9-10 - Medical Nursing - Joint and Connective Tissue Disorders

JOINTS AND CONNECTIVE
Asıl başlık stilini düzenlemek için tıklayın

TISSUE DISEASES
AND
NURSING CARE
1
General Symptoms
• Pain (It is the most specific symptom)
• Morning stiffness (short duration and not exceeding 15-20 min)
• Limitation of movement
• Decrease in muscle mass
• Crepitation (crackling sound coming from the joint with movement)
Asıl başlık
• A pot stilini
of redness, düzenlemek
warmth, içinandtıklayın
swelling, stiffness flexibility in the joint
• General weakness, malaise
• Muscle weakness
• Subcutaneous nodules
2
Assesment and Diagnostic Tests
Physical examination: Anamnesis
• Inspection, • Medical history, surgical

• palpation diseases, traumas, status of
• posture, performing ADL, symptoms and
Asıl başlık stilini düzenlemek içincomplaints
tıklayın (pain, limitation of
• joint functions,
movement, instability, swelling,
• bone smoothness,
stiffness, decrease in muscle
• muscle strength, mass, weakness, crepitation,
• gait. fatigue, deformity and the onset
of these symptoms, location,
condition) and family history.
3
DIAGNOSTIC TESTS
1.Lab tests 2.Radiological studies 3.Other tests
• Erythrocyte • MRI • Arthrocentesis

sedimentation rate • EMG (electro • Arthroscopy
• CRP (c-reactive protein) myogrophy)
• Rheumatoid factor (RF) • CT scan
• Anti streptolysin O titer • Radiography (X-ray)
Asıl başlık stilini
(ASO or ASTO)
düzenlemek için tıklayın
• Antinuclear antibody
(ANA)
• Antinotrophilic
cytoplasmic antibody
(ANCA)
• Synovial fluid analysis
4
ROMATOLOGICAL DISEASES
1-Connective Tissue Diseases
2-Degenerative Joint Diseases
5
6
Rheumatoid Arthritis
Gut Arthritis
Systemic Lupus Erythematosus
Systemic Sclerosis (Scleroderma)
7
8
Definition Epidemiology Etiology
• unknown etiology • It is estimated that one in • The cause of RA is

characterized by recurrent every 100 people in the unknown.
inflammation involving world has RA. • It is an autoimmune and
joint edges or synovium. • It is 3 times more common inflammatory disease.
• starts with inflammation of in women than in men. • It has been suggested that
the synovium and joints, • Although it can be seen at it occurs in individuals with
can also affect the skin, any age, its incidence genetic predisposition and
eyes, muscles, blood increases with age and that some unknown
vessels, heart lungs. occurs most often at 35-50 infectious agents or
• The course of the disease, years of age. endogenous antigens
which progresses with initiate the event.
goodness and exaserbation
periods, varies from
individual to individual.
9
Rheumatoid Arthritis-Pathophysiology
Regardless of the causative agent, it causes an immunoglobulin G (IgG)
response, causing the individual to perceive the tissue as foreign and produce
antibodies.
These differentiated antibodies are called Rheumatoid Factors (RFs).

RF, together with IgG, forms an immune complex and accumulates in the
synovial membrane where it initiates inflammation.
In RA, joint deformity develops as a result of recurrent attacks of inflammation.
The changes in the joint develop in four stages:

initial stage,
immune response stage,
inflammatory and
destruction stages.
10
11
12
ARA (American Society of Rheumatology) RF diagnostic criteria
1. At least one hour of morning stiffness
2. Swelling of three or more joints (arthritis)
3. Swelling of hand, wrist, foot, ankle, elbow, knee, shoulder, neck, hip joints (arthritis)
4. Symmetrical joint involvement

5. Subcutaneous nodules
6. RF positivity
7. Detection of RA-specific variables on hand radiography; these changes should

include erosions or bone decalcifications.
The presence of at least four of the criteria and the patient's complaints lasting for 6 weeks is
diagnostic.
13
Diagnostic criteria for rheumatoid arthritis
During the exacerbation of

RA, redness of the joints,
Repeated and prolonged
pain, swelling, increased Heart, pericardium, pleura,
heat, stiffness and limitation
periods of exacerbation
result in deformation and
vessels and eye involvement
of movement in the are also seen in severe cases.
deformity of the joints.
morning, and nodules under
the skin are seen.
14
Rheumatoid Arthritis / Symptoms and Signs
Synovial
Morning Stiffness Pain Joint Deformity
Inflammation
• Morning stiffness is • Painful, swollen, • It is the most • The most important
thought to be red, hot joints important problem reason for the
caused by usually occur in the of patients with RA. deformity is that
inflammation active phase of • Morning stiffness, the patient tries to
(synovitis) and inflammatory fatigue, anemia, keep the joint in the
edema in the synovitis. high sedimentation, position where he /
synovium.
• The duration of
and progression of she feels the least
pain.
radiological joint
stiffness is related damage are • Other causes are
to the degree of remarkable. cartilage and bone
inflammation. • Cartilage loss and damage and
periarticular erosion changes in tendons,
are characteristic ligaments and
features of muscles.
structural damage.
15
16
17
18
Rheumatoid Arthritis-Medical
Treatment
Asıl başlık stilini düzenlemek için tıklayınThe following factors are

considered in the preparation of
The aim of treatment is to relieve the treatment program:
There is no definitive treatment of pain, to prevent joint damage and
the disease. deformation, to prevent loss of • 1. State of joint functions
function. • 2. Degree of disease activity
• 3. Age, gender, occupation, family
responsibilities of the patient and
individual response to treatment
• 4. Results of previous treatments
19
Rheumatoid Arthritis-Drug therapy:
For the relief of pain and inflammation: Aspirin, NSAID
Oral, parenteral or intraarticular corticosteroid (prednisone, cortisone) administration

Disease-modifying antirheumatic drugs (gold salts, antimalarial drugs,
immunosuppressive agents, D-penicillamine)
20
Rheumatoid Arthritis-Non-Pharmacological
Approaches
Physiotherapy is
Various exercises
an important
are used to
treatment
increase muscle
modality that
strength and to
relieves pain and
maintain and
preserves joint
improve the
functions. Cold
movement and
application and
electrotherapy
function of joints.
Ergotherapy: some
simple devices
called "splint" can Splints are very
be used to protect effective in
the functions of preventing
joints and to deformities
prevent
deformities.
21
Rheumatoid Arthritis-Patient Education
Be sure to use very large joints rather than small joints
when doing business. For example; When opening the
door, push it with your arm, not with your hand, or with
your hand when opening the jar, not with your fingers.

Try to distribute the load to more than one insert
instead of a single joint. For example; When lifting a
book, hold it with both hands, not one.
Try to use your joints in the most "natural" position.

Avoid excessive bending and strain.
22
Juvenile Rheumatoid Arthritis
Signs and
Definition Prognosis: Treatment:
symptoms:
• It is a form of RA • Unlike their shape, • Recovery is better • Steroids are of
seen in young spleneomegaly than adult type. great benefit as
people and is and diffuse this age group is
called Style lymphadenopathy better tolerated of
disease. are frequently steroid treatment.
seen. • The patient is
• There may be given active and
pericartid and passive exercises.
pleural effusion.
23
24
Rheumatoid Arthritis- Nursing
Diagnosis
• Chronic pain (related to joint involvement)
• Impairment of physical movement (related to joint, pain, swelling and

deformity)
Asıl• başlık stilinitodüzenlemek

Fatigue (related içinpain
chronic inflammation, tıklayın
or depression)
• Impairment of body consciousness Impairment of self-esteem (Change in

fulfilling the role undertaken)
• Ineffective implementation of treatment plan (Complex drugs and use schemes

related to significant side effects of drugs, lack of self-care)
25
Gout
GUT HASTALIĞI
26
Gout
• Gouty arthritis develops as a result of genetic or acquired disorders in uric acid
metabolism, elevated serum uric acid levels, and accumulation of urate crystals in joints
and soft tissues.
• M > W; Frequent between 40-65 years
Asıl başlık
• Normalstilini düzenlemek
serum value için6tıklayın
of uric acid; it is below mg / dl in women and 7 mg / dl in men.
27
Gout
Causes of hyperuricemia Etiology
• Increased uric acid synthesis: Enzyme • Gout is a chronic metabolic disease of

abnormalities, excess intake of purine unknown origin, often familial,
foods characterized by the development of
• Decrease in uric acid excretion: Renal acute arthritis, which occurs as a result
Asıl
causesbaşlık stilini düzenlemek için tıklayın
of the accumulation of sodium urate in
the soft tissues of the whole body, as
well as the joints and surrounding
tissues.
• Gout patients are generally known to
be obese, hypertensive,
hyperlipidemic, diabetic and chronic
alcohol users.
28
Gout / Symptoms and Signs-1
Acute gout is usually monoarticular (involving one joint) and starts suddenly.
Fifty percent of patients have complaints of pain, tenderness, redness, swelling, temperature increase (signs of
inflammation) that start at night,
The patient may have fever and leukocytosis.

The patient joint is swollen, red and hot and very damaged.
With the slightest contact, even touching the bed linen, the pain increases.
It can also be seen on the wrist, knee and elbows except for the toe joint.
29
Gout / Symptoms and Signs-2
Under the skin visible depots of urate and Na salts are
formed and these are called «tofus»
Tofuses occur especially near joints, cartilage, elbow,

patella, cartilage and other tissues.
Asıl başlık stilini düzenlemek

Tofuses için
located in the ear are tıklayın
small and elbows are
large.
Urate stones and tofus may occur in the kidneys.
The disease occasionally shows attacks, and there are

asymptomatic periods between attacks.
30
31
32
33
Diagnosis of gout
Patient's history
Physical examination of the

Asıl başlık stilini düzenlemek için tıklayın affected joints
Aspiration of joint synovial fluid
34
• The aim of arthritis treatment is to reduce pain, increase functional level and quality
of life, stop or slow down the progression of cartilage damage.
Patient education

Protective measures and psychosocial assistance
Non-steroidal anti-inflammatory drugs are used as pharmacological treatment.

• These drugs have analgesic, antipyretic, anti-inflammatory and antirheumatic effects.
35
Gout Treatment and Nursing Care-4
36
Gout Treatment and Nursing Care-5
Diet: Obesity, dehydration and acidosis should be prevented.
There is a view that a purine-poor diet should be used to reduce uric acid formation. (Food
containing purine; liver, sardine, sleepiness, anchovies, asparagus, kidney)
It is recommended to avoid alcoholic beverages.
At least 3lt. fluid intake, per day to remove urine increases the excretion of urate in addition
to the oral liquid sodium bicarbonate is given to prevent uric acid collapse in the kidneys.
37
Gout Disease-Nursing Diagnosis
Chronic pain (due to inflammation in the joints)
Discomfort in body image (deformity in joints, due to development of tosses)
Asıl başlık stiliniNutritional

düzenlemek imbalance: Lessiçin
about medical nutrition therapy)
tıklayın
/ more than necessary (due to lack of knowledge
Risk of ineffective management of the therapeutic regimen (due to lack of

information on nutrition, use of drugs, physical therapy)
Lack of information (due to lack of information about nutrition, use of drugs, physical
therapy)
38
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
39
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Definition: Etiology
• SLE is an autoimmune disease seen • Although the cause of SLE is not

mostly in women between the ages known exactly, all genetic,
of 20-40. environmental and hormonal
Asıl başlık
• Chronic, stiliniacute
progressive, düzenlemek
illness için tıklayın
effects play a role in this disease.
and clinical course leading to • Most patients show a variable
recovery periods is an untreated process with relatively quiet
disease characterized by clinical periods following exacerbations.
symptoms related to organ systems • Symptoms range from minor skin
such as skin, joints, kidneys and and joint effects to severe internal
nervous system. organ involvement
40
Systemic Lupus Erythematosus(SLE)-Diagnosis American Rheumatology Society's revised
diagnostic criteria for Systemic Lupus Erythematosus (1997)
• Four of the classification system developed by the American Society of

Rheumatology concern the mucosal-skin system.
d pho
a p e tosens
- s h
Asıl başlık stiliniDidüzenlemek
sc rash için tıklayın
y
itivit
sk i n
eks ss
Mo
on d red y-
che ne
pe erfl
u th
sha Butt
ulc
ers
41
42
43
44
Systemic Lupus Erythematosus (SLE) - Diagnosis
Revised diagnostic criteria of the American Society of Rheumatology for Systemic Lupus Erythematosus
1997)

Positive
Kidney Neurological Hematologic Immunologica
Arthritis serositis antinuclear
Disease disorder disorder l disorders
antibody
45
Systemic Lupus Erythematosus (SLE) - Treatment-
1
Mild to moderate disease: Severe disease:
• In mild to moderate patients without • evidence of significant organ

any organ involvement, treatment involvement
typically consists of nonsteroidal anti- • glomerulonephritis,
inflammatory drugs (NSAIDs), • pneumonia,
Asıl başlık (<10
corticosteroids stilini
mg / düzenlemek
day), and için• tıklayın
vasculitis,
malaria drugs such as
• neurological disease,
hydroxychloroquine sulfate.
• myositis,
• cytopenias)
urgent treatment is required to suppress inflammation and prevent organ destruction in patients.
46
Systemic Lupus Erythematosus (SLE) - Patient education-1
• Diagnosis and classification of SLE can be confusing and panicic for patients, and
patients and their families should be educated about the disease and referred to
organizations such as Lupus Foundations.
• Lifestyle Changes
• Regular exercise, adequate rest:
• A healthy diet: Patients using corticosteroids with the development of hypernatremia,
Asıl başlık stilini
hyperglycemia, düzenlemek
hypokalemia, fluid retentioniçin tıklayın
• Relaxation, meditation and yoga techniques to reduce stress
• In the event of anorexia, tremor, fever or worsening of symptoms, it is advisable to
consult the healthcare facility immediately.
47
Systemic Lupus Erythematosus (SLE) - Medical treatment aims to reduce
tissue destruction and inflammation. Toxicities of drugs used in SLE:
• Non-steroidal anti-inflammatory drugs: Gastric ulcers and bleeding, high liver

enzymes, decreased renal function, HT, edema
• Corticosteroids: HT, hyperglycemia, osteoporosis, cataract, weight gain, adrenal
gland insufficiency, atherosclerosis, infection
• Hydroxychloroquine sulfate: Macular damage, skin redness, CNS side effects
• Azatyoprin (Imuran): Ki suppression, hepatotoxicity, lymphoproliferative disorders
48
Systemic Lupus Erythematosus (SLE) - Nursing Diagnoses-1
Risk of infection (depending on the use of drugs that suppress the immune system)
Risk of trauma (tendency to bleeding secondary to corticosteroid use, due to osteoporosis)
Asıl başlık stilini ofdüzenlemek

Deterioration için on
skin integrity (depending tıklayın
the nature of the disease)
Impairment of oral mucous membrane integrity (depending on the nature of the disease)
Fatigue (due to the effects of chronic inflammation and reduced mobility)
Weakness (depending on the unpredictability of the course 50

of the disease)
Systemic Lupus Erythematosus (SLE) - Nursing Diagnoses-2
Risk of discomfort in the self-concept (inadequacy secondary to the ypan
state, due to failure to accomplish developmental tasks and changes in
appearance)
Social isolation (Depending on the reaction of others to the changing physical

appearance, shame, shy)

Ineffective coping (due to unpredictable course of disease)
Risk of ineffective management of the therapeutic regimen (depending on

the situation, resting needs as well as activity, pharmacological treatment,
signs and symptoms of complications, risk factors, and lack of knowledge of
community resources)
51
2-Degenerative Joint Diseases
52
SPONDYLOARTHROPATIES (SPA)
53
Ankylosing Spondylitis (AS) -
Definition
AS is a chronic, systemic, rheumatic disease involving the joints of the spine and pelvis.
The disease usually begins insidiously and patients cannot exactly determine the time and place
where their symptoms begin.
The earliest and typical symptom of AS is pain in the patients, which begins and changes in the
sacroiliac joints.
They indicate that this pain spreads to the knee from the front and back of the thigh.
This pain, which may be intermittent and displaced at the beginning, may become bilateral and
continuous within a few months.
It also develops chronic low back pain and stiffness.
54
Ankylosing Spondylitis (AS) -Physiopathology
• As a result of inflammation in the joints and

ligaments that provide the movement of the spine,
joints or bones may fuse with each other in such a
way as to lose their movement.
Asıl başlık
• Apart from thestilini düzenlemek
spine, inflammation of theiçin tıklayın
hip, knee
and foot joints can be seen, and a few patients may
have various organ findings.
• It can completely limit the movements of the spine

in patients with severe involvement.
55
Ankylosing Spondylitis (AS)(AS)-
symptom
• In 75% of patients with AS, the first clinical symptom
may be low back pain.
• In the lower lumbar vertebrae region, pain and stiffness
may persist.
• In some patients, there may be an initial onset of pain
and stiffness in the lumbar region without gluteal pain.

Diagnosis
• Low back pain started before the age of 40 (16-35
years)
• Pain lasting longer than 3 months, limitation of
movement,
• Increased waist stiffness after mornings and long rest
• Improvement of pain and stiffness by movement or
exercise
56
Ankylosing Spondylitis (AS) - Prognosis
58
59
Ankylosing Spondylitis (AS) - Treatment
1. Early diagnosis and treatment
2. Prevention of pain and limitation of movement without joint fusion
3. Prevention of pain and limitation of movement by exercise

4. Patient training greatly improves patient compliance
5. Daily exercise (swimming, etc.) is very important (to maintain the limit of movement of the neck,
shoulders, hips, chest expansion).
6. Treatment and exercise should be continuous.
7. Primarily NSAIDs, antirheumatic drugs should be used appropriately

60
Ankylosing Spondylitis (AS) - Treatment 1-Patient education
61
Ankylosing Spondylitis (AS) - Treatment 2-Physical Therapy:
62
Ankylosing Spondylitis (AS) Nursing Diagnosis
Chronic pain (due to inflammatory process)
Impaired physical mobility (due to chronic pain)

Lack of knowledge (due to lack of prior training on drug use, exercise,
complications)
Risk of ineffective management of the therapeutic regimen

(treatments, lifestyle changes, due to lack of knowledge about
exercises)
63
OSTEOARTHRITIS
64
Osteoarthritis
Etiology
• Osteoarthritis (OA), also known as degenerative arthritis; It is characterized by

deterioration, erosion, progressive loss of the articular cartilage structure and
remodeling of the subchondral bone.
• OA; It is a complex disorder with risk factors ranging from biomechanical,

inflammatory and metabolic processes to age, sex and genetic factors.
65
66
Osteoarthritis-Pathophysiology
• OA may develop for biomechanical reasons such as recurrent or single joint trauma.
• Certain professions leading to recurrent joint trauma (toes in the assembly factory)
predispose to early OA.
• Gender and race are also important risk factors for OA.
• The prevalence of OA is equal in men and women under the age of 45, but more
common in women over the age of 55. It occurs in 60% -90% of individuals 65 years and
Asıl
older.başlık stilini düzenlemek için tıklayın
67
Osteoarthritis-Symptoms and Findings
• Limitation of motion and pain in joints

• Joint may appear swollen due to bone protrusions
• Cracking of the joint may be heard during movement
• The pain is usually seen during movement or later in the day,
Asıl
while başlık stilini
the symptoms düzenlemek
relieve relaxation. için tıklayın
• After prolonged rest or from sitting to action, there may be a
short stiffness in movements. This improves within minutes as it
moves,
• As joint cartilage disorders and wear progress, pain may occur
during rest and movements may be limited to disrupt daily life
functions.
68
69
Osteoarthritis Treatment and Nursing Care
It is not possible to completely replace the worn joint and

cartilage tissue
Pain eliminate

Ensuring an independent maintenance of GYA by preventing
movement limitation
Prevention of disease progression is the main objective
Weight loss is very important to reduce the burden on the

joints of obese patients and calories are regulated accordingly
70
Osteoarthritis Treatment and Nursing Care
The patient should avoid excessive
Adequate sleep and rest should be use of joints. Physical activity that
ensured. may cause trauma to the joints
should be prevented.
Physical therapy, local heat

application, immobilization,
supportive-passive and gradually Aspirin and NSAID are given.
increased active exercises may be
helpful.
Joint prostheses can be applied by

surgical methods.
71
Osteoarthritis Nursing Diagnosis
Chronic pain (due to muscle spasm and fractures related to disease process)
Risk of trauma (related to disease process)
Decreased physical mobility (due to ROM limitation secondary to changes in skeletal / bone
structure related to disease process)
Fear (Variable / course dependent on unpredictable nature)
Risk of ineffective management of the therapeutic regimen (depending on the situation, risk
factors, lack of knowledge of treatment and prevention by regulating nutrition)
72

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JOINTS AND CONNECTIVE

Asıl başlık stilini düzenlemek için tıklayın

Physical examination: Anamnesis

• Inspection, • Medical history, surgical

• Erythrocyte • MRI • Arthrocentesis

Systemic Sclerosis (Scleroderma)

Asıl başlık stilini düzenlemek için tıklayın

• unknown etiology • It is estimated that one in • The cause of RA is

These differentiated antibodies are called Rheumatoid Factors (RFs).

The changes in the joint develop in four stages:

1. At least one hour of morning stiffness

2. Swelling of three or more joints (arthritis)

4. Symmetrical joint involvement

7. Detection of RA-specific variables on hand radiography; these changes should

During the exacerbation of

Asıl başlık stilini düzenlemek için tıklayınThe following factors are

Oral, parenteral or intraarticular corticosteroid (prednisone, cortisone) administration

Asıl başlık stilini düzenlemek için tıklayın

Asıl başlık stilini düzenlemek için tıklayın

Try to use your joints in the most "natural" position.

• Impairment of physical movement (related to joint, pain, swelling and

Asıl• başlık stilinitodüzenlemek

• Impairment of body consciousness Impairment of self-esteem (Change in

• Ineffective implementation of treatment plan (Complex drugs and use schemes

• M > W; Frequent between 40-65 years

Causes of hyperuricemia Etiology

• Increased uric acid synthesis: Enzyme • Gout is a chronic metabolic disease of

The patient may have fever and leukocytosis.

Tofuses occur especially near joints, cartilage, elbow,

Asıl başlık stilini düzenlemek

Urate stones and tofus may occur in the kidneys.

The disease occasionally shows attacks, and there are

Physical examination of the

Aspiration of joint synovial fluid

Asıl başlık stilini düzenlemek için tıklayın

Non-steroidal anti-inflammatory drugs are used as pharmacological treatment.

Asıl başlık stilini düzenlemek için tıklayın

Diet: Obesity, dehydration and acidosis should be prevented.

Chronic pain (due to inflammation in the joints)

Discomfort in body image (deformity in joints, due to development of tosses)

Asıl başlık stiliniNutritional

Risk of ineffective management of the therapeutic regimen (due to lack of

Asıl başlık stilini düzenlemek için tıklayın

• SLE is an autoimmune disease seen • Although the cause of SLE is not

• Four of the classification system developed by the American Society of

Asıl başlık stilini düzenlemek için tıklayın

Mild to moderate disease: Severe disease:

• In mild to moderate patients without • evidence of significant organ

• Non-steroidal anti-inflammatory drugs: Gastric ulcers and bleeding, high liver

Risk of trauma (tendency to bleeding secondary to corticosteroid use, due to osteoporosis)

Asıl başlık stilini ofdüzenlemek

Fatigue (due to the effects of chronic inflammation and reduced mobility)

Weakness (depending on the unpredictability of the course 50

Social isolation (Depending on the reaction of others to the changing physical

Asıl başlık stilini düzenlemek için tıklayın

Risk of ineffective management of the therapeutic regimen (depending on

Asıl başlık stilini düzenlemek için tıklayın

Asıl başlık stilini düzenlemek için tıklayın

It also develops chronic low back pain and stiffness.

• As a result of inflammation in the joints and

• It can completely limit the movements of the spine

Asıl başlık stilini düzenlemek için tıklayın