Musculoskeletal: Autoimmune;

Inflammatory; Metabolic;
Infectious Disorders

Rheumatoid Arthritis; SLE; Pagets

Disease; Gout; Osteomyelitis

Carolyn Morse Jacobs, RN,

MSN, ONC 10/ 24/ 04

Autoimmune and Inflammatory Disorders:

Rheumatoid Arthritis

Chronic systemic, inflammatory disease

characterized by recurrent inflammation of
connective tissue, primarily of joints
(diarthroidal) and related structures.

Pathophysiology Rheumatoid
Arthritis

Normal antibodies (immunoglobulins)

become autoantibodies and attack
host tissues (RF)

Neutrophils, T cells synovial fluid cells acitavted;

Cystokines, interleukin-1 and TNR (tumor necrosing
factor) alpha; chrondroytes attack cartilage;
Synovium digests cartilage; inflammatory molecules
released containing interleukin-1 and TNF alpha

Pathophysiology: Rheumatoid
Arthritis

Pathophysiology

IgG/RF (HLA)= antigen-antibody

complex
Precipitates in synovial fluid
Inflammatory response
Cartilage connective tissue primarily
affected!

Rheumatoid arthritis: assessment:

manifestations and complications
Fatigue,
weakness, pain
Joint deformity
Rheumatic
nodules
Multisystem
involvement

How does Rheumatoid Arthritis Compare to

Osteoarthritis?

Definition: *wear and tear, progressive,

non-systemic, Degenerative Joint
Disease (DJD)

Pathophysiology

Osteoarthritis (top slide

only)

Identify which joints

are primarily
affected with
osteoarthritis.
What factors
contribute to the
development of
osteoarthritis?

Ankylosing
spondylitis (what
type of arthritis is
this?)

Structural changes with Osteoarthritis

Early
Cartilage softens, pits, frays
Progressive
Cartilage thinner, bone ends hypertrophy,
bone spurs develop and fissures form
Advanced
Secondary inflammation of synovial
membrane; tissue and cartilage destruction; late
ankylosis

What signs and

symptoms does
the person with
osteoarthritis
experience?

Normal Knee
structure

Moderately
advanced
osteoarthritis

Advanced
osteoarthritis

What symptoms/assessment for

the patient with osteoarthritis?
Onset of pain is insidious, individual is
healthy!
Pain is aching in nature; relieved by rest!.
Local signs and symptoms: swelling,
crepitation of joint and joint instability,
asymmetrical joint involvement

Deformities with Osteoarthritis

Carpometacarpocarpal joint of
thumb with subluxation of the
first MCP

Genuvarus

Herberdens nodes

Osteoarthritis (review
only)

Diagnostic Tests
None

specific
Late joint changes,
boney sclerosis,
spur formation
Synovial fluid inc.,
minimal
inflammation
Gait analysis

Nursing diagnosis
Interventions
determined by
complications
Supportive

devices
Medications (no
systemic treatment
with steroids)
Dietary to dec. wt.
Surgical
Intervention (joint
replacement)
Teaching

Comparison of RA and OA
RA

Cause unknown; auto-immune factor

Onset sudden
Remissions
*Body parts affected, systemic, small joints, symmetrical
Causes redness, warmth, swelling of joints
Females, age 20-30; 3-1 ratio

OA

Cause wear and tear, develops slowly

Non-systemic, weight bearing joints
Middle-aged and elderly, males 2-1 affected
Does not cause malaise
Begins after 40

Manifestations of RA

Systemically ill
Hematologic
Pulmonary/CV
Neurologic
Ocular symptoms
(Sjorgens)
Skin
Musculoskeletal
deformity, pain

Pain!

Pain!

Pain

Joints changes with RA

Early Pannus
Granulation,
inflammation at
synovial
membrane,
invades joint,
softens and
destroys
cartilage

RA

Mod advanced Pannus

joint cartilage disappears,
underlying bone destroyed,
joint surfaces collapse

Fibrous Ankylosis
Fibrous connective tissue
replaces pannus; loss of joint otion

Bony Ankylosis
Eventual tissue and joint
calcification

Joint Changes RA

Bilateral,
symmetrical,
PIPs, MCPs
Thumb instability
Swan neck,
boutonniere
deformity
Tensynovitis
Multans deformity

Subcutaneous
nodules
Genu valgum
Pes plano valgus
Prominent
metatarsal heads
Hammer toes

Assessment RA
Deformities
that may
occur with
RA

Synotenovitis
Ulnar drift
Swan neck
deformity
Boutonniere
deformity

Mutlans deformity
(rapidly progressing
RA)
Hitch-hiker thumb
Genu valgus

Subcutaneous nodules
(disappear and appear
without warning)

Hammer toes

Diagnostic Tests RA
ESR elevated
+ RA, ^ RA titer
Sed rate increased
CBC
C-reactive protein
Dec. serum complement
Synovial fluid inflammation
Joint and bone
Swelling,inflammation

Interventions RA

Nursing
Diagnosis
Comfort
Physical

mobility
Self image

Goals
Team Approach

Pain
management
Exercise
Surgery
Teaching

Medications RA

ASA & NSAIDS

Corticosteroids; low dose
DMARDs (diverse group) of remitting agents:
including antimalarial (hydroxychloroquine:plaquenil) *eye
effects; Penicillamine (empty stomach); Gold (Auranofin)
*dermatitis, blood dyscrasia ; and
Immunosuppressive agents as methotrexate and
cyclosporine
Biologic response modifiers

Adalimumab (Humira)
Infliximab (Remicade)

Joint Protection: Dos and Donts

Case Presentation;
Mrs. Michaels with Rheumatoid Arthritis
(PDS: Adult Health: Musculoskeletal Health: Mrs. Michaels)

Comparison to usual course

Diagnostic tests
Nursing diagnosis
Therapies

Medications

used

Exercise
Joint

Protection

Resources on the Web

Systemic Lupus
Erythematous (SLE)
Chronic multisystem disease
involving vascular and
connective tissue
Lupus Foun
dation

Etiology and Pathophysiology

SLE

Exact etiology unknown:

genes (HLA), hormones,
environment involved
Formation auto-antibodies;
immune complexes
deposited
Inflammatory response
triggered by deposition of
immune complexes
(kidney, brain)
Drug induced syndrome
similar to SLE (Procan-SR,
hydralazine, isonaiazid)
Pneumonia, infections,
*renal, CNS involvement!;

Course of disease varies

Mild
Episodic
Rapidly fatal

Manifestations/Complications
of SLE

Types: Discoid, SLE

Incidence: 1:2000
Women 1-9, childbearing age, african
americans
Periods remission
and exacerbation
Stress
Environmental
factors

Assessment
Low grade fever
Integumentary
MS involvement
CV
Respiratory
Urinary Renal failure
Neurologic CNS
GI
Hematologic
Endocrine
Reproductive

Characteristic
butterfly rash
associated with
SLE, especially
discoid lupus
erythematous

Barrys lupus

SLE characterized by periods of

remission and exacerbation.
Stimulated by sunlight, stress,
pregnancy, infections like strep and
some drugs. Some drugs like
apresoline, pronestyl, dilantin,
tetracycline, phenobarbital may cause
a lupus-like reaction which disappears
when drug is stopped.

Diagnostic Tests

LE cell
Ant-DNA
ANA, titer
Anti-DNA
Complement
fixation decreased
ESR
Other (and CBC,
UA)
Kidney biopsy

Criteria to Dx.
malar,

discoid

rash
photosensitivity
arthritis
renal disorder
immunological
disorder
DNA, ANA

Therapeutic Interventions/Management
SLE

Medications
NSAIDS
(Disease modifying agents)
Antimalarial drugs
Corticosteroids
Immunsuppressive therapy
Antineoplastic drugs
such as Imuran, cytoxan,
cyclosporine

Avoid UV
Reduce stress
Monitor/manage to prevent
complications

Nursing diagnosis

See RA
Impaired skin integrity
Ineffective protection
Impaired health
maintenance

Goal: control inflammation

Emotional support

Life Planning

Required Review

Case Study

Clinical Background:

18 year old patient admitted with recent

onset (3 months earlier) of malar rash and
constitutional symptoms (weakness and
malaise), now symptoms of renal failure.
She reported having a 5-year history of
Raynaud's phenomenon and arthralgia.

Abnormal results of laboratory studies

included the presence of ANA, anti-nDNA,
anti-SS-A autoantibodies and a proteinuria
of approximately 10 g/d.
Renal biopsy revealed a Class IV lupus
glomerulonephritis.

What assessment data is priority:

what additional date should you
collect?

What are the priority nursing

problems?

What are the priority

interventions?
What medications are
typically used and why?

Scleroderma (Systemic sclerosis)

Definition: progressive sclerosis of
skin and connective tissue; fibrous
and vascular changes in skin,
blood vessels, muscles, synovium,
internal organs. become hide
bound
Immune-mediated disorder; genetic
component

Scleroderma (Systemic sclerosis)

Abnormal amounts of fibrous
connective tissue deposited in
skin, blood vissels, lungs, kidneys,
other organs
Can be systemic or localized
(CREST) syndrome

CREST Syndrome

Calcinosis
Raynauds
phenomena
Esophageal
hypomotility
Sclerodactyl (skin
changes of fingers)
Telangiectasia
(macula-like
angioma of skin)

Crest Syndrome
More on
CREST

CREST Syndrome & scleroderma

Sclerodactyl (localized
scleroderma of
fingers)

Raynauds disease with

ischemia

Typical hidebound face of

person with
scleroderma
Tissue hardens;
claw-like
fingers; fibrosis

Manifestations & Complications

(systemic)

Female 4:1
Pain, stiffness,
polyartheritis
Nausea, vomiting
Cough
Hypertension
Raynaulds
syndrome
Skin atrophy,
hyperpigmented

Scleroderma cont.

Esophageal
hypomotility leads to
frequent reflux
GI complaints common
Lung-pleural thickening
and pulmonary fibrosis
Renal disease...leading
cause of death!

Diagnosis/Treatment Scleroderma

R/O autoimmune disease

Radiological: pulmonary
fibrosis, bone resorption,
subcutaneous calcification,
distal esophageal
hypomotility
ESR elevated
CBC anemia
Gammaglobulin lelels
elevaed; RA present
Skin biopsy to confirm

What are the KEY

components of care
for the individual with
Scleroderma?

Scleroderma: Patient Care

Dos
Avoid

cold
Provide small,
frequent feedings
Protect fingers
Sit upright post
meals
No fingersticks
Daily oral hygiene

Resources

Scleroderma: Patient Care

Medications: based
upon symptoms:

Immunosuppressive
agents & steroids &
remitting agents
Ca channels blockers
& alpha-adrenergic
blockers
H2 receptor blockers
ACE inhibitors
Broad spectrum
antibiotics

Ankylosing Spondylitis

Definitions: chronic
inflammatory
polyarteritis of
spine
Affects mostly
young men
Associated with
HLA-B27 antiget
positive antigen
(90%)

Pathophysiology &
Manifestations

Like arthritis have

inflammatory changes; erosion
of cartilage, ossification of
joint margins; scar tissue
replaces
Morning backache, flexion of
spine, decreased chest
expansion

Diagnosis

ESR elevation
Positive HLA-B27
antigen
Vertebral changes

Ankylosing
Spondylitis
Insidious
onset
Morning
backache
Inflammation
spine; later

of
spine

ossification

Oh my back hurts!

Comparison
of changes
with
ospeoporosis
and
Ankylosing
spondylitis

Identify a
PRIORITY
nursing
concern
related to
ankylosing
spondylitis

Management Ankylosing
Spondilitis

Dos
Maintain

spine

mobility
Pain management
Proper
positioning
Meds for pain,
inflammation

Other Collagen Diseases

Reiters Syndrome

Reactive arthritis
associated with enteric
disease

Lyme Disease (mimics

rheumatoid disease)
Caused by spirochete, borrelia
burgdorferi (tick)
Inflammatory disorder
3 stages
Initial rash (target)
Disseminated (arthitic like
symptoms)
Late (neurologic symptoms)

Diagnosis

Culture (difficult)
Antibody detection

Treatment: antibiotics
(amoxicillin, vibramycin,
tetracycline, etc);
NSAID)
Prevention

Other Collagen Diseases

Polymyositis

Systemic connective
tissue disorder
characterized by
inflamation of connective
tissue and muscle fibers
Autoimmune; affecting
women 2:1
If muscle fiber
inflammation is
accompanied by skin
lesion disease known as
dermatomyositis

Manifestations &
complications

Muscle pain, tenderness,

rash; arthralgias; fatigue;
fever and weight loss;
Skeletal muscle weakness
most prominent
Dusky red rash over face
Raynauds phenomenon
Malignancy with
dermatomyositis

Diagnosis

None specific
Elevated CK

Other Collagen Diseases cont

Reiters syndrome

Self-limited disease of
reactive arthritis
such as shingles,
venereal diseas,
associated with HLA
B27 antigen

Polyarteritis Nodosa
Collegan; diffuse
inflammation and
necrosis of wall of small
to medium sized arteries
especially in muscles ,
kidneys, heart liver, GI
and peripheral nerves like
SLE

Juvenile Rheumatoid
Arthritis