telangiectasia (macula-like angioma of skin) More on CREST

Diagnosis/Treatment Scleroderma n R/O autoimmune disease n Radiological: pulmonary fibrosis, bone resorption, subcutaneous calcification, distal esophageal hypomotility n What are the KEY components of care for the individual with Scleroderma?

Scleroderma: Patient Care n Do’s –Avoid cold –Provide small, frequent feedings –Protect fingers –Sit upright post meals –No fingersticks –Daily oral hygiene

Ankylosing Spondylitis n Definitions; polyarteritis of spine n Affects mostly men n Associated with HLA positive antigen n Signs and symptoms –Morning backache, flexion of spine, decreased chest expansion n Diagnosis n Nursing Diagnosis

Ankylosing Spondylitis Insidious onset Morning backache Inflammation of spine; later spine ossification Oh my back hurts!

Comparison of changes with ospeoporosis and Ankylosing spondylitis Identify a PRIORITY nursing concern related to ankylosing spondylitis

Management Ankylosing Spondilitis n Do’s –Maintain spine mobility –Pain management –Proper positioning –Meds for pain, inflammation

Other Collagen Diseases n Reiter’s Syndrome –Reactive arthritis associated with enteric disease n Lyme Disease –Caused by spirochete, borrelia burgdorferi –3 stages Initial rash disseminated Late –Antibiotics effective n Polyarteritis Nodosa –Inflammation, necrosis of walls small to medium sized arteries –Like SLE n Dermatomyositis –Affects skin and voluntary muscles n Sjogrens n JRA Rheumatoid Review