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Chapter 67: Nursing Management: Arthritis and Connective Tissue Diseases Key Points

ARTHRITIS Rheumatic diseases- marked by inflammation, pain, and loss of function in 1 or more parts of the body's connecting or supporting structures 

Arthritis, a type of rheumatic disease, involves inflammation of a joint or joints.

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The most prevalent types of arthritis are osteoarthritis, rheumatoid arthritis, and gout. OSTEOARTHRITIS

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Osteoarthritis (OA), the most common form of joint (articular) disease in North America, is a slowly progressive noninflammatory disorder of the diarthrodial (synovial) joints. Factors linked to OA - increasing age, genetics, obesity, occupations with frequent kneeling, and lack of exercise.

Etiology of OA is usually caused by a known event or condition that directly damages cartilage or causes joint instability and involves the formation of new joint tissue in response to cartilage destruction. *OA is highly seen in older adult women due to the reduction of estrogen during menopause

Cause

Effects on Joint Cartilage

Drugs

Drugs such as indomethacin, colchicine, and corticosteroids can stimulate collagen-digesting enzymes in joint synovium.

Cause

Effects on Joint Cartilage

Hematological or endocrine disorders

Chronic hemarthrosis (e.g., hemophilia) can contribute to cartilage deterioration.

Inflammation

Release of enzymes in response to local inflammation can affect cartilage integrity.

Joint instability

Damage to supporting structures causes instability, placing uneven stress on articular cartilage.

Mechanical stress

Repetitive physical activities (e.g., sports) cause cartilage deterioration.

Neurological disorders

Pain and loss of reflexes from neurological disorders, such as diabetic neuropathy, and in Charcot's joint cause abnormal movements that contribute to cartilage deterioration.

Skeletal deformities

Congenital or acquired conditions such as Legg–Calvé–Perthes disease or dislocated hip contribute to cartilage deterioration.

Trauma

Dislocations or fractures may lead to

Cause

Effects on Joint Cartilage avascular necrosis or uneven stress on cartilage.

The pathogenesis of OA is complex, with genetic, metabolic, and local factors that interact and cause a process of cartilage deterioration. -Progression of OA causes the normally smooth, white, translucent articular cartilage to become dull, yellow, and granular. Affected cartilage gradually becomes softer, less elastic, and less able to resist wear with heavy use.

Risk factors Modifiable- obesity, anterior cruciate ligament injury. Frequent kneeling and stooping OA joint manifestations Manifestations -range from mild discomfort to significant disability, with joint pain being the major symptom. ---pain at rest and trouble sleeping groin, buttock, outside of thigh/knee sitting is hard -local pain and stiffness -rest pain resolves in 30 min -crepitation -asymmetrical pain -weight bearing joints -Systemic manifestations (such as fatigue, fever, and organ involvement) are not present in OA, whereas they are present in inflammatory joint disorders such as rheumatoid arthritis.

*As OA progresses, increasing pain contributes significantly to disability and loss of function. -Osteoarthritis diagnostic assessment A bone scan, computed tomographic (CT) scan, or magnetic resonance imaging (MRI) may be useful for diagnosing OA because of the sensitivity of these tests in detecting early joint changes. Radiological studies are helpful in confirming disease and staging the progression of joint damage Symptoms - Joint pain - As OA progresses, increasing pain can contribute significantly to disability and loss of function. The pain of OA may be referred to the groin, the buttock, or the medial side of the thigh or knee. - As OA develops in the intervertebral (apophyseal) joints of the spine, localized pain and stiffness are common. -Early morning stiffness is common but generally resolves within 30 minute

Management The patient with OA must understand the importance of a balance between rest and activity. The affected joint(s) should be rested during any periods of acute inflammation and maintained in a functional position with splints or braces if necessary. However, immobilization should not exceed 1 week because of the risk for joint stiffness with inactivity. * Teach patients with knee OA to avoid prolonged periods of standing, kneeling, or squatting. Using an assistive device such as a cane, walker, or crutches can also help decrease stress on arthritic joints. 

Because there is no cure for OA, care focuses on managing pain and inflammation, preventing disability, and maintaining and improving joint function.

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Nonpharmacological interventions such as rest and joint protection, heat and cold applications (hot packs, whirlpool baths, ultrasound, and paraffin was baths) nutritional therapy and exercise are the foundation for OA management and should be maintained throughout a patient’s

treatment period. Drug therapy serves as an adjunct to nonpharmacological treatments. o Complementary and alternative therapies (such as acupuncture, yoga, massage, guided imagery, and therapeutic touch) for symptom management of arthritis are popular with patients who have failed to find relief through traditional medical Nutritional supplements such as glucosamine and chondroitin sulphate may be helpful in some patients for relieving moderate to severe arthritis pain in the knees and improving joint mobility. Drug therapy - Drug therapy is based on the severity of the patient's symptoms * mild to moderate joint pain may get relief from acetaminophen (Tylenol). The patient may receive up to 1 000 mg every 6 hours, with the daily dose not to exceed 4 g.

*topical agent such as capsaicin cream *For patients who do not obtain adequate pain management with acetaminophen or for patients with moderate to severe OA pain or signs of joint inflammation, an NSAID may be more effective for pain treatment. *Another treatment for mild to moderate OA is hyaluronic acid (HA) injection, a type of viscosupplementation. HA is found in normal joint fluid and articular cartilage. It contributes to both the viscosity and the elasticity of synovial fluid, and its degradation can result in joint damage. 

Arthroscopic surgery to remove debris (i.e., bits of cartilage known as loose bodies) may be recommended with OA progression.

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Teaching should include information about nature and treatment of OA, pain management, posture and body mechanics, use of assistive devices, principles of joint protection and energy conservation, nutritional choices and weight management, stressmanagement, and a therapeutic exercise program. Nursing assessment -The nurse should carefully assess and document the type, location, severity, frequency, and duration of the patient's joint pain and stiffness and the extent to which these symptoms affect his or her ability to perform activities of daily living (ADLs).

-physical examination of the affected joint or joints includes assessment of tenderness, swelling, limitation of movement, and crepitation. An involved joint should be compared with the contralateral joint if it is not affected. Planning The overall goals are that patients with OA will (a) maintain or improve joint function through a balance of rest and activity, (b) use joint protection measures (Table 67-4) to improve activity tolerance, (c) achieve independence in self-care and maintain optimal role function, and (d) use pharmacological and nonpharmacological strategies to manage pain satisfactorily. The following should be included when teaching patients with arthritis to protect joints and conserve energy: • Avoid forceful repetitive movements. • Avoid positions of joint deviation and stress. • Develop organizing and pacing techniques for routine tasks. • Maintain appropriate weight. • Modify home and work environment to create less stressful ways to perform tasks. • Seek assistance with necessary tasks that may cause pain. • Use assistive devices, if indicated. • Use good posture and proper body mechanics.

RHEUMATOID ARTHRITIS 

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease with inflammation in connective tissue of the diarthrodial (synovial) joints, often with periods of remission and exacerbation.

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The etiology of RA is unknown; it is probably due to a combination of genetics and environmental triggers.

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Onset is typically insidious with fatigue, anorexia, weight loss, and generalized stiffness.

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Articular signs include pain, stiffness, limitation of motion, and inflammation (e.g., heat, swelling, tenderness). Joint stiffness after periods of inactivity is common.

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As RA progresses, muscle atrophy and destruction of tendons around joint cause one articular surface to slip past the other ( subluxation).

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RA can affect nearly every body system. Most common extra-articular signs are rheumatoid nodules and SjAgren and Felty syndromes.

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Initial care usually involves drug therapy and education.

Drugs remain the cornerstone of RA treatment (see Table 67-3). Because irreversible joint changes can occur as early as the first year of RA, health care providers now aggressively prescribe disease-modifying antirheumatic drugs (DMARDs). These drugs have the potential to lessen the permanent effects of RA, such as joint erosion and deformity. o Treatment goals include reduction of inflammation, management of pain, maintenance of joint function, and prevention or correction of joint deformity. GOUT 

Gout is a type of recurring acute arthritis characterized by the accumulation of uric acid crystals in one or more joints.

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Deposits of sodium urate crystals occur in articular, periarticular, and subcutaneous tissues.

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Risk factors are obesity (in men), hypertension, diuretic use, and excessive alcohol consumption.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Key Points 67-3

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Affected joints may appear dusky or cyanotic and are extremely tender. Inflammation of great toe (podagra) is the most common initial problem.

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Chronic gout is characterized by multiple joint involvement and visible deposits of sodium urate crystals (tophi).

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Treatment includes drug therapy for pain management and to terminate an acute attack.

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Future attacks are prevented by drugs, weight reduction as needed, and possible avoidance of alcohol and food high in purine

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Nursing interventions include supportive care of inflamed joints.

Nursing Diagnoses for patients with RA may include, but are not limited to, the following: • Impaired physical mobility related to pain (joint pain, stiffness and deformity) • Chronic pain related to injury agent (joint inflammation, overuse of joints, and ineffective pain or comfort measures) • Disturbed body image related to alteration in self-perception (chronic disease activity, long term treatment, deformities, stiffness, and inability to perform usual activities) Planning goals are that patients with RA will (a) have satisfactory pain management, (b) have minimal loss of functional ability of the affected joints, (c) participate in planning and carrying out the therapeutic regimen, (d) maintain a positive self-image, and (e) perform self-care to the maximum extent possible. The primary goals in the management of RA are reduction of inflammation, management of pain, maintenance of joint function, and prevention or minimization of joint deformity.

Intervention begins with a careful physical assessment (e.g., joint pain, swelling, range of motion [ROM], and general health status). The nurse must also evaluate psychosocial needs (e.g., family support, sexual satisfaction, emotional stress, financial constraints, vocational and career limitations) and environmental concerns (e.g., transportation, home or work modifications). After problem identification, a carefully planned program for rehabilitation and education can be coordinated by the nurse for the interdisciplinary health care team.

LYME DISEASE 

Lyme disease is a spirochetal infection caused by Borrelia burgdorferi and transmitted by bite of an infected deer tick.

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A characteristic symptom of the early localized disease is erythema migrans (EM), a skin lesion occurring at the site of a tick bite 3 to 30 days after exposure.

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Flulike symptoms, such as fever, chills, headache, stiff neck, fatigue, swollen lymph nodes, and migratory joint and muscle pain, also occur.

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In late disease, arthritis pain and swelling may occur in large joints.

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Antibiotics are used for active disease and to prevent late disease.

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Reducing exposure to ticks is the best way to prevent Lyme disease. SEPTIC ARTHRITIS

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Septic arthritis (infectious or bacterial arthritis) is caused by microorganisms invading the joint cavity.

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Large joints (knee and hip) are frequently involved, causing severe pain, erythema, and swelling.

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This condition requires prompt treatment with antibiotics to prevent joint destruction and bone loss.

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Nursing care includes assessment and monitoring of joint inflammation, pain, and fever.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Key Points 67-4

SPONDYLOARTHROPATHIES • The spondyloarthropathies are a group of interrelated multisystem inflammatory disorders that affect the spine, the peripheral joints, and periarticular structures. ANKYLOSING SPONDYLITIS 

Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the axial skeleton (sacroiliac joints, intervertebral disc spaces, and costovertebral articulations).

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Most persons with AS are positive for HLA-B27 antigen.

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Extra-articular inflammation can affect eyes, lungs, heart, kidneys, and peripheral nervous system.

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Signs of AS are low back pain, stiffness, and limitation of motion.

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Care is aimed at maintaining maximal skeletal mobility while decreasing pain and inflammation. Heat applications, exercise, and medications (NSAIDs and salicylates are commonly prescribed) are often recommended.

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Surgery may be done for severe deformity and mobility impairment. PSORIATIC ARTHRITIS

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Psoriatic arthritis (PsA) is a progressive inflammatory disease that affects approximately 10% to 30% of people with psoriasis

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Psoriasis is a common benign, inflammatory skin disorder with a possible genetic predisposition.

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Although the exact cause of PsA is unknown, a combination of immune, genetic, and environmental factors is suspected.

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Psoriasis can occur in different forms, all having a degree of arthritis.

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Treatment includes splinting, joint protection, drugs, and physiotherapy. REACTIVE ARTHRITIS

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Reactive arthritis (Reiter’s syndrome) occurs more commonly in young men and is associated with a symptom complex that includes urethritis (cervicitis in women), conjunctivitis, and mucocutaneous lesions.

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The etiology is unknown, but it appears to occur after exposure to genito-urinary or gastro-intestinal tract infection.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Key Points 67-5 

The prognosis is favourable; most patients have a complete recovery after 2 to 16 weeks.

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Since reactive arthritis is associated with C. trachomatis infection, treatment of patients and their sexual partners with doxycycline is widely recommended

OTHER CONNECTIVE TISSUE DISORDERS SYSTEMIC LUPUS ERYTHEMATOSUS 

Systemic lupus erythematosus (SLE) is a multisystem, inflammatory, autoimmune disease.

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The etiology of abnormal immune response in SLE is unknown; a genetic influence is suspected.

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SLE is extremely variable in its severity, ranging from relatively mild to rapidly progressive and affecting many organ systems.

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Commonly affected tissues are the skin and muscle, the lining of the lungs, the heart, kidneys, and nervous tissue.

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Other signs include anemia, leukopenia, and thrombo-cytopenia. Infection is a major cause of death.

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A major treatment challenge is to manage active disease while preventing treatment complications.

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Patients with mild polyarthralgias or polyarthritis are treated with NSAIDs. Corticosteroids are given for severe cutaneous SLE. Antimalarial agents and immuno-suppressive drugs may also be used.

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Nursing care emphasizes health teaching and importance of patient cooperation for successful home management. SCLERODERMA

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Scleroderma, or systemic sclerosis, is a connective tissue disorder with fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs.

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The cause of SS is unknown. Immunological dysfunction and vascular abnormalities may play a role in systemic disease.

Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

Key Points 67-6 

In this disorder, collagen is overproduced, which leads to progressive tissue fibrosis and occlusion of blood vessels. Proliferation of collagen disrupts normal functioning of internal organs such as the lungs, kidneys, heart, and GI tract.

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Manifestations range from diffuse cutaneous thickening with rapidly progressive and widespread organ involvement, to the more benign limited cutaneous form.

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Clinical manifestations are described by the acronym CREST: Calcinosis, Raynaud’s phenomenon, Esophageal dysfunction, Sclerodactyly, and Telangiectasia.

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Raynaud’s phenomenon (an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes) is the most common initial complaint in limited scleroderma.

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No specific drug(s) have been proven effective for treating SS; however, many drugs can be used in treating the various manifestations of SS.

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Physiotherapy helps maintain joint mobility and preserves muscle strength. Occupational therapy assists in maintaining functional abilities. POLYMYOSITIS AND DERMATOMYOSITIS

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Polymyositis (PM) refers to diffuse, idiopathic, inflammatory myopathies of connective tissues, especially striated muscle, that produce bilateral weakness, usually most severe in proximal or limb-girdle muscles. When muscle changes associated with PM are accompanied by characteristic skin changes, the disorder is called dermatomyositis (DM).

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The exact cause of PM and DM is unknown; theories include an infectious agent, neoplasms, drugs or vaccinations, and stress.

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Patients with DM and PM ...