Exam 16 - Inflamm. Disorders

Inflammatory Disorders and Surgical Interventions

• Rheumatoid Arthritis (RA): A chronic, systemic autoimmune disease causing inflammation of synovial membranes (synovitis) in diarthrodial joints.
• Etiology:
  • Severe and crippling form of arthritis.
  • Affects approximately 1.5 million people.
  • Likely autoimmune with genetic predisposition.
  • Significantly more common in women (nearly three times more than men).
  • Most prevalent in women aged 30-60.
  • Smoking increases RA risk in men and women with genetic predisposition.
  • Bacterial and viral diseases are additional risk factors.
• Pathophysiology:
  • Chronic synovitis in diarthrodial joints.
  • Periods of remission and exacerbation.
  • Immune system malfunction, leading to ongoing immune response.
• Clinical Manifestations:
  • Chronic inflammation damages joints and surrounding tissue, leading to deformity and loss of function.
  • Potential stressful events as precipitating factors (infection, stress, exertion, childbirth, surgery, emotional upset).
  • Remission: inflammation, pain, stiffness, edema subside; tissue damage progression halts.
• Assessment (Subjective):
  • Joint pain, tenderness, swelling, or stiffness for 6 weeks or more.
  • More than one joint affected.
  • Morning stiffness lasting 30 minutes or more.
  • Small joints (wrists, hands, feet) affected.
  • Symmetrical joint involvement.
• Assessment (Objective):
  • Joint edema.
  • Joint tenderness.
  • Subcutaneous nodules.
  • Limited range of motion (morning stiffness).
  • Symmetrical joint involvement.
  • Fever.
• Diagnostic Tests:
  • No single definitive test.
  • Diagnosis based on history, physical examination, and four classic symptoms (morning stiffness, joint pain, muscle weakness, fatigue).
  • Radiographic studies show cartilage loss and subchondral bone changes.
  • Arthrocentesis reveals cloudy, milky, or dark yellow synovial fluid with inflammatory cells.
  • Anti-CCP antibody test frequently positive, can identify RA before symptoms. Other blood tests (C-reactive protein, CBC, ESR, ANA) may be elevated.
• Medical Management:
  • Aggressive treatment early on.
  • Disease-modifying anti-inflammatory drugs (DMARDs) to control disease activity.
  • Pain relief.
  • Reduce symptoms quickly (e.g., methotrexate).
  • NSAIDs may be used to further reduce inflammation.
  • Promote long-term joint function with physical therapy & splints.
  • Slow joint damage progression with ADL modification, exercise, weight management.
• Surgical Management:
  • Arthroplasty (joint replacement) can restore lost function and relieve pain.
• Nursing Management:
  • Educate patients about the disease, health maintenance, pain relief, stress reduction, and inflammation management.
  • Medication regimen instruction, including therapeutic and adverse effects.
  • Heat/cold application (safety instructions).
  • Collaboration with therapists for exercise, ADL modifications, and splints to maintain joint alignment and movement. Encourage nutrition and hydration.
• Prognosis:
  • Variable, characterized by remissions and exacerbations.
  • Stages exist, from early effects to terminal stage, marked by severe deformities, muscle atrophy, soft tissue lesions, bone-cartilage destruction, and ankylosis.

Other Inflammatory Joint Disorders

• Ankylosing Spondylitis:

  • Chronic connective tissue disorder of spine and surrounding joints.
  • More common in men; women have milder forms.
  • Etiology unknown—possible altered immune response.
  • Strong familial tendency in some.
  • Pathophysiology: Immobility/ankylosing of joints extending from the hip upwards.
  • Respiratory compromise with kyphosis (hunchback).
  • Cardiovascular involvement (enlarged heart, pericarditis).
  • Vision loss from glaucoma, pupil damage, iridocyclitis.
  • Pulmonary fibrosis.
  • GI involvement (inflammatory bowel disease).
  • Symptoms: Back pain, stiffness, sciatica (lasting a few days repeatedly), weight loss, abdominal distension, peripheral joint edema.
  • Diagnosis: Elevated ESR/CRP, elevated alkaline phosphatase/creatinine phosphokinase. HLA-B27 present in 90% of patients. X-rays/CT scans show joint fusion.
  • Medical Management: NSAIDs, corticosteroids, biologic response modifiers (Enbrel, Remicade, Humira). Firm mattress, exercise, back brace.
  • Nursing Management: Spine alignment maintenance. Supportive furniture and positioning. Breathing & positional exercises.

• Osteoarthritis (Degenerative Joint Disease):

  • Most common arthritis type; "wear-and-tear" disease, primarily in weight-bearing joints.
  • Non-systemic, non-inflammatory; progressive bone/joint degeneration.
  • Almost inevitable with age; most adults have joint changes by age 70.
  • Primary (unknown cause) and secondary (trauma, infection, prior fracture, RA, obesity, professional athletes, etc.) forms.
  • Risk factors: Increased age, prior joint injury, obesity, congenital/developmental disorders, hereditary, and bone diseases.
  • Symptoms: Joint stiffness, pain, enlargement, limited movement, Herberden's nodes (distal interphalangeal), Bouchard's nodes (proximal interphalangeal joints), crepitus, progressive ROM limitations.
  • Diagnosis: No specific test. Radiography, arthroscopy, synovial fluid exam, bone scans.
  • Medical Management (Non-pharmacological): Exercise, physical therapy, heat, relaxation techniques.
  • Medical Management (Pharmacological): NSAIDs (initially starting with OTC or acetaminophen), steroids (for immediate pain relief), acetaminophen, other analgesics.
  • Surgical Management: Reconstructive surgery for severely compromised mobility and quality of life (most common: hip and knee replacements). Materials: metal & high-density polyethylene.
  • Post-operative complications: Hemorrhage, subluxation/dislocation, infection, thromboembolism, vascular necrosis.
  • Nursing Management: Education on medications, activity modification, weight management, referrals, preoperative/postoperative assessments (e.g., maintain moderate activity appropriately), and neurovascular assessment.

• Gout:

  • Metabolic disease; uric acid accumulation in blood, acute inflammatory condition, ineffective purine metabolism.
  • 8 times more common in men; usually middle-aged men.
  • 85% of gout cases have genetic tendency.
  • Types: Primary (genetic, severe dieting, excessive purine intake), secondary (medications, other diseases), idiopathic (unknown origin).
  • Symptoms: Sudden onset pain, tenderness in one joint (first metatarsophalangeal), swelling/redness, hypersensitivity, potential fever, Tophi (urate deposits).
  • Diagnosis: Urate crystals in synovial fluid. Radiographs might reveal urate deposits. Elevated serum uric acid levels. 24-hr urine specimen showing high uric acid.
  • Medical Management: Uricosuric drugs to increase excretion, decreased purine intake, NSAIDs, colchicine for acute attacks (oral/IV).
  • Nursing Management: Bed cradle to protect affected joint, hourly colchicine administration instructions, monitoring for GI symptoms, encourage high fluid intake, long-term drug/diet explanation.

• Osteoporosis:

  • Disorder of deficient bone density interfering with mechanical support.
  • Impacts ~25% of women > 65.
  • Types: Postmenopausal (estrogen deficiency), senile (ages 70-85, more in women).
  • Risk factors: Small bone structure, white/Asian women, lack of exercise, smoking, alcohol, diseases (hyperthyroidism, COPD, cancer, IBD, alcoholism, vitamin D deficiency), steroid use, anticonvulsants.
  • Symptoms: Initially asymptomatic, first symptom is often vertebral fracture. Height loss, stooped posture.
  • Assessment: Pain, dowager hump, posture issues, loss of height over time.
  • Diagnostics: Blood tests (CBC, calcium, phosphorus, ALP, kidney/liver/thyroid function), BMD test (DEXA; spine/hip assessment).
  • Medical Management: Goal is bone density increase & loss retardation. Calcium supplements (1200-2000 mg/day), vitamin D (800 IU/day), weight-bearing exercise, alcohol restriction.
  • Medications: Bisphosphonates (Alendronate, Zolendronic acid), calcitonin (salmon), estrogen receptor modulators, parathyroid hormone. Medication administration instructions to minimize negative side effects.
  • Surgical Management: Vertebroplasty/kyphoplasty for vertebral compression fractures.
  • Nursing Interventions: Diet rich in calcium (dairy, fortified foods), Vitamin D, limit caffeine/protein intake, promote safety, prevent falls, exercise.

• Osteomyelitis:

  • Bone marrow/bone infection (from trauma, surgery, blood-borne bacteria).
  • Causing agents vary (Streptococcus viridans, etc.).
  • Pathophysiology:Bacteria invade, bone degenerates; chronic osteomyelitis—weak bone, predisposition to fractures.
  • Granulation tissue replaces necrotic tissue.
  • Symptoms: Severe, persistent bone pain/tenderness, muscle spasms, limited joint mobility. Potential for chronic recurrent infections.
  • Assessment: Complete history, vital signs, wound appearance (drainage), edema.
  • Diagnostic Tests: Complete history, CT/MRI, lab values (CBC, ESR, CRP, needle aspiration), cultures.
  • Medical Management: Wound care, prolonged/aggressive antibiotic therapy, necrotic tissue debridement, surgery to remove sequestra (dead bone).
  • Nursing Considerations: Gentle extremity movement, positioning, wound care, high-calorie/protein diet, teaching on infection signs.

• Fibromyalgia Syndrome (FMS):

  • Chronic pain syndrome (unknown origin); muscle/bone/joint pain, tenderness at multiple characteristic sites. Associated with poor sleep, headaches, cognitive alterations, stiffness.
  • Affects ~5 million people; often women (80-90%) aged 20-50.
  • Symptoms: Generalized achiness (axial locations like neck, lower back), stiffness worse in the morning, aggravated by cold weather, fatigue, physical activity, anxiety.
  • Diagnosis: Normal lab values (CBC, RF, chemistry, ESR). Potential sleep study.
  • Medical Management: No cure. Pt education & reassurances. Combination pharmacotherapy (tricyclic antidepressants).
  • Nursing Management: Good sleep hygiene education, consistent sleep schedule, regular exercise, avoidance of caffeine/alcohol/nicotine.

• Surgical Interventions:

  • Knee arthroplasty (total or unicompartmental) for pain, deformity correction, and functional restoration.
  • Hip arthroplasty (total) to relieve pain and improve function, due to various causes, including arthritis. Assessment, preoperative/postoperative interventions and education, pain management, activity protocols.
  • Various other surgical interventions for joint disorders. Specific assessment, care plans for each surgical procedure.

Test your knowledge on osteoporosis, osteomyelitis, and related bone health topics. This quiz covers dietary recommendations, nursing interventions, and specific characteristics of conditions affecting bone health. Ideal for healthcare students and professionals.