Ch 20 Iggy

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Connective tissue disease (CTD)

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is the major focus of rheu-matology, the study of rheumatic disease

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rheumatic disease

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is any disease or condition involving the musculoskeletal system.

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Arthritis

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means inflammation of one or more joints. In clini- cal practice, however, arthritis is categorized as either nonin- flammatory or inflammatory.

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Osteoarthritis

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-Noninflammatory, localizedarthritis

- the progressive deterioration and lossof cartilage in one or more joints (articular cartilage)

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osteophytes

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(bone spurs)

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crepitus

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a grating sound caused by the loosened bone and cartilage.

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primary OA

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the disease may be triggered byaging, genetic changes, obesity, and/or smoking.

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Secondary OA

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occurs less often than primary disease and can result from other musculoskeletal conditions, such as rheumatoid arthritis.

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OA pain assessment in detail.

Other questions to ask include:

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-If joint stiffness has occurred, where and for how long?

-When and where has any joint swelling occurred?

-What do you do to control the pain or stiffness? -Do you have any loss of function or difficulty in per- forming ADLs?

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Heberden’s nodes

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(at the distal interphalangeal [DIP] joints)

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Bouchard’s nodes

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(at the proximal interphalangeal [PIP] joints)

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Joint effusions

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(excess joint fluid)

are common when the knees are involved.

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infrapatellar notch

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(the area directly below the knee)

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suprapatellar area

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(directly above the knee).

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OA Disease pattern

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-May be unilateral, single joint

-Affects weight-bearing joints and hands, spine ---Metacarpophalangeal joints spared

-Nonsystemic

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OA Disease process

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Degenerative

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OA LAB FINDINGS

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Normal or slightly elevated ESR

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OA Common drug therapy

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NSAIDs (short-term use)

Acetaminophen

Other analgesics

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OA typical onset age

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older than 60yrs

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OA Risk Factors or cause

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-Aging

-Genetic factor (possible)

-Obesity

-Trauma

-Occupation

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OA- Local rest

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involves immobilizing any unstable joint, most often the knee, with a brace or splint

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OA Systemic rest

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refers to immobilizing the entire body, such as during a nap.

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OA Psychological rest

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is equally important because it allows relief from the daily stresses that can enhance pain.

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Glucosamine

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may decrease inflammation

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chondroitin

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may play a role in strengthening cartilage.

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totaljoint arthroplasty (TJA)

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-surgical creation of a joint

-The most common surgical procedure performed for older adults with OA

-aka total joint replacement (TJR )

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osteotomy

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(bone resection) may be performed to correct joint deformity, but this procedure is done most commonly for younger adults

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Osteonecrosis

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is bony necrosis secondary to lack of blood flow, usually from trauma or chronic steroid therapy.

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primary arthroplasty.

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The first time a patient receives any total joint arthroplasty, it is referred to as

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revision arthroplasty

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If the implant loosens, _______may be performed.

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neuroaxial

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(epidural/spinal) anesthesia for LOWER EXTREMITY SURGERY

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subluxation

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-(partial dislocation) or total dislocation.

-A major complication of THA(total hip arthroplasty)

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peripheral nerve blockade (PNB)

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One of the most recent advances in postoperative painmanagement for lower extremity total joint arthroplasty (TJA or TJR)

- the anesthesiologist injects the femoral or sciatic nerve with localanesthetic; the patient may receive a continuous infusion ofthe anesthetic by portable pump.

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hemiarthroplasty

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replacement of part of the joint), typically the humeral component, may be performed as an alternative to TSA ( TOTAL SHOULDER ARTHROPLASTY)

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Recreational exercise

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includes hobbies and sports, with no planned purpose other than relaxation.

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Therapeutic exercise

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-includes carefully planned activities that are designed to improve muscle strength, muscle tone, and joint range of motion.

-can also reduce pain and improve the patient’s psy- chological health.

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Rheumatoid arthritis (RA)

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is a common connective tissue disease that can be the most destructive to the joints

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Systemic

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means this disease affects the body system, affecting many joints and other tissues.

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pannus

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is vascular granulation tissue composed of inflammatory cells; it erodes articular cartilage and eventually destroys bone.

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vasculitis

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If blood vessel involvement occurs, the organ supplied by that vessel can be affected.

-The result is malfunction and eventual failure of the organ or system

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migratory arthritis.

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In early disease, the patient may report migrating symptoms known as

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gel phenomenon

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The patient usually has frequent morning stiffness ......which lasts for 45 minutes to several hours after awakening.

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effusions

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(joint swelling with fluid, especially the knees).

-On palpation, the joints feel soft and look puffy because of synovitis and

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Baker’s cysts

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(enlarged popliteal bursae behind the knee)

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periungual lesions

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Assess for ischemic skinlesions that appear in groups as small, brownish spots,

most commonly around the nail bed

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paresthesias

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-burning and tingling sensation,

-Peripheralneuropathy associated with decreased circulation can causefootdrop and ____ usually in older adults.

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Sjögren’s syndrome (RA)

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which includes a triad of:

-Dry eyes (keratoconjunctivitis sicca [KCS], or the sicca syndrome)

-Dry mouth (xerostomia)

-Dry vagina (in some cases)

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Felty’s syndrome (RA)

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hepatosplenomegaly (enlarged liver and spleen), and leukopenia

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Caplan’s syndrome (RA)

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is characterized by the presence of rheumatoid nodules in the lungs and pneumoconiosis, which is noted primarily in coal miners and asbestos removal workers.

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synovectomy

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to remove inflamed synovium may be needed for joints like the knee orelbow.

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disease-modifying antirheumatic drugs (DMARDs)

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-most patients are managed with

-As the name implies, thesedrugs are given to slow the progression of the disease (RA)

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Methotrexate(MTX) (Rheumatrex)

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-Patients taking MTX are at risk for infection.

-Teach themto avoid crowds and people who are ill.

-Remind patients to avoidalcoholic beverages while taking MTX to prevent liver toxicity.

-Teach them to observe and report other side and toxic effects,which include mouth sores and acute dyspnea from pneumoni-tis

- Strict birth control is recom-mended for childbearing women who are in need of MTX tocontrol their RA

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Leflunomide (Arava)

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- Teach patients to report these changes and monitor laboratoryresults carefully.

-Remind them to avoid alcohol.

-Inform themthat Arava can cause birth defects, and therefore recommendstrict birth control to women of childbearing age.

-Tell patientsto contact the health care provider immediately if pregnancyoccurs while taking the drug.

-Cholestyramine (Questran) isavailable to help block the drug’s action.

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Nonsteroidal Anti-inflammatory Drugs. NSAIDs

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aresometimes used for inflammatory arthritis to relieve pain andinflammation

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Plasmapheresis

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(sometimes called plasma exchange) is an in-hospital procedure prescribed by a health care provider in which the patient’s plasma is treated to remove the antibodies causing the disease

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energy conservation

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including:

- Pacing activities

- Allowing rest periods

- Setting priorities

- Obtaining assistance when needed

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RA typical age

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35-45 years

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RA risk factors or cause

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- Autoimmune (genetic basis)

-Emotional stress (triggers exacerbation)

-Environmental factors

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RA Disease process

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Inflammatory

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RA Disease pattern

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-Bilateral, symmetric, multiple joints

-Usually affects upper extremities first

-Distal interphalangeal joints of hands spared

-Systemic

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RA Lab findings

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-Elevated rheumatoid factor

-antinuclearantibody

-ESR

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RA common drug therapy

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-NSAIDs (short-term use)

-MethotrexateLeflunomide (Arava)

-Corticosteroids

-Biological response modifiers

-Other immunosuppressive agents

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The two main classifications of lupus are

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-discoid lupuserythematosus (DLE)

- systemic lupus erythematosus(SLE)

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systemic lupus erythematosus (SLE)

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is a chronic,progressive, inflammatory connective tissue disorder that cancause major body organs and systems to fail.

-characterized by spontaneous remissions and exacerbations (“flare-ups”), and the onset may be acute or insidious (slow).

- condition is potentially fatal, but the survival rate hasimproved dramatically when SLE is diagnosed early andtreated adequately

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lupusnephritis (SLE)

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- some degree of kidney involvement—the leading cause of death.

-Autoimmune complexes in SLE tend to be most attractedto the glomeruli of the kidneys.

-Other causes of deathfrom the disease are cardiac and central nervous systeminvolvement.

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Lupus caused by

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Like RA, lupus is probably caused by a

combination of genetic and environmental factors.

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“butterfly”rash

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The major skin manifestation of DLEand SLE is a dry, scaly, raised rash on the face

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discoid lesions

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-(coinlike)

the scarring lesions of discoid lupus. The lesions are especially evidentwhen the patient is exposed to sunlight or ultraviolet light.

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Osteonecrosis

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(bone necrosis from lack of oxygen)is often seen in those who have been treated for at least 5 yearswith steroids like prednisone

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myositis

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Observe for muscle atrophy, which can result from disuse,from skeletal muscle invasion by the immune complexes or from chronic steroid therapy

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Myalgia

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(muscle pain)

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Pericarditis

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is the most common cardiovascular manifesta-tion and causes tachycardia, chest pain, and myocardial ischemia.

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Raynaud’s phenomenon

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occurs in a small portion of lupuspatients. On exposure to cold or extreme stress, the patientreports the characteristic red, white, and blue color changesand severe pain in the digits; these changes are caused byarteriolar vasospasm.

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serositis

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(peritoneal involvement)

- Mesenteric arteritis, pancreatitis from arteritis of the pancreatic artery, and colonic ulcersalso can cause abdominal pain with lupus.

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pancytopenia

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(a decrease of all cell types)

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hydroxychloroquine (Plaquenil)

(SLE)

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- decreases the absorption of ultraviolet lightby the skin and therefore decreases the risk for skin lesions.

-Teach patients to have frequent eye examinations if they arereceiving _______

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discoid lupus erythematosus (DLE)

the patient’s major concern

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is the rash or discoid lesions

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Systemic sclerosis (SSc)

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-also called scleroderma

-is an uncommon chronic, inflammatory, autoimmune connective tissue disease.

-Formerly called progressive systemic disease, or PSS, this illness is not always progressive.

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Scleroderma

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means hardening of the skin, which is only one clinical manifestation of the problem.

-Some patients, often children, have only skin involvement, or localized scleroderma (also called linear scleroderma)

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sclerotic

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The inflamed tissue in patients with SSc be

comes fibrotic and ____ (hard)

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two classification for systemic sclerosis

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-Diffuse cutaneous SSc—skin thickening on the trunk, face, and proximal and distal extremities (over most of the body)

- Limited cutaneous SSc—thickened skin limited to sites distal to the face, neck, and distal extremities

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Patients with the limited form of systemic sclerosis often have the CREST syndrome

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-Calcinosis (calcium deposits)

-Raynaud’s phenomenon (1st symptom that ocurs)

-Esophageal dysmotility

-Sclerodactyly (scleroderma of the digits)

-Telangiectasia (spider-like hemangiomas)

The first symptom that usually occurs in patients with the diffuse form of the disease is hand and forearm edema, which may exist with bilateral carpal tunnel syndrome.

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Arthralgia

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(joint pain)

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indurative phase

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In this phase, the fingers are described as sausage-like. The skin is taut, shiny, and free of wrinkles. If diffusescleroderma occurs, swelling is replaced by tightening, hard-ening, and thickening of skin tissue

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autoamputation

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(the tips of the digits fall off spontaneously)

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Gout, or gouty arthritis

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is a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation

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Primary gout

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is the most common type and results from one of several inborn errors of purine metabolism.

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Secondary gout

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involves hyperuricemia (excessive uric acid in the blood) caused by another disease or factor. Sec- ondary gout affects people of all ages

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three clinical stages of the primary disease process of gout

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asymptomatic hyperuricemia,

acute gouty arthritis

chronic or tophaceous gout

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asymptomatic hyperuricemia

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- patient is usually unaware

- The serum uric acid level is elevated, but no treatment is needed in this stage

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acute gouty arthritis

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- The patient experiences excruciating pain and inflammationin one or more small joints, usually the metatarsophalangealjoint of the great toe, called podagra.

-The erythrocyte sedimentation rate (ESR) is usually increased as a result of theinflammatory process.

-- Joint inflammation is the most common finding and is usually so painful that the patient seeks medical care immedi- ately.

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chronic or tophaceous gout

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-uratekidney stone formation is more common than renal insufficiency.

- can begin anywhere between 3 and40 years after the initial gout symptoms occur

- inspect the skin for tophi, or deposits ofsodium urate crystals

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Polymyositis

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is a diffuse inflammatory disease of skeletal (striated) muscle that causes symmetric weakness and atrophy.

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dermatomyositis

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When a rash accompanies polymyositis, the diseaseis called

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polyarthralgia

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(aching around multiple joints),

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Necrotizing vasculitis

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is a term for a group of diseases whose primary manifestation is arteritis (inflammation of arterial walls), which causes ischemia in the tissues usually supplied by the involved vessels

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Polyarteritis nodosa

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affects middle-aged men most oftenand involves every body system. Treatment is similar tothat for systemic lupus, but the prognosis is not as promis-ing. Renal disorders and cardiac involvement are the mostcommon causes of death

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Hypersensitivity vasculitis

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is the most common form of vasculitis and primarily causes skin lesions as an allergic response to drugs, infections, or tumors.

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Takayasu’s arteritis

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or the aortic arch syndrome, is also called the “pulseless” disease

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Polymyalgia rheumatica (PMR)

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is a clinical syndrome characterized by stiffness, weakness, and aching of the proximal musculature (i.e., the shoulder and pelvic girdles).

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Giant cell arteritis (GCA)

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-or temporal arteritis (TA), occurs in as many as 20% of people with PMR.

-GCA is a systemic vasculitis that affects large and midsize arteries

- the cause of both PMR and GCA is unknown, but a geneticpredisposition related to HLA-DRB1 is likely.

- GCA istreated urgently with high doses of corticosteroids, often ashigh as 40 to 80 mg daily

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Ankylosing spondylitis (AS)

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s also known as Marie-Strüm-pell disease or rheumatoid spondylitis.

-The disease affects thevertebral column and causes spinal deformities.

- Other features include:

iritis (inflamma-tion of the iris),

arthritis or arthralgia (joint aching), andnonspecific systemic manifestations such as malaise andweight loss.

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Reiter’s Syndrome

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- As with ankylosing spondylitis, Reiter’s syndrome is associatedwith the HLA-B27 antigen.

-This disease usually affects youngwhite men but can also affect women.

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balanitis circinata

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(ringlike inflammation of the glans penis)

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Marfan syndrome

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is an autosomal dominant connective tissue disease in which abnormalities of the skeletal, ocular, cardiopulmonary, and central nervous systems result from a basic defect in extracellular microfibrils. Microfibrils are very small fibers within cells.

- tend tobe excessively tall and have elongated hands and feet.

- Cardiovascular problems are responsible for most deathsresulting from ______

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Infectious Arthritis

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Any infectious agent can invade the joint space and causeinflammation and tissue destruction.

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Lyme disease

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is a reportable systemic infectious diseasecaused by the spirochete Borrelia burgdorferi and results fromthe bite of an infected deer tick, also known as the black-legged tick.

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erythema migrans

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round or oval, flat orslightly raised rash

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Pseudogout

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is a disease that mimics the clinical manifesta- tions of gout.

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Psoriatic arthritis (PsA)

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affects about 30% of people who have psoriasis—a skin condition characterized by a scaly, itchy rash, usually on the elbows, knees, and scalp

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Fibromyalgia syndrome (FMS)

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also referred to as simplyfibromyalgia, is a chronic pain syndrome, not an inflamma-tory disease.

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trigger points (FMS)

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-can typically be palpated to elicit pain in a predictable, reproducible pattern.

-The pain is typically described as burningand gnawing.

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Chronic fatigue syndrome (CFS),

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also known as chronic fatigue and immune dysfunction syndrome (CFIDS),

- is a chronic illness in which patients have severe fatigue for 6 months or longer, usually following flu-like symptoms.