Care of Patients with Arthritis and other Connective Tissue Diseases Chapter 20 Care of Patients with Arthritis and other Connective Tissue Diseases Diagram of the knee showing hypotrophy of the synovium and bony erosion and osteoporosis seen in rheumatoid arthritis.

Osteoarthritis Most common arthritis type Progressive loss of cartilage Joint pain, loss of function characterized by progressive deterioration Osteophytes (bone spurs) Cartilage disintegrates, bone and cartilage “float” into joint causing crepitus

Joint changes in Degenerative Joint Disease

Collaborative Management History Usually older than 60 years Physical assessment/clinical manifestations: Joint pain and stiffness Crepitus Heberden's nodes Bouchard’s nodes Joint effusions Atrophy of skeletal muscle

Herberden’s Nodes

Assessment Psychosocial Laboratory Radiographic Other diagnostic: Severe pain may cause depression/anxiety Laboratory ESR nsCRP Radiographic Other diagnostic: MRI CT studies

Chronic Pain: Nonsurgical Management Drug therapy Rest, immobilization Positioning Thermal modalities Weight control Integrative therapies Glucosamine, chondroitin

Chronic Pain: Surgical Management Total joint arthroplasty (TJA) Total joint replacement (TJR) Arthroscopy Osteotomy

Postoperative Care Collaborate with patient/family to become safety partners to prevent complications Hip dislocation VTE Infection Anemia Neurovascular compromise

Hip Flexion after Total Hip Replacment Correct and incorrect hip flexion after a total hip replacement.

Continuous Passive Motion Machine

Rheumatoloty Noninflammatory localized arthritis (osteoarthritis) is not systemic, not an autoimmune disease Inflammatory arthritis: Rheumatoid arthritis Systemic lupus erythematosus Autoimmune disease

Rheumatoloty Connective tissue disease (CTD) major focus Noninflammatory or inflammatory Rheumatic disease = any disease/ condition involving musculoskeletal system Arthritis = inflammation of one or more joints

Rheumatoid Arthritis (RA) Common connective tissue disease, destructive to joints Chronic, progressive, systemic inflammatory autoimmune disease; affects primarily synovial joints Transformed autoantibodies (rheumatoid factors) form, attack healthy tissue causing inflammation

RA Pathology Schematic presentation of the pathologic changes in rheumatoid arthritis. The inflammation (synovitis) leads to pannus formation, obliteration of the articular space, and finally ankylosis. The periarticular bone shows disuse atrophy in the form of osteoporosis.

RA Collaborative Management Assessment Physical assessment/clinical manifestations: Early—joint stiffness, swelling, pain, fatigue, generalized weakness Late—joints become progressively inflamed and quite painful

RA Joint Involvement Common joint deformities seen in rheumatoid arthritis.

RA Systemic Complications Weight loss, fever, extreme fatigue Exacerbations Subcutaneous nodules Respiratory, cardiac complications Vasculitis Periungual lesions Paresthesias

RA - Associated Syndromes Sjögren’s syndrome Felty’s syndrome Caplan’s syndrome

RA Assessments Psychosocial Laboratory—rheumatoid factor, antinuclear antibody titer, ESR, serum complement (C3 & C4), serum protein electrophoresis, serum immunoglobulins Thrombocytosis can occur with late RA Other diagnostic—x-ray, CT, arthrocentesis, bone scan

RA Drug Therapy DMARDs NSAIDs BRMs Other: Glucocorticoids Immunosuppressive agents E788 awaiting approval

RA Nonpharmacologic Interventions Adequate rest Proper positioning Ice and heat application Plasmapheresis (not common) Complementary and alternative therapies Promotion of self-management Management of fatigue Enhance body image

Systemic Lupus Erythematosus (SLE) Chronic, progressive, inflammatory connective tissue disorder Can cause major body organs/systems to fail Spontaneous remissions and exacerbations Autoimmune process Autoimmune complexes tend to be attracted to glomeruli of the kidneys Often some degree of kidney involvement

SLE Clinical Manifestations Skin involvement Butterfly rash Polyarthritis Osteonecrosis Muscle atrophy Fever and fatigue

SLE Clinical Manifestations Renal involvement Pleural effusions Pericarditis Raynaud’s phenomenon Neurologic manifestation Serositis

Characteristic “Butterfly” Rash of SLE

Assessments for SLE Psychosocial results can be devastating Laboratory: Skin biopsy (confirms diagnosis) Immunologic-based laboratory tests CBC (often shows pancytopenia) Body system function

SLE Drug Therapy Topical cortisone drugs Plaquenil Tylenol or NSAIDs Chronic steroid therapy Immunosuppressive agents New drugs in clinical trials Lupozor Belimumab (Benlysta)

Scleroderma (Systemic Sclerosis) Chronic, inflammatory, autoimmune connective tissue disease Not always progressive Hardening of the skin Classifications: Diffuse cutaneous Limited cutaneous

Scleroderma Late-stage skin changes seen in patients with systemic sclerosis.

CREST Syndrome C—calcinosis R—Raynaud’s phenomenon E—esophageal dysmotility S—sclerodactyly T—telangiectasia Hands and forearm edema with bilateral carpal tunnel syndrome usually first symptoms to occur

Scleroderma Clinical Manifestations Arthralgia Renal and cardiac system involvement Problems with GI tract Lung involvement

Scleroderma Interventions Drug therapy Identify early organ involvement Skin protective measures Comfort GI management Mobility

Gout Also called gouty arthritis Urate crystals deposit in joints and other body tissues, causing inflammation Primary gout Secondary gout—hyperuricemia

Tophi Typical appearance of tophi, which may occur in chronic gout, on an index finger.

Gout Interventions Drug therapy Nutrition therapy Limit proteins Avoid trigger foods Plenty of fluids pH increased with alkaline foods Low purine diet

Other Connective Tissue Diseases Polymyositis (dermatomyositis) Systemic necrotizing vasculitis Polymyalgia rheumatica and temporal arteritis Ankylosing spondylitis Reiter’s syndrome

Other Connective Tissue Diseases Marfan syndrome Infectious arthritis Lymes Disease Pseudogout Psoriatic Arthritis

Lyme Disease Caused by spirochete Borrelia burgdorferi, resulting from bite of infected deer tick Stages I and II Chronic complications—arthralgias, fatigue, memory/thinking problems Sometimes first and only sign/symptom is arthritis

Lyme Disease Rash Examples of erythema migrans associated with Lyme disease. A, Many sources describe a characteristic bull's-eye rash with Lyme disease. B, However, a wide range of skin reactions labeled as erythema migrans may occur with Lyme disease, as shown. Some skin rashes may be so minor as to be ignored or go unnoticed by the affected individual.

Psoriatic Arthritis Skin condition characterized by scaly, itchy rash of elbows, knees, scalp Joints stiff especially in morning Treatment focus = managing pain

Fibromyalgia Syndrome Chronic pain syndrome, not an inflammatory disease Pain, stiffness, tenderness at certain areas of neck, upper chest, trunk, low back, extremities

Theoretic Pathophysiologic Model of Fibromyalgia

Chronic Fatigue Syndrome Severe fatigue for 6 months or longer, usually following flu-like symptoms Four or more criteria must be met for CFS diagnosis Treatment is supportive

Case Senario The patient is a 63-year-old woman admitted to the acute medical care unit. She is 5’4” and weighs 211 lb. Her medical history includes hypertension and GERD. On admission, she reports pain in her hands and joints that is unrelieved by OTC medications. What additional assessment data should you collect from the patient at this time? Based on her age and reports of pain, the patient is most likely experiencing osteoarthritis, which may be precipitated by her weight. It is important to know when the pain started, and she should be asked to rate her pain on a 0-10 scale. Which OTC medications has she taken? How long has she experienced this pain? Does she have a family history?

Case Senario While completing your admission assessment, you observe the patient’s hands appear as shown. How would you document this finding? What do you suspect the patient may be suffering from? Nodes should be described as reddened, swollen on ends of all fingers. The patient has Heberden’s nodes, which is a finding of osteoarthritis. A complete work-up will need to be completed by the provider.

Case Senario An hour later, the patient is crying because of severe joint pain in her hands. What are your priority actions at this time? Assess the patient’s level of pain. Check for pain medication orders and administer prn meds as ordered. Reassess her pain level after administering pain medication.

Case Senario While the patient is in pain, her vital signs are taken and recorded. Are any of these vital signs a cause for concern? All of the patient’s vital signs are within normal range except for her blood pressure. It is possible that the pain she is experiencing could be making her blood pressure rise. Further history and assessment of the patient’s blood pressure should be taken and the findings documented for the provider.

Case Senario Two hours later, laboratory values are drawn to investigate the patient’s symptoms. The results are: Sodium 136 mEq/L HCT 41.6% Potassium 4.6 mEq/L HGB 12.8 g/dL Calcium 8.9 mg/dL ESR 28 mm/hr Are any of these results of concern? CBC and electrolytes (sodium, potassium, calcium, HCT, and HGB) are within normal limits. The patient’s ESR is high-normal, which is common in patients with osteoarthritis.

Audience Response System Questions Chapter 20 Audience Response System Questions 50

Question 1 Which population group is most likely to be diagnosed with fibromyalgia syndrome? Men between 30 and 50 years of age Women between 30 and 50 years of age Men between 50 and 70 years of age Women between 50 and 70 years of age Answer: B Rationale: Most patients diagnosed with fibromyalgia syndrome are women between 30 and 50 years of age.

Question 2 The assessment of a patient status post total knee arthroplasty for which continuous femoral nerve blockade was utilized reveals that the patient is nervous and vital signs are BP 92/58, HR 62, RR 12, and SpO2 89%. What should the nurse do next? Take vital signs every 10 minutes Notify the physician of the vital signs Anticipate administering IV fluids Notify the Rapid Response Team Answer: D Rationale: Although patients having continuous femoral nerve blockade after TKA have been found to require less opioids and antiemetics postoperatively, symptoms that may indicate the local anesthetic is getting into the patient’s system include metallic taste, tinnitus, nervousness, slurred speech, bradycardia, hypotension, decreased respirations, and seizures. This patient’s vital signs suggest instability and a Rapid Response Team should be activated immediately.

Question 3 During a health history assessment of a patient with RA, chronic HTN, and a recent CVA, she states that she takes 2 fish oil capsules (5 g) daily as a supplement for her RA. What additional question should the nurse ask? “Have you found the fish oil to help your RA?” “Does your physician know you are taking the fish oil capsules to treat your RA?” “Are you taking any anticoagulant medications as well?” “How long have you been taking the fish oil capsules?” Answer: C Rationale: Some supplements have been found to help decrease inflammation and prevent bone loss for patients with RA. These supplements include calcium, fish oil capsules containing omega-3 fatty acids, and gamma-linolenic acid. Calcium supplements should not be taken in excess to prevent kidney stones, and fish oil capsules should not be taken if the patient is taking anticoagulant therapy. (Source: Accessed July 28, 2011, from http://nccam.nih.gov/health/RA/#supplements)