Rheumatoid Diseases

Osteoarthritis

Rheumatoid Arthritis

Systemic Lupus Erythematosis

Scleroderma

Osteoarthritis

Definition: *wear and tear, progressive, non-systemic, Degenerative Joint Disease (DJD)

Pathophysiology

Identify which joints are primarily affected with osteoarthritis.

What factors contribute to the development of osteoarthritis?

Note top slide only

Structural changes with Osteoarthritis

Early

Cartilage softens, pits, frays

Progressive

Cartilage thinner, bone ends hypertrophy, bone spurs develop and fissures form

Advanced

Secondary inflammation of synovial membrane; tissue and cartilage destruction; late ankylosis

Normal Knee structure

Moderately advanced osteoarthritis

Advanced osteoarthritis

What signs and symptoms does the person with osteoarthritis experience?

Assessment

Onset of pain is insidious, individual is healthy!

Pain is aching in nature; relieved by rest!.

Local signs and symptoms: swelling, crepitation of joint and joint instability, asymmetrical joint involvement

Deformities with Osteoarthritis

Genuvarus

Herberden’s nodes

Carpometacarpocarpal joint of thumb with subluxation of the first MCP

Osteoarthritis

Diagnostic Tests– None specific– Late joint changes,

boney sclerosis, spur formation

– Synovial fluid inc., minimal inflammation

– Gait analysis

Nursing diagnosis Interventions

determined by complications– Supportive devices– Medications (no

systemic treatment with steroids)

– Dietary to dec. wt.– Surgical

Intervention (joint replacement)

– Teaching

Rheumatoid Arthritis

Chronic systemic, inflammatory disease characterized by recurrent inflammation of diarthroidal joints and related structures.

Comparison of RA and OARA

Cause unknown

Remissions

*Body parts affected, systemic, small joints, symmetrical

Females, age 20-30; 3-1 ratio

OA

Cause “wear and tear”, weight

Non-systemic, weight bearing joints

Middle-aged and elderly, males 2-1 affected

Manifestations of RA

Systemically ill Hematologic Pulmonary/CV Neurologic Ocular (Sjorgen’s) Skin MS, deformity, pain

Pain!

Pain!

Pain

Assessment

Fatigue, weakness, pain

Joint deformity Rheumatic

nodules

Pathophysiology– IgG/RF (HLA)=

antigen-antibody complex

– Precipitates in synovial fluid

– Inflammatory response

Joints changes with RA Early Pannus

• Granulation, inflammation at synovial membrane, invades joint, softens and destroys cartilage

Diagnostic Tests ESR elevated + RA, ^ RA titer Dec. serum

complement Synovial fluid

inflammation

Joint and bone swelling,inflammation

Mod advanced Pannusjoint cartilage disappears, underlying bone destroyed, joint surfaces collapse

Fibrous AnkylosisFibrous connective tissue

replaces pannus; loss of joint otion

Bony AnkylosisEventual tissue and joint calcification

Joint Changes

Bilateral, symmetrical, PIP’s, MCP’s

Thumb instability Swan neck,

boutonniere deformity

Tensynovitis Multans deformity

Subcutaneous nodules

Genu valgum Pes plano valgus Prominent

metatarsal heads Hammer toes

Assessment

Deformities that may occur with RA

Synotenovitis

Ulnar drift

Swan neck deformity

Boutonniere deformity

Mutlans deformity (rapidly progressing RA)

Hitch-hiker thumb

Genu valgus

Hammer toes

Subcutaneous nodules (disappear and appear without warning)

Interventions

Nursing Diagnosis– Comfort– Physical mobility– Self image

Goals Team Approach

Pain management

Exercise Surgery Teaching

Medications ASA *cornerstone NAISD Steroids (burst therapy) Remitting agents

– antimalarial (plaquinal) *eye effects– Penicillamine– gold *dermatitis, blood dyscrasia

Immunosuppressive agents

Joint Protection: Do’s and Don’t’s

Case Presentation

Comparison to ‘usual’ course Diagnostic tests Nursing diagnosis Therapies

– Medications used– Exercise– Joint Protection

Systemic Lupus Erythematous (SLE)

Chronic multisystem disease involving vascular and connective tissue Lupus help

Characteristics of SLE

Types: Discoid, SLE

Incidence Periods remission

and exacerbation Stress factor

Assessment– Low grade fever– Discoid erythema– MS involvement– Pericarditis– Raynauld’s– RENAL– CNS– Digestive,anemia

Characteristic butterfly rash associated with SLE, especially discoid lupus erythematous

Barry’s lupus

SLE characterized by periods of remission and exacerbation. Stimulated by sunlight, stress, pregnancy, infections like strep and some drugs. Some drugs like apresoline, pronestyl, dilantin, tetracycline, phenobard may cause a lupus-like reaction which disappears when drug is stopped.

Diagnostic Tests

LE cell ANA, titer Anti-DNA Complement

fixation ESR Other

Criteria to Dx.– malar, discoid

rash– photosensitivity– arthritis– renal disorder– immunological

disorder– DNA, ANA

Management SLE

Nursing diagnosis

Goal to control inflammation

Emotional support

Life Planning

Medications Avoid UV Reduce stress Monitor/manage

to prevent complications

Scleroderma

Definition: progressive sclerosis of skin and connective tissue; fibrous and vascular changes in skin, blood vessels, muscles, synovium, internal organs. become “hide bound”

CREST syndrome: benign variant of disease

Typical “hide-bound” face of person with scleroderma

Tissue hardens; claw-like fingers; fibrosis

Assessment of Scleroderma

Female 4:1 Pain, stiffness,

polyartheritis Nausea, vomiting Cough Hypertension Raynauld’s

syndrome

Scleroderma cont.

Esophageal hypomotility leads to frequent reflux

GI complaints Lung-pleural

thickening and pulmonary fibrosis

Renal disease...leading cause of death!

CREST Syndrome

Calcinosis Raynaud’s

phenomena Esophageal

hypomotility Sclerodactyl (skin

changes of fingers) Telangiectasia

(macula-like angioma of skin)

Crest Syndrome

More on CREST

Diagnosis/Treatment Scleroderma

R/O autoimmune disease

Radiological: pulmonary fibrosis, bone resorption, subcutaneous calcification, distal esophageal hypomotility

What are the KEY components of care for the individual with Scleroderma?

Scleroderma: Patient Care

Do’s– Avoid cold– Provide small,

frequent feedings– Protect fingers– Sit upright post

meals– No fingersticks– Daily oral hygiene

Ankylosing Spondylitis

Definitions; polyarteritis of spine

Affects mostly men

Associated with HLA positive antigen

Signs and symptoms– Morning backache,

flexion of spine, decreased chest expansion

Diagnosis Nursing

Diagnosis

Ankylosing Spondylitis

Insidious onset

Morning backache

Inflammation of spine; later spine

ossification

Oh my back hurts!

Comparison of changes with ospeoporosis and Ankylosing spondylitis

Identify a PRIORITY nursing concern related to ankylosing spondylitis

Management Ankylosing Spondilitis

Do’s– Maintain spine

mobility– Pain

management– Proper

positioning– Meds for pain,

inflammation

Other Collagen Diseases Reiter’s Syndrome

– Reactive arthritis associated with enteric disease

Lyme Disease– Caused by spirochete,

borrelia burgdorferi– 3 stages

• Initial rash• disseminated• Late

– Antibiotics effective

Polyarteritis Nodosa– Inflammation,

necrosis of walls small to medium sized arteries

– Like SLE Dermatomyositis

– Affects skin and voluntary muscles

Sjogrens JRA

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