Chapter 34 Assessment & Management of Patients w/ Inflammatory Rheumatic Disorders Flashcards
Rheumatic Disorders
Numerous disorders affecting skeletal muscles, bones, cartilage, ligaments, tendons, and joints
Examples of Inflammatory Rheumatic Disorders
Rheumatoid Arthritis
Spondyloarthropathies
Systemic Lupus Erythematosus
Impact of Rheumatic Disorders
Limitations in mobility & ADLs
Pain
Fatigue
Altered self-image
Sleep disturbances
Systemic effects that can lead to organ failure & death
Rheumatic diseases most commonly manifest the clinical features of…
…arthritis & pain
Arthritis
Inflammation of a joint
Which population is more affected by rheumatic disorders? Women or Men?
Generally, women are 2-9 X more commonly affected by rheumatic disorders
These disorders tend to be marked by…
… periods of remission & exacerbation
Remission
A period when the disease symptoms are reduced or absent
Exacerbation
A period when symptoms occur or increase
Inflammation
A complex physiologic process mediated by the immune system that occurs in response to harmful stimuli
Meant to protect the body from insult by removing the triggering antigen or event
Steps of Inflammatory Process
1) Antigen stimulus
2) Body’s immune system activates & forms antibodies like monocytes & T lymphocytes (T-cells)
3) Immunoglobulin antibodies form immune complexes w/antigens
4) Phagocytosis of the immune complexes is initiated
- Produces chemicals (leukotrienes & prostaglandins)
5) Inflammatory response is generated
- Joint effusion
- Edema
- Pain
Leukotrienes
Contribute to the inflammatory process by attracting other WBCs to the area
Prostaglandins
Act as modifiers to inflammation
- Can either increase or decrease it
Collagenase
Breaks down collagen
- Causes edema & proliferation of the synovial membrane
Pannus
The proliferation of newly formed synovial tissue infiltrated w/ inflammatory cells
Autoimmunity
Body recognizes own tissue as foreign antigen
Degeneration
Secondary response to inflammation
Common Symptoms of Rheumatoid Disease
Joint pain & swelling
Limited movement
Stiffness
Weakness
Fatigue
Assessment: Obtaining a Health History
Onset of symptoms & how they have evolved
Family hx
Past history
Patient’s perception of the problem
Previous treatments & their effects
Patient’s support system
Patient’s current knowledge base & source of info
Gerontological Considerations for Rheumatoid Disorders
Musculoskeletal problems are the most frequently reported conditions in older adults
- Will be seen more frequently by health professionals in the coming years along w/ associated disability
- Especially frail older adults
Comorbid conditions have the ability to mask or alter presenting symptoms
These need to be assessed in older adults:
- Frequency
- Pattern of onset
- Clinical features
- Severity
- Effects on function of the rheumatic disease in older adults
Behavioral clues may aid the nurse in assessing the patient’s pain when cognitive impairment is present:
- Gait patterns
- Guarding
- Flexion
Rheumatoid Arthritis (RA)
Chronic Inflammatory Disease that can affect people of all ages
Chronic joint inflammation by a disruption in immune system
Rheumatoid Arthritis (RA) Risk Factors
Environmental factors (pollution)
Cigarette smoking: Highly related to RA
Family Hx of 1st-degree relatives
Bacterial & viral illnesses
What does rheumatoid arthritis attack?
Mostly conjunctive tissue (synovial membrane, tendons, & ligaments)
The effect of RA on the joints
Inflammation causes swelling, pain, & burning sensation
Clinical Manifestations of Rheumatoid Arthritis (RA)
Symmetric joint pain & morning stiffness (last longer than 1 hr)
Spongy/boggy tissue (fluid may be aspirated)
Symptoms begin in small joints & move to larger joints as disease progress
Symptoms are bilateral & symmetric
Limited func may be present before the presentation of bony changes
- Loss of function due to contractures
Ulnar deviation & swan neck deformity
System Manifestations:
- Fever
- Fatigue
- Weight loss
- Anemia
- Lymph node enlargement
- Raynaud’s phenomenon
Pharmacological Treatment of RA
Biologic of Non-Biologic Disease-modifying antirheumatic drug (DMARD)
-Hydroxychloroquine:can cause retinal degeneration -Methotrexate:bone marrow suppression, GI ulcerations, skin rashes
-Infliximab (Remicade): Must have TB test before administration
Gout
Most common form of inflammatory arthritis
A type of inflammatory arthritis characterized by deposits of uric acid crystals in the joints
Why does gout mainly affect the big toe?
Mainly affects the big toe due to being the most distal part & the coldest part of the body
- Decrease in temperature turns uric acid-> crystals
-> Worsens at night due to this
Tophi
Crystalline deposits accumulating in articular tissue, osseous tissue, soft tissue, and cartilage
Primary Hyperuricemia Causes
Results from severe dieting or starvation, excessive intake of foods high in purines (shellfish, organ meats) or hereditary
Secondary Hyperuricemia Causes
Results from a clinical feature secondary to genetic or acquired processes, including:
- leukemia
-multiple myeloma
-some types of anemia
-psoriasis
-diuretics (thiazides and furosemide)
-low-dose salicylates, or ethanol
Acute Gouty Arthritis
Recurrent attacks of severe articular and periarticular inflammation
What are some triggers for acute gouty arthritis?
Triggered by trauma, ETOH ingestion, dieting, meds, surgical stress or illness
Clinical Manifestations of Acute Gouty Arthritis
Abrupt onset (often at night)
Severe pain, redness, swelling, and warmth of affected joint
What elements should the nurse assess in a patient with Gout?
Lab values (uric acid)
Diet
Gait
Pain
Assess for signs of inflammation, which joints are involved, & extent
Education on disease process, readiness to learn
The 4 Stages of Gout
1) Asymptomatic hyperuricemia
2) Acute gouty arthritis
- Triggered by trauma, ETOH ingestion,
dieting, meds, surgical stress or illness
Abrupt onset often at night
Severe pain, redness, swelling, and
warmth of affected join
3) Intercritical gout (symptom-free gout)
4) Chronic tophaceous gout
Name 3 priority nursing diagnosis for a patient with gout?
Acute Pain
Impaired Mobility
Knowledge deficit
Nursing Interventions for Gout: Medications
Colchicine for acute attacks
NSAIDs (indomethacin)
Corticosteroids
Allopurinol - uric acid lowering therapy given post acute attacks
Probenecid - uricosuric agent for patients with frequent attacks
Nursing Interventions for Gout: Patient Education
Lifestyle changes
-Avoiding purine-rich foods
-Weight loss
-Decreasing alcohol consumption
-Avoiding certain medications
Pain management and avoidance of factors that increase pain and inflammation, such as trauma, stress, and alcohol
Foods to Avoid in Patients w/ Gout
Purine Rich Foods: Anchovies, liver, sardines, lentils, & alcoholic beverages
Osteoarthritis
Progressive Mechanical Disease
Degradation of articular cartilage caused by friction causing pain and stiffness (non-inflammatory)
Associated w/ aging & overworked joints
Osteoarthritis Risk Factors
65 years or older
Work-related issues
Female
Obesity
Hispanic/African American Descent
What occurs in a joint affected w/ osteoarthritis?
Degradation of articular cartilage caused by friction causing pain and stiffness (non-inflammatory)
The effect of osteoarthritis on tendons & ligaments
Tendons and ligaments lose their elasticity and wear out, reducing their mobility
Clinical Manifestations of Osteoarthritis
Pain and brief morning stiffness, lasting < 30mins
Functional impairment
Joints aggravated by movement or exercise
-Relieved by rest
Affected joints may be enlarged w/ decreased ROM
Crepitus may be palpated, especially over the knee Mild joint effusion, a sign of inflammation
Heberden’s and Bouchard’s nodes
Herberden’s: Distal interphalangeal
Bouchard’s: Proximal interphalangeal
No systemic manifestations
Pharmacological Treatment of Osteoarthritis
Acetaminophen: Initial therapy
NSAIDS: Cox-2 enzyme blockers for those at risk for GI complications
Opioids and Corticosteroids:Topical diclofenac sodium gel (Voltarengel)
Glucosamine and chondroitin
Surgical Treatments for both RA & OA
Osteotomy or Arthroplasty
Rehab with physical therapy w/in 1st 24hrs
Arthroplasty
Surgical removal of an unhealthy joint removal & replacement of joint surfaces w/metal or synthetic materials
Common Conditions that May Require Arthroplasty
Osteoarthritis (OA), RA, congenital deformities
Frequently Replaced Joints
Hips, knees, & fingers
Total Hip Arthroplasty
Replacement of a severely damaged hip w/ an artificial
joint
Total Hip Arthroplasty Indications
Osteoarthritis or Rheumatoid arthritis
Femoral neck fractures,
Failure of previous reconstructive surgeries
Conditions resulting from developmental dysplasia
(avascular necrosis of the hip in childhood)
*Prostheses chosen based on skeletal structure and activity level
Complications of Total Hip Arthroplasty
Dislocation of hip prothesis
Excessive wound drainage
VTE
Infection
Heel pressure injury
Long-Term Complications:
- Heterotopic ossification
- Avascular necrosis
- Loosening of the prosthesis
Heterotopic Ossification
Formation of bone in periprosthetic space
Signs & Symptoms of Hip Dislocation
Increased pain, swelling, and immobilization
Acute groin pain in the affected hip or increased discomfort
Shortening of the affected extremity
Abnormal external or internal rotation of the affected extremity
Restricted ability or inability to move the leg
Reported “popping” sensation in the hip
Hip Dislocation Prevention
Always maintain correct position
- Supine, head slightly elevated, affected leg in neutral position
Use abductor splints or pillows to support extremity
Support leg and place pillows between the affected legs when patient is turning. Always turn to the unaffected side.
Avoid acute flexion of the hip (head of the bed 90 degrees or less) or crossing legs
Assess for dislocation (notify surgeon immediately if suspected)
Which position does the performed hip need to be in?
Abduction
Abduction
Movement away from the center or median line
Adduction
Movement towards the center or median line
- The affected hip needs to be protected from this
Gerontological Considerations for Total Hip Arthroplasty (THA)
Early THA surgery is recommended for hip fractures w/in a 24- 36 hrs after patient’s condition has been stabilized properly
If there are no contraindications (bleeding disorder) low-molecular-weight heparin is recommended for VTE prevention
- In the case of contraindications, mechanical devices should be used
Consult w/ pain management specialist would be helpful due to altered LOC, medical co-morbidities, & polypharmacy
ALL older adults who are post-THA they are put on a higher-specification, foam pressure-relieving mattress vs regular mattress
Early assisted mobilization is key
Total Knee Arthroplasty
A surgical procedure in which parts of the knee joint are replaced with artificial (prosthetic) parts
Total Knee Arthroplasty Indications
Considered for patients:
- Joint pain cannot be managed w/ nonsurgical treatment
- Has severe pain
- Functional disability related to destruction of joint surfaces
Benefits of Total Knee Arthroplasty
Successful, cost-effective, low-risk
therapy
Offers significant pain relief
Restores of quality of life and function
Nursing Management of Total Knee Arthroplasty
Knee is dressed w/ compression bandage
Cold/ice packs may be applied to reduce postop swelling & bleeding
Assess the neurovascular status of the surgical extremity & compare it w/ contralateral extremity every 2-4hrs
Wound suction drain is used to remove fluid accumulating around the knee
- Usually left in place 24-48hrs to prevent infection
Acute rehab usually takes between 1-2 weeks
- Total recovery takes 6 weeks or longer (especially those 65 yrs or older)
Osteolysis
Lysis of bone from an inflammatory reaction against polyethylene particulate debris
Nursing Management of Post-Arthroplasty Care: Managing Blood Loss
Assess dressing (saturation, color change) multiple times per protocol
-> Draw around area of bleed
-> DO NOT remove aqua-seal dressing (decreases risk for bleeding & infection-> has antibiotic properties)
-> Anything over 250 mL of blood loss is EXCESSIVE
Monitor H & H (baseline & watch for anemia)
Administer fluids & blood products (donor blood, autologous blood, plasma) as ordered
Assess for signs of bleeding
Nursing Management of Post-Arthroplasty Care: Managing Pain
Pre & Post-op Pain assessment
OLDCARTS pain assessment
Early ambulation
Administer pain meds as ordered
Compression therapy
Numeric Pain Scale to assess current pain level
PQRST Pain assessment
Imagery
Provide education on expectations of pain ( meds may not completely make pain go away but, make it tolerable)
Assess for cultural influence
Nursing Management of Post-Arthroplasty Care: Monitoring Wound Drainage
Assess bandage
- Assess drainage characteristics: color, smell, & amount
- Trend documentation of drainage
Assess pulses, cap refill, color, temp, motion, strength, & sensation of extremity
Assess for signs of shock: hypotension, tachycardia, diaphoresis, fever, tachypnea
Acceptable drainage: Lower than 250 mL
- 25 to 30 mL drainage level to remove drain
Nursing Management of Post-Arthroplasty Care: Promoting Ambulation
Set distance goals
Educate on benefits
Pain management
Assess for fall risk, assistive devices, orthostatic hypotension
Make short term goals
Assess for tolerance, medicate before ambulation
Avoid flexion contractures (do not bend leg for extended periods of time)
Nursing Management of Post-Arthroplasty Care: Preventing Venous Thromboembolism (VTE)
Assess for unilateral calf pain/ tenderness every 8 hrs
Avoid pressure on popliteal blood vessels from equipment (pillows, abductor splint straps, sequential compression stockings)
Compression devices
Assess pulses, cap refill
Early ambulation
Anticoagulants: Heparin, Lovenox
Routine nuerovascular checks q8 hrs (initially q 15mins)
- Take SCDs off for at least 20 mins 2X every shift
Nursing Management of Post-Arthroplasty Care: Preventing Infection
Proper wound care
- Aseptic technique
Assess for s/s of infection
- Monitor CBC panel
Employ hand hygiene
Admin antibiotics prophylactically 30 mins- 1hr before surgery
Note date & time of dressing
Nursing Management of Post-Arthroplasty Care: Providing Patient Education & Support
Positioning
Physical limitations per PT recommendations
How to use assistive devices
Ambulate per provider orders
Pain management
S/s of post-op complications
Avoid flexion contractures
Gradually progress
Teach back for post-op instructions & follow-up care
Which disease is associated w/aging or overworked joints (Osteoarthritis/Rheumatoid arthritis)?
Osteoarthritis is associated
Which disease is chronic and affects all ages (Osteoarthritis/Rheumatoid arthritis)?
Rheumatoid arthritis is associated
Common Blood Studies: Erythrocyte Count
Measures circulating erythrocytes
Clinical Significance of Erythrocyte Count
Decrease can be seen in RA due to inflammation
Common Blood Studies: Erythrocyte Sedimentation Rate (ESR)
Measures the rate at which RBCs settle out of unclotted blood in 1 hour
Clinical Significance of ESR
Increase is usually seen in inflammatory connective tissue diseases.
-RBCs become more thick & heavy-> quickly fall to the bottom
An increase indicates rising inflammation, resulting in clustering of RBCs, which makes them heavier than normal.
The higher the ESR, the greater the inflammatory activity
Common Blood Studies: Hematocrit
Measures the size, capacity, and number of cells present
in blood
Clinical Significance of Hematocrit
Decrease can be seen in chronic inflammation
- Anemia in chronic disease
- Blood loss via GI bleed
Common Blood Studies: Uric Acid
Measures level of uric acid in serum
Clinical Significance of Uric Acid
An increase in this substance is seen w/ gout
During acute flare, levels may be normal
After flare has subsided, levels will be elevated in gout
Common Blood Studies: Antinuclear Antibody (ANA)
Measures antibodies that react with a variety of nuclear antigens
Clinical Significance of ANA
Positive test may be associated with RA, Raynaud’s disease, and necrotizing arteritis.
- The higher the titer, the greater the inflammation
Common Blood Studies: Uric Acid
Measures level of uric acid in serum
Common Blood Studies: C-Reactive Protein (CRP)
Shows presence of abnormal glycoprotein due to inflammatory process
Clinical Significance of CRP
A positive reading indicates active inflammation
Common Blood Studies: Rheumatoid Factor (RF)
Determines the presence of abnormal antibodies seen in connective tissue disease
Clinical Significance of RF
Positive titer >1:80
- - Every 1 part of blood, there is 80 rheumatoid factors in the solution
Present in 80% of those with RA
The higher the titer (number at right of colon), the greater the inflammation
Nursing Considerations for Salicylates (Aspirin)
Administer w/ food, milk, antacids or large glass of water to reduce GI effects.
Assess for tinnitus, gastric intolerance, GI bleeding, and purpura.
Administer enteric coated or extended-release whole, do not crush
Examples of Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
Diclofenac
Naproxen
Meloxicam
Ibuprofen
COX-2 enzyme blockers
Nursings Considerations for NSAIDs
Administer NSAIDs w/ food
Monitor for GI, CNS, cardiovascular, renal, hematologic, and dermatologic adverse effects
Avoid salicylates; use acetaminophen for additional analgesia
Watch for possible confusion in older adults
Example of COX-2 Enzyme Blockers
Celecoxib
Nursing Considerations for COX-2 Enzyme Blockers
Monitoring is the same as for other NSAIDs
Indications: Those at risk for GI complications
Increased risk of cardiovascular events, including MI and stroke
Appropriate for older adults & patients who are at high risk for gastric ulcers
Examples of Disease-Modifying Antirheumatic Drugs (DMARDs)
Hydroxychloroquine & chloroquine
Nursing Considerations for DMARDs
May be administered concurrently w/ NSAIDs
Assess for visual changes (retinal degeneration), GI upset, skin rash, headaches, photosensitivity, bleaching of hair
Emphasize need for ophthalmologic examinations (every 6-12 mo)
Examples of Tumor Necrosis Factor (TNF)-blocking agents
Enbrel, Remicade, & Humira
Nursing Considerations for TNF-blocking Agents
Patient should be tested for tuberculosis before beginning this med
- It can re-activate TB in patients that actively have it
Educate patient about SQ self-injection
Monitor for injection site reactions
Educate patient about increased risk for infection and to wi/hold med if fever occurs
Notify provider if any illness or infection occurs & med is held
Examples of Corticosteroids
Prednisone, prednisolone, & hydrocortisone
Nursing Considerations for Corticosteroids
Assess for toxicity: Cataracts, GI irritation, hyperglycemia, hypertension, fractures, avascular necrosis, hirsutism, psychosis
Repeated injections can cause joint damage
Use caution in patients diagnosed with diabetes, due to effects causing elevation in blood sugar
What elements should the nurse consider w/self-management programs of RA & OA?
Medication adherence
Lab work
Exercise
Nutrition
Educate on adverse effects of meds
Assistive equipment & personnel
Educate on limitations of ADLs, resting in between activities, modifications to ADLs to promote independence
Address body-image distortion secondary to deformities, support
Identify effects of the disorder that can impact the patient’s lifestyle, independence, & psychological status
Social isolation
Body dysmorphia & decreased self-esteem
Limited ROM & ADLs
Depression & grief over loss of independence
Dependence on assistive devices
Watch for association of debilitating joint pain w/ signs of aging
Pain meds can alter LOC, hearing, & vision
Risk of providers under & over-prescribing meds
What is the nurse specifically looking for in a functional assessment in RA & OA?
Muscle size & contour
Symmetry
ROM (limitations)
Abnormal Movements
Combination of history & observation
Assess for joint deformities
Posture, gait
The goal of nursing care is to decrease pain & stiffness & improve joint mobility. How can this be achieved?
Exercise
Knee braces & insoles
Weight management (decrease stress on joints)
Ice & heat therapy
Physical & nutritional therapies
Alternative & integrative therapies
- Yoga
- Acupuncture
- Massage
- TENS units
- Copper bracelets
Additional Issues to Consider w/ RA & OA
Limited access to resources
Muscle atrophy & contractures
Decreased movement due to movement
Immobility/ decreased movement due to pain
Limitations in job performance-> decreases financial resources
Assess the impact RA/OA may have on co-morbidities
Lack of support
Can affect rest & sleep
Systemic Lupus Erythematosus (SLE)
Inflammatory autoimmune disorder that affects nearly every organ in the body
Clinical Manifestations of Systemic Lupus Erythematosus (SLE)
Baldness
CNS symptoms
Butterfly rash
Oral ulcers
Pleuritis Pneumonitis
Anemia
Thrombocytopenia
Neutropenia
Splenomegaly
Lupus glomerulonephritis
Osteoporosis
Fingertip lesions
Myositis
Polyarthritis
Lymphadenopathy
Tell-tale Sign of SLE
“Butterfly” rash
Lab Studies to Order for SLE
Antinuclear antibody (ANA)
Anti-DNA
Anti-dsDNA
Anti-Sm
CBC
Goal of SLE Treatment
Prevent progressive loss of organ func
Reduce acute disease
Minim disease-related disability
Prevent complications from therapy
Nursing Interventions for Patients w/ SLE
Nursing management of fatigue, impaired skin integrity, body image disturbances, and lack of knowledge for self-management decisions
Encourage patient participation in support groups
Educate patient to avoid sun and UV light exposure or protect themselves w/ sunscreen and appropriate clothing
Routine periodic screenings and health promotion activities
-Smoking cessation programs -Continuing prescribed medications and addressing changes and potential side effects
-Screen for osteoporosis
Monitor for s/s of infection
Examples of Spondyloarthropathies (3)
Ankylosing Spondylitis (AS)
Reactive Arthritis (Formerly known as Reiter’s Syndrome)
Psoriatic Arthritis
Ankylosing Spondylitis (AS)
Chronic inflammatory disease of the spine
Ankylosing Spondylitis (AS) Prevalence
More prevalent in males than females
Joints/Systems affected in Ankylosing Spondylitis (AS)
Cartilaginous joints of the spine & surrounding tissues
Large synovial joints, such as the hips, knees, or shoulders
Clinical Manifestations of Ankylosing Spondylitis (AS)
Rigid joints, decreasing mobility, leading to kyphosis (a stooped position), decreased stability & balance
Back pain is the characteristic feature which may mask symptoms of a cervical fracture, leading to neurologic problems if left untreated
Systemic Effects/Complications of Ankylosing Spondylitis
Increased risk for CV disease
Pulmonary fibrosis, respiratory compromise w/ disease progression
Osteoporosis
Reacting Arthritis
The arthritis occurs after an infection
Reactive Arthritis Prevalence
Mostly affects young adult males
Joints/Systems Affected by Reactive Arthritis
GI & GU
Clinical Manifestations of Reactive Arthritis
Primarily characterized by urethritis, arthritis, & conjunctivitis
Dermatitis and ulcerations of the mouth and penis may be present
Low back pain is common
Psoriatic Arthritis
Inflammatory arthritis associated with the skin disease psoriasis
Psoriatic Arthritis Prevalence
Most common autoimmune disease in the US
Onset between 30-50 years of age, equally affecting men & women
Joints/Systems Affected by Psoriatic Arthritis
Spine, Achilles tendon, plantar fascia, or tibial tuberosity areas
Clinical Manifestations of Psoriatic Arthritis
Synovitis, polyarthritis, and spondylitis
Inflammatory back pain is a common symptom
Differentiated from other back pain by symptoms presenting at a young age, pain improving w/activity, & pain occurring at night
Systemic Effects/Complications of Psoriatic Arthritis
Infections
Nursing Management of Sponkyloarthropathies
Symptom management: Focuses on treating pain & maintaining mobility by suppressing inflammation
Good body position for AS patients
Maintenance of optimal functioning
-Maintaining ROM with regular exercise and muscle-strengthening program
Address psychological changes
-Depression
-Emotional stress
Pharmacological Management of Sponkyloarthropathies
NSAIDS as 1st line of treatment
-Methotrexate, sulfasalazine, and leflunomide
-Help w/ skin and peripheral joint disease but may not prevent spinal changes
Corticosteroid injections for periodic flares
Anti-TNF therapies, such as Enbrel, Remicade, Humira Additional agents include apremilast(Otezla) and ustekinumab (Stelara)
Surgical Management of Sponkyloarthropathies
Osteotomy of the spine for advanced AS and debilitating kyphosis
Total joint replacement
Fibromyalgia
Autoimmune condition w/ widespread aching and pain in the muscles and fibrous soft tissue
Predisposing Factors of Fibromyalgia-Associated Pain
Anxiety
Depression
Physical trauma
Emotional stress
Sleep disorders
Viral infection
Nursing Interventions for Fibromyalgia
Treatment of symptoms:
-NSAIDs
-Tricyclic antidepressants (amitriptyline and nortriptyline)
-Muscle relaxants (cyclobenzaprine)
Cognitive behavioral therapy to improve sleep and attentional dysfunction
Pay special attention to patient’s concerns and symptoms
-Provide support and encouragement during program of therapy
