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Rheumatoid Diseases Osteoarthritis Rheumatoid Arthritis Systemic Lupus Erythematosis Scleroderma Osteoarthritis Definition: *wear and tear, progressive, non-systemic, Degenerative Joint Disease (DJD) Pathophysiology Note top slide only Identify which joints are primarily affected with osteoarthritis. What factors contribute to the development of osteoarthritis? 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 What signs and symptoms does the person with osteoarthritis experience? Normal Knee structure Moderately advanced osteoarthritis Advanced osteoarthritis 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 Carpometacarpocarpal joint of thumb with subluxation of the first MCP Genuvarus Herberden’s nodes 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 OA RA 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 Pannus joint cartilage disappears, underlying bone destroyed, joint surfaces collapse Fibrous Ankylosis Fibrous connective tissue replaces pannus; loss of joint otion Bony Ankylosis Eventual 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 “hidebound” 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 Polyarteritis Nodosa – Inflammation, necrosis of walls small to medium sized arteries – Like SLE Lyme Disease – Caused by spirochete, borrelia burgdorferi Dermatomyositis – 3 stages – Affects skin and • Initial rash voluntary muscles • disseminated • Late – Antibiotics effective Rheumatoid Review Sjogrens JRA