Chapter 18 Care of Patients with Arthritis and Other Connective Tissue Diseases
Terms in this set (97)
Hard or bony swellings that can develop in the distal interphalangeal joints (DIP) (the joints closest to the end of the fingers and toes). They are a sign of osteoarthritis and are caused by formation of osteophytes (calcific spurs) of the articular (joint) cartilage in response to repeated trauma at the joint.
What are these called?
Is localized arthritis (osteoarthritis) inflammatory?
No, it is Noninflammatory. It is not systemic, not an autoimmune disease
What is an example of an inflammatory arthritis?
Rheumatoid arthritis, Systemic lupus erythematosus (SLE), Autoimmune disease
What is the most common arthritis type?
Joint Changes in Degenerative Joint Disease
Progressive loss of cartilage, Joint pain, Osteophytes (bone spurs), Cartilage disintegrates; bone and cartilage "float" into joint, causing crepitus
Physical assessment findings/clinical manifestations of osteoarthritis
Joint pain and stiffness, Crepitus, Heberden's nodes, Bouchard's nodes, Joint effusions, Atrophy of skeletal muscle
What finding would you expect in a psychosocial assessment of someone suffering from arthritis?
Severe pain may cause depression/anxiety
What Laboratory tests would be used to diagnose arthritis?
ESR- erythrocyte sedimentation rate and/or hsCRP- high-sensitivity C-reactive protein
What radiologic tests would be used to diagnose arthritis?
CT, Computed tomography; MRI, magnetic resonance imaging
Examples of Nonsurgical Management of Chronic pain
Drug therapy- Acetaminophen (Tylenol) drug of choice, Rest, Immobilization, Positioning, Thermal modalities, Weight control, Integrative therapies- Glucosamine, chondroitin
Examples of Surgical Management of Chronic Pain associated with arthritis
Total joint arthroplasty (TJA), Total joint replacement (TJR), Arthroscopy, Osteotomy
Postoperative complications of surgical joint management
Hip dislocation, VTE, Infection, Anemia, Neurovascular compromise
Which photo shows and incorrect hip flexion after a total hip replacement?
What is this machine called?
Continuous Passive Motion Machine
What disease progression is shown in this photo?
Rheumatoid Arthritis (RA) -Common connective tissue disease, destructive to joints; Chronic, progressive, systemic inflammatory autoimmune disease; affects primarily synovial joints, Transformed autoantibodies (rheumatoid factors) form and attack healthy tissue, causing inflammation
Schematic presentation of the pathologic changes in rheumatoid arthritis. The inflammation (synovitis) leads to pannus formation, obliteration of the articular space, and finally ankylosis. The periarticular bone shows disuse atrophy in the form of osteoporosis.
Physical assessment/clinical manifestations of rheumatoid arthritis
Early - Joint stiffness, swelling, pain, fatigue, generalized weakness & Late - Joints become progressively inflamed and quite painful
joint deformities as shown in photo are common with what condition
What are some RA Systemic Complications
Weight loss, fever, extreme fatigue; Exacerbations; Subcutaneous nodules; Respiratory, cardiac complications; Vasculitis; Periungual lesions; Paresthesias
syndromes associated with rheumatoid arthiritis
Sjögren's syndrome, Felty's syndrome, Caplan's syndrome
Laboratory tests for RA
Rheumatoid factor, antinuclear antibody titer, ESR, serum complement (C3 & C4), serum protein electrophoresis, serum immunoglobulins
Diagnostic tests for RA
X-ray, CT, arthrocentesis, bone scan
RA Drug Therapy includes what classifications of drugs
Glucocorticoids; Immunosuppressive agents; BRMs, Biological response modifiers; DMARDs, disease-modifying antirheumatic drugs; NSAIDs, nonsteroidal anti-inflammatory drugs.
RA Nonpharmacologic Interventions
Adequate rest, Proper positioning, Ice and heat application, Plasmapheresis (not common), Complementary and alternative therapies, Promotion of self-management, Management of fatigue, Enhance body image
Chronic, progressive, inflammatory connective tissue disorder which can cause major body organs/systems to fail
Lupus Erythematosus- can have Spontaneous remissions and exacerbations, Autoimmune complexes tend to be attracted to glomeruli of the kidneys and Often have some degree of kidney involvement
Skin involvement of lupus
Lupus Clinical Manifestations
Polyarthritis, Osteonecrosis, Muscle atrophy, Fever and fatigue, Renal involvement, Pleural effusions, Pericarditis, Raynaud's phenomenon, Neurologic manifestation, Serositis
What clinical sign is indicated in this photo?
Characteristic "Butterfly" Rash of SLE
Lab Assessments for Lupus
Skin biopsy (confirms diagnosis), Immunologic-based laboratory tests, CBC (often shows pancytopenia), Body system function
SLE Drug Therapy
Topical cortisone drugs, Plaquenil, Tylenol or NSAIDs, Chronic steroid therapy, Immunosuppressive agents, Belimumab (Benlysta)
Chronic, inflammatory, autoimmune connective tissue disease which causes Hardening of the skin
Scleroderma (Systemic Sclerosis)
Classifications of Scleroderma
Diffuse cutaneous and Limited cutaneous
What condition is shown in this photo?
What is CREST Syndrome
C - Calcinosis, R - Raynaud's phenomenon, E - Esophageal dysmotility, S - Sclerodactyly, T - Telangiectasia
What is the first symptoms to occur in CREST Syndrome?
Hands and forearm edema with bilateral carpal tunnel syndrome
Scleroderma Clinical Manifestations
Arthralgia, Renal and cardiac system involvement, Problems with GI tract, Lung involvement, Scleroderma Interventions
Drug therapy, Identify early organ involvement, Skin protective measures, Comfort, GI management, Mobility
Urate crystals deposit in joints and other body tissues, causing inflammation
Gout Also called gouty arthritis
Secondary gout called
What condition is shown here
Drug therapy & Nutrition therapy
Examples of Nutrition therapy in treatment of gout
Limit proteins, Avoid trigger foods, Plenty of fluids, pH increased with alkaline foods, Low purine diet
Caused by spirochete Borrelia burgdorferi, resulting from bite of infected deer tick
Chronic complications of Lyme Disease
Arthralgias, Fatigue, Memory/thinking problems, Sometimes first and only sign/symptom is arthritis
The rash shown in the photo indicate what condition
Skin condition characterized by scaly, itchy rash on elbows, knees, scalp sometimes with stiff joints, especially in morning
Treatment focus with psoriasis
Chronic pain syndrome which is not an inflammatory disease characterized by Pain, stiffness, tenderness at certain areas of neck, upper chest, trunk, low back, extremities
Severe fatigue for 6 months or longer, usually following flu-like symptoms
Chronic Fatigue Syndrome (CFS) , Four or more criteria must be met for CFS diagnosis
The patient is a 63-year-old woman admitted to the acute medical care unit. She is 5'4" and weighs 211 lb. Her medical history includes hypertension and GERD. On admission, she reports pain in her hands and joints that is unrelieved by OTC medications. What additional assessment data should you collect from the patient at this time?
Based on her age and reports of pain, the patient is most likely experiencing osteoarthritis, which may be precipitated by her weight. It is important to know when the pain started, and she should be asked to rate her pain on a 0-10 scale.Which OTC medications has she taken? How long has she experienced this pain? Does she have a family history?
While completing your admission assessment, you observe the patient's hands, which appear as shown. 1.How would you document this finding? 2.What do you suspect the patient may be suffering from?
1. Nodes should be described as reddened, swollen on ends of all fingers. 2. The patient has Heberden's nodes, which is a finding of osteoarthritis. A complete work-up will need to be completed by the provider.
An hour later, the patient is crying because of severe joint pain in her hands. What are your priority actions at this time?
Assess the patient's level of pain. Check for pain medication orders and administer prn meds as ordered. Reassess her pain level after administering pain medication.
Which population group is most likely to be diagnosed with fibromyalgia syndrome? A-Men between 30 and 50 years of age B-Men between 50 and 70 years of age C-Women between 30 and 50 years of age D- Women between 50 and 70 years of age
Answer- C Rationale- Most patients diagnosed with fibromyalgia syndrome are women between 30 and 50 years of age.
The nurse is assessing a patient who has undergone total knee arthroplasty for which continuous femoral nerve blockade was utilized. The nurse notes that the patient is anxious. Vital signs include BP 92/58, HR 62, RR 12, and SpO2 89%. What is the priority nursing intervention? A- Take vital signs every 10 minutes. B-Notify physician of the vital signs. C-Anticipate administering IV fluids. D-Notify the Rapid Response Team.
Answer- D Rationale- Although patients having continuous femoral nerve blockade after TKA have been found to require fewer opioids and antiemetics postoperatively, symptoms that may indicate the local anesthetic is getting into the patient's system include metallic taste, tinnitus, nervousness, slurred speech, bradycardia, hypotension, decreased respirations, and seizures. This patient's vital signs suggest instability, and a Rapid Response Team should be activated immediately.
During a health history assessment, a patient with rheumatoid arthritis, chronic hypertension, and diagnosis of a recent cerebrovascular accident states that she takes 2 fish oil capsules (5 g) daily as a supplement for her RA. What additional question(s) should the nurse ask? (Select all that apply.) A- "Are you taking anticoagulant medications?" B- "Have you found the fish oil to help your RA?" C-"What other supplements do you currently take?" D-"How long have you been taking fish oil capsules?" D-"Have you notified your physician about taking fish oil capsules?"
Answer- A, B, C, D, E - Rationale- Some supplements have been found to help decrease inflammation and prevent bone loss for patients with RA. These supplements include calcium, fish oil capsules containing omega-3 fatty acids, and gamma-linolenic acid. Calcium supplements should not be taken in excess to prevent kidney stones, and fish oil capsules should not be taken if the patient is taking anticoagulant therapy. The nurse should ask all questions in A, B, C, D, and E as part of a complete health history.
What is the major focus of rheumatology
Connective tissue disease (CTD)
What is rheumatology
the study of rheumatic disease.
A rheumatic disease is
any disease or condition involving the musculoskeletal system.
Most connective tissues diseases are classified as
In autoimmune disease, the immune system does not recognize body cells as
self and therefore triggers an immune response; antibodies attack healthy normal cells and tissues.
Most autoimmune diseases are characterized by chronic PAIN and joint deterioration, which results in
decreased function and impaired MOBILITY.
The usual protective nature of the immune system does not function properly in patients with
autoimmune connective tissue disorders.
Be aware that most of the Connective tissue disease -CTDs and arthritic disorders have a genetic basis as part of their etiology
most are also classified as autoimmune diseases and have remissions and exacerbations.
Osteoarthritis is primarily a noninflammatory or inflammatory degenerative joint disease
rheumatoid arthritis (RA) is a noninflammatory or inflammatory systemic disease
Osteoarthritis is primarily a noninflammatory systemic or degenerative joint disease
degenerative joint disease.
rheumatoid arthritis (RA) is a noninflammatory systemic or degenerative joint disease
T/F Older patients have osteoarthritis more than younger patients.
T/F Younger patients have rheumatoid arthritis more than older adults.
IMMUNITY and INFLAMMATION factors cause _______ damage in patients with RA.
Name some diseases that often accompany arthritis
psoriasis, Crohn's disease, hemophilia.
About half of patients with osteoarthritis who have hand involvement have what nodes
Heberden's nodes & Bouchard's nodes.
The purpose of drug therapy in patients with OA or RA is to
reduce PAIN and secondary joint INFLAMMATION.
Teach patients who have osteoarthritis or are prone to the disease to
eat a well-balanced diet, follow a weight reduction program if obese, avoid trauma, and limit strenuous weight-bearing activities.
The main priority in overweight patients diagnosed with osteoarthritis is
to lose weight.
What type of patients would you teach about the benefits of exercise, joint protection techniques, and energy conservation guidelines
Instruct patients with arthritic PAIN to use multiple modalities for pain relief, including
ice/heat, rest, positioning, complementary and alternative therapies, and medications as prescribed.
Implement interventions to prevent venous thromboembolic complications such as
anticoagulants, exercises, and sequential compression devices.
Observe the patient for bleeding when he or she is taking
Recognize that patients with rheumatoid arthritis may have body image disturbance as a result of
potentially deforming joint involvement and nodules.
Remind patients to avoid crowds and other possible sources of infection when they are taking
An abduction pillow is placed between the patient's legs to prevent
Monitor for signs of INFECTION post surgery, such as
elevated temperature and foul-smelling draining. Exercise caution with older adults who may not have a fever but may experience an altered mental state. Obtain a sample of drainage for culture and sensitivity to determine causative organism.
The two main classifications of lupus are
discoid lupus erythematosus and systemic lupus erythematosus (SLE).
Thought to be an autoimmune disorder, systemic lupus erythematosus is a chronic, progressive, inflammatory CTD that can cause major body organs and systems to fail. It is characterized by
spontaneous remissions and exacerbations ("flare-ups"), and the onset may be acute or insidious (slow).
Prioritize care for patients with SLE by monitoring for
life-threatening complications, such as renal failure and pericarditis.
Manifestations of systemic lupus erythematosus can include
a dry, scaly "butterfly" rash on the face, discoid lesions, alopecia, polyarthritis, and joint changes.
Teach patients with lupus to avoid
sunlight since exacerbations of the disease may be triggered.
Prioritize care by assessing for swallowing ability in patients who have ______________ and collaborate with the nutritionist for food modifications if needed.
Where should you look for acute joint inflammation in patients with gout
the great toe and other small joints are most typically affected.
What is the most common finding in gout
Remind patients with gout to avoid factors that trigger an attack, such as
aspirin, organ meats, and alcohol.
Recognize that patients with fibromyalgia syndrome (FMS) have a
chronic PAIN syndrome
Patients with fibromyalgia syndrome (FMS) are often frustrated because
they have not been diagnosed or have been misdiagnosed.
Teach patients with fibromyalgia and chronic fatigue syndrome that antidepressant drugs can
promote sleep and decrease pain as well as prevent or treat the depression that is common with these illnesses.
Ankylosing spondylitis affects the vertebral column and causes
spinal deformities. Other features include iritis, arthritis or arthralgia, and nonspecific systemic manifestations such as malaise and weight loss.