Rheumatic Disorders - Lecture notes Lecture 4 PDF

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Rheumatic Disorders Notes...

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Rheumatic Disorders: Chapter 38 Pathophysiology - Inflammation • Continued inflammation destroys joint cartilage and bone - Autoimmunity • The body mistakenly recognizes its own tissues as a foreign antigen initiates inflammatory response against self - Degeneration • Cartilage inflammation and erosion Rheumatic Disorders: Clinical Manifestations - Pain - Joint swelling - Limited movement - Stiffness - Weakness - Fatigue - Major problems • Altered self-image • Immobility, ADLs • Sleep disturbance • Systemic effects with organ failure Assessment, Diagnostic, Management - Physical and functional assessment - Laboratory studies - Serum: e.g., Creatinine, Erythrocyte Sedimentation Rate (ESR), Erythrocyte count, WBC, etc. • Serum immunology: e.g., Antinuclear Antibody (ANA), Rheumatoid Factor (RF), C-Reactive Protein (CRP), etc. - Other diagnostic studies: X-ray, CT, MRI - Medical management: • Pharmacologic therapy • NSAIDs and disease-modifying antirheumatic drugs (DMARDs) - Nonpharmacologic therapy • Heat applications, exercises, braces, splints, and assistive devices Rheumatoid Arthritis (RA) Chronic, progressive, systemic, inflammatory autoimmune connective tissue disease that affects primarily synovial joints - Etiology (females > males) • Cause unknown, although a genetic link is thought to trigger an auto immune response • RA is commonly (~ 80%) associated with a peculiar group of anti-IgG autoantibodies called serum rheumatoid factors • Combination of environmental (cigarette smoking) and genetic factors • Reproductive hormones Rheumatoid Arthritis (RA): Clinical Manifestations - Early sings & symptoms

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Joints – erythema, stiffness (especially in the morning), swelling, pain, warmth, lack of function Systemic – weakness, anorexia, low-grade fever signs & symptoms Joints – progressively inflamed and painful, deformities, cervical disease can be life threatening Systemic – weight loss, fever, extreme fatigue, subcutaneous nodules, vasculitis, skin lesions, peripheral neuropathy, respiratory and cardiac complications (cardiovascular disease)

Assessment and Diagnostic Findings - The history and physical assessment • Includes, joint inflammation, cardiovascular assessment - Laboratory – positive rheumatoid factor (present in about 80% of pts), elevated antinuclear antibody (ANA), decreased serum complement, increased ESR, high sensitivity CRP - X-ray, CT scan - Arthrocentesis Pharmacological Interventions - Disease-modifying antirheumatic drugs (DMARD) • Methotrexate (MTX) – most commonly used, increased risk for infection, liver toxicity, birth defects • Leflunomide (Arava) – increased liver enzymes, birth defects • Azathioprine (Imuran), Cyclophosphamide (Cytoxan) – bone marrow suppression (increased risk for infection, hemorrhagic cystitis) • Hydroxychloroquine (Plaquenil) antimalarial agent – retinal damage - Biologic DMARD - Immunosuppressant • Cyclosporine - Biological response modifiers (BRMs) • Ex: etanercept (enbrel), adalimumab (humira), anakinra (kineret) • Avoid BRMs if patient has a serious infection, report site reactions, allergic reactions - NSAIDs (naproxen, ibuprofen) • GI bleeding, sodium retention; cyclo-oxygenase 2 (COX-2) enzyme blockers have less GI side effects: Celecoxib (Celebrex), but increased risk of CV disease - Steroids (Glucocorticoids) • take calcium and vitamin D daily to prevent osteoporosis - Sort-term low-dose antidepressant - Surgery may be performed for persistent RA Nonpharmacological Interventions: Nursing management - Adequate rest, managing fatigue - Nutrition - Proper positioning - Pain management, ice and heat application - Complementary and alternative therapies - Promoting self-management but limiting joint stress - Enhancing body imaging, self-care - Enhancing ADL (PT/OT consults) - Monitoring potential complications

Systematic Lupus Erythematosus (ESL) Chronic, progressive, inflammatory autoimmune connective tissue disease, can affect any body system - Classifications of lupus: • Systemic lupus erythematosus (SLE) – common • Discoid lupus erythematosus (DLS) – rare, primarily affects skin on the face - Risk factors: • Combination of environmental and genetic factors • Cigarette smoke may be a trigger • Affect women 6-10 times more often than men (women 20-30’s the most) • Taken certain medications (sulfa, PCN, etc.) • Emotional and physical stress ESL: -

Clinical Manifestations Skin involvement – butterfly-shaped erythematous rash, alopecia ever, malaise, anorexia and fatigue – very common earliest findings Lupus nephritis – leading cause of death Pericarditis (most common cardiac manifestation), MI, stroke, HTN Raynaud’s phenomenon (causes the blood vessels to narrow when you are cold or feeling stressed) - Neurological –central nervous system impairment - Joint symptoms –arthritis, arthralgia (joint stiffness) - Pancytopenia - Pleural effusion - Abdominal pain - Affects anybody system ESL: Diagnostic Findings Laboratory - Skin biopsy - Immunological-based laboratory tests – antinuclear antibody (ANA) is positive in more than 95% of pts with SLE - Complete blood count - Body system functioning (renal function, liver function, cardiovascular & neurological assessment) ESL: Pharmacologic Interventions Drug therapies focus on pain management & nonspecific immunosuppression: - Topical cortisone for skin management - Belimumab (Benlysta): B-Cell activating factor inhibitor - Hydroxychloroquine (plaquenil) - Steroids (corticosteroids) - Immunosuppressive agents (methotrexate, azathioprine) Nursing Management - Skin protection, avoid prolonged exposure to sunlight, avoid powder and other drying agents - Pace activities - Smoking cessation - Continue prescribed medications - Monitor signs of infection - Monitor side effects of medication (side effects of steroid use: osteoporosis) - Monitor sings of complications (cardiovascular disease, renal function)

Scleroderma – very rare Uncommon chronic, inflammatory, autoimmune connective tissue disease: - Higher mortality rate than SLE, women affected 3-5 times more than men - Localized – affecting only the cutaneous system - Systemic – also known as Systemic Sclerosis; affecting multiple organ systems - Raynaud’s phenomenon and edema in hand and forearm – first symptom - Skin is dry. Face appears masklike, immobile – cutaneous changes may remain localized for years - Extremities stiffen and lose mobility - Renal involvement – leading cause of death - Cardiovascular involvement – Raynaud’s phenomenon, myocardial fibrosis, HTN, HF - Lung involvement – pulmonary HTN, fibrosis of alveoli and interstitial tissue - Hardening/sclerosing of the esophagus and intestinal mucosa – gastroesophageal reflux disease (GERD), peristalsis, diarrheal stools Scleroderma: Clinical Manifestations CREST Syndrome (Scleroderma signs & symptoms): - C – Calcinosis: the formation of calcium deposits in any soft tissue - R - Raynaud’s phenomenon – first symptom - E - Esophageal dysmotility - S – Sclerodactyly: a localized thickening and tightness of the skin of the fingers or toes - T- Telangiectasia: widened venules (tiny blood vessels) cause threadlike red lines or patterns on the skin • Pulmonary hypertension Assessment and Diagnostic Findings - Physical assessment • Skin, fingers, GI, cardiac, renal and pulmonary symptoms - There is no one conclusive diagnostic test (ANA may be the indication) Nursing Management No medication is effective in modifying the scleroderma process. Medications are used to treat organ involvement - Identify early organ involvement and treat it: • Skin and lung function – systemic steroids and immunosuppressants • Raynaud’s phenomenon – calcium channel blockers • Arthralgia, stiffness – anti-inflammatory medications • GERD – PPIs, histamine antagonists, antacids - Skin protection and prevent effects of Raynaud’s phenomenon • Collaboration with speech and language pathologist: • Minimize the intake of foods/fluids that stimulate gastric secretion (e.g. spicy foods, caffeine, alcohol), small frequent meal • Keep HOB elevated for 1-2 hours after meals Gout Systemic inflammatory arthritis caused by hyperuricemia (increased serum uric acid) - Types of gout: • Primary gout – inborn errors of purine metabolism • Secondary gout – hyperuricemia caused by another disease - Clinical manifestations:

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Acute gout – joint inflammation (gouty arthritis) Chronic gout – tophi, renal calculi, renal dysfunction Elevated uric acid level (laboratory)

Pharmacological Interventions - Acute gout – a combination of colchicine and an NSAID - Chronic gout – allopurinol (zyloprim) or febuxostat (uloric) - Probenecid (benemid) – promote the uric acid excretion Nursing Management - Restrict consumption of purine-rich food, especially organ meats Limit alcohol intake Avoid starvation Avoid aspirin and diuretics Maintain normal body weight Stress management Increase fluid intake Increase intake of alkaline foods (citrus fruits, broccoli, Kale, etc.) Sjogren’s syndrome - Systemic autoimmune disease (female>male) • Affects lacrimal and salivary glands • Genetic and environmental factors - Clinical manifestations • Dry eyes, dry mouth • Evaluation of eyes and mouth for diagnostic work-up - Medical management • Symptom management • Artificial tears - Nursing Management • Patient education for prescribed therapies Key Points: - Rheumatic disorder pathophysiology (inflammation, autoimmunity, degeneration)

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Sjogren’s syndrome

Practice Question #1 The nurse informs the patient with a bacterial pneumonia that the most important factor in antibiotic treatment is A. Antibiotics should have been used to prevent pneumonia. B. All of the supplied antibiotics should be taken even when symptoms have resolved. C. Enough antibiotics for 2 days’ treatment should be reserved in case symptoms recur. D. Patients should request antibiotics for upper respiratory infections to prevent development of streptococcal-related diseases. Practice Question #2 A diagnosis of AIDS can be made for a patient with HIV with which of the following: A. CD4+ T-cell count...