ANKYLOSING SPONDYLITIS

A case study presented

to the Faculty of College of Nursing

Cebu Normal University

In Partial Fulfillment

of the Requirements of the Degree

Bachelor of Science in Nursing

Delight Grace W. Largo

2010
I. DEFINITION OF TERMS

Ankylosing Spondylitis (anayle—stiff joint; osing—condition; spondyl—

vertebrae; itis—inflammation ) - a chronic progressive, inflammatory disease that

affects the cartilaginous joints of the spine and surrounding tissues.

Ankylosis - complete cementing together (fusion) of the vertebrae

Annulus Fibrosus - tough outer covering of the intervertebral disc

Arthritis: Inflammation of a joint.

Choroid: In the eye, a thin vascular layer between the sclera and the retina.

Chronic: comes from the Greek chronos, time and means lasting a long time.

Ciliary body: Part of the eye, a thin vascular middle layer of the eye that is

situated between the sclera and the retina.

Costochondritis: Costochondritis is inflammation of the cartilage of the chest

wall, usually involving that which surrounds the breast bone (sternum)

Fasciitis: Inflammation of the fascia (a lining tissue under the skin that covers a

surface of underlying tissues).

Fatigue: A condition characterized by a lessened capacity for work and reduced

efficiency of accomplishment, usually accompanied by a feeling of weariness and

tiredness.

Fracture: A break in bone or cartilage.

Heart failure: Inability of the heart to keep up with the demands on it and,

specifically, failure of the heart to pump blood with normal efficiency.

Heredity: Genetic transmission from parent to child.

Immune: Protected against infection.

Immunity: The condition of being immune

Inflammation: A basic way in which the body reacts to infection, irritation or

other injury, the key feature being redness, warmth, swelling and pain.

Inflammation is now recognized as a type of nonspecific immune response.

Iritis: Inflammation of the iris.

Nausea: the urge to vomit.

Pain: An unpleasant sensation that can range from mild, localized discomfort to

agony.

Plantar fasciitis: Inflammation of the plantar fascia (fasciitis), the "bowstring-

like" tissue in the sole of the foot stretching from the heel to the front of the foot.

Progressive: a disease that is progressive is going from bad to worse.

Range of motion: The range through which a joint can be moved, usually its

range of flexion and extension.

Sedimentation rate: A blood test that detects and monitors inflammation in the

body

Spondylitis – chronic inflammation of the spine

Syndesmophyte - bony growth originating inside a ligament, commonly seen in

the ligaments of the spine, specifically the ligaments in the intervertebral

joints leading to fusion of vertebrae

Tendinitis: Inflammation of a tendon

Tumor necrosis factor: A member of a superfamily of proteins, each with 157

amino acids, which induce necrosis of tumor cells and possess a wide range of

proinflammatory actions.

Uveitis: Inflammation of the uvea, the part of the eye that collectively refers to

the iris, the choroid of the eye, and the ciliary body.
 TNF-8
II. SCHEMATIC DIAGRAM
Positive HLA-B27 Inflammatory Response

Etiology: Enthesopathy Romanus lesion

Family History
Exposure to Klebsiella
bacterial strain Ankylosing of sacroiliac,
apophyseal, and Spondylytis
costovertebral joints

Inflammatory process Syndesmophyte

progress to the spine formation

Fatigue Lordosis Bamboo spine

Pain and stiffness in

the low back, upper Respiratory
buttock area, neck, Kyphosis
and the remainder of Breathing difficulty
the spine
Limited lung capacity

Worsens with inactivity Joints

Pain, stiffness, heat,
Other
swelling, warmth, and/or
Nausea, Anorexia, redness in joints such as
weight loss the hips, knees, and
ankles
Costochondritis,
tendinitis, Achilles
tendinitis, plantar
fasciitis

Eyes
Iritis; pain & redness in
the eyes, especially with
bright lights
Eye damage and
impaired vision
Uveitis; involves the iris,
ciliary body and choroid
Inflammation of aorta
Heart (rare)
Scarring of the heart's
Leakage of aortic electrical system
valve
Heart Block
Shortness of breath,
Dizziness, Heart
failure
Kidneys (advanced)
Amyloid deposition

Kidney failure
III. NARRATIVE OF EXPLANATION

Heredity factors play an important role in the development of AS. There is

strong evidence of a familial tendency but no other specific causes are known. A

specific histocompatibility antigen (antigen that identifies self), human leukocyte

antigen (HLA)-B27, is formed that stimulates an immune response. Tumor

necrosis alpha (TNF-8), a naturally occurring cytokine also plays a role in the

inflammatory process by triggering the release of enzymes that damage cartilage

and promote bone destruction.

The basic pathologic process is an inflammatory focus, predominantly

lymphocytic, that targets both articular joints as well as the insertion of ligaments,

tendons and capsules to bone (entheses). Reactive bone formation at these

entheses, termed enthesopathy, ultimately results in progressive ankylosis of the

axial skeleton, typically involving the sacroiliac, apophyseal, and costovertebral

joints. The course of the disease includes progressive ossification of cartilage,

resulting in the characteristic joint stiffness and ankylosis. Symptoms usually

begin in at the sacroiliac joints and progress proximally in the spine.

The “Romanus lesion” is an erosion of the anterior and lateral border of

the vertebral endplate at the site of vascular attachment of the annulus fibrosus.

This lesion represents a focal area of spondylitis, ultimately resulting in

syndesmophyte formation and ossification of the annulus fibrosus. These

osseous changes result in the classic “bamboo spine” appearance

radiographically, which is the hallmark of anklylosing spondylitis.

The symptoms of ankylosing spondylitis are related to inflammation of the

spine, joints, and other organs. Fatigue is a common symptom associated with

active inflammation. Inflammation of the spine causes pain and stiffness in the

low back, upper buttock area, neck, and the remainder of the spine. These

symptoms are often worse in the night, morning or after prolonged periods of

inactivity.
Chronic spondylitis and ankylosis can cause the normal curvature of the lower

back (lordosis) to flatten and increase in the curvature of the upper back

(kyphosis) which limits breathing capacity. It also affects the areas where ribs

attach to the upper spine, further limiting lung capacity. This can further cause

inflammation and scarring of the lungs, causing coughing and shortness of

breath, especially with exercise and infections. This poses a risk for developing

serious respiratory complications.

People with ankylosing spondylitis can also have arthritis in joints other

than the spine. Patients may notice signs of inflammation in joints such as the

hips, knees, and ankles. Inflammation can occur in the cartilage around the

breast bone (costochondritis) as well as in the tendons (tendinitis) and in

ligament attachments to bone. Some people with this disease develop Achilles

tendinitis, causing pain and stiffness in the back of the heel, especially when

pushing off with the foot while walking up stairs. Inflammation of the tissues of

the bottom of the foot, plantar fasciitis, occurs more frequently in people with

ankylosing spondylitis.

Ankylosing spondylitis affects other areas of the body including the eyes,

heart, and kidneys. Patients can develop inflammation of the iris (iritis)

characterized by redness and pain in the eye, especially when looking at bright

lights. In addition to the iris, the ciliary body and choroid of the eye can become

inflamed; referred to as uveitis. Both can be serious complications of ankylosing

spondylitis that can damage the eye and impair vision.

A rare complication of the disease involves scarring of the heart's

electrical system, causing an abnormally slow heart rate (referred to as heart

block). In some cases, there is inflammation of the part of the aorta closest to

the heart, resulting in leakage of the aortic valve. Patients can develop shortness

of breath, dizziness, and heart failure.

 Advanced spondylitis can lead to deposition of amyloid, a protein material

into the kidneys and result in kidney failure.

IV. NURSING DIAGNOSES

a. Chronic pain related to deteriorating bone and cartilage of joints

b. Ineffective breathing pattern related to inflammation and scarring of the

lungs

c. Activity intolerance related to pain and inflammation of joints

d. Impaired Physical Mobility related to spinal or hip joint deformities

e. Disturbed sensory perception (visual) related to eye inflammation

f. Risk for Injury related to altered mobility

g. Fatigue related to presence of active inflammation

h. Disturbed Body Image related to flattening of the lower back and forward

curvature of upper back

i. Sleep Deprivation related to increased recurrence of pain during periods

of inactivity

j. Deficient diversional activity related to pain, stiffness, and limitation of

spinal motion

V. DIAGNOSTICS

Findings such as a positive family history, radiographs of the joints, a positive

HLA-B27 blood test, and negative Rh confirm a diagnosis of ankylosing

spondylitis. There are no specific Immunological tests to diagnose ankylosing

spondylitis.

• Spinal x-ray: joints show the characteristic Bamboo spine; late sign

• Blood serum contains the HLA-B27 antigen, which is present in about 90

percent of those with AS.

 o Elevated ESR. In the erythrocyte sedimentation rate (ESR) test,

inflammation is signalled by elevation in the speed at which the red

blood cells settle to the bottom of a tube of blood.

o The C-reactive Protein (CRP) test indicates inflammation by the

presence of a protein that the liver produces as part of the immune

system response to injury or infection.

• The Schober's test is a useful clinical measure of flexion of

the lumbar spine performed during examination.

o The examiner makes a mark approximately at the

level of L5 (fifth lumbar vertebra). The examiner then places one

finger ~5 cm below this mark, and another, second, finger, ~10 cm

above this mark. The patient is asked to touch his/her toes. By

doing so, the distance between the two fingers of the examiner

increases. However, a restriction in the lumbar flexion of the patient

reduces this increase; if the distance increases less than 5 cm, then

there is an indication that the flexion of the lower back is limited.

NORMAL VALUES:

> HLA-B27 Test - A normal (negative) result means HLA-B27 is absent.

However, HLA-B27 is found in 5 - 7% of Caucasians who do not have an

autoimmune disorder.

> C-reactive protein (CRP) in blood - 0-1.0 mg/dL or less than 10 mg/L (SI units)

> ESR:

Men 0-15 millimetres per hour (mm/hr)

Women 0-20 mm/hr

Children 0-10 mm/hr

Newborns 0-2 mm/hr

REFERENCES:

Journal:

Darren Bergey M.D.,2006.Ankylosing Spondylitis, 1-2

Book sources:

Handbook of Medical-Surgical Nursing.2005.4th Ed.Lippincott William & Wilkins,

Philadelphia, 439

Williams, L.et.al.2007.Understanding Medical-Surgical Nursing.3rd Ed.F.A. Davis

Company, U.S.A., 319

Jackson, D. RN, MSN,.et.al.2007.Medical Surgical Nursing Demystified.Mc-Graw Hill

Companies, U.S.A., 140

Smeltzer, Suzanne RN, EdD, FAAN, et.al.2006.Brunner and Suddarth’s Textbook of

Medical Surgical Nursing.11th Ed.Lippincott Williams & Wilkins, Philadelphia, 1629

Internet Sources:

Wilfred CG Peh, MD, MBBS, FRCP, last updated March 25, 2009

http://emedicine.medscape.com/article/386639-overview, accessed August 29, 2010

William C. Shiel Jr., MD, FACP, FACR, last updated 6/24/2010

http://www.medicinenet.com/ankylosing_spondylitis/page5.htm, accessed August 29,

2010

Normal values

HLA B27 - David C. Dugdale, III, MD, last updated 5/21/2009,

http://www.nlm.nih.gov/medlineplus/ency/article/003551.htm, accessed August 29,

2010

CRP – Robin Parks, MS, last updated March 26, 2008 http://www.webmd.com/a-to-

z-guides/c-reactive-protein-crp?page=2, accessed August 29, 2010.

ESR - Shannon Erstad, MBA/MPH, last updated June 12, 2008,

http://www.webmd.com/a-to-z-guides/sedimentation-rate?page=2 accessed August

29, 2010

Schober’s Test – last updated February 18, 2009,

http://en.wikipedia.org/wiki/Schober's_test, accessed August 29, 2010