1. Care of Patients with Arthritis and Other Connective Tissue Diseases
Chapter 20
Care of Patients with Arthritis and Other Connective Tissue Diseases

2. Rheumatology
Connective tissue disease (CTD) is a major focus of rheumatology.
Rheumatic disease is any disease or condition involving the musculoskeletal system.
Arthritis means inflammation of one or more joints.

3. Rheumatology (Cont’d)
Noninflammatory arthritis (osteoarthritis) is not systemic. OA is not an autoimmune disease.
Inflammatory arthritis:
Rheumatoid arthritis
Systemic lupus erythematosus
Autoimmune disease
Connective tissue disease that is inflammatory

4. Osteoarthritis Most common type of arthritis
Joint pain and loss of function characterized by progressive deterioration and loss of cartilage in the joints
Osteophytes
Synovitis
Subluxation

5. Joint Changes in Degenerative Joint Disease

6. Collaborative Management
History
Physical assessment and clinical manifestations:
Joint involvement
Heberden's nodes
Bouchard’s nodes
Joint effusions
Atrophy of skeletal muscle

7. Heberden’s Nodes

8. Ballottement

9. Assessments Psychosocial
Laboratory assessment of erythrocyte sedimentation rate and C-reactive protein (may be slightly elevated)
Radiographic assessment
Other diagnostic assessments:
MR imaging
CT studies

10. Chronic Pain: Nonsurgical Management
Analgesics
Rest
Positioning
Thermal modalities
Weight control
Integrative therapies

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

12. Total Hip Arthroplasty
Preoperative care
Operative procedures
Postoperative care:
Prevention of dislocation, infection, and thromboembolic complications
Assessment of bleeding
Management of anemia

13. Hip Flexion After Total Hip Replacement

14. Prevention of Complications
Assessment for neurovascular compromise
Management of pain
Progression of activity
Promotion of self-care

15. Total Knee Arthroplasty
Preoperative care
Operative procedures
Postoperative care:
Continuous passive motion machine
Hot/ice device
Pain management
Neurovascular assessment

16. Continuous Passive Motion Machine

17. Rheumatoid Arthritis
One of the most common connective tissue diseases and the most destructive to the joints
Chronic, progressive, systemic inflammatory autoimmune disease affecting primarily the synovial joints
Autoantibodies (rheumatoid factors) formed that attack healthy tissue, especially synovium, causing inflammation
Affects synovial tissue of any organ or body system

18. RA Pathology

19. RA—Collaborative Management
Assessment
Physical assessment and clinical manifestations:
Early disease manifestations—joint stiffness, swelling, pain, fatigue, and generalized weakness and morning stiffness
Late disease manifestations—as the disease worsens, the joints become progressively inflamed and quite painful

20. RA Joint Involvement

21. RA Systemic Complications
Weight loss, fever, and extreme fatigue
Exacerbations
Subcutaneous nodules
Pulmonary complications
Vasculitis
Periungual lesions
Paresthesias
Cardiac complications

22. RA—Assessments Psychosocial assessment
Laboratory assessment—rheumatoid factor, antinuclear antibody titer, erythrocyte sedimentation rate, serum complement, serum protein electrophoresis, serum immunoglobulins
Other diagnostic assessments—x-ray, CT, arthrocentesis, bone scan

23. RA—Drug Therapy Disease-modifying antirheumatic drugs NSAIDs
Biologic response modifiers
Other drugs:
Glucocorticoids
Immunosuppressive agents
Gold therapy
Analgesic drugs

24. RA—Nonpharmacologic Interventions
Adequate rest
Proper positioning
Ice and heat applications
Plasmapheresis
Gene therapy
Complementary and alternative therapies
Promotion of self-care

25. RA—Nonpharmacologic Interventions (Cont’d)
Management of fatigue
Enhancement of body image
Community-based care:
Home care management
Health teaching
Health care resources

26. Lupus Erythematosus
Chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail.
Characterized by spontaneous remissions and exacerbations.
Autoimmune process.
Autoimmune complexes tend to be attracted to the glomeruli of the kidneys.
Many patients with SLE have some degree of kidney involvement.

27. Lupus Erythematosus—Clinical Manifestations
Skin involvement
Polyarthritis
Osteonecrosis
Muscle atrophy
Fever and fatigue

28. Characteristic “Butterfly” Rash of Systemic Lupus Erythematosus

29. LE—Clinical Manifestations
Renal involvement
Pleural effusions
Pericarditis
Raynaud’s phenomenon
Neurologic manifestation
Serositis

30. Assessments for Lupus Psychosocial results can be devastating.
Laboratory:
Skin biopsy (only significant test to confirm diagnosis)
Immunologic-based laboratory tests
Complete blood count
Body system function assessment

31. SLE—Drug Therapy Topical drugs Plaquenil Tylenol or NSAIDs
Chronic steroid therapy
Immunosuppressive agents

32. Scleroderma (Systemic Sclerosis)
Chronic, inflammatory, autoimmune connective tissue disease
Not always progressive
Hardening of the skin

33. Scleroderma

34. CREST Syndrome C—calcinosis R—Raynaud’s phenomenon
E—esophageal dysmotility
S—sclerodactyly
T—telangiectasia

35. Scleroderma—Clinical Manifestations
Arthralgia
GI tract
Cardiovascular system
Pulmonary system
Renal system

36. Scleroderma—Interventions
Drug therapy
Identify early organ involvement
Skin protective measures
Comfort
GI manifestation
Mobility

37. Gout
Also called gouty arthritis, a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation
Primary gout
Secondary gout—hyperuricemia

38. Gout—Interventions
Drug therapy
Nutritional therapy

39. Other Connective Tissue Diseases
Polymyositis
Systemic necrotizing vasculitis
Polymyalgia rheumatica and temporal arteritis
Ankylosing spondylitis
Reiter’s syndrome
Marfan syndrome
Infectious arthritis

40. Lyme Disease
Reportable systemic infectious disease caused by the spirochete Borrelia burgdorferi, resulting from the bite of an infected deer tick.
Stages I and II.
If not diagnosed and treated in early stages, chronic complications such as arthralgias, fatigue, and memory and thinking problems can result.
For some patients, the first and only sign of Lyme disease is arthritis.

41. Lyme Disease Rash

42. Fibromyalgia Syndrome
Chronic pain syndrome, not an inflammatory disease

43. Chronic Fatigue Syndromes
Chronic illness in which patients have severe fatigue for 6 months or longer, usually following flu-like symptoms
Sore throat; substantial impairment in short-term memory or concentration; tender lymph nodes; muscle pain; multiple joint pain with redness or swelling; headaches of a new type, pattern, or severity; unrefreshing sleep; and postexertional malaise lasting more than 24 hours

44. Chapter 22
Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity

45. Hypersensitivities/Allergies
Increased or excessive response to the presence of an antigen to which the patient has been exposed
Degree of reaction ranging from uncomfortable to life threatening
Sentences and phrases

46. Type I: Rapid Hypersensitivity Reactions
Also called atopic allergy, this is the most common type of hypersensitivity.
Some reactions occur just in the areas exposed to the antigen.

47. Type I: Rapid Hypersensitivity Reactions (Cont’d)
Allergens can be contacted in these ways:
Inhaled (plant pollens, fungal spores, animal dander, house dust, grass, ragweed)
Ingested (foods, food additives, drugs)
Injected (bee venom, drugs, biologic substances)

48. Type I: Rapid Hypersensitivity Reactions (Cont’d)
Contacted (pollens, foods, environmental proteins)
Other reactions may involve all blood vessels and bronchiolar smooth muscle, causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction, which is known as anaphylaxis

49. Allergic Rhinitis

50. Patient-Centered Collaborative Care
History
Laboratory assessment—increased eosinophils, immunoglobulin E (IgE), RAST
Allergy testing
Patient preparation
Procedure
Follow-up care
Oral food challenges

51. Interventions Avoidance therapy: Environmental changes:
Air-conditioning and air-cleaning units
Cloth drapes
Upholstered furniture
Carpeting
Pet-induced allergies

52. Drug Therapy Decongestants Antihistamines Corticosteroids
Mast cell stabilizers
Leukotriene antagonists
Complementary and alternative therapy
Desensitization therapy

53. Anaphylaxis
First feelings of uneasiness, apprehension, weakness, and impending doom.
Pruritus and urticaria.
Erythema and sometimes angioedema of the eyes, lips, or tongue.

54. Anaphylaxis (Cont’d)
Histamine causes capillary leak, bronchoconstriction, mucosal edema, and excess mucus secretion.
Congestion, rhinorrhea, dyspnea, and increasing respiratory distress with audible wheezing result.
Anaphylaxis can be fatal.

55. Interventions
First assess respiratory function; an airway must be established.
CPR may be needed.
Epinephrine (1:1000) 0.3 to 0.5 mL subcutaneous is given as soon as symptoms appear.
Antihistamines treat angioedema and urticaria.
Oxygen.
Treat bronchospasm.
IV fluids.

56. Type II: Cytotoxic Reactions
The body makes special autoantibodies directed against self cells that have some form of foreign protein attached to them.
Clinical examples include hemolytic anemias, thrombocytopenic purpura, hemolytic transfusion reactions, Goodpasture’s syndrome, and drug-induced hemolytic anemia.

57. Antibody-Antigen Complexes

58. Type III: Immune Complex Reactions
Excess antigens cause immune complexes to form in the blood. These circulating complexes usually lodge in small blood vessels.
Usual sites include the kidneys, skin, joints, and small blood vessels.

59. Type III: Immune Complex Reactions (Cont’d)
Deposited complexes trigger inflammation, resulting in tissue or vessel damage.
Rheumatoid arthritis, systemic lupus erythematosus, and serum sickness occur.

60. Immune Complex in a Type III Hypersensitivity Reaction

61. Type IV: Delayed Hypersensitivity Reactions
In a type IV reaction, the reactive cell is the T-lymphocyte (T-cell).
Antibodies and complement are not involved.
Local collection of lymphocytes and macrophages causes edema, induration, ischemia, and tissue damage at the site.

62. Type IV: Delayed Hypersensitivity Reactions (Cont’d)
Other examples include positive purified protein derivative, contact dermatitis, poison ivy skin rashes, insect stings, tissue transplant rejection, and sarcoidosis.

63. Type V: Stimulatory Reaction
Excess stimulation of a normal cell surface receptor by an autoantibody, resulting in a continuous “turned-on” state for the cell.
Graves’ disease.

64. Autoimmunity
Autoimmunity is the process whereby a person develops an inappropriate immune response.
Antibodies and/or lymphocytes are directed against healthy normal cells and tissues.
For unknown reasons, the immune system fails to recognize certain body cells or tissues as self and triggers immune reactions.
Sentences and phrases

65. Sjögren’s Syndrome
Group of problems that often appear with other autoimmune disorders
Dry eyes, dry mucous membranes of the nose and mouth (xerostomia), and vaginal dryness
Insufficient tears causing inflammation and ulceration of the cornea
No cure; intensity and progression can be slowed by suppressing immune and inflammatory responses

66. Goodpasture’s Syndrome
Autoimmune disorder in which autoantibodies are made against the glomerular basement membrane and neutrophils
Lungs and kidneys
Shortness of breath, hemoptysis, decreased urine output, weight gain, edema, hypertension, and tachycardia
Treatment—high-dose corticosteroids