MEDSURG CH 20

• Following are study notes on Osteoarthritis, Rheumatoid Arthritis, Scleroderma, Lupus, Gout, and Fibromyalgia

Osteoarthritis (OA; degenerative joint disease)

• Cartilage and bone ends break down slowly, leading to narrowed joint spaces, bone spurs, and inflamed joint lining.
• Weight-bearing joints, hands, and the vertebral column are commonly affected.
• Risk factors include heredity, being overweight, mechanical stress on synovial joints, trauma, sepsis, congenital anomalies, certain metabolic diseases, and rheumatoid arthritis (RA).
• Symptoms include pain, stiffness (improves with movement, worst in the morning), joint swelling, Heberden and Bouchard nodes (painful bony nodes on finger joints, more common in women), and radiating pain and muscle spasms in limbs if the spinal column is affected.
• Diagnosis involves X-rays, MRIs, and synovial fluid analysis.
• Treatment includes exercise (early morning movement), joint splinting for severe inflammation, yoga and tai chi to stretch/reduce stiffness, muscle strengthening exercises to prevent atrophy, provide joint stabilization (avoid positioning that may lead to contractures).
• Other treatments are weight management to decrease stress on joints, medications (NSAIDs, acetaminophen, corticosteroids, OTC topical creams), Synvisc-One or SYNVISC to replace synovial fluid in knee joints, heat & cold therapy, acupressure, acupuncture, hydrotherapy, imagery, music therapy, massage and total joint replacement
• Nursing care assessment involves unsteady gait, bony enlargement or swelling of affected joints, fatigue, painful range of motion of affected joints, elevated serum creatinine secondary to NSAID use, elevated liver enzymes related to multiple medication use, constipation secondary to decreased physical activity and/or use of narcotic analgesics, vital signs (HTN caused by chronic NSAID use from renal failure), and skin integrity related to decreased mobility.
• Nursing diagnoses include pain related to the disease process and ineffective sleep patterns related to pain.
• Additional nursing diagnoses are self-care deficit related to decreased range of motion and impaired mobility.
• Nursing interventions include administering analgesic and anti-inflammatory medications as ordered, providing cold packs (reduce inflammation), and providing a heat pad (relaxes muscles).
• Nursing education involves taking medications only as prescribed, reporting chest pain, abdominal pain, abnormal bleeding, and blood in the stool or emesis if using NSAIDs, participating in regular physical activity, referrals to PT/OT, referral to orthopedic surgery, and referral for home healthcare.
• Treatment goals are to minimize pain, maximize movement, and foster independence.

Rheumatoid Arthritis (RA):

• RA is a chronic, progressive, systemic inflammatory disease that destroys synovial joints/connective tissues, including major organs.
• Synovitis leads to thickening of synovium, resulting in fluid accumulation, joint swelling, and pain.
• Joint cartilage and bone are eventually destroyed, leading to joint deformity
• Blood vessels, nerves, kidneys, pericardium, lungs, and subcutaneous tissue may be affected, leading to organ failure or death.
• Unpredictable remissions and exacerbations occur.
• Causes include family history (2-3x more prevalent), and oral pathogens.
• Symptoms include bilateral, symmetrical joint inflammation (usually starting in upper extremities; red, swollen, warm, stiff, painful joints, activity reduces pain typically), low-grade fever, malaise, depression, lymphadenopathy, weakness, fatigue, anorexia, and weight loss, joint deformities, and secondary osteoporosis & fracture.
• Diagnosis involves increased WBC, platelets, immunological testing (presence of rheumatoid factor, decreased RBC, decreased C4 complement), increased ESR, + antinuclear antibody test, + CRP, XR, MRI, bone or joint scan, and arthrocentesis.
• Treatment includes ABX, disease-modifying antirheumatic drugs (DMARDs), NSAIDs, corticosteroids, capsaicin cream (analgesic), fish oil, and antioxidants
• Heat is used for stiffness, while cold is used for acute inflammation and total joint replacement.
• Nursing care assessment includes unsteady gait, bony enlargement or swelling of affected joints, warmth and redness of joints, painful range of motion of affected joints, increased incidence of infection, elevated serum creatinine secondary to NSAID use, elevated liver enzymes secondary to methotrexate or leflunomide, constipation secondary to decreased physical activity and/or use of narcotic analgesics, nausea and oral ulcers related to methotrexate use, cough and/or shortness of breath due to interstitial lung disease (caused by RA or methotrexate therapy), assess for pleural effusion, pericarditis, pleuritic, scleritis, episcleritis, and osteopenia, self-care deficit and fatigue.
• Nursing diagnoses include pain related to the disease process, ineffective sleep patterns related to pain, self-care deficit related to decreased range of motion, and impaired joint mobility and function.
• Nursing interventions are to administer analgesics and anti-inflammatories as ordered, corticosteroids as ordered, DMARD therapy as ordered (slows disease progression by modulating the immune system and decreasing the inflammatory process such as methotrexate), and biological therapies as ordered (slow or halt the progression of RA through inhibition of tumor necrosis factor (TNF) or interleukins (ILs) such as Humira, Remicade).
• Nursing education involves adherence to treatment plan to control disease progression, reporting signs, symptoms of infection because of treatment with anti-inflammatories and immunosuppressive therapy, discontinuing immunosuppressive therapy if patients have an active infection, assisting with referral to an infectious disease specialist for patients with chronic or atypical infections, keeping current with vaccinations (should not receive live vaccines if on immunosuppressive therapy), and referral to PT/OT.
• Evaluating outcomes is to ensure proper and consistent use of the treatment plan, patients will have very few or no tender or swollen joints with minimal morning stiffness while experiencing little or no adverse effects from pharmacological therapy

Scleroderma

• Scleroderma is an autoimmune disorder marked by chronic inflammation of the body's connective tissue, resulting in damage and occlusion to the blood vessels (vasculitis).
• It causes overproduction of collagen, which causes tissues to become inflamed, fibrotic, and sclerotic (hard).
• Approximately 20% of patients with scleroderma also have lupus, with some having more than one autoimmune disease (polyautoimmunity).
• Broadly, there are two main types of scleroderma: limited and diffuse.
• Diffuse scleroderma involves skin thickening over most of the body and some internal organs, such as the heart, lungs, and kidneys.
• Limited scleroderma involves skin thickening mostly limited to extremities (fingers, hands, and toes), also called CREST syndrome, which includes Calcinosis (extra calcium deposits), Raynaud's syndrome (color changes/numbness in fingertips/toes), Esophageal dysfunction (difficulty swallowing/acid reflux), Sclerodactyly (tight skin on fingers), and Telangiectasias (red/discolored spots on skin).
• Sine Scleroderma is also known as limited cutaneous systemic sclerosis which is a variant of systemic sclerosis characterized by absence of skin thickening but the presence of other systemic symptoms
• Risk factors include being female, age of onset between 30 and 50 years, and repeated exposure to harmful substances or chemicals.
• Symptoms may be asymptomatic, or include patches/streaks of thickened, waxy skin, arthralgia (joint pain), numbness/swelling (especially in hands and feet), reflux/dysphagia if the esophagus is affected, digestive tract issues (bloating, constipation, diarrhea), arrhythmias/fluid buildup around the heart (pericardial effusion), fibrosis (thickened heart muscle) if the heart is affected, coughing/dyspnea due to scleroderma in the lungs, hypertension and renal failure due to sclerosis of kidneys, and erectile dysfunction (ED) and vaginal dryness.
• Complications include Reynaud's syndrome (blood vessels in digits suddenly contract, making skin pale or bluish, digital infarctions, and wound infections (potential finger amputations)).
• Sjogren's Syndrome occurs by the production of less moisture in certain glands (salivary glands, tear ducts) as well as muscle and joint pain.
• Severe complications include kidney failure, pulmonary hypertension (high blood pressure in arteries carrying blood from heart to lungs), pulmonary fibrosis (scarring in lung tissue), cardiovascular disease, congestive heart failure, a weakened immune system (immunodeficiency), gastrointestinal diseases conditions that affect how your body processes food and absorbs nutrition), and cancer.
• Diagnosis involves blood tests to assess the immune system, pulmonary function tests to show lung/respiratory system effects, biopsy to remove a sample of affected skin/tissue, endoscopy, ECG/echo, and CT/CXR.
• Treatment includes skin treatments (topical glucocorticoids, topical lubricants), immunosuppressants (methotrexate), medicines to manage specific symptoms (antihistamines, low-dose aspirin, vasodilators, analgesics, NSAIDs, low-dose corticosteroids, and proton pump inhibitors), physical therapy, phototherapy, stem cell transplant, and surgeries

Lupus:

• Lupus is a chronic autoimmune condition and has two forms
  • Systemic Lupus Erythematosus (SLE): affects multiple organs and systems including skin, joints, kidneys, heart, lungs, and the nervous system.
  • Discoid Lupus Erythematosus (DLE): a type of cutaneous lupus erythematosus whose people get round sores, usually on their face or scalp.
• Diagnosis involves blood tests such as antinuclear antibody (ANA) test, Anti-dsDNA and anti-Smith antibodies, complete blood count (CBC), Urinalysis, Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), or a Kidney biopsy
• Common Treatments options
  • Medications: like Nonsteroidal anti-inflammatory drugs (NSAIDs), Antimalarial drugs, Corticosteroids, Immunosuppressive agents:
• Some Nursing Interventions involve sun protection and vaccinations

Gout

• An acute, inflammatory arthritis caused by poor metabolism of purines in the blood
• The poorly metabolized purines result in the formation of urate crystals in and around joints
• Diagnosis can be made by performing an arthrocentesis or withdrawal of synovial fluid from the affected joint.
• the synovial fluid findings will indicate urate monohydrate crystals in the joint fluid

Fibromyalgia

General Info

• Its a chronic pain disorder of soft connective tissues
• This is characterized by widespread pain and other symptoms such as insomnia, fatigue, stiffness, and cognitive dysfunction
• The body is becoming hypersensitive to pain from sensory stimuli including heat, touch and auditory tones. However, a definitive etiology is unknown.