1 Inflammatory Diseases

2 Objectives Identify the S/S of inflammatory disease. Classify the common disease modifying drugs used to treat inflammatory disease. Develop a nursing plan of care for individuals with inflammatory disease.

3 Inflammatory Arthritis An inflammatory process with the target organ being the synovial membrane leading to pannus formation (inflammatory exudate in the lining of the synovial cells).

4 Inflammatory Disorders RA/JRA SLE Scleraderma Sjogren’s Syndrome Polymyositis/Giant Cell Arteritis Psoriatric Arthritis

5 Inflammatory Disorders con’t Ankylosing Spondylitis Reiter’s Syndrome Fibromyalgia Bursitis Arthritic Infections Gout

6 Rheumatoid Arthritis Osteopenia - demineralization of the bone Early on in the inflammatory process,only the periarticular portion of the bones are affected. Over time, the inflammatory pain causes disuse of affected joints leading to generalized osteopenia of whole bones.

7 Question #1 A common hand deformity in rheumatoid arthritis is: a. Radial deviation. b. Supination deformity. c. Ulnar deviation. d. Flexion contracture.

8 Answer #1 A common hand deformity in rheumatoid arthritis is: Ulnar deviation occurs when the MCP joints are affected by RA

9 Rheumatoid Arthritis Uniform joint space narrowing Marginal erosions at bare areas where synovium lies on bone Subluxation

RA of the Hands

RA of the Hips

13 RA-Epidemiology Develops most often between ages 20 & 50 2 million Americans have RA Roughly twice as many women as men Genetic predisposition

14 RA-Etiology Theories Autoimmune Infectious Genetics Family history of RA Stress Exacerbations

15 RA-Pathophysiology Rheumatoid Factor develops in synovium Antibody/antigen complexes  inflammation Synovitis develops Synovial lining thickens & invades surrounding tissue Granulation forms (Pannus)

16 Answer #2 Which of the following symptoms would you expect a patient with RA to have? Morning stiffness usually lasts about 4 hours

17 RA-Symptoms Pain & swelling in hands & feet Morning stiffness & stiffness after rest Loss of ROM Fatigue (severe during a flare-up) Rheumatoid Nodules Flares & Remissions

18 RA Complications Flexion contractures Joint Instability Tendon Rupture Septic Arthritis Cord Compression Sensory/motor loss

19 RA Complications TMJ Cricoarytenoid joint involvement Carpal Tunnel Sjogren’s Still’s Depression

20 Answer #3 Which of the following is a therapeutic modality used for symptom management in RA? Exercise to promote ROM & flexibility

21 RA - Treatment Modalities Drug therapy (pyramid) NSAIDs, DMARDs, Steroid, Exp. Avara, Remicaide (IV) ***See handouts for lists of drugs used Exercise/ PT ROM, strength, endurance, splints Use of heat & cold Joint Replacement

22 RA Nursing Interventions Pt & Family Education!!!!! Joint protection/work simplification Respect pain Balance work/rest Reduce effort on joint/avoid positions Use larger/stronger/stable joints Avoid remaining in one position Avoid activities that don’t allow stopping/break

23 Amyotrophic Lateral Sclerosis ALS (Lou Gehrig Disease) - chronic progressive degeneration of motor neurons - muscle weakness and atrophy M 3x>F, age % die in 3 years Rx: symptomatic

24 Gout Monosodium urate crystals Deposited into soft tissue Activate inflammatory process and inflammatory cytokines (IgG, IL-1, IL-2, free radicals) Etiology/Demographics Seen mostly in males years / women after Menopause Renal dysfunction Alcohol use Defect in purine metabolism

25 Gout Clinical Presentation Sudden onset Generally involves one joint – Lower extremity Physical examination Red swollen joint, usually first MTP Extremely painful point Fever 103°F / tachycardia / headaches Urate acid crystal nodules (tophi) noted on helix of ears

26 Gout Diagnostics Serum uric acid levels – ↑ WBC –↑ during acute episode SED rate – ↑ Joint Aspiration – Synovial fluid Crystals of sodium urate noted under special light → glow red under light X-Rays Non-specific soft tissue swelling Erosive changes occur with disease progression

27 Gout Clinical Management Weight bearing activity restriction until after acute episode subsides NSAIDs – indomethacin preferable Colchicine- narrow window of toxicity Uricosurics Allopurinol-never use for acute episode- For chronic Rx Interferes with uric acid production Diet Protein Restriction ???-controversial Alcohol / Purine Restriction Weight Loss if Obese

28 Gout Complications Major concern is renal disease from recurrent renal calculi Often form large calculi called staghorn calculi that fill renal calyx and causes renal dysfunction Stones cause interstitial inflammation and can result in chronic renal failure

29 Reiter’s Syndrome Classic presentation is a young male with a triad of : Urethritis, Conjunctivitis Oligoarticular arthritis.

30 SLE Is an autoimmune disease that can involve the skin, kidneys, blood vessels, joints, nervous system, heart, and other internal organs

31 SLE - Symptoms Skin rash Arthritis Fever Anemia Hair loss Ulcers in the mouth Kidney damage

32 SLE - Epidemiology Inherited tendency Affects women about 9 to 10 times as often as men 3x more common in African- American women All ages, average age 30

33 Lyme Disease Spirochete B. Burgdorferi transmitted from a tick bite Erythema Migrans-”target lesion” Unexplained fever, sweats, chills, flushing, swollen glands, sore throat, fever, HA, stiff neck, body aches & fatigue. Treated with Doxycycline, Amoxicillin or Cephalosporins

34 Giant Cell Arteritis Early symptoms of giant cell arteritis also may resemble the flu. People are likely to experience headaches, pain in the temples, and blurred or double vision. Pain may also affect the jaw and tongue.

35 Polymyalgia Rheumatica Primary symptoms of polymyalgia rheumatica are moderate to severe stiffness and muscle pain near the neck, shoulders, or hips. The stiffness is more severe upon waking or after a period of inactivity, and typically lasts longer than 30 minutes. People with this condition also may have flu-like symptoms, including fever, weakness, and weight loss.

36 Sjogren's Syndrome Affects an estimated 2 million to 4 million people in the United States Dry eyes Dry mouth Dental cavities Fatigue Low-grade fever Enlarged parotid glands Difficulty swallowing or chewing

37 Sjogren's Syndrome con’t Oral yeast infections Nosebleeds Bruising Skin rashes or dry skin Vaginal dryness Shortness of breath

38 Sjogren's Syndrome-risk factors Having a rheumatic disease. Approximately half of the people who have Sjogren's syndrome also have a rheumatic disease Being female. Women are nine times more likely than men to have Sjogren's syndrome. Being a certain age. Sjogren's syndrome is usually diagnosed in people between the ages of 45 and 55. It rarely occurs in children or teenagers. Having a family history. Sjogren's syndrome sometimes runs in families.

39 Psoriatic Arthropathy Affects about 7% of patients with psoriasis Enteropathic Arthritis About 10-20% of Crohn’s disease and ulcerative colitis patients can develop peripheral joint arthritis. Tuberculous Arthritis Seen in undiagnosed TB and affects spine (Potts dz) and lower extremities

40 Fibromyalgia A condition with generalized muscular pain, fatigue, and poor sleep Affects nearly 4 million people Fibromyalgia means pain in the muscles, ligaments and tendons

41 Scleroderma Causes thickening and hardening of the skin

42 Multiple Sclerosis MS Chronically progressive degenerative disease caused by sporadic plaques, demyelination slowly stops impulse conduction of a nerve Etiol: unknown - illness, trauma F>M 75% prolonged remissions 4 stages

43 Multiple Sclerosis Dx: MRI Rx: Low fat diet, Linoleic acid Plasmapheresis during exacerbations Drugs to  autoimmunity Nursing - Safety  sensation Support: Physical 2˚ weakness Emotional - Financial

44 Myasthenia Gravis Chronic autoimmune deficit in neuro- transmission to motor end plates of voluntary muscles F 2x > M, age F, > 40yrs M  Thymus 80%, weak shoulder girdle Dx & Rx: Anti-cholinesterase (tensilon) with improve symptoms. Thymectomy

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46 Question #1 A common hand deformity in rheumatoid arthritis is: a. Radial deviation. b. Supination deformity. c. Ulnar deviation. d. Flexion contracture.

47 Question #2 Which of the following symptoms would you expect a patient with RA to have? a. Morning stiffness. b. High energy level. c. Bouchard’s nodes. d. Increased flexibility.

48 Question #3 Which of the following is a therapeutic modality used for symptom management in RA? a. Avoid periods of rest throughout the day. b. Exercise to promote ROM & flexibility. c. Acetaminophen as 1st line drug. d. Raisins soaked in apple cider vinegar.

Question #4 Which of the following inflammatory disorders classically presents in young men along with urethritis, conjunctivitis, and oligoarticular arthritis? A) Amyotrophic Lateral Sclerosis B) Gout C) Reiter’s Syndrome D) SLE 49

Question #5 Which of the following does NOT usually present with flu-like symptoms? Lyme Disease Giant Cell Arteritis Polymyalgia Rheumatica Sjorgen’s Syndrome 50

Patients with which of the following conditions sometimes develop arthritis: Psoriasis Chrohn’s Disease Tuberculosis All of the above None of the above 51 Queston #6

Question #7 Which pair of conditions BOTH affect nerves A) Fibromyalgia and Scleroderma B) Multiple Sclerosis and Fibromyalgia C) Myesthenia Gravis and Multiple Sclerosis D) Scleroderma and Myesthenia Gravis 52