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

Question 1

Osteoarthritis risk

Answer 1

Age is the biggest risk factor. Genetic changes, obesity, smoking, and trauma. Athletes often have it in the hip and knee. Diabetes mellitus and Paget’s disease can lead to it. Blood disorders such as hemophilia and sickle cell disease can cause joint degeneration. Rheumatoid arthritis can cause it. Rarely congenital anomalies and joint sepsis can result in it. Most often in people older than 60 and more often in women.

To reduce the risk, decrease obesity, stop smoking, limit activities that cause stress on the joints, limit participation in sports, wear supportive shoes, avoid repetitive activities, avoid activities that are high in trauma

Question 2

Osteoarthritis assessment

Answer 2

Pain level, joint stiffness, joint swelling, how do you control it, is there loss of function?

Question 3

Osteoarthritis manifestations

Answer 3

Pain, crepitus, hypertrophy, inflammation, muscle atrophy, decreased ROM,

Hand: Heberden’s nodes at DIP
Bouchard’s nodes at PIP

Knee: joint effusion that you can move from infrapatellar notch to suprapatellar notch. Ballottement of the patella

Spine: nerve compression results in radiating pain, stiffness, spasms

Question 4

Osteoarthritis nursing diagnosis

Answer 4

Common: pain related to muscle spasm, deterioration, and joint inflammation. Impaired physical mobility related to pain and muscle atrophy.

Additional include activity intolerance, self-care deficit, disturbed body image, impaired walking, ineffective coping, imbalanced nutrition.

Question 5

Capsaicin

Answer 5

A topical over-the-counter drugs that works by blocking substance P which is a neurotransmitter for pain. Expect burning sensation for a short time after applying. Use plastic gloves for application. Avoid burning the eyes by washing hands immediately. It may be used for osteoarthritis

Question 6

CAM drugs for osteoarthritis

Answer 6

GLA & Efamol Is founded evening Primrose oil, Borige seed oil, and blackcurrant seed oil. It is an omega six fatty acids and is used for osteoarthritis and rheumatoid arthritis. They are found in fish and maybe taken in fish oil capsules.

Glucosamine/chondroitin are widely used. They are natural products found around bone Cartlidge for repairs and maintenance. Glucosamine decreases inflammation and chondroitin helps strengthen Cartlidge. Tell your healthcare provider if you are taking it. Do not take if you have hypertension, Pregnant, or breast-feeding. Monitor for bleeding. Monitor glucose levels if diabetic. They may cause a rash, G.I. disturbances, diarrhea, drowsiness, and headache. Take the dosage recommended for your weight. Read drug labels.

Question 7

Continuous peripheral nerve blockade CPNB

Answer 7

Is often used for total knee replacement. Femoral or sciatic nerve is infused with local anesthetic with a continuous infusion. This decreases pain and allows earlier rehab. Preform neurovascular assessment every 2 to 4 hours. The patient should be able to plantar flex and dorsiflex the foot but not feel pain. Check for movement, sensation, warm, color, pulses, capillary refill. Monitor for symptoms that indicate it is getting into the patient’s system such as a metallic taste, tinnitus, restlessness, Nervousness, slurred speech, bradycardia, hypertension, decreased respirations, and possible seizure.

Question 8

Rheumatoid arthritis pathophysiology

Answer 8

It is a chronic, progressive, systemic inflammatory autoimmune disease that affects primarily the synovial joints. Autoantibodies known as rheumatoid factors are formed that attack healthy tissue especially synovium which causes inflammation.

Inflammation occurs first and the synovial membrane, moves to the articular Cartlidge, joint capsule, surrounding ligaments and tendons. The synovium thickens, fluid accumulates, and a pannus forms. Pannus Is vascular granulation tissue composed of inflammatory cells. It errodes Cartlidge and destroys the bone. Secondary osteoporosis occurs. Early aggressive treatment may suppress synovitis and lead to remission. there are periods of remission and exacerbations. Because RA is a systemic disease, any organ or body system may be affected by inflammation.

Question 9

Manifestations of Rheumatoid arthrits

Answer 9

Early manifestations include joint inflammation,swelling, stiffness, and pain. Systemically includes a low-grade fever, fatigue, weakness, anorexia, paresthesias.

Late manifestations include deformity such as swan neck or ulnar deviation and moderate to severe pain with morning stiffness. Systemically you may see osteoporosis, severe fatigue, anemia, weight loss, subcutaneous nodules, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung disease, Sjogrens syndrome, renal disease.

If only one joint is swollen and inflamed, it may indicate infection.
Morning stiffness is called the gel phenomenon which lasts for about 45 min.

If it involves the first and second vertebrae, it could be life-threatening because branches of the phrenic nerve supply the diaphragm are restricted and respiratory function is compromised. The patient could also become a quadriplegic.

Joint deformity often occurs. Baker’s cyst behind the knee occur often. Can often cause tendon rupture and Achilles tendon rupture.

Question 10

Systemic complications of rheumatoid arthritis

Answer 10

Weight loss, fever, extreme fatigue are late exacerbations. They are called flareups. Subcutaneous nodules which are round, movable, and nontender and usually appear on the ulnar surface of the arm, fingers, or Achilles’ tendon. They disappear and reappear and are associated with severe destructive disease. They can open up and become infected.

Vasculitis is inflammation of the blood vessels. Organs can become ischemic and malfunction. Periungual lesions are brownish spots that appear in groups around the nail bed. Increased # of lesions indicates and increased vasculitis. Peripheral neuropathy can cause foot drop and paresthesias.

Respiratory complications pleurisy, pneumonitis, diffuse interstitial fibrosis, and pulmonary hypertension.

Cardiac includes pericarditis and myocarditis
Eye iritis and scleritis shows reddened sclera and irregular shaped pupils.

Question 11

Associated syndromes with rheumatoid arthritis

Answer 11

Most common is Sjögren’s syndrome which includes dry eyes (keratoconjunctivitis sicca); dry mouth (xerostomia); dry vagina in some cases.

Felty’s syndrome: RA, hepatosplenomegaly (enlarged liver and spleen), and leukopenia

Caplans syndrome: rheumatoid nodules in the lungs and pneumoconiosis (coal and aspestos workers)

Question 12

Labs for RA

Answer 12

Rheumatoid Factor: Increase (or positive) is indicative of RA, CTD, but possible elevated with leukemia, liver, and renal disease

ANA antinuclear antibody: positive in 30% of RA, and also seen in lupus and scleroderma. If RA has Sjrgens syndrome, antiSS is positive in 75%

Serum complement: 75-160 decreased shows active autoimmune disease such as RA, lupus and other problems like anemia, infection, and malnutrition

ESR: Male up to 15, female 20; Increase shows inflammatory diseases such as RA, SLE, PMR, temporal arteritis. Elevated with bacterial infections or severe anemia. This test is helpful in monitoring the course of the disease

Most chronic diseases cause anemia. Monitor the pts CBC, RBC, WBC

X-rays, CT scan, bone scan, MRI show joint changes
Arthrocentesis of joint fluid to check for RF and inflamatory cels. Monitor for Bleeding and or leakage. Ice and rest for 24 hours

Question 13

Drug therapy for RA

Answer 13

See pg 341&342
DMARDS Disease modifying anti-rheumatic drugs may slow the progression of the disease.

Methotrexate: immunosuppresive, once week, takes 4-6 weeks to start working. Monitor for adverse effects such as low WBC and platelets, or elevated liver and creatnine. No alcohol. Toxic symptoms include mouth sores, dyspnea from pneuomonitis, lymph node tumor. Folic acid may help decrease side effects. Birth control must (dc at least 3 months)

Question 14

Nonpharm therapies for RA

Answer 14

Plasmapheresis where antibodies are removed.
Physical therapy
Ice and Heat
Gene Therapy is experimental

Foods high in calcium to prevent bone loss
Fish oil and Omega 3s reduct inflammation (do not take with anticoagulant)
Foods high in antioxidants (vitamins C&E) to help immune system
Herbs: valerian for sleep, ginger, curcumin, and boswellia for inflammation

Question 15

Teaching for RA

Answer 15

Make sure they know the treatment plan and can adhere to it.

Do not try over the counter remedies without consulting doc or arthritis foundation

Teach about drug therapy, joint protection, energy conservation, rest, exercise.

Promote and allow self care

Question 16

Cuny’s test questions about RA

Answer 16

Althought arthritis is not curable, many types of cures are marketed to patients. What does the nurse tell pt?
A: check with arthritis foundation

What problem is associated with RA? osteoporosis

What is NOT consistent with RA? Ischemia (wt loss is found in RA)

In RA, autoantibodies formed attack tissue and synovium causing what? inflammation

Match RA drugs with side effects

Analgesics: headache, dizzy, drowsy
Steroids: diabetes, infection, htn
NSAIDS: GI problems
Methotrexate: bone marrow suppression and mouth sores
Gold injections: rash, blood dyscrasias, renal involvement
Enbrel: red, itchy rash at injection site

Question 17

Lupus Erythematosus pathophysiology

Answer 17

DLE discoid lupus (only affects the skin)
SLE systemic lupus

Systemic lupus is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. It has periods of remissions and exacerbations. It is thought to be an autoimmune disease that causes inflammation and damage. It invades organs and causes vasculitis and deprives organs of blood and oxygen. It is usually has kidney involvement, which is what usually causes of death. The onset usually occurs during childbearing years but can be in young children and older adults.

Question 18

Risk for systemic lupus

Answer 18

The combination of genetic and environmental factors. Affects more women than men. It is seen often in African-American. It is more common among Native Americans, Asian Americans and Hispanics. It is seen the least European and American women

Question 19

Manifestations of systemic lupus

Answer 19

Inflamed and red rash, discoid lesions, renal nephritis, pericarditis(tachycardia, chest pain, myocardial ischemia), Raynaud’s phenomenon, pleural effusions, CNS lupus( psychoses, paresis, seizures, migrains, CN palsies), abdominal pain, joint inflammation, myositis, fever(sign of a flare up), fatigue, anorexia, vasculitis, possible enlarged lymph nodes

They often have a butterfly rash on the face that is dry and scaly. The discoid lesions are scaring lesions. They appear more often when exposed to sunlight. The patient may have alopecia. They often have polyarthritis and have early joint changes. Osteonecrosis may occur for those taking steroids longer than five years.

Question 20

Laboratory assessment for lupus

Answer 20

For DLE, a skin biopsy

Same as for RA. RF, ANA, ESR, serum protein,

May have a false positive syphilis test
CBC shows pancytopenia

Question 21

Drug therapy for lupus

Answer 21

Topical Cortizone to reduce inflammation and promote fading of skin lesions. Antimalarial agent called Plaquenil to decrease the inflammatory response. If using it they need to have frequent eye examinations.

Systemically lupus is treated aggressively until remission. Often uses steroid therapy. Methotrexate and Imuran can be used. During remission they will follow a maintenance dose. This makes patients prone to infection. They should avoid crowds and ill people.
For severe renal involvement immunosuppressants and steroids are used in combination. If that doesn’t work, high-dose IV bolus of glucocorticoids, cyclophosphamide, and plasmapheresis maybe given for 3 days. Renal transplant has been successful.

Question 22

Skin protection for lupus

Answer 22

Avoid exposure to sunlight and UV light. This includes certain fluorescent lights. wear long sleeves and a large brim hat. Sunscreen of at least SPF 30. Avoid perfumed substances. Choose cosmetics carefully.

Hair should be taken care of carefully because of alopecia. Use mild protein shampoo and avoid harsh treatment such as permanent and highlights.

Question 23

Care of Lupus

Answer 23

It is a lot like rheumatoid arthritis. Rehab is not usually used because joint deformity is rare. One difference includes how to protect the skin. The second difference is to teach them to monitor body temperature. Fever is the first sign of exacerbation.

Teach them that pregnancy can cause exacerbation of the disease either during or after delivery. There is increased risk of miscarriage, stillbirth, or premature birth. The arthritis foundation and Lupus foundation can be of help.

Question 24

Scleroderma

AKA systemic sclerosis

Answer 24

Chronic, inflammatory, autoimmune connective tissue disease. It is a hardening of the skin. It has a higher mortality rate than lupus because it does not respond to steroids and immunosuppressants as well. Early on it is similar to lupus and is often misdiagnosed. The inflamed tissue with scleroderma become inflamed, fibrotic, and then sclerotic/hard. Renal involvement is the leading cause of death. Respiratory involvement and hypertension are common.

Diffuse: skin thickening of the trunk, face, proximal and distal extremities

Limited: thick skin distal to elbows an knees, on the face and neck

CREST Syndrome
Calcinosis (calcium deposits
Raynaud's phenomenon
Esophageal dysmotility
Sclerodactyly (scleroderma of digits0
Telangiectasia (spider like hemangiomas)

Risk for it is four times more in women than men. Onset between 25 and 65. Higher in coal miners and silicosis. Choctaw American Indians from Oklahoma have the highest incidence.

Question 25

Manifestations of scleroderma

Answer 25

The skin is inflamed, fibrotic, sclerotic, and edamatous. There is renal failure, myocardial fibrosis, Raynaud’s phenomenon, interstitial fibrosis, pulmonary hypertension, esophagitis, ulcers, joint inflammation, myositis, fever, fatigue, anorexia, vasculitis.

Joint pain and stiffness are the most common. Deformities are rare. There is often pitting edema of the hands and fingers that can progress to the upper and lower extremities and face. The skin is taught, shiny, and free of wrinkles. Indurative phase is when the swelling is replaced by tightening, hardening, and thickening of skin. The skin loses elasticity, range of motion is decreased, ulcers may occur. Joint contractures may develop. The organs mostly affected by the G.I. tract, cardiovascular system, pulmonary system, and renal system.

Assess the ability of the patient to swallow. Peristalsis maybe diminished. Malabsorption is common. In severe cases, there may be autoamputation of the distal digits. The lungs often have fibrosis of the alveoli and interstitial tissues. Renal involvement causes malignant hypertension and death. Assess for signs of impending organ failure.

Question 26

Testing for scleroderma

Answer 26

Is similar for those with systemic lupus. Clinical findings and the response to drug therapy help the doctor differentiate between the two diseases. Often an upper and lower G.I. is performed because of the frequency of G.I. manifestations.

Question 27

Treatment for scleroderma

Answer 27

Drug therapy is used but is often unsuccessful. Systemic steroids and immunosuppressants are used in large doses and in combination. Often the organ that is involved is treated. Teach the patient to take care of skin. Nurses should take careful care of the skin and avoid chilling room temperature. Smoking and stress should be avoided.

Esophageal involvement: keep the head elevated at least 60° during meals and for 1 to 2 hours after meals. Provide frequent small meals. Give the patient small amounts of bites. Provide soft foods. Liquids are most likely to cause choking. Give antiacids. Avoid foods such as caffeine, pepper, and spices. A swallowing study may be needed

Question 28

Gout

Answer 28

Systemic disease in which hearing crystal deposits in the joint and other tissues causing inflammation. Most often in older adults.

Primary gout: most common, results from error of purine metabolism, uric acid production exceeds excretion from the kidneys. It is deposited into synovium and other tissues causing inflammation. It is often an x linked trait affecting older men 40-50 and postmenopausal women.

Secondary gout: hyperuricemia which is excessive uric acid in the blood. It affects all ages and is often from secondary disease. Renal insufficiency, diuretic therapy, crash diets, and chemotherapeutic agents help decrease excretion of uric acid. Treat the underlying disorder.

Primary
Asymptomatic Hyperuricemia stage: unaware, but high levels
Acute gouty arthritis stage: Excruciating pain and inflammation usually in the great toe (calle podagra). ESR increased
Chronic or tophaceous gout: after having repeated episodes, urate crystals may form in the skin and organs, especially renal causing urate kidney stones.

Question 29

Assessment of gout

Answer 29

A complete family history. And drug history especially diuretics.

Acute gout has joint inflammation and pain. A uric acid level is checked and repeated. >8.5 is abnormal. urinary levels >750 in 24 hrs. Possible BUN, creatnine. Synovial fluid aspiration is difinitive.

Chronic: skin has tophi (deposits of urate crystals) especially on ear. May have a yellow gritty discharge if broken open. Kidney stones and dysfunction.

Question 30

Treatment of gout

Answer 30

Acute gout: Colsalide IV and an NSAID for 4-7 days.

Chronic: Drugs to promote uric acid excretion or reduce its production. Allopurinol is drug of choice. Probenecid also used and may be combined. Avoid aspirin because it inactivates these drugs.

Patient should avoid foods such as organ meats, shellfish, oily fish with bones such as sardines. Limited foods should include redmeat. Excessive alcohol intake and starvation diet can cause a gouty attack. Avoid aspirin and diuretics. Stress can exacerbate the disease. Drink plenty of fluids to decrease stones.

Question 31

Polymyositis

Answer 31

Inflammatory disease of skeletal muscle that causes symmetric weakness and atrophy. If accompanied by a rash is called dermatomyositis. Women are affected twice as men and between 30 to 60 years of age. They often have polyarthritis, polyarthralgia, Raynaud’s phenomenon, a lilac rash, periorbital edema. They develop difficulty swallowing or talking because of muscle weakness. Treat with high-dose steroids, immunosuppressive agents, and supportive care.

Question 32

Systemic Necrotizing Vasculitis

Answer 32

a group of diseases that primary manifestation is arteritis (inflamation of the arterial walls) Which causes ischemia in the tissues supplied by the vessels. Chronic steroid therapy and immunosuppressive drugs may be used.

Question 33

PMR Polymyalgia rheumatica

Answer 33

Syndrome characterized by stiffness, weakness, aching of the proximal musculature. May have low-grade fever, arthralgias, stiffness, fatigue, weight loss. Most common joints include the neck, shoulder, and hip. Stiffness is worse in morning. Occurs women over 50 and respond to low-dose steroids

GCA giant cell arteritis and TA temporal arteritis
Possible scalp tenderness, amaurosis fugax (temporary vision loss in one eye. Diplopia or any vision change requires urgent management.

Take calcium and Vitamin D to prevent osteoporosis from steroids.

Question 34

Ankylosing spondylitis

Answer 34

Also known as the Marie/Strum/pell disease or rheumatoid spondylitis. This affects the vertebral column and causes spinal deformities. White men younger than 40 are most affected. There is iritis and arthralgia. Systemic manifestations include malaise and weight loss. Respiratory function may be compromised from a stiff chest wall. Heat, physical therapy, and anti-inflammatories are the key to management. DMARDs may slow the progression.

Question 35

Reiters Syndrome

Answer 35

Usually affects young white men. It’s a triad of arthritis, conjunctivitis, and urethritis resulting from exposure to STDs or from dysentery which is infectious diarrhea. May have balanitis circinata (ring like inflammation of glans penis) and skin lesions.
Treatment normally consists of NSAIDs and physical therapy.

Question 36

Marfan Syndrome

Answer 36

Autosomal dominant, connective tissue disease with abnormalities of the skeletal, ocular, cardiopulmonary, and central nervous systems from a defect in extracellular microfibrils. Patients are usually tall and have elongated hands and feet. Scoliosis, funnel shaped chest, loss of normal curve, hyperextensibility of joints, subluxation of the lens occurs by five years old. Cardiovascular problems are responsible for most death. Average lifespan is usually 30s. It is common to have mitral valve prolapse with regurgitation and aortic aneurysm. Carefully monitor by EKG.

Question 37

Lyme disease

Answer 37

Systemic infectious disease from the bite of deer tick. Most cases are seen in the new in England and mid-Atlantic state, the upper Midwest during the summer months. Stage one the patient appears with flulike symptoms, erythema migrans (raised rash) And pain and stiffness in the muscles and joints. Most patients in the US only have one bullseye lesion. Symptoms begin in 3 to 30 days of the bite. Antibiotic therapy using doxycycline, amoxicillin, or cefuroxime should be prescribed for days for 2-3 weeks. Symptoms may disappear without treatment in 4 to 5 weeks. Stage II occurs 2 to 12 weeks after the bite. The patient can develop carditis, dysrhythmias, dyspnea, dizziness, palpitations, meningitis, facial paralysis, peripheral neuritis. For severe disease IV antibiotics for at least 30 days

If lyme disease is not diagnosed and treated early it can turn into chronic/late stage. It occurs months to years after it. The first and only sign may be arthritis. Prevention is the best strategy for Lyme disease.

Question 38

How to prevent Lyme disease

Answer 38

Avoid heavily wooded areas in the spring and summer months. Walk on the trail. Avoid dark clothing, light clothing makes spotting ticks easier. Use insect repellent with DEET on skin and clothes. Wear long sleeves and long pants, tuck your shirt into your pants and pants into boots. wear hat or cap and close tennis shoes. Shower and inspect after being in a prone area. Check your pets for tix. Gently remove with tweezers or fingers covered with gloves. Do not squeeze. Flushing down the toilet but do not burn. Clean the area with alcohol. Wait for to six weeks after being bitten to be tested. Report symptoms such as flu or rash

Question 39

Pseudogout

Answer 39

Disease that mimics the clinical manifestations of gout, but the crystals are calcium pyrophosphate. The person most susceptible to pseudogout is an older hospitalized male. NSAIDs usually control this disease

Question 40

Psoriatic arthritis

Answer 40

Affect 5 to 10% of people who have psoriasis. Fingernail pitting and lifting may occur. Joint pain with stiffness in the morning. Neck and back pain are common. Usually between the ages of 20 and 50 years of age. Can be genetic or environmental, infectious, or immune system ddysfunction

Treatment is focused on managing joint pain and inflammation, controlling skin lesions, and slowing the progression of the disease. It is similar to the treatment of rheumatoid arthritis.

Question 41

Fibromyalgia syndrome

Answer 41

It is a chronic pain syndrome. Pain and tenderness are located at specific sites in the back of the neck, upper chest, trunk, low back, and extremities. They are known as triggerpoints and can be palpated to elicit pain in a predictable reproducible pattern. The pain is usually burning and gnawing. May have muscle tenderness. The pain comes and goes but usually worsens with stress, increased activity, and weather. The patient has mild to severe fatigue with sleep disturbances. Some people reported numbness and tingling, noxious odors, loud noises, Brightlight, headache, and jaw pain. Other symptoms include abdominal pain, diarrhea, constipation, heartburn, dysuria, urinary frequency and urgency, pelvic pain, dyspnea, chest pain, dysrhythmias, blurred vision, dry eyes. Patients are frustrated because they are not diagnosed and are in constant pain and discomfort.

Usually occurs in women between 30 and 50. Teach patients to limit caffeine, alcohol, and substances that interfere with sleep. Secondary fibromyalgia accompanies lupus, rheumatoid disease. Lyrica Is approved for nerve pain. It may cause drowsiness and sleepiness and alcohol should be avoided. Antidepressants may help. It should be used in caution with older adults. Physical therapy and then NSAID may be used. Exercise regularly.

Question 42

Chronic fatigue syndrome CFS

Answer 42

Chronic illness in which patients have severe fatigue for six months or longer, usually following flulike symptoms. In addition FOUR of the following must be met. Sore throat, short-term memory or concentration impairment, tender lymph nodes, muscle pain, multiple joint pain with redness or swelling, new headaches, unrefreshing sleep, or postexertional malaise lasting more than 24 hours.

Most common in women. There is no lab test to confirm. Treatment is supportive and focuses on alleviating or reducing symptoms. Teach the patient to follow a healthy practices, get adequate sleep and exercise, stress management, energy conservation.

Question 43

Prednisone

Answer 43

Decreases inflammatory and immune response by decreasing white blood cell count. Observed for cushingoid changes such as moon face, buffalo hump, striae, acne, thin-skinned, bruising, fluid retention, and increase blood pressure. These changes are expected and diminished as the dose decreases. Monitor electrolytes, glucose, and weight. Steroid therapy causes sodium or fluid retention, potassium depletion, and elevated glucose levels. Observed for long-term side effects such as osteoporosis, cataracts, hypertension, diabetes, impaired feeling. Increase calcium and vitamin D. These Complications May need to be treated with other medications. Instruct the patient to avoid crowds and people with infections such as influenza.

Question 44

Enbrel

Answer 44

Is a biological response modifier that decreases the immune response. Given subcutaneously by injection once or twice a week. Report any reaction to this site. It is often used in combination with methotrexate. You should monitor the labs such as CBC, creatinine, liver panel about every four weeks. Teach how to self administer injections. Ice and hydrocortisone cream can be used if there is a red itchy rash at the injection site. Mild increase risk of upper respiratory infection.