Chapter 65: Nursing Management: Arthritis and Connective Tissue Diseases

ARTHRITIS

Arthritis is inflammation of a joint. The most prevalent types of arthritis are osteoarthritis, rheumatoid arthritis, and gout.

OSTEOARTHRITIS • Osteoarthritis (OA), the most common form of joint (articular) disease in North America, is a slowly progressive noninflammatory disorder of the diarthrodial (synovial) joints. • •

Factors linked to OA include increasing age, genetics, obesity, occupations with frequent kneeling, and lack of exercise. OA results from cartilage damage, leading to fissuring, fibrillation, and erosion of articular surfaces. Systemic manifestations (fatigue, fever) are not present in OA, whereas they are present in inflammatory joint disorders such as rheumatoid arthritis. Manifestations range from mild discomfort to significant disability, with joint pain being the major symptom. As OA progresses, increasing pain contributes significantly to disability and loss of function. Care focuses on managing pain and inflammation, preventing disability, and maintaining and improving joint function. Symptoms are initially managed conservatively through medication, joint rest, heat and cold, nutrition, and exercise. Arthroscopy to repair cartilage or remove bone bits or cartilage may be recommended with OA progression. Teaching should include information about nature and treatment of OA, pain management, posture and body mechanics, use of assistive devices, principles of joint protection and energy conservation.

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RHEUMATOID ARTHRITIS • Rheumatoid arthritis (RA) is a chronic, systemic disease with inflammation in connective tissue of the diarthrodial (synovial) joints, often remission and exacerbations. • • • The etiology of RA is unknown; it is probably due to autoimmune and genetic factors. Onset is typically insidious with fatigue, weight loss, and generalized stiffness. Articular signs include pain, stiffness, limitation of motion, and inflammation (e.g., heat, swelling, tenderness). Joint stiffness after periods of inactivity is common.

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As RA progresses, muscle atrophy and destruction of tendons around joint cause one articular surface to slip past the other (subluxation). RA can affect nearly every body system. Most common extraarticular signs are rheumatoid nodules and Sjögren’s and Felty syndromes. o Treatment goals include reduction of inflammation, management of pain, maintenance of joint function, and prevention/correction of joint deformity o Initial care usually involves drug therapy and education.

ANKYLOSING SPONDYLITIS • Ankylosing spondylitis (AS) is a chronic inflammatory disease primarily affecting the axial skeleton (sacroiliac joints, intervertebral disk spaces, and costovertebral articulations). • • • • • Most persons are positive for HLA-B27 antigen. Extraarticular inflammation can affect eyes, lungs, heart, kidneys, and peripheral nervous system. Signs of AS are low back pain, stiffness, and limitation of motion. Care is aimed at maintaining maximal skeletal mobility while decreasing pain and inflammation. Heat applications, exercise, and medications are often recommended. Surgery may be done for severe deformity and mobility impairment.

PSORIASIS • Psoriasis is a common benign, inflammatory skin disorder with a possible genetic predisposition. • Approximately 10% of people with psoriasis for reasons unknown develop psoriatic arthritis, a progressive inflammatory disease. • • Psoriasis can occur in different forms, all having a degree of arthritis. Treatment includes splinting, joint protection, drugs, and physical therapy.

REACTIVE ARTHRITIS • Reactive arthritis (Reiter’s syndrome) occurs more commonly in young men and is associated with a symptom complex that includes urethritis (cervicitis in women), conjunctivitis, and mucocutaneous lesions. • •

The etiology is unknown, but it appears to occur after genitourinary or gastrointestinal tract infection. The prognosis is favorable; most patients have a complete recovery after 2 to 16 weeks. Since reactive arthritis is associated with C. trachomatis infection, patients and their sexual partners are often treated with antibiotics.

SEPTIC ARTHRITIS • Septic arthritis (infectious or bacterial arthritis) is caused by invasion of joint cavity with microorganisms. • • • Large joints (knee and hip) are frequently involved, causing severe pain, erythema, and swelling. This condition requires prompt treatment with antibiotics to prevent joint destruction. Nursing care includes assessment and monitoring of joint inflammation, pain, and fever.

LYME DISEASE • Lyme disease is a spirochetal infection transmitted by bite of an infected deer tick. • • • • • GOUT

A characteristic symptom of the early localized disease is erythema migrans, a skin lesion occurring at site of tick bite 2 to 30 days after exposure. Viral-like symptoms, such as fever, chills, headache, swollen lymph nodes, and migratory joint and muscle pain, also occur. In late disease, arthritis pain and swelling may occur in large joints. Antibiotics are used for active disease and to prevent late disease. Reducing exposure to ticks is the best way to prevent Lyme disease.

Gout is caused by an increase in uric acid production, underexcretion of uric acid, or increased intake of foods containing purines, which are metabolized to uric acid by the body. • • • • Deposits of sodium urate crystals occur in articular, periarticular, and subcutaneous tissues. This leads to recurrent attacks of acute arthritis. Risk factors are obesity (in men), hypertension, diuretic use, and excessive alcohol consumption. Affected joints may appear dusky or cyanotic and are extremely tender. Inflammation of great toe (podagra) is a common initial problem. Chronic gout is characterized by multiple joint involvement and visible deposits of sodium urate crystals (tophi).

Treatment includes drug therapy for pain management and to terminate an acute attack. • • Future attacks are prevented by drugs, weight reduction as needed, and possible avoidance of alcohol and food high in purine (red and organ meats). Nursing interventions include supportive care of inflamed joints.

SYSTEMIC LUPUS ERYTHEMATOSUS • Systemic lupus erythematosus (SLE) is a chronic multisystem inflammatory disease with immune system abnormalities. • • • The etiology of abnormal immune response is unknown; a genetic influence is suspected. Extremely variable in its severity, ranging from a relatively mild disorder to rapidly progressive and affecting many organ systems. Commonly affected are the skin (butterfly rash over nose, cheeks), muscles (polyarthralgia with morning stiffness), lungs (tachypnea), heart (dysrhythmias), nervous tissue (seizures), and kidneys (nephritis). Other signs include anemia, mild leukopenia, and thrombocytopenia. Infection is a major cause of death. A major treatment challenge is to manage active disease while preventing treatment complications that cause long-term tissue damage. Patients with mild polyarthralgias or polyarthritis are treated with NSAIDs. Corticosteroids are given for severe cutaneous SLE. Antimalarial agents and immunosuppressive drugs may also be used. Nursing care emphasizes health teaching and importance of patient cooperation for successful home management.

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SYSTEMIC SCLEROSIS • Systemic sclerosis (SS), or scleroderma, is a connective tissue disorder with fibrotic, degenerative, and occasionally inflammatory changes in the skin, blood vessels, synovium, skeletal muscle, and internal organs. • • The cause of SS is unknown. Immunologic dysfunction and vascular abnormalities may play a role in systemic disease.

In this disorder, collagen is overproduced. Disruption of cell is followed by platelet aggregation and fibrosis. Proliferation of collagen disrupts normal functioning of internal organs. • Manifestations range from diffuse cutaneous thickening with rapidly progressive and fatal visceral involvement, to the more benign variant of limited cutaneous SS.

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Clinical manifestations are described by the acronym CREST, including calcinosis, Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia. No specific drug(s) have been proven effective for treating SS. However many drugs can be used in treating the various manifestations of SS. Physical and occupational therapy maintains joint mobility, preserves muscle strength, and assists in maintaining functional abilities.

POLYMYOSITIS AND DERMATOMYOSITIS • Polymyositis (PM) and dermatomyositis (DM) are diffuse, idiopathic, inflammatory myopathies of striated muscle that produce bilateral weakness, usually most severe in proximal or limb-girdle muscles. • • • • • • The exact cause of PM and DM is unknown; theories include infectious agent, neoplasms, drugs or vaccinations, and stress. Patients with DM and PM experience weight loss and increasing fatigue, with gradual weakness of muscles that leads to difficulty in performing routine activities. DM skin changes include classic violet-colored (heliotrope), cyanotic, or erythematous symmetric rash with edema around eyelids. DM and PM diagnosis is confirmed by EMG findings, muscle biopsy, and serum enzyme levels. PM and DM are initially treated with high-dose corticosteroids. If corticosteroids are ineffective and/or organ involvement is occurring, immunosuppressive drugs may be given. The nurse should assist the patient to organize activities and use pacing techniques to conserve energy.

SJÖGREN’S SYNDROME • Sjögren’s syndrome is an autoimmune disease that targets moisture-producing glands, leading to xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes). • • • It appears to be caused by genetic and environmental factors. Lymphocytes attack and damage the lacrimal and salivary glands in this syndrome. Treatment is symptomatic, including instillation of preservative-free artificial tears for hydration and lubrication, surgical punctual occlusion, and increased fluids with meals.
• Myofascial pain syndrome is characterized by musculoskeletal pain and tenderness in one anatomic region of the body.

MYOFASCIAL PAIN SYNDROME

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Regions of pain are often within taut bands and fascia of skeletal muscles. With pressure, trigger points are thought to activate a pattern of pain. Treatment can include massage, physical therapy, acupuncture, and biofeedback. Fibromyalgia syndrome (FMS) is a chronic disorder characterized by widespread, nonarticular musculoskeletal pain and fatigue with multiple tender points.

FIBROMYALGIA SYNDROME

Nonrestorative sleep, morning stiffness, irritable bowel syndrome, and anxiety may also be noted.

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The cause and pathology of FMS are being studied. It is known to be a disorder of central processing with neuroendocrine/neurotransmitter dysregulation. Treatment is symptomatic and requires a high level of patient motivation, including rest, medication, relaxation strategies, and massage.

CHRONIC FATIGUE SYNDROME • Chronic fatigue syndrome (CFS), also called chronic fatigue and immune dysfunction syndrome, is a disorder characterized by debilitating fatigue. • • • • The etiology and pathology are largely unknown. It is often difficult to distinguish between CFS and FMS, as many of the clinical features are similar. There is no definitive treatment. Supportive management is essential. This condition does not appear to progress. Most patients recover or at least gradually improve over time.