RHEUMATIC DISORDERS

Rheumatoid Arthritis, Systemic Lupus Erythematosus, Scleroderma, Fibromyalgia

Rheumatic Disorders/Diseases include

Osteoarthritis (OA) degenerative joint disease Rheumatoid arthritis (RA) autoimmune disease Systemic Lupus Erythematosus (SLE) disturbed immune regulation Scleroderma diffuse connective tissue disease Arthritis inflammation of a joint Fibromyalgia chronic pain syndrome

Cause problems of
Limitations in mobility Limitations in activities of daily living (ADLs) Systemic effects leading to organ failure or death Pain Fatigue Altered self-image Sleep disturbances

Rheumatic Diseases
Onset acute or insidious May have periods of remission or exacerbation Treatment may be simple or complex May have permanent changes and disability

Pathophysiology
Most commonly affected area? The joint All involve some degree of inflammation and degeneration

Clinical Manifestations
Pain Joint swelling Limited movement Stiffness Weakness Fatigue

Diagnostic Studies
X-rays Cat Scans MRI

Gerontologic Considerations
Identify patients lifestyle, Independence Other chronic or acute conditions Pattern of onset Clinical severity Pharmacology ADLs

Rheumatoid Arthritis
Autoimmune disease of unknown origin Affects more women than men

Pathophysiology
Reaction occurs primarily in synovial tissue Causes edema, increase of synovial membrane and pannus formation Results in loss of articular surface and joint motion, and muscle fiber degeneration Tendon and ligament elasticity and contractility are lost

Clinical manifestations
Bilateral joint pain Bilateral Swelling Warm joints Erythema of joints Loss of function Joint stiffness (greater in the morning) Deformities of the hands and feet

RA Medical Management
Provide pain relief Reduce joint inflammation Protect articular surfaces Maintain or improve joint function Control systemic involvement

Pharmacologics
NSAIDS Disease Modifying Rheumatic Agents (DMARDS) Biologic Response Modifiers (BRM) HCQ antimalarial drug MTX methotrexate Corticosteroids Research drugs (vaccines, ICE)

RA NURSING DIAGNOSIS
Chronic pain Fatigue Sleep deprivation Impaired Physical Mobility Chronic Low Self Esteem Risk for Ineffective Therapeutic Regimen Management

SURGICAL Management of RA
Tendon transfer and Osteotomy Synovectomy Arthrodesis Joint replacement Nursing Management (pre- post op)

SYSTEMIC LUPUS ERYTHEMATOSIS (SLE)

Exaggerated production of autoantibodies resulting from disturbed immune regulation B and T cells contribute to immune response

SLE
Clinical Manifestations
Involves musculoskeletal system with arthralgias and arthritis Joint swelling Tenderness Pain on movement Morning stiffness Insidious or acute Chronic rash

butterfly-shaped rash across bridge of nose

SLE medical management

For acute disease Control increased disease activity Control exacerbations that involve organ system For chronic disease Periodic monitoring Recognizing clinical changes Goals Prevent progressive loss of organ function Minimize disease related disabilities Prevent complications

SLE
Assessment Fever, fatigue, weight loss, pericarditis, erythematous rashes, friction rub Diagnostics C-Reactive protein, Antinuclear antibodies (ANAs) assay, blood test revealing anemia, leukocytosis, thrombocytopenia Pharmacology Corticosteroids NSAIDs Immunosuppressive agents

SCLERODERMA HARD SKIN

Relatively rare Poorly understood Cause unknown Pathophysiology Begins with skin involvement Initial inflammatory response causes edema with taut, smooth, shiny skin This leads to loss of elasticity and movement Eventually becomes nonfunctional also occurs in blood vessels, major organs, and body systems

Scleroderma
Clinical Manifestations Starts insidiously with swelling in the hands, becoming increasingly hard and rigid, dryextremities stiffen and lose mobility, face is masklike Changes within body more important than visible changes affecting heart, lungs, kidneys

Scleroderma
Diagnostic Findings
No conclusive test to diagnose

Medical Management
Tx depends on clinical manifestations Counseling Support measure Moderate exercise No proven effective medication for scleroderma Meds used to treat organs

Scleroderma
Nursing Diagnosis Impaired skin integrity Self care deficits Imbalance Nutrition Less than Body Requirements Disturbed Body Image Impaired Gas Exchange Decreased Cardiac Output Impaired Swallowing Constipation

Scleroderma

FIBROMYALGIA
Chronic Pain Syndrome Chronic fatigue Generalized muscle aching and stiffness

Treatment
NSAIDS Antidepressants Exercise programs

OTHER AUTOIMMUNE DISORDERS

Spondyloarthropathies Systemic inflammatory disorder of the skeleton and associated with inflammatory bowel disease (Chrohns Disease) Inflammation at site of attachment Tends to occur during young adulthood Affects more men than women Strong familial tendency

ANKYLOSING SPONDYLITIS
Disease of young men Morning backache or stiffness Costovertebral arthritis Fused or inflamed vertebrae Chronic pain

Types of Spondyloarthropathies
Ankylosing Spondylitis 1. Affects cartilaginous joints of the spine and surrounding tissues 2. Back pain is characteristic feature 3. Leads to respiratory complications and compromises

Reactive Arthritis (Reiters Syndrome)

called reactive because it occurs after an infection Presents with triad of symptoms: 1. Arthritis 2. Conjunctivitis 3. Urethritis
Dermatitis and ulcerations of the mouth and penis

Types of Spondyloarthropathies
Medical management 1. Treat pain 2. Maintain mobility by suppressing inflammation 3. Maintain good body positioning and posture 4. Maintain ROM with exercise and musclestrengthening

Types of Spondyloarthropathies
Pharmacologic Management
1. NSAIDS 2. Corticosteroid 3. Methotrexate

Surgical Management
1. May include total joint replacement

Other Autoimmune Disorders

Polymyalgia Rheumatica (RMA)
Morning stiffness Pain in the proximal musculature Shoulder and pelvis Systemic symptoms (fever, arthralgias, fatigue, weight loss) Diagnosed by elevated SED rate Women older than 50 most common

PSORIATIC ARTHRITIS
15-25% of patients have psoriasis Morning stiffness Fingernail and toenail lifting Neck and back pain synovitis polysarthritis spondylitis

LYME DISEASE
Infected deer tick (Borrelia burgdorferi) Early presentation- flu-like symptoms, weakness, joint pain, HA, fever, bullseye rash Treatment antibiotic therapy Doxcycline Amoxicillin Cefurixime (Ceftin)