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Autoimmune Disorders
That Affect the
Musculoskeletal System
Rheumatoid Arthritis
Rheumatoid Arthritis (RA)
 Chronic,
systemic autoimmune disease
 Inflammation of connective tissue in
diarthrodial (synovial) joints
 Periods of remission and exacerbation
 Frequently accompanied by extra-articular
manifestations
Incidence
 Occurs
globally, affecting all ethnic groups
 Occurs at any time of life
 Incidence increases with age

Peaks between 30s and 50s
 Nearly
2.1 million Americans affected
 Women have incidences three times
higher than men
Etiology
 Cause
of RA is unknown
 No infectious agent found
 Two etiologies

Autoimmune etiology
• Most widely accepted

Genetic factor etiology
Etiology and Pathophysiology of
Rheumatoid Arthritis
Main Pathology is chronic inflammation leading to
scar tissue (pannus) & joint cartilage destruction
Etiology and Pathophysiology of
Rheumatoid Arthritis
 Inflammatory
pannus causes destruction
of bone.
 This
leads to joint deformities.
Pathophysiology
 If

unarrested, RA progresses in 4 stages
Stage 1: Early
• No destructive changes on x-ray, possible x-ray
evidence of osteoporosis

Stage 2: Moderate
• X-ray evidence of osteoporosis, with or without
slight bone or cartilage destruction
• No joint deformities, adjacent muscle atrophy,
possibly presence of extra-articular soft tissue
lesions
Etiology and Pathophysiology
 RA

progresses in four stages (cont'd)
Stage 3: Severe
• X-ray evidence of cartilage and bone destruction in
addition to osteoporosis; joint deformity; extensive
muscle atrophy; possible presence of extraarticular soft tissue lesions

Stage 4: Terminal
• Fibrous or bony ankylosis, stage III criteria
Clinical Manifestations
Onset
 Onset
is typically insidious
 Nonspecific manifestations may precede
onset of arthritic complaints

 Some
report a history of precipitating
events
Clinical Manifestations
Joints

Specific articular
involvement


Symptoms occur
symmetrically
 Frequently affect small
joints of hands and
feet
 Larger peripheral joints
may also be involved
Typical Deformities of
Rheumatoid Arthritis
Fig. 65-4
Clinical Manifestations
Joints
 Patient
experiences joint stiffness after
periods of __________
 Morning stiffness may last from 60
minutes to several hours or more
 MCP and PIP joints typically swollen
 Fingers may become spindle shaped from
synovial hypertrophy and thickening of
joint capsule
Clinical Manifestations
Joints
 Joints
become tender, painful, and warm
 Joint pain



Increases with ______
Varies in intensity
May not be proportional to degree of
inflammation
 Tenosynovitis
frequently affects extensor and
flexor tendons near wrists
 RA progresses
Extraarticular Manifestations of
Rheumatoid Arthritis
Fig. 65-5
Clinical Manifestations
Extraarticular Manifestations
 Three
most common



 Rheumatoid
nodules develop in up to 25%
of all patients with RA
 Those
affected usually have high RF titers
Clinical Manifestations
Extraarticular Manifestations
 Sjögren’s


syndrome
Seen in 10% to 15% of patients with RA
Can occur as a disease by itself or in
conjunction with other arthritic disorders
• RA and systemic lupus erythematosus (SLE)



Complaints of burning, gritty, itchy eyes
Decreased tearing, photosensitivity
Clinical Manifestations
Extraarticular Manifestations
 Felty’s


syndrome
Most commonly in patients with severe,
nodule-forming RA
Characterized by
•
•
•
•
•
Inflammatory eye disorder
Splenomegaly
Lymphadenopathy
Pulmonary disease
Blood dyscrasias
Complications
 Joint
destruction begins as early as first
year of disease without treatment
 Flexion contractures and hand deformities


Cause diminished grasp strength
Affect patient’s ability to perform
self-care tasks
 Cataract
development and loss of vision
can result from scleral nodules
Complications
 Rheumatoid
nodules
 On the skin can ulcerate, similar to
pressure ulcers
 On vocal cords leads to progressive
hoarseness
 In vertebral bodies can cause bone
destruction
Complications
 Cardiopulmonary
effects may occur later
in RA

Pleurisy, pleural effusion, pericarditis,
pericardial effusion, cardiomyopathy
 Carpal
tunnel syndrome can result from
swelling of synovial membrane
Diagnostic Studies

RA is defined as having at least 4 of the
following seven criteria. Following must
be present for at least 6 wks:
Morning stiffness that lasts ≥1 hour
Swelling in three or more joints
Swelling in hand joints
Symmetrical joint swelling
Erosions or decalcification seen on hand
x-rays
6. Rheumatoid nodules
7. Presence of serum RF
1.
2.
3.
4.
5.
Diagnostic Testing

History & PE
 Blood Studies





Synovial fluid analysis



Rheumatoid factor (RF)
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)
Antinuclear antibodies (ANA) titers are seen in some
Straw-colored fluid with fibrin flecks
WBC is elevated to >25,000/μl
X-rays

Will not confirm diagnosis – only show bone changes
Collaborative Care
 Care
begins with a comprehensive
program of education and drug therapy

Education of drug therapy




Patient and family educated about disease
process and home management strategies
Involve PT and OT
Drug Therapy
 Drugs
remain cornerstone of treatment
 DMARDs can lessen permanent effects of
RA
 Choice of drug is based on patient’s
 disease activity
 level of function
 lifestyle considerations: e.g; choices for a
woman of childbearing age?
Treatment and Nursing Care for
Rheumatoid Arthritis
 See
Table 65-3 for meds used for arthritis
p. 1698-1700.










Salicylates
NSAIDs
Antibiotics
Topical analgesics
Corticosteroids
DMARDs
Gold compounds
Antimalarials
Immunosupressants
Biologic/Targeted therapy
Drug Therapy
DMARD
 Methotrexate
(Rheumatrex) is drug of
choice




Rapid antiinflammatory effect decreases
clinical symptoms in days to weeks
Inexpensive
Lower toxicity compared to other drugs
Side effects: bone marrow suppression,
hepatotoxicity
Drug Therapy
DMARD
 Other
DMARDs for mild to moderate
disease


Sulfasalazine (Azulfidine)
Antimalarial drug hydroxychloroquine
 Leflunomide
(Arava) - a newer synthetic:
DMARD that blocks immune cell overproduction
Drug Therapy
 Biologic/targeted
drug therapies can also
slow disease progression in RA
 Can be used in patients with moderate to
severe disease who have not responded
to DMARDs or in combination therapy with
an established DMARD
Drug Therapy
 Corticosteroid
therapy can aid in symptom
control

Intraarticular injections may relieve pain and
inflammation associated with flare-ups
• Long-term use should not be a mainstay


Risk osteoporosis, avascular necrosis
Low-dose prednisone for a limited time to
decrease disease activity until DMARD effect is
seen
Drug Therapy
 Various
NSAIDs and salicylates are used
to treat pain and inflammation
 Aspirin is often used in high dosages of 4
to 6 g/day (10 to 18 tablets)
 NSAIDs have antiinflammatory, analgesic,
and antipyretic properties; full
effectiveness may take 2 to 3 weeks
 NSAIDS may be used when patient cannot
tolerate high doses of aspirin
Combination Drug Therapy
 Use
of two more drugs simultaneously
 Can slow symptoms and joint damage
while improving function
 Often include a DMARD, an NSAID, and a
corticosteroid
Relieve Pain
 NSAIDs
 DMARDs
 Non-Pharmacological



Heat or Cold applications
Rest
Relaxation techniques
Nursing Implementation
Acute Intervention
 Usually
treated on an outpatient basis
 Hospitalization may be necessary for
patients with extraarticular complications
or advancing disease

Reconstructive surgery for disabling
deformities
 Nursing
intervention begins with a careful
physical assessment
Nursing Management
Assessment
 Nurse


must also
Evaluate psychosocial needs and
environmental concerns
After problem identification, coordinate a
carefully planned program for rehabilitation
and education for interdisciplinary health care
team
Nursing Management
Problems
 Chronic
pain
 Impaired physical mobility
 Activity intolerance
 Self-care deficit
 Ineffective therapeutic regimen
management
 Disturbed body image
Nursing Management
Planning
 Overall





goals
Satisfactory pain relief
Minimal loss of functional ability of affected
joints
Perform self-care
Participate in planning and carrying out
therapeutic regimen
Maintain a positive self-image
Nursing Management
Interventions
 Discuss
drug actions, side effects, need
for timely administrations to sustain drug
levels and lab monitoring
 Many
patients take several different drugs
so the nurse must make the drug regimen
as understandable as possible
Nursing Management
Interventions
 Nonpharmacologic







relief of pain
Therapeutic heat and cold
Rest
Relaxation techniques
Joint protection
Biofeedback
Transcutaneous electrical stimulation
Hypnosis
Nursing Management
Interventions
 Lightweight
splints may be prescribed to
rest an inflamed joint & prevent deformity

Should be removed regularly to perform skin
care and ROM exercises and reapplied as
prescribed
OT may help identify additional self-help
devices to assist in activities of daily living
 AM care and procedures should be
planned around morning stiffness

Nursing Management
Interventions
 Morning
care and procedures should be
planned around patient’s morning stiffness
 Assist with activities to help relieve joint
stiffness: warm shower, warm towels
around shoulder, etc.
 Gentle skin care if bedridden
Ambulatory and Home Care
Rest
 Alternate
scheduled rest periods with
activity throughout day


Helps relieve pain and fatigue
Amount of rest varies
 Total


bed rest
Rarely necessary
Should be avoided to prevent stiffness and
immobility
Ambulatory and Home Care
Rest
 Good
body alignment while resting can be
maintained through use of a firm mattress
or bed board
 Encourage positions of extension

Avoid flexion positions
 Splints
and casts can help maintain proper
alignment and promote rest
Ambulatory and Home Care
Heat and Cold Therapy
 Help
relieve pain, stiffness, and muscle
spasm
 Ice
 Superficial
 Moist
heat
heat sources
Ambulatory and Home Care
Exercise
 Inadequate
joint movement can result in
progressive joint immobility and muscle
weakness
 Overaggressive exercise can result in
increased pain, inflammation, and joint
damage
 Gentle ROM exercises are usually done
daily to keep joints functional
Ambulatory and Home Care
Psychologic Support
 Patient’s
value system and perception of
disease must be considered
 Patient is constantly challenged by
problems of




Limited function and fatigue
Loss of self-esteem
Altered body image
Fear of disability or deformity
Gout
Gout
 Deposits
of sodium urate crystals in
articular, periarticular, and subcutaneous
tissues
 May be primary or
secondary


Primary – hereditary error
of purine metabolism
Secondary – drugs that inhibit uric acid
excretion or increase rate of cell death or
another acquired disorder
Incidence and Risk Factors
 Primary
 Affects
 Risk
gout accounts for 90% of cases
primarily middle aged men
factors: obesity, HTN, thiazide
diuretics, excess alcohol use
Pathophysiology
 Uric
acid is end product of purine
metabolism and is excreted by the kidneys
 Causes
 Diet
of hyperuricemia
high in purines will not cause gout,
but may trigger an attack in a susceptible
person
Clinical Manifestations
 Gouty
arthritis in one or more joints (but
less than four)
 Great toe joint most common first
manifestation; other joints may be the foot,
ankle, knee, or wrist
 Joints are tender & cyanotic
 May be precipitated by trauma, surgery,
alcohol ingestion, or infection
Clinical Manifestations
 Onset
usually nocturnal, with sudden
swelling and excruciating pain
 May have low grade fever
 Usually subsides within 2-10 days
 Joints are normal, with no symptoms
between attacks
Complications
 Joint
deformity
 Osteoarthritis
 Tophi
may produce draining sinuses that
may become infected
 Renal
stones, pyelonephritis, obstructive
renal disease
Diagnosis
 History
& physical examination
Clinical symptoms alone are sufficient
to
make accurate DX in most cases
 Family
history of gout
 Diagnostic
studies
Diagnostic Studies

Serum uric acid levels

May be caused by other factors

WBC elevated during acute attack
 ESR
 24 hour urine uric acid levels
 Synovial fluid aspiration contains uric acid
crystals


Seldom necessary
X-rays appear normal in early stages; tophi
appear as eroded areas of bone
Collaborative Care
 Acute





attack
Colchicine produces dramatic antiiflammatory
effects with relief within 24-48 hours
NSAIDs for additional pain relief
Corticosteroids (po or intraarticular)
Adrenocorticotropic hormone (ACTH)
Joint aspiration to decompress
Collaborative Care
 Prevention

of acute attacks
Colchicine combined with:
• allopurinol (Zyloprim, Alloprim) – blocks production
of uric acid
• probenecid (Benemid), sulfinpyrazone (Anturane)
– inhibit tubular reabsorption of uric acid
• febuxostat (Uloric) – inhibits xanthine oxidase,
recently shown to reduce serum uric acid levels
Collaborative Care
 Uricosuric

Agents
Probenecid (Benemid)
 Precautions



Sulfinprazone (anturan) block resorption uric acid
High fluid intake, alkaline urine
Not effective if creatinine clearance is elevated
 Cozaar

Angiotension II receptor angonist
• Monitoring

Force Fluids while on these medications!!
Collaborative Care
 Dietary



measures
Weight reduction
Avoidance of alcohol
Avoidance of foods high in purines
• High: Sardines, anchovies, herring, mussels, liver,
kidney, goose, venison, meat soups, sweetbreads,
beer & wine
• Moderate: Chicken, salmon, crab, veal, mutton,
bacon, pork, beef, ham
Treatment and Nursing Care

Bedrest and position for comfort

Joint immobilization and protect joint from pressure

Local application of heat or cold

Assess for complications
 Formation of kidney stones
 Hypertriglyceridemia
 Hypertension
Collaborative Care
 Prevention



of renal stones
Increase fluid intake to maintain adequate
urine output
Allopurinol
ACE inhibitor losartin (Cozaar) – promotes
urate diuresis
Nursing Care
 Acute




gouty arthritis – pain control
Gentle, supportive care of affected joints
Immobilize and rest affected joints – bed rest
or NWB
Cradle or footboard to prevent pressure from
bedcovers
Monitor ROM and degree of pain
Nursing Care
 Patient/Family
teaching

Gout is a chronic disease

Drug teaching

Need to monitor serum uric acid levels

Precipitating factors
Systemic Lupus
Erythematosus (SLE)
Chronic multisystem disease involving
vascular and connective tissue
Incidence
 SLE
affects 2 to 8 persons per 100,000 in
United States
 Most cases occur in women of
childbearing years
 African, Asian, Hispanic, and Native
Americans three times more likely to
develop than Whites
Etiology
 Etiology
is unknown
 Most probable causes




Genetic influence
Hormones
Environmental factors
Certain medications
SLE
Pathophysiology
 Chronic
multisystem inflammatory disease
 Associated with abnormalities of immune
system
 Results from interactions among genetic,
hormonal, environmental, and
immunologic factors
 Because the antibodies and
accompanying cells of inflammation can
affect tissues anywhere in the body, lupus
can affect a variety of areas
Systemic Lupus Erythematosus
A



variable disease
Chronic
Unpredictable
Characterized by exacerbations & remissions
Clinical Manifestations
 Ranges
from a relatively mild disorder to
rapidly progressing, affecting many body
systems
 Most commonly affects the skin/muscles,
lining of lungs, heart, nervous tissue, and
kidneys
Systematic Lupus
Erythematosus

Affects the
 Skin
 Joints
 Serous membranes
 Renal system
 Hematologic
system
 Neurologic system
Clinical Manifestations
 Dermatologic




Cutaneous vascular lesions
Butterfly rash
Oral/nasopharyngeal ulcers
Alopecia
Clinical Manifestations
 Musculoskeletal


Polyarthralgia with morning stiffness
Arthritis
• Swan neck fingers
• Ulnar deviation
• Subluxation with hyperlaxity of joints
Clinical Manifestations
 Cardiopulmonary





Tachypnea
Pleurisy
Dysrhythmias
Accelerated CAD
Pericarditis
Clinical Manifestations
 Renal

Lupus nephritis
• Ranging from mild proteinuria to
glomerulonephritis
• Primary goal in treatment is slowing the
progression
Clinical Manifestations
 Nervous



system
Generalized/focal seizures
Peripheral neuropathy
Cognitive dysfunction
• Disorientation
• Memory deficits
• Psychiatric symptoms
Clinical Manifestations
 Hematologic






Formation of antibodies against blood cells
Anemia
Leukopenia
Thrombocytopenia
Coagulopathy
Anti-phospholipid antibody syndrome
Clinical Manifestations
 Infection



Susceptibility to infections
Fever should be considered serious
Infections such as pneumonia are a common
cause of death
Diagnostic Studies

No specific test
 SLE is diagnosed primarily on criteria relating to
patient history, physical examination, and
laboratory findings
Diagnosis
These tests are not diagnostic for SLE, but
help in the diagnosis
 Autoantibody



Testing:
Anti-DNA- specific
Anti- Smith antibody (Anti-Sm)
These 2 tests ar emost specific to SLE
Anti nuclear antibody (ANA) – establishes
presence of autoimmune disease
Diagnosis
 Inflammatory
Activity:
* ESR
* C-reactive protein
These tests are helpful in monitoring the
disease activity.
Diagnostic Tests
 CBC
 UA
 X-rays
 Chest
 ECG
x-ray
Collaborative Care
 Prognosis



is improved with
Earlier diagnosis
Earlier and better treatment regimens
Careful monitoring for organ
involvement
Collaborative Care
 Drug





therapy
NSAIDs - for mild disease
Antimalarial drugs – for fatigue/skin/joint
problems
Steroid-sparing drugs - Exs: Methotrexate
Corticosteroidsdoes - for exacerbations and
severe disease
Immunosuppressive drugs – Exs: Cytoxan,
Imuran; to reduce long term corticosteroid use
Nursing Management
Nursing Assessment
 Assess
patient’s physical, psychologic,
and sociocultural problems with long-term
management of SLE
 Assess pain and fatigue daily
 Obtain subjective and objective data
 Educate and counsel on expected issues
Nursing Management
Nursing Diagnoses
 Fatigue
 Acute
pain
 Impaired skin integrity
 Ineffective therapeutic regimen
management
 Body image disturbance
Nursing Management
Nursing Implementation
 Health
promotion
Promote early diagnosis and treatment
 Relieve pain and discomfort and fatigue
 Application of heat and cold
 Encourage to alternate rest and activity
 Support devices – braces, splints, firm
mattress
 Analgesics and anti-inflammatory medications

Nursing Care

Maintain Skin Integrity



Apply topical antiinflammatory
Avoid direct sunlight
Increase Mobility


ROM
Assistive devices
Nursing Management
Nursing Implementation
 Acute



intervention
During exacerbation, patient will become
abruptly, dramatically ill
Record severity of symptoms and response to
therapy
Observe for
•
•
•
•
•
Fever pattern
Joint inflammation
Limitation of motion
Location and degree of discomfort
Fatigability
Nursing Management
Nursing Implementation
 Acute





intervention (cont’d)
Monitor weight and I & O
Collect 24-hour urine sample for protein and
creatinine clearance
Assess neurological status
Explain nature of disease
Provide support
Nursing Management
Nursing Implementation
 Ambulatory




and home care
Reiterate that adherence to treatment does
not necessarily halt progression
Minimize exposure to precipitating factors –
fatigue, sun, stress, infection
Teach energy conservation and relaxation
exercises
For joint problems, all the teaching for RA
related to joint protection, ROM, and
positioning to prevent contractures
Treatment and Nursing Care

Facilitate self care



Improve body image


Provide adaptive equipment for eating, bathing,
toileting, dressing
Allow patient extra time to complete care
Encourage patient to verbalize feelings, perceptions,
and fears
Monitor for complications

Assess for serious adverse effects of medications
used in treatment
Nursing Management
Nursing Implementation
 Lupus

and pregnancy
Infertility

SLE is associated with complications of
pregnancy
Pregnancy & post partum

Women with serious SLE

Nursing Management
Nursing Implementation
 Psychosocial



issues
Counsel patient and family that SLE has good
prognosis
Physical effects can lead to isolation, selfesteem, and body image disturbances
Assist patient in developing goals
Nursing Management
Evaluation
 Expected









outcomes
Completion of priority activities
Verbalization of having more energy
Expression of satisfaction with pain relief measures
Performance of activities of daily living without pain
Limitation of direct exposure to sun
No open skin lesions
Expression of satisfaction with activity level
Pacing of activities to match level of tolerance
Expression of confidence in ability to manage SLE
over time and in home environment