Connective Tissue Diseases Flashcards
* Osteoarthritis (OA) * Rheumatoid arthritis (RA) * Gouty arthritis (gout)
Arthritis, or inflammation of the joints, has many etiologies
Most prevalent are -
* Osteoarthritis (OA)
* Rheumatoid arthritis (RA)
* Gout/gouty arthritis
Differential features of RA & OA
RA
- inflammatory, autoimmune, genetic component, younger onset; women to men 3:1
- Inc RF factor, ESR, ANA
- Meds: NSAIDs, methotrexate, corticosteroids, biologic response modifiers, other immunosuppressants
OA
- degenerative, possibly genetic component; older age of onset, obesity; traumatic event; 55-60 y.o.; after 55 yrs women to men is 2:1
- Normal to sl elevated ESR
- Meds: Tylenol, analgesics, NSAIDs usually short-term & later in the dz process
OA is classified as idiopathic or secondary
Note, RA can lead to OA
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Caused from another dz process (DM, Paget’s, hemophilia, sickle cell, RA)
Probably prev trauma or infection; infection can cause joint sepsis
Secondary
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No known cause; seen more in the hips, knees, & spine
More in women than in men; people older than 65 yrs probably genetic link
idiopathic/primary
Risk factors - primary OA
- Middle-aged & older adults
- Obesity
- Repetitive joint injuries/trauma
- Genetic component
- Smoking
Age is the biggest risk factor
OA - Pathophysiology
- Articular cartilage degeneration & uneven surfaces
- Thickening of subchondral bone
- Osteophyte formation
- Narrowing of joint space
- Decline in synovial fluid protection
- Central cartilage loss & peripheral growth of cartilage & bone causes uneven surfaces that have a grating sound (crepitus) upon movement
- Dec in synovial fluid causes less lubrication & circulation of nutrients to the joint; these in turn cause pain, limited ROM & loss of function
- Late in the dz process → 2° synovitis (inflammation) & joint effusions; bone cysts lead to bone deformations & atrophy of skeletal muscle (from guarding & not using) may be seen
S/S - OA
- Localized pain & stiffness
- Pain relieved w/rest, not systemic pain
- Stiffness possible; atrophy of skeletal muscle that may effect ambulation
- Crepitus - grating sensation w/movement
- Asymmetrical - joint enlargement; monoarticular or polyarticular; usually r/t bony hypertrophy; not usually an inflammatory process
- Possible mild swelling
- not usually warm; may have joint effusions esp in knees from inc synovial fluid
- Pain w/activity, improves w/rest
- pain early on; pain dec w/rest & gets worse w/activity; late phase, pain can occur @ rest
- Joint enlargement incl Heberden’s & Bouchard’s nodules
- Possible “locking” or “giving way” of joints
Bouchard’s & Heberden’s Nodes in OA
- Heberden in the DIP joint (distal interphalangeal joints)
- Bouchard in the PIP joints (proximal interphalangeal joints)
- Can appear in both hands; may be red & painful
Diagnostic testing (OA findings)
- Arthroscopy for visualization of articular surfaces - degeneration
- MRI
- X-ray films - narrowing of joint space & osteophyte formation
- Serological studies to look @ uric acid (gout), rheumatoid factor (RF), lyme titre, ESR for systemic sx’s [poss slightly elevated]
- Synovial fluid for color & consistency; signs of infection; crystals
Medications
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Analgesic: acetaminophen - Tylenol
> For mild to mod pain w/o inflammation - 1st choice
> Monitor LFT’s @ beginning of therapy and q6-12 mos
! Not for persons w/liver dz or increased ETOH intake
! No greater than 3g max/day incl additive effects of Percocet & Darvocet, etc.
NSAIDs (nonselective):
- Ibuprofen - Motrin
- Naproxen - Naprosyn
- Indomethacin - Indocin
COX-2 selective inhibitor: Celecoxib [Celebrex]
NSAIDs
- analgesic & anti-inflammatory; prevent prostaglandin formation
- caution w/cardiac dz - inc fluid overload & BP
- caution for GI bleeding - misoprostol (Cytotec) can be given w/NSAID; Cytotec produces prostaglandins for mucosal protection
- Monitor renal & liver fxn tests
- Avoid use w/other NSAIDs, steroids, anticoagulants, & ETOH - inc bleeding
- Celecoxib is less of an issue w/dec GI prostaglandins
- NSAIDs may actually disrupt articular cartilage metabolism
- COX-2 inhibitors - not used as much r/t evidence of cardiovascular disorders like MI
Opioid analgesics
- codeine
- oxycodone - Percodan, Percocet
- Propoxyphene - Darvon, Darvocet [taken off market for cardiac arrhythmias]
Steroid injection - Kenalog, Depo-Medrol
Viscosupplementation
- Synvisc - Hylan G-F 20
- Orthovisc - Hyaluranon/hyaluronic acid
Opioids
- Monitor for CNS & respiratory depression
- s/e: nausea, constipation, dizziness
- Monitor for renal/hepatic toxicity; safety precautions; drug dependence
- Hyaluronan is a polysaccharide similar to synovial fluid & promotes independent articular production of synovial fluid for several mos
Dietary supplements
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This improves elasticity of cartilage; ! monitor for bleeding
condroitin
SAM-e (5-adenosylmethionine)
Repairs cartilage by improving proteoglycans
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Used to make & repair cartilage; s/e - inc blood glucose lvls & INR; diarrhea, HA
glucosamine
Topical Agents
- Capsaicin - may produce a cutaneous burning sensation that resolves w/time
- Icy Hot
- Aspercreme
- Lidocaine 5% patch [! can slow cardiac electrical activity]
For inflammation, should we treat with cold or heat?
Cold
Non-Medication Interventions
- Weight loss
- Smoke cessation
- Rest
- Repositioning
- Heat/cold
- Protect joints from trauma/stress
! Heat inc circulation & dec muscle tension; can create edema
! Cold numbs nerve endings; also vasoconstricts
- Protect & cover skin - thermo source not directly on skin; 20 min on/off & check skin following protocol
Surgical Management
- Joint debridement or abrasion
> Abrasion chondroplasty performed w/arthroscopy stimulates growth - Cartilage transplant
> w/graft or chondrocyte inj - Osteotomy - surgical incision in bone to redistribute the load-bearing surface of a joint
- Arthrodesis - fusion of the bones of a joint usually of cervical & lumbar spine, finger, wrist, & ankle
- Arthroplasty - joint replacement usually of the hip & knee but can be performed on shoulder, fingers, ankle, & elbow
! preserves ROM
Varus deformity - knee osteotomy
- Tibial osteotomy may delay knee replacement for 10 yrs
Arthrodesis
- Joint fusion w/allograft, cadaver bone or hardware
> bone graft in hardware [photo]
Arthroplasty
- Joint replacement w/hardware maintains ROM as compared to arthrodesis
Total knee replacement (TKR)
- Gen anesthesia w/opiates or continuous femoral nerve block (CFNB) into the femoral or sciatic nerve
- Less opiates req’d >surgery so faster rehab
- Knee brace, CMS checks, plantar & dorsiflexion but no pain is normal
! systemic warning of infusion -
slurred speech, hypotension, dec resp, metallic taste, tinnitus
Continuous passive motion (CPM) machine
- Leg is placed slightly abducted
- Pt’s leg is started at 0° of flexion & over a period of days inc the ° of flexion to the hcp’s orders; HOB no more than 15° off CPM to elevate HOB & eat
- Can be very uncomfortable; there’s conflicting research on the efficacy on the use of CPM
Key Points - CPM
↣ Lining up the knee joint w/the joint in the CPM for flexion
↣ Making sure that the pt has the controller to stop the machine
↣ Shut off when the leg is in extension
↣ Check the skin for any reddened areas & instruct the pt to notify you if any discomfort noted
↣ Pre-medicate for pain; straight leg raises & isometrics to inc extremity muscle strength
↣ MD may order a knee brace for knee extension
↣ CryoPad, ConstaVac
↣ ! No hyperextension of knee - usually no pillow under the popliteal space - can contribute to contracture
↣ May lock the bottom of the bed so the knee will not flex
OA of hip
e.g., hardware - hemiarthroplasty prosthesis
Anterior approach - more muscle damage but dec risk of dislocation
Posterior approach - less muscle damage but inc risk for dislocation & sciatic nerve injury
Complications of TKR & THR
! Infection
! Blood vessel injury/blood loss/hypotension
! Nerve injury
! Fat embolism
! DVT/PE
! Dislocation or instability of joint
! Loosening of prosthesis
! Compartment syndrome
- Prosthesis can be cemented or non-cemented
- Non-cemented has a rough coat on the prosthesis so that the bone grows into the prosthetic
- Cemented joints usually able to be PWB to FWB as tolerated
- Non-cemented-PWB for a few wks until bone grows in
- Start w/walker or crutches & advance to single cane 4-6 wks >surgery
- Collaboration w/PT for early ambulation & leg exercises to strengthen muscles, improve balance, dec risk of clots
Nursing Interventions
↣ No adduction beyond midline; abduction splint/wedge (hip)
↣ No flexion of hip beyond 90°
↣ No extreme external/internal rotation (hip)
↣ No lying on operated side (hip)
↣ Report acute pain, rotation, & extremity shortening
↣ Maintain drain(s)
- JP/Hemovac - make sure they’re compressed
- ConstaVac - able to autologously re-transfuse blood; empty q4h & prn
↣ Prevent thrombus formation - anticoag’s, dorsiflexion/plantar flexion
- Heels off bed - risk for decubitus
! prevent infection
↣ Regular pulmonary toilette
↣ Do not put pillow under knee for TKR, keep knee @ 180°
↣ Weight-bearing activities as ordered w/inc activities as tol/assistive devices
↣ Pain control/PCA/CFNB
- check CMS q2-4 hrs - alt sensation, alt amb r/t nerve block
↣ CPM machine
- knee brace to help stabilize
↣ Prophylactic abx (for dental work hardware)
↣ Metal may activate metal detectors/MRI
↣ If getting into systemic circulation = restlessness, metallic taste, hypotension, bradycardia, dec resp, slurred speech
↣ Pillow placement less bulky
↣ Fracture bed pan vs regular pan
↣ Observe dressing for drainage & reinforce/aseptic dressing change >1st MD change
↣ CMS checks (compared to unoperated extrem) - monitor for DVT, ! compartment synd
↣ Keep incision dry, no tub baths/shower seat
- no showers for about 3 days; then cover with Tegaderm
- shower seat d/t instability created from incision
↣ Rehab; PT/OT
- Pt may be d/c’d home (usually about 4-5 days post-op) if can transfer independently to & from the bed, walk alone 150 ft on a flat surface, & safely negotiate stairs
- If not, then may go to a SNF or rehab center
- OT & PT will need to work w/pt to strengthen the muscles that had been severed during surgery
- Pt unable to drive for until muscles heal & strength & stability return
! Hip dislocation - shortening of LE; inc pain; leg rotation adduction
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Chronic, inflammatory dz of connective tissue throughout the body
Systemic manifestations incl anorexia, wt loss, fatigue, muscle aching & stiffness, joint pain & stiffness
Is autoimmune & has a genetic component (allele of the MHC on the short arm of chromosome 6)
Inflamed synovial membrane & bone erosions
Periarticular osteopenia in hand or wrist joints is common
Rheumatoid Arthritis
- Usually dx’d @ a younger age & more prevalent among women
- Subchondral cysts, inflamed synovial membrane, eroded cartilage
Pathophysiology
↣ Inflammation w/an unk etiology
- most likely autoimmune etiology
↣ Proliferation of the synovial membrane
↣ Erosion of articular cartilage & subchondral bone
↣ Can extend beyond joint into soft tissue
- can become systemic
S/S - RA
- Painful, stiff, red, warm, swollen joints
- Bilateral & symmetrical
- Mostly hands, knees, elbows, feet, wrist, ankle
- Systemic involvement
- Muscle atrophy
- Joint fusion/dislocation
- Inflammatory response (systemic sx’s) - low-grade fever, fatigue, weakness, anorexia, paresthesias
- Mod to severe pain w/morning stiffness
- Ulnar deviation
- Systemic involvement - fatigue, anemia, wt loss, fever, vasculitis, SC nodules over bony prominences, bone erosions
RA - late stage
- Tenosynovitis (inflammation of the tendon sheath) on the wrist is common & carpal tunnel can result
- Boutonniere deformity (of thumb)
- Ulnar deviation (of metacarpophalangeal joints)
- Swan-neck deformity (of fingers)
- Nodules over extensor surfaces
- Not painful in themselves but expose a person to integument issues if traumatized & skin breaks
- Other systemic sx’s may incl osteoporosis, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung dz, Sjogren’s dz, renal dz
Systemic complications
- Vasculitis
- Pulmonary - pleurisy, pneumonitis, diffuse interstitial fibrosis, Caplan’s syndrome
- Cardiac - pericarditis, myocarditis
- Eyes - iritis, scleritis
Sjogren’s syndrome
- dry eyes
- dry mouth (xerostomia)
- dry vagina
- Felty’s syndrome - hepatosplenomegaly, leukopenia
Diagnostics
- xray bone erosion in hand or wrist joints; narrowing joint space
- (+) serum rheumatoid factor (RF) test
- elevated ESR & C-reactive protein (CRP)
> indicators of inflammation
- inc synovial fluid
- inc WBC, cloudy, volume, rf
- ice & rest for 24h; monitor for bleeding or synovial leakage
- RF is an antibody to IgG
- anti-CCP, cyclic citrullinated protein, antibodies are more specific for RA
- Elevated WBC, anemia, thrombocytosis
- Elevated ANA
Medications
- NSAIDs
DMARDs: disease-modifying anti-rheumatic drugs
- methotrexate (Rheumatrex)
- sulfasalazine (Azulfidine)
- penicillamine (Depen)
- azathioprine (Imuran)
- gold compounds
- hydroxychloroquine (Plaquenil)
- NSAIDs + steroids + DMARDs for complete treatment
- GI s/e’s controlled w/H2 blocker, PPI’s, or sucralfate
- Steroid-induced osteoporosis counteracted w/calcium (1200-1500 mg/day) & vit D
- Do not stop meds abruptly
- Monitor for F&E balance, glucose lvls, HTN, dec healing, thinning skin, purpura
- Methotrexate + folic acid 1 mg/day dec toxicity
> Inhibits DNA synthesis of inflammatory cells
s/e’s
> GI complaints, liver, bone marrow suppression
> incl pneumonitis, leukopenia, thrombocytopenia, anemia, n/d, stomatitis
- check kidney & liver function before & w/liver q4-8wks
- avoid sunlight
penicillamine (Azulfidine)
> GI upset, liver dysfunction, bone marrow suppression
hydroxychloroquine (Plaquenil)
> suppresses formation of antigens responsible for hypersensitivity rxns
s/e’s
> HA, GI/visual disturbances, pruritus (esp palms, soles, scalp), impaired hearing
> Retinopathy can progress even after med d/c’d
! Monitor CBC & liver function
400-600 mg/daily for 5-10 days, gradually inc to optimum response
Maintenance in 4-12 wks - dec dose 50% then maintain @ 200-400 mg/day
Tumor Necrosis Factor (TNF) blockers
leflunomide (Arava)
adalimumab (Humira)
infliximab (Remicade)
etanercept (Enbrel)
↣ Neutralize the biologic activity of TNF to dec immune responses
↣ BRMs (biologic response modifiers) are a branch of DMARDs - do not give to pt w/serious infection, TB, or MS
> Mantoux prior to starting drugs
↣ May take wks to mos to reach therapeutic effect so NSAIDs & steroids stay on board until that time
↣ All DMARDs are toxic to multiple body organs incl the liver, kidneys, GI, lungs, bone marrow, & eyes
> They suppress bone marrow & place pt @ risk for infection, anemia, & bleeding
Tumor necrosis factor
A member of a super family of proteins, each w/157 amino acids, which induce necrosis (death) of tumor cells & possess a wide range of pro-inflammatory actions
TNF-alpha antagonists
s/e
! flu-like sx’s
! infections
! injection site irritation
! fatal pulmonary response
- Blocking the action of TNF has been shown to be beneficial in reducing the inflammation in inflammatory cases such as Crohn’s dz & RA
- Remicade - infusion rxn = CP, tachy, dyspnea, light-headed, check CBC
Surgical treatment
- Tendon transfer & osteotomy
> Tendon transfers w/osteotomy & arthrodesis (fusions) are used commonly in the fingers to give them more function - Synovectomy - is removal of the synovia in the elbows, wrists, fingers, or knees b/c the dz process starts in the synovial membrane & destruction cont to other local tissues
- Arthrodesis
- Arthroplasty = joint replacement
Other Interventions
- Low impact exercises/wt loss/diet
- yoga, walking, bike riding, tai chi all inc muscle tone to keep off wt
- Heat & cold application
> heat to inc circulation & elasticity of joint
> cold to dec inflammation - Utilization of assistive devices
- Steps for joint protection
- 1st line of attack is through meds, PT w/poss assistive devices, exercise, wt loss; if interventions fail, then surgery may be considered
Gouty arthritis
- Overproduction or under-excretion of uric acid - collects in joints
- S/S: acute pain, redness, edema in 1 joint last approx 1 wk
- primary s/s may incl systemic findings like fever, malaise
- Chronic collection in kidneys (calculi), soft tissues (tophi), & arteries (atherosclerosis)
- purine crystals
- Joints usually incl the great toe, fingers, wrist, ankle, knees
Tophi
Collection of uric acid crystals in the soft tissue
Diagnostics
- Inc serum ESR
- Inc serum uric acid
- 24 hr urine
- Joint aspirate positive for uric acid crystals
- Painful, swollen joints
- Tophi, renal stones w/chronic gout - check renal function
Serum > 8.5 mg/dL = abn
Urine >750 mg/24hr
Aspirate is definitive
Treatment
- Ice (to dec inflammation), bedrest
- Increase fluid intake (2L H2O/day), weight reduction
- Lower purine diet, avoid physical/emotional stress & alcohol (is dehydrating & will inc conc of uric acid crystals)
- Medications - avoid aspirin & diuretics
- Incr pH of urine w/alkaline ash foods - milk, citrus juices
- Proper fitting shoes
- Use of bed cradle (to keep sheets off skin)
! Foods high in purines -
> fish/seafood: anchovies, herring, mackerel
> meats: brains, organ meats, wild game
> veggies: asparagus, cauliflower, green peas, mushrooms, spinach
> grains: legumes, oatmeal, wheat bran, whole grains
