INTRODUCTION

Polymyalgia rheumatica (PMR) is a relatively common clinical syndrome of unknown etiology that affects elderly individuals. It is characterized by proximal myalgia of the hip and shoulder girdles with accompanying morning stiffness that lasts for more than 1 hour. Approximately 15% of patients with polymyalgia rheumatica develop giant cell arteritis (GCA), and 40-50% of patients with giant cell arteritis have associated polymyalgia rheumatica. Despite the similarities of age and some of the clinical manifestations, the relationship between GCA and PMR is not yet clearly established. Polymyalgia rheumatica is a clinical diagnosis based on the complex of presenting symptoms and exclusion of the other potential diseases. Corticosteroids are considered the treatment of choice, and a rapid response to low-dose corticosteroids is considered pathognomonic. Patients have an excellent prognosis, although exacerbations may occur if steroids are tapered too rapidly, and relapse is common

ANATOMY AND PHYSIOLOGY The musculoskeletal system The musculoskeletal system consists of the bones, muscles, ligaments and tendons. Function The function of the musculoskeletal system is to: protect and support the internal structures and organs of the body allow movement give shape to the body produce blood cells store calcium and phosphorus produce heat.

The skeletal system The skeletal system is comprised of bones and joints and provides the basic supporting structure of the body. It consists of the joined framework of bones called the skeleton. The human skeleton is made up of 206 bones. Roll your mouse over the different parts of the skeleton to reveal the bone names.

Bones Bone is a dry, dense tissue composed of a calcium-phosphorus mineral and organic matter and water. Bone is covered with a living membrane called the periosteum. The periosteum contains bone-forming cells, the osteoblasts. The centre of bone contains marrow where blood vessels, fat cells and tissue for manufacturing blood cells are all found. There are four main shapes of bones: flat e.g. ribs irregular e.g. vertebrae short e.g. hand (carpals) long e.g. upper arm (humerus)

In this activity you will learn about the location of the bones of the skeletal system. Joints A joint is an area where two or more bones are in contact with each other. Joints allow movement. The bones forming the joint are held together by ligaments. There are 3 types of joints: 1. fibrous or immovable e.g. skull 2. cartilaginous or slightly moveable e.g. vertebrae 3. synovial or freely movable: a. ball and socket e.g. hip b. hinge e.g. elbow. c. gliding e.g. carpals at wrist d. pivot e.g. radius and ulna Movement There are certain terms that are used to describe the movement of bones: abduction - movement away from the body adduction - movement towards the body

flexion - bending a limb towards the body extension - extending a limb away from the body rotation - movement around a central point

You have learnt the names of the various joints of the body, but there are also words that describe the various directions in which limbs move. The muscular system The muscular system allows us to move and you will need to learn about the muscles of the body in order to understand how this system contributes to the overall design of the human body. The human body is composed of over 500 muscles working together to facilitate movement. It is very important to understand the muscular system and how it works in conjunction with the skeletal system to allow us to move and maintain our posture. The major function of the muscular system is to produce movements of the body, to maintain the position of the body against the force of gravity and to produce movements of structures inside the body. Structure Tendons attach muscle to bone. There are 3 types of muscles: 1. skeletal (voluntary) muscles are attached to bone by tendons 2. smooth (involuntary) muscles control the actions of our gut and blood vessels 3. cardiac muscle in the heart Muscles contract (shorten) and relax in response to chemicals and the stimulation of a motor nerve. Some examples of muscles are the triceps, deltoid and the biceps in the upper arm and the gluteal muscle, the hamstrings and the quadriceps in the buttocks and the top of the leg. Roll your curser over the graphic. Click on the arrows at the bottom of the image to view both the anterior and posterior views. Movement Movement occurs when muscles contract or shorten, pulling the bones with them. Muscles work in pairs; when one shortens, the corresponding muscle lengthens.

PATHOphysiology

POLYMYALGIA RHEUMATICA Pathophysiology The underlying mechanism involved with polymyalgia rheumatica is unknown. This disease occurs predominately in Caucasians and often in rst-degree relatives. An associa- tion with the genetic marker HLA-DR4 suggests a familial predisposition. Immunoglobulin deposits in the walls of in- amed temporal arteries also suggest an autoimmune process. Polymyalgia rheumatica and giant cell arteritis are found almost exclusively in people older than 50 years of age. Polymyalgia rheumatica has an annual incidence rate of 52 cases per 100,000 people older than 50 years. Giant cell arteritis varies by geographic location and has the highest incidence in Scandinavian countries

Assessment and Diagnostic Findings Assessment focuses on musculoskeletal tenderness, weakness, and decreased function. Careful attention should be directed toward assessing the head (for changes in vision, headaches, and jaw claudication). Often, diagnosis is difficult because of the lack of specicity of tests. A markedly high ESR is a screening test but is not denitive. Diagnosis is more likely to be made by eliminating other potential diagnoses, but this is highly dependent on the skills and experience of the di- agnostician. The dramatic and immediate response to treatment with corticosteroids is considered by some to be diagnostic.

Nursing Management

Nursing care of the patient with polymyalgia rheumatica is based on the fundamental plan of nursing care presented earlier. The most common nursing diag- noses are pain and insufcient knowledge of the medication regimen. A management concern is that the patient will take the prescribed medication, frequently corticosteroids, until symptoms improve and then discontinue the medication. The decision to discontinue the medication should be based on clinical and laboratory findings and the physi- cians prescription. Nursing implications are related to helping the patient prevent and monitor side effects of medications (eg, infections, diabetes mellitus, gastroin- testinal problems, and depression) and adjust to those side effects that cannot be prevented (eg, increased appetite and altered body image). Medical Management The treatment for patients with polymyalgia rheumatica (without giant cell arteritis) is moderate doses of cortico- steroids. NSAIDs are sometimes used for mild disease. The treatment for patients with giant cell arteritis is rapid initiation of and strict adherence to a reg- imen of corticosteroids. This is essential to avoid the complication of blindness. Aspirin is a useful adjunctive.

NURSING DIAGNOSIS: Acute and chronic pain related to inammation and increased disease activity, tissue damage, fatigue. GOAL: Improvement in comfort level; incorporation of pain management techniques into daily life

Nursing Interventions 1. Provide variety of comfort measures a. Application of heat or cold b. Massage, position changes, rest c. Foam mattress, supportive pillow, splints d. Relaxation techniques, diversional activities 2. Administer anti-inammatory, anal- gesic, and slow-acting antirheumatic medications as prescribed. 3. Individualize medication schedule to meet patients need for pain man- agement. 4. Encourage verbalization of feelings about pain and chronicity of disease. 5. Teach pathophysiology of pain and rheumatic disease, and assist patient to recognize that pain often leads to unproven treatment methods. 6. Assist in identication of pain that leads to use of unproven methods of treatment.

7. Assess for subjective changes in pain. Rationale 1. Pain may respond to nonpharmaco- logic interventions such as joint pro- tection, exercise, relaxation, and thermal modalities. 2. Pain of rheumatic disease responds to individual or combination medica- tion regimens. 3. Previous pain experiences and man- agement strategies may be different from those needed for persistent pain. 4. Verbalization promotes coping. 5. Knowledge of rheumatic pain and ap- propriate treatment may help patient avoid unsafe, ineffective therapies. 6. The impact of pain on an individuals life often leads to misconceptions about pain and pain management techniques. 7. The individuals description of pain is a more reliable indicator than objec- tive measurements such as change in vital signs, body movement, and facial expression. Expected Outcomes Identies factors that exacerbate or inuence pain response Identies and uses pain management strategies Verbalizes decrease in pain Reports signs and symptoms of side effects in timely manner to prevent additional problems Verbalizes that pain is characteristic of rheumatic disease Establishes realistic pain relief goals Verbalizes that pain often leads to the use of nontraditional and unproven self-treatment methods Identies changes in quality or inten- sity of pain

NURSING DIAGNOSIS: Fatigue related to increased disease activity, pain, inadequate sleep/rest, deconditioning, inadequate nutrition, and emotional stress/depression GOAL: Incorporates as part of daily activities strategies necessary to modify fatigue Nursing Interventions 1. Provide instruction about fatigue. a. Describe relationship of disease activity to fatigue.

b. Describe comfort measures while providing them. c. Develop and encourage a sleep routine (warm bath and relaxation techniques that promote sleep). d. Explain importance of rest for re- lieving systematic, articular, and emotional stress. e. Explain how to use energy conservation techniques (pacing, del- egating, setting priorities). f. Identify physical and emotional factors that can cause fatigue. 2. Facilitate development of appropriate activity/rest schedule. Rationale 1. The patients understanding of fa- tigue will affect his or her actions. a. The amount of fatigue is directly related to the activity of the dis- ease. b. Relief of discomfort can relieve fatigue. c. Effective bedtime routine pro- motes restorative sleep. d. Different kinds of rest are needed to relieve fatigue and are based on patient need and response. e. A variety of measures can be used to conserve energy. f. Awareness of the various causes of fatigue provides the basis for measures to modify the fatigue. 2. Alternating rest and activity con- serves energy while allowing most productivity. Expected Outcomes Self-evaluates and monitors fatigue pattern Verbalizes the relationship of fatigue to disease activity Uses comfort measures as appropriate Practices effective sleep hygiene and routine Makes use of various assistive devices (splints, canes) and strategies (bed rest, relaxation techniques) to ease different kinds of fatigue Incorporates time management strate- gies in daily activities Uses appropriate measures to prevent physical and emotional fatigue Has an established plan to ensure well-paced, therapeutic activity schedule Adheres to therapeutic program Follows a planned conditioning program

Assessment o> fatigue

Diagnosis Acute and chronic pain related to inammation and increased disease activity, tissue damage, fatigue.

Planning Improvement in comfort level; incorporation of pain management techniques into daily life

Intervention

Rationale

Evaluation