Lewis Med Surg Ch. 65 - Arthritis and Connective Tissue diseases

Terms	Definitions
• Arthritis is _	_inflammation of a joint.
• The most prevalent types of arthritis _	_are osteoarthritis, rheumatoid arthritis, and gout.
• Osteoarthritis (OA) is _	_a slowly progressive noninflammatory disorder of the diarthrodial (synovial) joints.
• Factors linked to OA include _	-increasing age, genetics, obesity, occupations with frequent kneeling, and lack of exercise.
• OA results from _	_cartilage damage, leading to fissuring, fibrillation, and erosion of articular surfaces.
• Manifestations of OA range from _	_mild discomfort to significant disability, with joint pain being the major symptom. Systemic manifestations (fatigue, fever) are not present.
• There is no cure for OA_	_care focuses on managing pain and inflammation, preventing disability, and maintaining and improving joint function.
• Symptoms if OA are initially managed conservatively through _	_medication, joint rest, heat and cold, nutrition, and exercise.
• As OA progresses_	_increasing pain contributes significantly to disability and loss of function. Drug therapy to manage pain is based on the severity of symptoms.
• Arthroscopy to repair cartilage or remove bone bits or cartilage_	_ may be recommended with OA progression.
• 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.
• Rheumatoid arthritis (RA) is _	_a chronic, systemic disease with inflammation in connective tissue of the diarthrodial (synovial) joints, often characterized by remissions and exacerbations.
• The etiology of RA is unknown_	_; it is probably due to autoimmune and genetic factors.
• Onset of RA is typically _	_insidious with fatigue, weight loss, and generalized stiffness.
• Articular signs of RA include _	_pain, stiffness, limitation of motion, and inflammation (e.g., heat, swelling, tenderness). Joint stiffness after periods of inactivity is common.
• As RA progresses_	_muscle atrophy and destruction of tendons around joints cause one articular surface to slip past the other (subluxation).
• RA can affect nearly every body system. Most common extraarticular signs are _	_rheumatoid nodules and Sjögren's and Felty syndromes.
• A diagnosis is often made based on_	_history and physical findings, but some laboratory tests, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and antinuclear antibody (ANA) titers, are useful for confirmation and to monitor disease progression. X-rays are not specifically diagnostic.
• Treatment goals of RA include _	_reduction of inflammation, management of pain, maintenance of joint function, and prevention/correction of joint deformity. These goals are met through a comprehensive program of drug therapy, rest, joint protection, thermal applications, exercise, and teaching.
• The use of disease-modifying antirheumatic drugs for RA_	-is the cornerstone of drug treatment.
• Biologic/targeted therapies for RA_	_are used in patients with moderate to severe disease.
• Ankylosing spondylitis (AS) is _	_a chronic inflammatory disease primarily affecting the axial skeleton (sacroiliac joints, intervertebral disk spaces, and costovertebral articulations).
• The cause of AS is unknown_	_however, most persons are positive for HLA-B27 antigen.
• Signs of AS are _	_low back pain, stiffness, and limitation of motion. Pain can also occur in other joints, including the hands. Extraarticular inflammation can affect eyes, lungs, heart, kidneys, and peripheral nervous system.
• X-rays are essential for the diagnosis of AS:_	_when the suspicion of AS is high, the presence of the HLA-B27 antigen improves the likelihood of this diagnosis.
• Care for AS is aimed at _	_maintaining maximal skeletal mobility while decreasing pain and inflammation. Heat applications, exercise, and medications are often recommended.
• Surgery may be done for _	_severe deformity and mobility impairment in cases of AS.
• Approximately 10% of people with psoriasis (common benign inflammatory skin disease), for reasons unknown_	_develop psoriatic arthritis (PsA), a progressive inflammatory disease.
• PsA can occur in five different forms_	_which mimic gout, RA, and/or OA.
• Treatment for PsA includes _	_splinting, joint protection, physical therapy, and drug therapy with disease-modifying antirheumatic drugs.
• 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.
• The etiology of Reiter's syndrome is unknown_	_, but it appears to occur after genitourinary or gastrointestinal tract infection.
• The prognosis of Reiter's syndrome is favorable_	_most patients have a complete recovery after 2 to 16 weeks.
• Since reactive arthritis is associated with Chlamydia trachomatis infection_	_patients and their sexual partners are often treated with antibiotics.
• Septic arthritis (infectious or bacterial arthritis) is caused by _	_invasion of joint cavity with microorganisms.
• Large joints (knee and hip) are frequently involved in septic arthritis_	_, causing severe pain, erythema, and swelling.
• Septic arthritis requires prompt treatment with antibiotics _	_to prevent joint destruction.
• Nursing care for septic arthritis includes _	_assessment and monitoring of joint inflammation, pain, and fever.
• Lyme disease is _	_a spirochetal infection transmitted by bite of an infected deer tick.
• A characteristic symptom of the early localized Lyme disease is _	_erythema migrans (EM), a skin lesion occurring at the site of a tick bite 2 to 30 days after exposure.
• Viral-like symptoms of Lyme disease_	_such as low-grade fever, chills, headache, swollen lymph nodes, and migratory joint and muscle pain, also occur.
• If Lyme disease is not treated_	_the spirochete can disseminate within several weeks or months to the heart, joints, and central nervous system.
• The diagnosis of Lyme is often based on clinical manifestations_	_in particular the EM lesion, and a history of exposure in an endemic area. A two-step laboratory testing process is used to confirm the diagnosis.
• Antibiotics are used for active Lyme disease _	_and to prevent late disease.
• Reducing exposure to ticks _	_is the best way to prevent Lyme disease.
• Gout is caused by _	_an increase in uric acid production, underexcretion of uric acid, or increased intake of foods containing purines, which are metabolized to uric acid by the body.
• With gout_	_deposits of sodium urate crystals occur in articular, periarticular, and subcutaneous tissues. This leads to recurrent attacks of acute arthritis.
• Risk factors for gout include _	_obesity (in men), hypertension, diuretic use, and excessive alcohol consumption.
• In the acute phase of gout_	_affected joints may appear dusky or cyanotic and are extremely tender and swollen. Inflammation of great toe (podagra) is a common initial problem.
• Chronic gout is characterized by _	_multiple joint involvement and visible deposits of sodium urate crystals (tophi).
• There is no specific diagnostic test for gout_	_; the diagnosis is generally made on the history and physical assessment.
• Treatment of an acute attack of gout consists of_	_drug therapy for pain management and inflammation.
• Future attacks of gout are prevented by the use of_	_of targeted drug therapy, weight reduction, adequate hydration, and possible avoidance of alcohol and food high in purine (red and organ meats).
• Nursing interventions for gout_	_include supportive care of inflamed joints.
• Systemic lupus erythematosus (SLE) is _	_a chronic multisystem inflammatory disease with immune system abnormalities.
• The etiology of abnormal immune response with SLE is unknown_	_a genetic influence is suspected.
• SLE is extremely variable in its severity_	_ranging from a relatively mild disorder to rapidly progressive and affecting many organ systems.
• Commonly affected tissues of persons with SLE are _	_the skin (butterfly rash over nose, cheeks), muscles (polyarthralgia with morning stiffness), lungs (tachypnea), heart (dysrhythmias), nervous tissue (seizures), and kidneys (nephritis).
• Other signs of SLE include _	_anemia, mild leukopenia, and thrombocytopenia. Infection is a major cause of death.
• The diagnosis of SLE is based on _	_the presence of distinct criteria revealed through patient history, physical examination, and laboratory findings.
• A major treatment challenge of SLE is _	_to manage active disease while preventing treatment complications that cause long-term tissue damage.
• Patients with mild polyarthralgias or polyarthritis are treated with _	_nonsteroidal antiinflammatory drugs.
• Corticosteroids are given for _	_severe cutaneous SLE. Antimalarial agents and immunosuppressive drugs may also be used.
• Systemic sclerosis (SS), or scleroderma, is _	_a connective tissue disorder with fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs.
• The cause of SS is unknown_	_immunologic dysfunction and vascular abnormalities may play a role in systemic disease.
• In Systemic sclerosis (SS), _	_collagen is overproduced. Disruption of cell is followed by platelet aggregation and fibrosis. Proliferation of collagen disrupts normal functioning of internal organs.
• Manifestations of SS range from diffuse cutaneous thickening with rapidly progressive and fatal visceral involvement_	_to a benign variant of limited cutaneous SS.
• Clinical manifestations are described by the acronym CREST_	_including calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia.
• No specific drug(s) have been proven effective for treating SS_	_however, many drugs can be used in treating the various manifestations of SS.
• Physical and occupational therapy for SS maintains joint mobility_	_preserves muscle strength, and assists in maintaining functional abilities.
• Polymyositis (PM) and dermatomyositis (DM) are _	_diffuse, idiopathic, inflammatory myopathies of striated muscle that produce bilateral weakness, usually most severe in proximal or limb-girdle muscles.
• The exact cause of PM and DM is unknown_	_theories include infectious agent, neoplasms, drugs or vaccinations, and stress.
• Patients with DM and PM experience _	_weight loss and increasing fatigue, with gradual weakness of muscles that leads to difficulty in performing routine activities.
• DM skin changes include _	_classic violet-colored (heliotrope), cyanotic, or erythematous symmetric rash with edema around eyelids.
• DM and PM diagnosis is confirmed by _	_electromyography findings, muscle biopsy, and serum enzyme levels.
• PM and DM are initially treated with _	_high-dose corticosteroids. If corticosteroids are ineffective and/or organ involvement is occurring, immunosuppressive drugs may be given.
• Patients having a combination of clinical features of several rheumatic diseases are described as having _	_mixed or overlapping connective tissue disease.
• For most patientswith mixed or overlapping connective tissue disease, this is a stage in the progression to_	_SLE, Sjögren's syndrome, or Poymyelitis (PM).
• With Sjögren's syndrome_	_an autoimmune disease, lymphocytes attack the moisture-producing glands, leading to xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes).
• Sjögren's appears to be caused by_	_genetic and environmental factors.
• Treatment for Sjögren's is symptomatic, including_	_instillation of preservative-free artificial tears for hydration and lubrication, surgical punctual occlusion, and increased fluids with meals.
• Myofascial pain syndrome is characterized by _	_musculoskeletal pain and tenderness in one anatomic region of the body.
• With myofascial pain syndrome, regions of pain are often_	_within taut bands and fascia of skeletal muscles. With pressure, trigger points are thought to activate a pattern of pain.
• Treatment for myofascial pain syndrome can include _	_anesthesia to trigger points, massage, physical therapy, acupuncture, and biofeedback.
• Fibromyalgia syndrome (FMS) is _	_a chronic disorder characterized by widespread, nonarticular musculoskeletal pain and fatigue with multiple tender points.
• With firbromyalgia_	_nonrestorative sleep, morning stiffness, irritable bowel syndrome, and anxiety may also be noted.
• The cause and pathology of FMS are being studied. It is known to be _	_a disorder of central processing with neuroendocrine/neurotransmitter dysregulation.
• Treatment for fibromyalgia is symptomatic and requires _	_a high level of patient motivation, including rest, medication, relaxation strategies, and massage.
• Chronic fatigue syndrome (CFS), also called _	_chronic fatigue and immune dysfunction syndrome, is a disorder characterized by debilitating fatigue.
• The etiology and pathology of CFS_	_is unknown
• It is often difficult to distinguish between CFS and FMS_	_since many of the clinical features are similar.
• There is no definitive treatment for CFS_ Supportive management is essential.	_supportive management for CFS is essential.
• CFS does not progress_	_most patients recover or at least gradually improve over time.

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Lewis Med Surg Ch. 65 - Arthritis and Connective Tissue diseases

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