Inflammatory Joint Diseases and rheumatic disorders and Nursing Intervention Lecture

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Inflammatory Joint Diseases
Rheumatic Disorders
– More than 100 different disorders that affect muscles, bones, ligaments, tendons and joints.
Rheumatoid arthritis – it is a systemic inflammatory disorder of the connective tissue/joints characterized by chronicity, remissions and exacerbations.
Systemic Lupus Erythematosus (SLE) – A diffuse connective tissue disease affecting multiple body systems – skin, joints, kidney, serous membrane of heart, lungs, lymph nodes and GI tract.
Scleroderma– is a chronic autoimmune disease characterized by fibrosis or progressive hardening of skin in patches or diffusely with rigidity of underlying tissues. The cause is unknown ,so there is no direct cure for scleroderma.– Polymyalgia rheumatica (PMR)– is an inflammatory condition of the muscles, which causes pain or stiffness, usually in the neck, shoulders, and hips. The pain can be very sudden, or can occur gradually over a period of time. PMR usually goes away within a year or two after treatment. PMR is usually treated with long courses of oral steroid

Osteoarthritis – is a group of diseases and mechanical abnormalities involving degradation of joints. Clinical manifestations of OA may include joint pain, tenderness, stiffness, creaking, locking of joints. Treatment of OA consists of exercise, manual therapy, lifestyle modification, medication and other interventions to alleviate pain

Ankylosing spondylitis – chronic connective tissue disorder of spine and surrounding cartilaginous joints such as sacroiliac joints and soft tissues around vetebrae. No cure is known for AS, although treatments and medications are available to reduce symptoms and pain
Reiter’s syndrome – is an autoimmune condition that develops in response to an infection in another part of the body. Coming into contact with bacteria and developing an infection can trigger reactive arthritis. The main goal of treatment is to identify the underlying infectious source with the appropriate antibiotics if still present.

Psoriatic arthritis – a skin disease characterized by reddish marinated patches with profuse silvery scaling on extensor surfaces like knees and elbows. Affects around 10-30% of people suffering from the chronic skin condition psoriasis.
Gout – is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis (red, tender, hot, swollen joint) affects the feet, elbows, ankles and knees. It is caused by elevated levels of uric acid in the blood.
Systemic Lupus Erythematosus SLE
– Increased autoantibody production resulting from abnormal suppressor T-cell function.
– Caused by combination of genetic, hormonal and environmental factors.
– Onset often in childbearing years and may be insidious or acute.
Signs and symptoms:
– Arthritis, joint swelling, tenderness and pain.
– Skin lesions and butterfly shaped rash on nose and cheeks.
– Pericarditis and pleural effusions.
– Inflammation of arterioles causing lesions and necrosis.
– Lymphadenopathy: swollen/enlarged lymph nodes
– Behavioral and cognitive changes
– Depression and psychosis
– Fever, fatigue, weight loss

SLE Management

– Can be life threatening
– Control acute exacerbations that may damage organs
– NSAIDS and corticosteroids
– Antimalarial medications
– Immunosuppressive agents.
Nursing Diagnosis of SLE:
– Fatigue.
– Impaired skin integrity
– Body image disturbance
Rheumatoid Arthritis
– Autoimmune disease
– Result of immune response
– The arthritis of joints known as synovitis, is inflammation of the synovial membrane that lines joints and tendon sheaths. Joints become swollen, tender and warm, and stiffness limits their movement
– Degenerative changes – loss of articular surfaces and joint motion.
– Inflammation involves other areas as well as joints, blood vessels, lungs, heart, kidneys.

Assessment Of Rheumatic Arthritis
– Functional assessment – gait, posture.
– Family History – hereditary component
Signs and symptoms:
– Acute onset of bilateral and symmetric pain, joint swelling, warmth, erythema, loss of function.
– Begins in small joints of hands, wrists, feet.
– Progresses to knees, shoulders, hips, elbows, spine.
– Deformity in hands and feet is common, caused by swelling and joint destruction.
– Rheumatoid nodules (nontender, movable in subcutaneous tissue over bony prominences).
– Raynaud’s phenomenon (cold and stress induced vasospasm in fingers and toes causing cyanosis).
Systemic effects
Fever, weight loss, fatigue, anemia, lymph node enlargement, arteritis, neuropathy, pericarditis, splenomegaly, dry eyes and mucous membranes.
Rheumatic Arthritis Tests
– Arthrocenteseis (needle aspiration of synovial fluid – cloudy with increased inflammatory cells)
– X-ray shows cartilage abnormality, joint erosion, narrowing of joint space.
– Blood tests
– Rheumatoid factor,
– Increased ESR,
– Decreased RBC
Management of Rheumatic Arthritis
– Early education, balance of rest and exercise
– Salicylates, NSAIDS (anti-inflammatory and analgesic)
– Antirheumatic agents
– Antimalarials, methotrexate.
– Corticosteroids
– Antidepressant (amitriptylline) for sleep disturbance
– Reconstructive surgery when pain unrelieved.
– Immunosuppressive agents (methotrexate, cyclophosphamide) for advanced diseaseincreased – toxicity, bone marrow suppression, anemia, GI disturbance.
Osteoarthritis
– Degenerative joint disease
– Inflammation and degeneration of cartilage and bone
– Many types, some hereditary, related top obesity, joint trauma, heavy physical activity.

Symptoms of Osteoarthritis
– Pain, stiffness in morning relieved with movement
– Functional impairment
– Occurs most often in weight bearing joints (hips, knee, spine) but dinger joints often involved
– Bony nodules (painless)
– Tender and enlarged joints.
– X-ray: loss of joint cartilage, spurs.
– Blood studies not useful
Management
– Preventive measures can slow progress
– Weight reduction, prevent injuries
– Apply heat, rest the joint
– Splints and braces to support inflamed joints
– Acetaminophen, NSAIDS
– Intraarticular injection of corticosteroids
Surgery when pain not manageable or function loss (arthroplasty).
Gout
– Defect in purine metabolism resulting in hyperuricemia
– Oversecretion of uric acid or decreased excretion, or combination
– Urate crystals precipitate within the joint causing inflammatory response
– Repeated attacks cause accumulations of sodium urate crystals (Tophi) to be deposited in greater toe, hands, ear.
– Urate deposits in kidneys cause kidney stones
– Causes : severe diet, starvation, excessive intake of high purine foods (shellfish, organ meats) heredity, leukemia, multiple myeloma, altered renal function (caused by diuretics, ASA, ethanol).
Signs and symptoms of Gout
– Acute gouty arthritis (recurrent, severe attacks of inflammation) triggered by trauma, alcohol ingestion, dieting, medications, stress, illness.
– Abrupt onset at night of severe pain, redness, swelling and warmth.
– Tophi is a deposit of monosodium urate crystals in people with longstanding high levels of uric acid in the blood
– Renal impairment and kidney stones.
Management  Of Gout
– Colchicine lowers deposits of uric acid
– NSAIDS to decrease inflammation
– Uricosuric agents (probenecid) to correct hyperuricemia and dissolve deposited urate.
– Allopurinol prevents uric acid formation (side effects of bone marrow suppression, vomiting, abdominal pain).

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