Chapter 54 Assessment and Management of Patients With Rheumatic Disorders

More than 100 different disorders Rheumatic Diseases “Arthritis” More than 100 different disorders Affect primary the joints, but also muscles, bone, ligament, tendons, cartilage Classification Monoarticular or polyarticular Inflammatory or noninflammatory

Characteristic Degenerative Changes— “Degradation” Although the cause of degeneration of the articular cartilage is poorly understood, the process is known to be metabolically active and therefore is more accurately called “degradation.” Joint space narrowing and osteophytes (bone spurs) are characteristic of degenerative changes in joints.

Factors associated with degenerative joint changes Mechanical Stress (The articular plate (subchondral bone) thins, and its ability to absorb shock decreases) Altered Lubrication Immobility

Clinical Manifestations Pain Joint swelling Limited movement Stiffness Weakness Fatigue Warmth, Erythema

Joint involvement begins in the small joints of the hands, wrists, and feet. As the disease progresses, the knees, shoulders, hips, elbows, ankles, and cervical spine joints are affected. The onset of symptoms is usually acute. Symptoms are usually bilateral and symmetric. In addition to joint pain and swelling, another classic sign of RA is joint stiffness, especially in the morning, lasting at least 30 to 45 minutes

Pathophysiology and Associated Physical Signs of Rheumatoid Arthritis Pannus (newly formed synovial tissue infiltrated with inflammatory cells)

Patient Assessment and Diagnostic Findings Health history: include onset of and evolution of symptoms, family history, past health history, and contributing factors Functional assessment Arthrocentesis (to take fluid for sampling and to relieve pain caused by pressure of increased fluid volume. After procedure, observe the patient for signs of infection and hemarthrosis) X-rays, bone scans, CTs, and MRIs Tissue biopsy Blood studies

Treatment

Nursing Process: The Care of the Patient with a Rheumatic Disease—Assessment Health history and physical assessment focus on current and past symptoms, and also include the patient's psychological and mental status, social support systems, ability to participate in daily activities, comply with treatment regimen, and manage self-care

Nursing Process: The Care of the Patient with a Rheumatic Disease—Diagnoses Acute and chronic pain Fatigue Disturbed sleep pattern Impaired physical mobility Self-care deficits Disturbed body image Ineffective coping

Collaborative Problems/Potential Complications Adverse effects of medications

Nursing Process: The Care of the Patient with a Rheumatic Disease—Planning Major goals may include: Relief of pain and discomfort Relief of fatigue Promotion of restorative sleep Increased mobility Maintenance of self-care Improved body image Effective coping Absence of complications

Systemic Lupus Erythematosus More common in women than men An autoimmune disease. The immunoregulatory disturbance is brought about by some combination of genetic factors, hormonal factors (as evidenced by the usual onset during the childbearing years), environmental factors (eg, sunlight, thermal burns), and some medications (hydralazine (Apresoline), isoniazid (INH), chlorpromazine, and some antiseizure medications).

Clinical Manifestations The onset of SLE may be insidious or acute. For this reason, SLE may remain undiagnosed for many years. It can affect any body system (musculoskeletal system, with arthralgias and arthritis (synovitis), skin (butter fly rash), Oral ulcers, Pericarditis, renal involvement (increased creatinine) which leads to hypertension, CNS (subtle changes in behavior patterns or cognitive ability)

Gout Is a heterogeneous group of conditions related to a genetic defect of purine metabolism that results in hyperuricemia. Occur as a result of uversecretion of uric acid or a renal defect to excrete uric acid, or a combination of both. Primary hyperuricemia may be caused by severe dieting or starvation, excessive intake of foods that are high in purines (shellfish, organ meats), or heredity. Secondary hyperuricemia is due to conditions in which there is an increase in cell turnover (leukemia, some types of anemias, psoriasis) and an increase in cell breakdown.

Pathophysiology With hyperuricemia, accumulations of sodium urate crystals, called tophi, are deposited in peripheral areas of the body, such as the great toe, the hands, and the ear. Renal urate lithiasis (kidney stones), with chronic renal disease secondary to urate deposition, may develop.

Clinical Manifestations Acute gouty arthritis (recurrent attacks of severe articular and periarticular inflammation), tophi (crystalline deposits accumulating in articular tissue, osseous tissue, soft tissue, and cartilage) The metatarsophalangeal joint of the big toe is the most commonly affected joint (90%). The ankle or knee may also be affected. Less commonly, the wrists, fingers, and elbows. Severe pain, redness, swelling, & warmth of the affected joint Gouty nephropathy (renal impairment), and uric acid urinary calculi.

Medical Management Pharmacology Diet