Nursing Management of Arthritis and Fibromyalgia

Introductory Medical-Surgical Nursing, 13e - Chapter 63: Caring for Clients With Orthopedic and Connective Tissue Disorders

• Objectives: Explain differences between rheumatoid arthritis and osteoarthritis, describe nursing management of arthritis, summarize TMD clinical manifestations, define pathophysiology of gout, fibromyalgia, bursitis, and ankylosing spondylitis, delineate nursing care for these conditions, discuss systemic lupus erythematosus multisystem involvement, identify causes of osteomyelitis, explain inflammatory processes associated with Lyme disease, identify risk factors for osteoporosis and Paget's disease, differentiate between bunions and hammer toe, and discuss benign and malignant bone tumors.

Inflammatory Disorder Arthritis

• Arthritis: Characterized by joint inflammation and/or degeneration.
• Osteoarthritis: Degenerative joint disease, often associated with wear and tear.
• Rheumatoid Arthritis (RA): Autoimmune inflammatory disorder of connective tissue structures/joints. Characterized by chronicity, remissions, and exacerbations; most common sites are hands, wrists, knees, and ankles. Symmetrical, proximal joint involvement, acute onset typically in 20-40s, with genetic predisposition. Symptoms: stiffness, joint pain, warmth around joints.
• RA Pathophysiology and Etiology: Immune system attacks joint synovial tissue, releasing cytokines causing inflammation. Can affect eyes, heart, lungs, etc.
• RA Assessment Findings: Subcutaneous nodules, muscle atrophy, flexion contractures, classic/characteristic deformities, warm joints, chronic pain worse in morning, and weight loss.
• RA Diagnostic Findings: Radiography, serum protein, rheumatoid factor (RF) electrophoresis, arthrocentesis, CRP. ANA.

Inflammatory Disorders: Rheumatoid Arthritis (RA) Continued...

• RA Medical Management: Decreasing joint inflammation, relieving discomfort, preventing deformities, restoring function. (refer to 63-1 Drug Therapy Table) Use of DMARDS.

Joint Changes in RA

• Diagrams showing the pannus formation and loss of cartilage in RA joints are included.

Rheumatoid Blood Tests

• Rheumatoid factor (RF): Type of antibody found in autoimmune disease patients. Estimated 80% found in RA patients.
• Erythrocyte sedimentation rate (ESR): Measures inflammation in the body.
• C-reactive protein: Measures body inflammation.
• Antinuclear antibody (ANA) test: Detects antibodies in the nucleus of cells, identifying autoimmune disorders.

RA Continued - Nursing Management

• Teaching RA disease management.
• Managing anti-inflammatory drugs
• Steroids
• Immunosuppressants
• Physical therapy
• Nutrition
• Maintaining independence
• Adaptive devices
• Relaxation techniques
• Sleep strategies

RA Remission: By the Numbers

• 1.5 Million adults with RA in the United States.
• 10% to 33% remission rates for those not treated quickly or who don't use biologics.
• 60% or higher remission rates with early and aggressive treatment.

Inflammatory Diseases: Degenerative Joint Disease (Osteoarthritis)

• Pathophysiology and Etiology: Repeated trauma, degenerative joint changes, usually occurring after age 40.
• Primary Osteoarthritis: Without known cause.
• Secondary Osteoarthritis: Known cause like injury or congenital issues.
• Assessment Findings (Signs and Symptoms): Stiffness, pain, painless nodules. Heberden's and Bouchard's nodes (distal joints of fingers), cartilage degeneration, ROM issues crepitus, deformity, limitations, and bone spurs.
• Diagnostic Findings: Radiography

Osteoarthritis Management

• Medical and Surgical Management: Rest, exercise program, transcutaneous electrical nerve stimulation (TENS) unit, drug therapy, joint surgery, intra-articular injection
• Nursing Management: Teaching methods to reduce inflammation and pain.
• Client teaching: Medication, weight-loss, dietary changes, avoiding stresses on joints.

Osteoarthritis cont.

• Exacerbated by overuse.
• Weight bearing joint issues are often asymmetrical.
• More common after age 40
• Develops slowly over years.
• Usually pain is noted with motion initially.
• Stiffness localized to affected joints.
• Not a systemic condition
• No remissions

Heberden Nodes and Bouchard Nodes

• Diagrams depicting these joint abnormalities are included.

Joint Changes in Osteoarthritis (Diagram)

• Diagram showing degenerative changes in joints.

Inflammatory Disorders: Temporomandibular Disorders (TMD)

• Pathophysiology and Etiology: Degenerative arthritis, malocclusion, bruxism, dislocation during endotracheal intubation, or other jaw injuries and trauma.
• Assessment Findings: Jaw pain, muscle spasms, tenderness of masseter/temporalis muscles, headache, tinnitus (ringing in ears), and ear pain.
• Medical and Surgical Management: Dentist referral, NSAIDs, mouth guards, TENS units, muscle relaxants, tricyclics, reconstructive surgery, bite guards.
• Nursing Management: Nutrition, teaching on foods easily consumed without chewing, nutrition consult.

Temporomandibular Joint (Diagram)

• Diagram illustrating the temporomandibular joint.

Gout Hyperuricemia

• Primary Gout: Inflammatory disorder with uric acid accumulation in the blood (hyperuricemia).
• Excessive Ingestion of Purines: Organ meats, steak, shellfish, sardines, genetics, starvation can cause this condition to arise
• Secondary Gout: Abnormal purine metabolism, increased rate of protein synthesis with overproduction or underexcretion of uric acid, increased cellular turnover( some anemias, leukemias, multiple myleomas, psoriasis), decreased excretion of uric acid, due to diuretics, salicylates and/or excessive alcohol intake notably beer.

Inflammatory Disorders: Gout

• Pathophysiology and Etiology: Inherited, painful metabolic disorder impacting joints, causing inflammatory reactions, primarily affects men>women.
• Assessment Findings: Edema, recurrent jaw pain, tender joints/one joint, possible tophi (urate crystals), fever, possible kidney stones.
• Diagnostic Findings: Blood work (clinical findings/urine test), arthrocentesis, radiography, or ultrasound for elevated uric acid levels.
• Medical and Surgical Management: Uricosuric drugs, reduced purine intake, NSAIDs, colchicine, phenylbutazone, steroids (refer to relevant 63-2 Drug Therapy Table).

Gout Management of Diet

• Adequate protein intake with limited purine-rich foods to reduce contributing issues
• High complex carbs and low in fats- for enhanced urate excretion/reduces fat retardation
• Encouraging overweight clients to reduce weight.
• Increasing fluid intake for uric acid excretion.

Inflammatory Disorders: Fibromyalgia Syndrome

• Pathophysiology and Etiology: Widespread inflammatory illness, unknown cause.
• Assessment Findings: Chronic musculoskeletal pain, fatigue, sleep disturbances, commonly affects middle-aged women. Affects muscles, ligaments, and tendons.
• Diagnostic Findings: Difficult to diagnose. Ruling out other conditions, noting widespread chronic pain for 3 months
• Medical and Surgical Management: Analgesics, steroids, additional nontraditional therapies (refer to 63-1 Evidence Based Practice chart), rheumatologist involvement.
• Nursing Management: Goal is to decrease pain, improve sleep. Treatments may include Antiseizure medications, antidepressants, and muscle relaxers along with Cam therapies like massage therapy, acupuncture, biofeedback, water therapy, guided imagery, mindfulness, and counseling. Education, support, encouragement to live healthy lifestyle

Inflammatory Disorders: Bursitis

• Pathophysiology and Etiology: Inflammation of the bursae, and may result from repetitive motion, trauma, infection, and as a reaction gout or RA.
• Assessment Findings: Painful joint movement (elbow, knee, or shoulder), distinct lump (bursa)
• Diagnostic Findings: Radiograph, fluid aspiration.
• Medical and Surgical Management: Rest, salicylates, NSAIDs corticosteroid treatment. Mild ROM exercises.
• Nursing Management: Support, teaching, and resources.

Bursitis of the Knee

• Diagram depicting the swollen knee joint.

Inflammatory Disorders: Spondylitis

• Pathophysiology and Etiology: Chronic connective tissue disorder. Progressive immobility and fusing of the vertebrae. Etiology is unknown.
• Assessment Findings: Low back pain, flattened lumbar curve, aortic regurgitation, Permanent neck flexion, reduced lung sounds if Kyphosis develops.
• Diagnostic Findings: ESR, CT scan, radiographs, and CX-SF.
• Management: Primarily supportive, including medications, back brace, sleep instruction guidelines, and exercises. No cure exists with only supportive care available.
• Nursing Management: Education and support. Increased flexibility, and strength
• Diagram of an affected spine is included showing inflammation of the vertebrae.

Question #1 (True or False)

• Gout affects more women than men is False.

Question #2 (True or False)

• There is no cure for ankylosing spondylitis. Is True.

Inflammatory Disorders: Systemic Lupus Erythematosus (SLE)

• Pathophysiology and Etiology: Autoimmune disorder, unknown cause, destroying connective tissues, impacting multiple body systems (skin, joints, kidneys, heart/lungs, etc.). Chronic disease.
• Assessment Findings: "Great Imitator" (mimics other inflammatory diseases , Lyme Disease), more frequent in Black and Hispanic/Asian women. Symptoms may include facial rash, proteinuria, hematuria, EKG changes, enlarged spleen, Raynaud's phenomenon, musculoskeletal issues, arthritis, joint swelling, and pain.
• Lupus cont.: Discoid Lupus (chronic rash), Subacute Cutaneous Lupus (papules/scaling), and other behavioral disturbances. Confusion, hallucinations, irritability, chest pain, pericarditis, fluid retention, and renal complications. Exposure to UV light can often reactivate the disorder.
• Medical Management: Producing remission, preventing/treating exacerbations, and medication strategies
• Renal, cardiac, GI, and CNS symptomatic treatment
• Diagnostic Findings: Presenting symptoms, blood tests, renal biopsy, urinalysis, Anemia, thrombocytopenia, leukopenia, positive ANA, and Anti-dsDNA testing
• Other Test: Cardiac, GI and Respiratory changes, Epstein-Barr Virus tests.
• Nursing Management: Client and family teaching, focuses on exacerbations to alleviate symptoms, support, education, mobility issues, safety, and skin protection from triggers. Reduce exposure to triggers (stress, smoking, UV sunlight).
• Diagram of Butterfly Rash is included to portray the condition's presentation

Musculoskeletal Infectious Disorders: Osteomyelitis

• Pathophysiology and Etiology: Bacterial infection of bone tissue, often resulting from pathogens like Staphylococcus aureus.
• Assessment Findings: Sudden, acute, or chronic infection.
• Diagnostic Findings: Elevated leukocyte count and ESR; positive blood culture; anemia; radiographs, bone scans, MRI.
• Medical and Surgical Management: Immobilization, surgical debridement, closed saline irrigation. Antibiotic-impregnated beads, bone/muscle flaps. Amputation is a last resort.
• Nursing Management: Supportive care, management of the infectious process, and potential for amputation surgery.

Musculoskeletal Infectious Disorders: Lyme Disease

• Pathophysiology and Etiology: Tick-borne bacterial infection, impacting multiple areas (joints, brain, cardiac, skin), chronic inflammatory, multisystem disease.
• Assessment Findings (3 Stages):
• Stage 1: Localized rash (bull's-eye pattern); feelings of being unwell; numbness, tingling, chills, fatigue.
• Stage 2: Symptoms become more spread out in the body; worsen; short-term memory loss.
• Stage 3: Mental health issues are possible; MS, and fibromyalgia are some other disorders
• Diagnostic Findings: Presentation of signs, and use of ELISA/Western blot tests.
• Nursing Management: Supportive care, managing the infection, understanding the 3 stages of this disease
• Diagram depicting the characteristic rash is included.

Lyme Disease cont.

• Diagnostic findings: based on presenting signs and symptoms; ELISA test identifies antibodies to B. burgdorferi, Western blot test needed if ELISA is positive.
• Medical and Surgical Management: Antibiotics are important; supportive care is crucial to management prognosis. Good results are often seen in early treatment stages
• Nursing Management(client teaching): Education on preventing Lyme disease. Ticks must be removed in 36-48 hours to be effective.

Question #3 (True or False)

• Lyme disease is spread via mosquito bites is False. It is spread by deer tick bites.

Structural Disorders: Osteoporosis

• Pathophysiology and Etiology: Loss of bone mass, more prevalent in women>men, contributing factors exist like genetic factors
• Women: often slim framing, and postmenopausal women, from the European descent group
• Assessment Findings: Lumbosacral, thoracic back pain, kyphosis, brittle and porous bones , bone loss affecting the vertebrae(spinal cord).
• Diagnostic Findings: Radiography, DEXA scans.
• Diagram of Spine is included to portray the affect on the spine.

Osteoporosis Management

• Medical and Surgical Management: Calcium, vitamin D, drug therapy, hormone replacement therapy (HRT), exercise, pain relief, and preventing injuries. refer to 63-3 Drug therapy, and Nutrition notes.
• Nursing Management: Important Education on reducing bone loss includes emphasizing sufficient calcium/vitamin D intake and well-balanced foods. Wt bearing activities, medications: Bisphosphonates, calcitonin, estrone receptor modulators, HRT and Denosumab (slows bone loss), done as needed (Q6 months). The Nurse should also be aware of nutrition notes and supplements that may be useful.

Structural Disorders: Osteomalacia

• Pathophysiology and Etiology: Insufficient calcium absorption, and phosphate deficiency results in softening of bones.
• Assessment Findings: Bone pain, weakness, deformities, and a waddling gait from bowed legs.
• Diagnostic Findings: Radiography, serum levels
• Medical and Surgical Management: Adequate nutrition and exposure to sunlight, exercise, braces, and/or surgery as needed.
• Nursing Management: Addressing dietary deficiencies, maintaining safety precautions, and pain management techniques are necessary.

Structural Disorders: Paget's Disease

• Pathophysiology and Etiology: Abnormal bone remodeling. Bones grow larger, but also become weaker.
• Assessment Findings: Bone pain, tenderness, and skeletal deformity, mostly impacting long bones (spine, pelvis, skull, legs).
• Diagnostic Findings: Radiography, bone scans
• Medical and Surgical Management: Drug therapy, surgery if needed( when limbs are misaligned).
• Nursing Management: Refer to Nursing Care Plan 61-1 in Chapter 61.

Structural Disorders: The Feet

• Pathophysiology and Etiology: Heredity, arthritis, and improperly fitting shoes.
• Conditions: Bunions, hammertoes, and mallet toe
• Assessment Findings: Pain, tenderness, deformity, corns, and calluses.
• Diagnostic Findings: Radiography
• Medical and Surgical Management: Well-fitted shoes, exercises, pads, surgery (bunionectomy).
• Nursing Management:Refer to 63-3 Client/Family teaching, for educational resources.
• Diagrams of hallux valgus (bunion) and hammertoe are included.

Benign Bone Tumors

• Pathophysiology and Etiology: Overgrown clusters of normal bone cells.
• Assessment Findings: Pain, deformity, swelling
• Diagnostic Findings: Radiography, bone scans, biopsy
• Medical and Surgical Management: Surgery, curettage (scraping), bone grafts, splints, or casts
• Nursing Management: Supportive care, and education on potential treatments.

Malignant Bone Tumors

• Pathophysiology and Etiology: Radiation, toxic chemical exposure, heredity are potential factors
• Assessment Findings: Primary tumors; unusual locations, pathologic fractures, and difficulty in movement. Abnormal gait, and pain are also symptoms to pay attention to.
• Diagnostic Findings: Radiography, MRI, bone scans, biopsy
• Medical and Surgical Management: Surgery, radiation, chemotherapy
• Nursing Management: Supportive care for the patient is a necessity, as well as a focus on the treatment plan for the patient, understanding of the severity, and the importance of support and education to the patient is important