Connective Tissue Disorders.pdf

Nursing Care of the Client with Arthritis and Connective Tissue Disorders/Nursing Care of the Adult and Geriatric Client with Joint Replacement N14B Student Learning Outcomes 1. Develop knowledge of pathophysiogy of Lupus, Osteoarthritis, Rheumatoid Arthritis, Chronic Fatigue Syndrome, Fibromyalgia,...

Nursing Care of the Client with Arthritis and Connective Tissue Disorders/Nursing Care of the Adult and Geriatric Client with Joint Replacement N14B Student Learning Outcomes 1. Develop knowledge of pathophysiogy of Lupus, Osteoarthritis, Rheumatoid Arthritis, Chronic Fatigue Syndrome, Fibromyalgia, Lyme Disease, and Gout. 2. Describe the clinical manifestations, collaborative care, and nursing management of Lupus, Osteoarthritis, Rheumatoid Arthritis, Chronic Fatigue Syndrome, Fibromyalgia, Lyme Disease, and Gout 3. Apply Nursing Process to care of patients with critical Muscle Skeletal Disorders and Diseases 4. Develop knowledge of multiple orthopedic trauma. 5. Apply nursing process to multiple trauma patient. Lyme Disease A Vector Borne Disease Bacterial Infection – Spirochete Borrelia burgdorferi (Bb) Tick Bite – Ixodes Pacificus Lyme Disease: Prevalence USA (All cases are reportable) – # 1 Vector-Borne Disease in US ✴ 2023 is expected to be a higher than normal year California – Lyme disease found in 53 of 58 counties in CA – Most Frequent Counties Humboldt Mendocino Sonoma Marin Santa Cruz Lyme Disease: Early Symptoms Early – – – – – – – – – – – – Fever and chills Malaise Fatigue Headache Stiff neck Backache Nausea and vomiting Anorexia Sore throat Arthralgias Myositis Swollen glands Erythema Migrans Classic presentation Present < 50% of cases. Lyme Disease: Chronic Symptoms Unexplained fever, sweats, chills Fatigue, pain Arthritis, myositis Shortness of breath, cough, Asthma Headache, confustion, memory loss, mood swings, disturbed sleep Problems with sight and hearing Gastritis, colitis-unexplained weight change Tremor, twitching, poor balance Skin hypersensitivity Mood swings Lyme Disease: Nursing Care Antibiotic Regime – Usually Doxycycline or Amoxicillin – Symptom management for new symptoms – 1:100 may develop worsening Neuro Lyme, Carditis and/or Arthritis – Carditis would be manifest as Cardiac Block Rhythm Patient teaching – Nutrition, sleep & exercise – Support groups Gout Etiology and Pathophysiology – Caused by an increase in uric acid production, underexcretion of uric acid by the kidneys, or increased intake of foods containing purines. – Deposits of monosodium urate crystals occur in articular, periarticular and subcutaneous tissues. – Joint involvement includes recurrent attacks of acute arthritis. – Primary and secondary gout Gout (cont) Clinical Manifestations and Complications – Acute phase: 1-4 joints affected Affected joints may look cyanotic and are extremely tender May involve big toe, midtarsal area of foot, ankle, knee and wrist Onset rapid, pain and swelling peaking within hours, may have low-grade fever Subsides in 2-10 days with or without treatment – Chronic gout: multiple joint involvement with visible deposits of sodium urate crystals (tophi) Variable course--may be infrequent, mild attacks or multiple severe episodes assoc. with slowly progressive disability Chronic inflammation--->joint deformity and cartilage destruction www.thesahara.info/feet/gout_disfigurement.jpg May predispose joint to secondary OA Gout (cont) Diagnostic Studies – Serum uric acid level elevated, but not specific to gout – 24-hour urine acid level to determine if cause is excretion or overproduction of uric acid – Synovial fluid aspiration contains crystals of sodium urate Collaborative Care – Drug Therapy Colchicine-antiinflammatory drug inhibits the migration of leukocytes to inflamed site--for use during acute attack Allopurinol (Zyloprim) inhibits final steps in uric acid biosynthesis--->decreased serum uric acid levels and preventing the precipitation of an attack Probenecid (Benemid)increases rate of uric acid excretion by inhibiting its reabsorption Should not be used in acute attacks Uloric (febuxostat)lowers uric acid levels but tolerated better with kidney problems Gout (cont) Nutritional Therapy – Limit ETOH and foods high in purine -mostly proteins – Weight reduction program Nursing Management – Supportive care of inflamed joints – Pain management – Teaching Systemic Lupus Erythematosus Chronic autoimmune disease where body doesn’t recognize various organs - varies per patient Mainly in women of childbearing age 15-45. More common is African American, Asian American and Hispanic women SLE: Diagnosis History Lab tests – Antinuclear antibodies (ANA) + in 95% of pts with idiopathic SLE and in 100% with druginduced SLE ANA done to identify problems with immune system, but is not specific to SLE Anti-DNA , Anti Smith (found exclusively in Lupus) Antineuronal, Anticoagulant, Anti WBC, Anti RBC Anti Platelet,Anti Basement membrane SLE: Treatment Symptom Management – Minimize symptoms – Reduce inflammation – Maintain normal bodily functions Supportive – Support groups, counseling, social support Preventative Avoid excessive sun exposures, Regular use of sunscreen SLE Treatment Nonsteroidal anti-inflammatory drugs (NSAIDs). Over-the-counter NSAIDs, such as naproxen (Aleve) and ibuprofen (Advil, Motrin, others), may be used to treat pain, swelling and fever associated with lupus. Stronger NSAIDs are available by prescription. Side effects of NSAIDs include stomach bleeding, kidney problems and an increased risk of heart problems. Antimalarial drugs. Medications commonly used to treat malaria, such as hydroxychloroquine (Plaquenil), also can help control lupus. Side effects can include stomach upset and, very rarely, damage to the retina of the eye. Corticosteroids. Prednisone and other types of corticosteroids can counter the inflammation of lupus, but often produce long-term side effects — including weight gain, easy bruising, thinning bones (osteoporosis), high blood pressure, diabetes and increased risk of infection. The risk of side effects increases with higher doses and longer term therapy. Immune suppressants. Drugs that suppress the immune system may be helpful in serious cases of lupus. Examples include cyclophosphamide (Cytoxan), azathioprine (Imuran, Azasan), mycophenolate (Cellcept), leflunomide (Arava) and methotrexate (Trexall). Potential side effects may include an increased risk of infection, liver damage, decreased fertility and an increased risk of cancer. A newer medication, belimumab (Benlysta) also reduces lupus symptoms in some people. Side effects include nausea, diarrhea and fever. Chronic Fatigue Syndrome (SEID): Signs and Symptoms Unexplained, persistent, relapsing incapacitating fatigue Depression mild to severe Others: – Unrefreshing sleep – Neurological - severe headaches, impairment of cognitive function – Sleep disturbances - sleep is seldom restorative, can be excessive or insomnia – Painful joints – Post-exertional malaise Newer names: CFIDS (Chronic fatigue and immune dysfunction syndrome), ME (myalgic encephalopathy) (SEID)Chronic Fatigue Syndrome: Nursing & Collaborative Management Treatment focuses on symptom management and maintaining function. Symptom Management – Antidepressants Pain management Treatment for organisms Antihistamines for allergies Maintaining Function Support and education Avoid total rest CBT opportunistic Fibromyalgia Rheumatologic condition characterized by spontaneous, widespread soft tissue pain, sleep disturbance, fatigue and extensively distributed areas of tenderness known as tender points Associated with other conditions - migraine headache, Chronic fatigue, Irritable bowel syndrome, Depression, Restless leg syndrome, TMJ, myofascial pain syndrome Common in women ages of 25 and 55. Fibromyalgia: Collaborative Care Symptom Management Best Evidence – Antidepressants – Exercise – Acupuncture. Others – – – – Massage Gentle stretching - Yoga, Tai Chi Diet - Limit sugar, caffeine, alcohol Relaxation exercises, biofeedback, TENS Systemic Sclerosis Scleroderma-mild form of disease Disorder of connective tissue characterized by fibrotic, degenerative, and occasionally inflammatory changes of skin, blood vessels, synovium, muscle, internal organs Collagen is greatly increased Systemic Sclerosis: Complications GI - dysphagia, constipation and diarrhea Lungs - fibrotic lungs, cough and dyspnea Heart - pericarditis, pericardial effusion, arrhythmias, CHF Renal - major cause of death, renal failure Diagnosis: lab findings, xrays Systemic Sclerosis: Management Treatment goal is to prevent and treat complications of involved organs Antiinflammatory agents Calcium channel blockers - Raynaud’s disease NSAIDS Prednisone in moderation - for joint involvement Skin creams, skin protection PT & OT Psychological support Rheumatoid Arthritis (RA) A chronic, systemic, autoimmune disease characterized by recurrent inflammation and destruction of the synovial joint and related structure. RA is characterized by periods of remission and exacerbation. Mortality rates are higher Rheumatoid Arthritis: S&S Joints Pt report pain, swelling, and stiffness after periods of inactivity, particularly in the morning Morning stiffness lasts several hrs Affects hands first, then feet, and then larger joints – Metacarpal and PIP typically swollen – Eventually becomes a symmetric, additive disease of the joints. – Deformities Rheumatoid Arthritis: Deformities Ulnar Drift Boutonniere’s Deformity Hallux valgus Swan-neck deformity Rheumatoid Arthritis: S&S Extraarticular Can affect every system on body Vasculitis Rheumatoid Nodules – Most common findings, affects 25% to 50% of pts – Usually on extensor surface of forearm. – Not removed, high probability of recurrence Sjogren Syndrome – 10-15% of pts – Diminished lacrimal and salivary gland secretion Felty Syndrome – Splenomegaly and low WBC--> recurrent infections and Rheumatoid Arthritis: Diagnostic Studies Symmetric inflammatory arthritis involving the appropriate joints and prolonged morning stiffness lasting > 1 h. Rheumatoid factor (RF) is present in about 80% of pts. ANA titer positive. X-rays of involved joints Sed Rate (ESR) & C-reactive protein elevated. CRP level can determine effectiveness of medications. Rheumatoid Arthritis: Pharmacology – – – – – – Treatment of Pain and Swelling NSAIDS Opioid Analgesics Low-dose prednisone Disease-Modifying Antirheumatic Drugs Methotrexate, Azulfidine, Arava, penicillamine Gold compounds Antimalarials - (Hydroxychloroquine) Plaquenil Immunosuppressant - Cytoxan, Imuran Biologic Agents - Enbrel, Remicade, Kinert, Humira Antibiotics - Minocycline Rheumatoid Arthritis: Nursing Care Physical Needs – – – – Joint pain Swelling ROM General health status Environmental needs – – Transportation Home/work modification Psychosocial Needs – – – – – Family support Sexual satisfaction Emotional stress Financial constraints Vocation/career limitations Rheumatoid Arthritis: Nsg Interventions Lightweight splints Regularly scheduled rest periods Minimize excessive weight bearing Avoid total bed rest AM care planned around pt’s morning stiffness Good body alignment while resting-firm mattress Gentle ROM exercise daily to keep joints functional Support Groups Arthritis: Osteoarthritis (OA) Degenerative joint disease (DJD) Slow progressive disorder of articulating joints, particularly weightbearing joints Characterized by degeneration of articular cartilage. The damage is confined in the joints and surrounding tissues. Osteoarthritis: Signs/Symptoms Systemic: None Joints – – – – Pain Stiffness Crepitation Asymmetrical Deformity – Heberden’s Nodules Red, swollen and painful Osteoarthritis: Signs/Symptoms Pain: – Pain on motion and weight bearing – Relieved by rest. – Caused by swelling and stretching of soft tissue structures surrounding the joint and not by the arthritic joint it self. – Aggravated by periods of rest and static positions – Aggravated by rising humidity and falling barometric pressure Crepitus - grating sensation caused by rubbing together of abnormal joint surfaces. Osteoarthritis: Nodules Heberden’s nodes Reactive bony overgrowth located at distal interphalangeal joints. Tend to appear in families Osteoarthritis: Hips Extremely disabling. Congenital or structure abnormalities are frequent causes. Men > women. Pain may radiate to groin, buttock, thigh or knee. Difficult to sit down and rise from chair. Eventually, loss of ROM is significant. Osteoarthritis: Knees Young people -softening of the posterior surface of patella Older people degeneration of weight bearing surfaces of femoral and tibial condyles Obesity mechanical stress. Osteoarthritis: Vertebral Localized symptoms of stiffness and pain. Nucleus pulpous deteriorates-disk becomes brittle and inelastic. Herniation: compress a nerve root-muscle, causing spasm and pain. Osteophytes (spurs) may fuse and limit ROM, or press nerve root and cause pain. Osteoarthritis: Diagnosis History and Physical X-Ray findings. MRI is more sensitive. ESR and WBC are normal. Synovial fluid analysis shows only mild leukocytosis. Osteoarthritis: Collaborative Care PT/OT Rest Joint Protection Good body mechanics. Heat/cold applications Regular exercise. Weight reduction Alternative Therapies –Acupuncture, massage, yoga, guided imagery, therapeutic touch, –herbal supplements Osteoarthritis: Non-Surgical Intervention Medications: – Goal of medications is pain relief and reduction of inflammation Nonopioid Analgesics – Acetaminophen Salicylates – Aspirin – topical agents (Capsaicin cream)blocks pain by interfering with transmission of pain impulses--may burn at first NSAIDS – block production of prostaglandin by inhibiting production of cycloxygenase – Ibuprofen (Motrin, Advil), Indocin, Clinoril. – COX 2 inhibitor - Celebrex,Vioxx, Bextra Supplements – Glucosamine & chondroitin for cartilage re-growth Osteoarthritis: Surgical Intervention Joint replacement – Hip – Knee Joint Surgery Terms Synovectomy - removal of synovial membrane, useful in rheumatoid arthritis Osteotomy - removing or adding a wedge or slice of bone to change alignment Debridement - removing degenerative debris Arthroplasty - reconstruction or replacement of a joint Arthodesis - fusion of a joint Rotator Cuff Injury Group of 4 muscles: Supraspinatus Infraspinatous Teres minor Subscapularis Purpose of Rotator Cuff is to provide stability to the shoulder while assisting with ROM Rotator Cuff Injury Tear – Gradual, degenerative injury – Repetitive stress Rupture – Abrupt injury from sudden adduction forces applied to the cuff while the arm is held in abduction Presents as pain and immobility of shoulder Rotator Cuff Injury Diagnosis – XRay – MRI – Shoulder Tests Treatment – Conservative Treatment – Surgical Intervention