1. 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.

2. 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

3. Joint changes in Degenerative Joint Disease

4. 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

5. Herberden’s Nodes

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

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

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

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

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

11. Continuous Passive Motion Machine

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

13. 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

14. 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

15. 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.

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

17. RA Joint Involvement
Common joint deformities seen in rheumatoid arthritis.

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

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

20. 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

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

22. 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

23. 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

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

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

26. Characteristic “Butterfly” Rash of SLE

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

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

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

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

31. 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

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

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

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

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

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

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

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

39. 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

40. 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.

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

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

43. Theoretic Pathophysiologic Model of Fibromyalgia

44. 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

45. 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?

46. 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.

47. 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.

48. 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.

49. 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.

50. Audience Response System Questions
Chapter 20
Audience Response System Questions 50

51. 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.

52. 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.

53. 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