Autoimmune Disorders Autoimmune Disorders That Affect the That Affect the
Musculoskeletal SystemMusculoskeletal System
Rheumatoid ArthritisRheumatoid Arthritis
Rheumatoid Arthritis (RA)Rheumatoid Arthritis (RA)
Chronic, systemic autoimmune disease Chronic, systemic autoimmune disease Inflammation of connective tissue in Inflammation of connective tissue in
diarthrodial (synovial) joints diarthrodial (synovial) joints Periods of remission and exacerbationPeriods of remission and exacerbation Frequently accompanied by extra-articular Frequently accompanied by extra-articular
manifestations manifestations
IncidenceIncidence Occurs globally, affecting all ethnic groupsOccurs globally, affecting all ethnic groups Occurs at any time of lifeOccurs at any time of life Incidence Incidence increases with ageincreases with age
Peaks between 30s and 50sPeaks between 30s and 50s Nearly 2.1 million Americans affectedNearly 2.1 million Americans affected Women have incidences three times Women have incidences three times
higher than menhigher than men
EtiologyEtiology
Cause of RA is unknownCause of RA is unknown No infectious agent foundNo infectious agent found Two etiologies Two etiologies
Autoimmune etiologyAutoimmune etiology• Most widely accepted Most widely accepted
Genetic factor etiologyGenetic factor etiology
Etiology and Pathophysiology of Rheumatoid Etiology and Pathophysiology of Rheumatoid ArthritisArthritis
Main Pathology is chronic inflammation leading to scar Main Pathology is chronic inflammation leading to scar tissue (pannus) & joint cartilage destructiontissue (pannus) & joint cartilage destruction
Etiology and Pathophysiology of Etiology and Pathophysiology of Rheumatoid ArthritisRheumatoid Arthritis
Inflammatory pannus causes destruction of Inflammatory pannus causes destruction of bone.bone.
This leads to joint deformities. This leads to joint deformities.
PathophysiologyPathophysiology
If unarrested, RA progresses in 4 stagesIf unarrested, RA progresses in 4 stages Stage 1: Stage 1: EarlyEarly
• No destructive changes on x-ray, possible x-ray No destructive changes on x-ray, possible x-ray evidence of osteoporosisevidence of osteoporosis
Stage 2: Stage 2: ModerateModerate• X-ray evidence of osteoporosis, with or without slight X-ray evidence of osteoporosis, with or without slight
bone or cartilage destructionbone or cartilage destruction• No joint deformities, adjacent muscle atrophy, No joint deformities, adjacent muscle atrophy,
possibly presence of extra-articular soft tissue lesionspossibly presence of extra-articular soft tissue lesions
Etiology and PathophysiologyEtiology and Pathophysiology
RA progresses in four stages (cont'd)RA progresses in four stages (cont'd) Stage 3: Stage 3: SevereSevere
• X-ray evidence of cartilage and bone destruction in X-ray evidence of cartilage and bone destruction in addition to osteoporosis; joint deformity; extensive addition to osteoporosis; joint deformity; extensive muscle atrophy; possible presence of extra-muscle atrophy; possible presence of extra-articular soft tissue lesionsarticular soft tissue lesions
Stage 4: Stage 4: TerminalTerminal• Fibrous or bony ankylosis, stage III criteria Fibrous or bony ankylosis, stage III criteria
Clinical ManifestationsClinical ManifestationsOnsetOnset
Onset is typically insidiousOnset is typically insidious Nonspecific manifestations may precede Nonspecific manifestations may precede
onset of arthritic complaintsonset of arthritic complaints
Some report a history of precipitating Some report a history of precipitating eventsevents
Clinical ManifestationsClinical Manifestations JointsJoints
Specific articular Specific articular involvementinvolvement
Symptoms occur Symptoms occur symmetricallysymmetrically
Frequently affect small Frequently affect small joints of hands and feetjoints of hands and feet
Larger peripheral joints Larger peripheral joints may also be involvedmay also be involved
Typical Deformities of Typical Deformities of Rheumatoid Arthritis Rheumatoid Arthritis
Fig. 65-4Fig. 65-4
Clinical ManifestationsClinical Manifestations JointsJoints
Patient experiences joint stiffness after Patient experiences joint stiffness after periods of __________periods of __________
Morning stiffness may last from 60 Morning stiffness may last from 60 minutes to several hours or moreminutes to several hours or more
MCP and PIP joints typically swollenMCP and PIP joints typically swollen Fingers may become spindle shaped from Fingers may become spindle shaped from
synovial hypertrophy and thickening of synovial hypertrophy and thickening of joint capsule joint capsule
Clinical ManifestationsClinical Manifestations JointsJoints
Joints become tender, painful, and warmJoints become tender, painful, and warm Joint painJoint pain
Increases with ______Increases with ______ Varies in intensityVaries in intensity May not be proportional to degree of May not be proportional to degree of
inflammationinflammation Tenosynovitis frequently affects extensor and Tenosynovitis frequently affects extensor and
flexor tendons near wrists flexor tendons near wrists RA progressesRA progresses
Extraarticular Manifestations of Extraarticular Manifestations of Rheumatoid ArthritisRheumatoid Arthritis
Fig. 65-5Fig. 65-5
Clinical ManifestationsClinical Manifestations Extraarticular ManifestationsExtraarticular Manifestations
Three most commonThree most common
Rheumatoid nodules develop in up to 25% Rheumatoid nodules develop in up to 25% of all patients with RAof all patients with RA
Those affected usually have high RF titersThose affected usually have high RF titers
Clinical ManifestationsClinical Manifestations Extraarticular ManifestationsExtraarticular Manifestations
SjSjöögren’s syndrome gren’s syndrome Seen in 10% to 15% of patients with RASeen in 10% to 15% of patients with RA Can occur as a disease by itself or in Can occur as a disease by itself or in
conjunction with other arthritic disorders conjunction with other arthritic disorders • RA and systemic lupus erythematosus (SLE)RA and systemic lupus erythematosus (SLE)
Complaints of burning, gritty, itchy eyesComplaints of burning, gritty, itchy eyes Decreased tearing, photosensitivity Decreased tearing, photosensitivity
Clinical ManifestationsClinical Manifestations Extraarticular ManifestationsExtraarticular Manifestations
Felty’s syndromeFelty’s syndrome Most commonly in patients with severe, Most commonly in patients with severe,
nodule-forming RA nodule-forming RA Characterized by Characterized by
• Inflammatory eye disorderInflammatory eye disorder• SplenomegalySplenomegaly• Lymphadenopathy Lymphadenopathy • Pulmonary diseasePulmonary disease• Blood dyscrasias Blood dyscrasias
ComplicationsComplications
Joint destruction begins as early as first Joint destruction begins as early as first year of disease without treatmentyear of disease without treatment
Flexion contractures and hand deformities Flexion contractures and hand deformities Cause diminished grasp strengthCause diminished grasp strength Affect patient’s ability to perform Affect patient’s ability to perform
self-care tasksself-care tasks Cataract development and loss of vision Cataract development and loss of vision
can result from scleral nodulescan result from scleral nodules
ComplicationsComplications
Rheumatoid nodules Rheumatoid nodules On the skin can ulcerate, similar to On the skin can ulcerate, similar to
pressure ulcers pressure ulcers On vocal cords leads to progressive On vocal cords leads to progressive
hoarseness hoarseness In vertebral bodies can cause bone In vertebral bodies can cause bone
destructiondestruction
ComplicationsComplications
Cardiopulmonary effects may occur later Cardiopulmonary effects may occur later in RAin RA Pleurisy, pleural effusion, pericarditis, Pleurisy, pleural effusion, pericarditis,
pericardial effusion, cardiomyopathypericardial effusion, cardiomyopathy Carpal tunnel syndrome can result from Carpal tunnel syndrome can result from
swelling of synovial membraneswelling of synovial membrane
Diagnostic StudiesDiagnostic Studies RA is defined as having at least 4 of the RA is defined as having at least 4 of the
following seven criteria. following seven criteria. Following must be Following must be present for at least 6 wks:present for at least 6 wks:
1.1. Morning stiffness that lasts ≥1 hourMorning stiffness that lasts ≥1 hour2.2. Swelling in three or more jointsSwelling in three or more joints3.3. Swelling in hand jointsSwelling in hand joints4.4. Symmetrical joint swellingSymmetrical joint swelling5.5. Erosions or decalcification seen on hand Erosions or decalcification seen on hand
x-rays x-rays 6.6. Rheumatoid nodulesRheumatoid nodules7.7. Presence of serum RFPresence of serum RF
Diagnostic TestingDiagnostic Testing History & PE Blood Studies
Rheumatoid factor (RF) Erythrocyte sedimentation rate (ESR) C-reactive protein (CRP) Antinuclear antibodies (ANA) titers are seen in some
Synovial fluid analysis Straw-colored fluid with fibrin flecks WBC is elevated to >25,000/μl
X-rays Will not confirm diagnosis – only show bone changes
Collaborative CareCollaborative Care
Care begins with a comprehensive Care begins with a comprehensive program of education and drug therapyprogram of education and drug therapy Education of drug therapyEducation of drug therapy
Patient and family educated about disease Patient and family educated about disease process and home management strategies process and home management strategies
Involve PT and OTInvolve PT and OT
Drug TherapyDrug Therapy
Drugs remain cornerstone of treatment Drugs remain cornerstone of treatment DMARDs can lessen permanent effects of DMARDs can lessen permanent effects of
RA RA Choice of drug is based on patient’s Choice of drug is based on patient’s
disease activitydisease activity level of functionlevel of function lifestyle considerations: e.g; choices for a lifestyle considerations: e.g; choices for a
woman of childbearing age? woman of childbearing age?
Treatment and Nursing Care for Treatment and Nursing Care for Rheumatoid ArthritisRheumatoid Arthritis
See Table 65-3 for meds used for arthritis p. See Table 65-3 for meds used for arthritis p. 1698-1700. 1698-1700. SalicylatesSalicylates NSAIDsNSAIDs AntibioticsAntibiotics Topical analgesicsTopical analgesics CorticosteroidsCorticosteroids DMARDsDMARDs Gold compoundsGold compounds AntimalarialsAntimalarials ImmunosupressantsImmunosupressants Biologic/Targeted therapyBiologic/Targeted therapy
Drug TherapyDrug TherapyDMARDDMARD
Methotrexate (Rheumatrex) is drug of Methotrexate (Rheumatrex) is drug of choicechoice Rapid antiinflammatory effect Rapid antiinflammatory effect decreases decreases
clinical symptoms in days to weeksclinical symptoms in days to weeks InexpensiveInexpensive Lower toxicity compared to other drugsLower toxicity compared to other drugs Side effects: bone marrow suppression, Side effects: bone marrow suppression,
hepatotoxicityhepatotoxicity
Drug TherapyDrug TherapyDMARDDMARD
Other DMARDs for mild to moderate Other DMARDs for mild to moderate diseasedisease Sulfasalazine (Azulfidine)Sulfasalazine (Azulfidine) Antimalarial drug hydroxychloroquineAntimalarial drug hydroxychloroquine
Leflunomide (Arava) - Leflunomide (Arava) - a newer synthetica newer synthetic: : DMARD that blocks immune cell overproduction DMARD that blocks immune cell overproduction
Drug TherapyDrug Therapy
Biologic/targeted drug therapies can also Biologic/targeted drug therapies can also slow disease progression in RAslow disease progression in RA
Can be used in patients with moderate to Can be used in patients with moderate to severe disease who have not responded severe disease who have not responded to DMARDs or in combination therapy with to DMARDs or in combination therapy with an established DMARDan established DMARD
Drug TherapyDrug Therapy
Corticosteroid therapy can aid in symptom Corticosteroid therapy can aid in symptom controlcontrol Intraarticular injections may relieve pain and Intraarticular injections may relieve pain and
inflammation associated with flare-upsinflammation associated with flare-ups• Long-term use should not be a mainstayLong-term use should not be a mainstay
Risk osteoporosis, avascular necrosis Risk osteoporosis, avascular necrosis Low-dose prednisone for a limited time to Low-dose prednisone for a limited time to
decrease disease activity until DMARD effect is decrease disease activity until DMARD effect is seenseen
Drug TherapyDrug Therapy Various NSAIDs and salicylates are used to Various NSAIDs and salicylates are used to
treat pain and inflammationtreat pain and inflammation Aspirin is often used in high dosages of 4 to Aspirin is often used in high dosages of 4 to
6 g/day (10 to 18 tablets) 6 g/day (10 to 18 tablets) NSAIDs have antiinflammatory, analgesic, NSAIDs have antiinflammatory, analgesic,
and antipyretic properties; fand antipyretic properties; full effectiveness ull effectiveness may take 2 to 3 weeksmay take 2 to 3 weeks
NSAIDS may be used when patient cannot NSAIDS may be used when patient cannot tolerate high doses of aspirin tolerate high doses of aspirin
Combination Drug TherapyCombination Drug Therapy
Use of two more drugs simultaneouslyUse of two more drugs simultaneously Can slow symptoms and joint damage Can slow symptoms and joint damage
while improving functionwhile improving function Often include a DMARD, an NSAID, and a Often include a DMARD, an NSAID, and a
corticosteroid corticosteroid
Relieve PainRelieve Pain NSAIDsNSAIDs
DMARDsDMARDs
Non-PharmacologicalNon-Pharmacological Heat or Cold applications Heat or Cold applications RestRest Relaxation techniquesRelaxation techniques
Nursing ImplementationNursing ImplementationAcute InterventionAcute Intervention
Usually treated on an outpatient basisUsually treated on an outpatient basis Hospitalization may be necessary for Hospitalization may be necessary for
patients with extraarticular complications patients with extraarticular complications or advancing disease or advancing disease Reconstructive surgery for disabling Reconstructive surgery for disabling
deformities deformities Nursing intervention begins with a careful Nursing intervention begins with a careful
physical assessment physical assessment
Nursing ManagementNursing ManagementAssessmentAssessment
Nurse must alsoNurse must also Evaluate psychosocial needs and Evaluate psychosocial needs and
environmental concernsenvironmental concerns After problem identification, coordinate a After problem identification, coordinate a
carefully planned program for rehabilitation carefully planned program for rehabilitation and education for interdisciplinary health care and education for interdisciplinary health care teamteam
Nursing ManagementNursing ManagementProblemsProblems
Chronic painChronic pain Impaired physical mobility Impaired physical mobility Activity intoleranceActivity intolerance Self-care deficit Self-care deficit Ineffective therapeutic regimen Ineffective therapeutic regimen
managementmanagement Disturbed body imageDisturbed body image
Nursing ManagementNursing ManagementPlanningPlanning
Overall goalsOverall goals Satisfactory pain reliefSatisfactory pain relief Minimal loss of functional ability of affected Minimal loss of functional ability of affected
jointsjoints Perform self-carePerform self-care Participate in planning and carrying out Participate in planning and carrying out
therapeutic regimentherapeutic regimen Maintain a positive self-imageMaintain a positive self-image
Nursing ManagementNursing ManagementInterventionsInterventions
Discuss drug actions, side effects, need Discuss drug actions, side effects, need for timely administrations to sustain drug for timely administrations to sustain drug levels and lab monitoringlevels and lab monitoring
Many patients take several different drugs Many patients take several different drugs so the nurse must make the drug regimen so the nurse must make the drug regimen as understandable as possibleas understandable as possible
Nursing ManagementNursing ManagementInterventionsInterventions
Nonpharmacologic relief of painNonpharmacologic relief of pain Therapeutic heat and coldTherapeutic heat and cold RestRest Relaxation techniquesRelaxation techniques Joint protectionJoint protection BiofeedbackBiofeedback Transcutaneous electrical stimulation Transcutaneous electrical stimulation HypnosisHypnosis
Nursing ManagementNursing ManagementInterventionsInterventions
Lightweight splints may be prescribed to Lightweight splints may be prescribed to rest an inflamed joint & prevent deformityrest an inflamed joint & prevent deformity Should be removed regularly to perform skin Should be removed regularly to perform skin
care and ROM exercises and reapplied as care and ROM exercises and reapplied as prescribed prescribed
OT may help identify additional self-help OT may help identify additional self-help devices to assist in activities of daily livingdevices to assist in activities of daily living
AM care and procedures should be AM care and procedures should be planned around morning stiffnessplanned around morning stiffness
Nursing Management Nursing Management InterventionsInterventions
Morning care and procedures should be Morning care and procedures should be planned around patient’s morning stiffnessplanned around patient’s morning stiffness
Assist with activities to help relieve joint Assist with activities to help relieve joint stiffness: warm shower, warm towels stiffness: warm shower, warm towels around shoulder, etc.around shoulder, etc.
Gentle skin care if bedridden Gentle skin care if bedridden
Ambulatory and Home CareAmbulatory and Home CareRestRest
Alternate scheduled rest periods with Alternate scheduled rest periods with activity throughout dayactivity throughout day Helps relieve pain and fatigueHelps relieve pain and fatigue Amount of rest varies Amount of rest varies
Total bed rest Total bed rest Rarely necessary Rarely necessary Should be avoided to prevent stiffness and Should be avoided to prevent stiffness and
immobilityimmobility
Ambulatory and Home CareAmbulatory and Home CareRestRest
Good body alignment while resting can be Good body alignment while resting can be maintained through use of a firm mattress maintained through use of a firm mattress or bed boardor bed board
Encourage positions of extension Encourage positions of extension Avoid flexion positionsAvoid flexion positions
Splints and casts can help maintain proper Splints and casts can help maintain proper alignment and promote rest alignment and promote rest
Ambulatory and Home CareAmbulatory and Home CareHeat and Cold TherapyHeat and Cold Therapy
Help relieve pain, stiffness, and muscle Help relieve pain, stiffness, and muscle spasmspasm
IceIce
Superficial heat sourcesSuperficial heat sources
Moist heatMoist heat
Ambulatory and Home CareAmbulatory and Home CareExerciseExercise
Inadequate joint movement can result in Inadequate joint movement can result in progressive joint immobility and muscle progressive joint immobility and muscle weaknessweakness
Overaggressive exercise can result in Overaggressive exercise can result in increased pain, inflammation, and joint increased pain, inflammation, and joint damagedamage
Gentle ROM exercises are usually done Gentle ROM exercises are usually done daily to keep joints functionaldaily to keep joints functional
Ambulatory and Home CareAmbulatory and Home CarePsychologic SupportPsychologic Support
Patient’s value system and perception of Patient’s value system and perception of disease must be considereddisease must be considered
Patient is constantly challenged by Patient is constantly challenged by problems of problems of Limited function and fatigueLimited function and fatigue Loss of self-esteemLoss of self-esteem Altered body imageAltered body image Fear of disability or deformityFear of disability or deformity
GoutGout
GoutGout Deposits of sodium urate crystals in Deposits of sodium urate crystals in
articular, periarticular, and subcutaneous articular, periarticular, and subcutaneous tissuestissues
May be primary or May be primary or secondarysecondary Primary – hereditary error Primary – hereditary error of purine metabolismof purine metabolism Secondary – drugs that inhibit uric acid Secondary – drugs that inhibit uric acid
excretion or increase rate of cell death or excretion or increase rate of cell death or another acquired disorderanother acquired disorder
Incidence and Risk FactorsIncidence and Risk Factors
Primary gout accounts for 90% of casesPrimary gout accounts for 90% of cases
Affects primarily middle aged menAffects primarily middle aged men
Risk factors: obesity, HTN, thiazide Risk factors: obesity, HTN, thiazide diuretics, excess alcohol usediuretics, excess alcohol use
PathophysiologyPathophysiology
Uric acid is end product of purine Uric acid is end product of purine metabolism and is excreted by the kidneysmetabolism and is excreted by the kidneys
Causes of hyperuricemiaCauses of hyperuricemia
Diet high in purines will not cause gout, Diet high in purines will not cause gout, but may trigger an attack in a susceptible but may trigger an attack in a susceptible personperson
Clinical ManifestationsClinical Manifestations
Gouty arthritis in one or more joints (but Gouty arthritis in one or more joints (but less than four)less than four)
Great toe joint most common first Great toe joint most common first manifestation; other joints may be the foot, manifestation; other joints may be the foot, ankle, knee, or wristankle, knee, or wrist
Joints are tender & cyanoticJoints are tender & cyanotic May be precipitated by trauma, surgery, May be precipitated by trauma, surgery,
alcohol ingestion, or infectionalcohol ingestion, or infection
Clinical ManifestationsClinical Manifestations
Onset usually nocturnal, with sudden Onset usually nocturnal, with sudden swelling and excruciating painswelling and excruciating pain
May have low grade feverMay have low grade fever Usually subsides within 2-10 daysUsually subsides within 2-10 days Joints are normal, with no symptoms Joints are normal, with no symptoms
between attacksbetween attacks
ComplicationsComplications
Joint deformityJoint deformity
OsteoarthritisOsteoarthritis
Tophi may produce draining sinuses that may become Tophi may produce draining sinuses that may become infectedinfected
Renal stones, pyelonephritis, obstructive renal diseaseRenal stones, pyelonephritis, obstructive renal disease
DiagnosisDiagnosis
History & physical examinationHistory & physical examination Clinical symptoms alone are sufficient Clinical symptoms alone are sufficient
to to make accurate DX in most cases make accurate DX in most cases
Family history of goutFamily history of gout
Diagnostic studiesDiagnostic studies
Diagnostic StudiesDiagnostic Studies Serum uric acid levelsSerum uric acid levels
May be caused by other factorsMay be caused by other factors WBC elevated during acute attackWBC elevated during acute attack ESR ESR 24 hour urine uric acid levels 24 hour urine uric acid levels Synovial fluid aspiration contains uric acid crystalsSynovial fluid aspiration contains uric acid crystals
Seldom necessarySeldom necessary X-rays appear normal in early stages; tophi appear X-rays appear normal in early stages; tophi appear
as eroded areas of boneas eroded areas of bone
Collaborative CareCollaborative Care
Acute attackAcute attack Colchicine produces dramatic antiiflammatory Colchicine produces dramatic antiiflammatory
effects with relief within 24-48 hourseffects with relief within 24-48 hours NSAIDs for additional pain reliefNSAIDs for additional pain relief Corticosteroids (po or intraarticular)Corticosteroids (po or intraarticular) Adrenocorticotropic hormone (ACTH)Adrenocorticotropic hormone (ACTH) Joint aspiration to decompressJoint aspiration to decompress
Collaborative CareCollaborative Care
Prevention of acute attacksPrevention of acute attacks Colchicine combined with: Colchicine combined with:
• allopurinol (Zyloprim, Alloprim) – blocks production allopurinol (Zyloprim, Alloprim) – blocks production of uric acid of uric acid
• probenecid (Benemid), sulfinpyrazone (Anturane) probenecid (Benemid), sulfinpyrazone (Anturane) – inhibit tubular reabsorption of uric acid– inhibit tubular reabsorption of uric acid
• febuxostat (Uloric) – inhibits xanthine oxidase, febuxostat (Uloric) – inhibits xanthine oxidase, recently shown to reduce serum uric acid levelsrecently shown to reduce serum uric acid levels
Collaborative CareCollaborative Care Uricosuric Agents
Probenecid (Benemid)Probenecid (Benemid)PrecautionsPrecautions
Sulfinprazone (anturan) block resorption uric acidSulfinprazone (anturan) block resorption uric acid High fluid intake, alkaline urineHigh fluid intake, alkaline urine Not effective if creatinine clearance is elevatedNot effective if creatinine clearance is elevated
Cozaar Angiotension II receptor angonistAngiotension II receptor angonist
• MonitoringMonitoring
Force Fluids while on these medications!!Force Fluids while on these medications!!
Collaborative CareCollaborative Care
Dietary measuresDietary measures Weight reductionWeight reduction Avoidance of alcoholAvoidance of alcohol Avoidance of foods high in purinesAvoidance of foods high in purines
• High: Sardines, anchovies, herring, mussels, liver, High: Sardines, anchovies, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads, kidney, goose, venison, meat soups, sweetbreads, beer & winebeer & wine
• Moderate: Chicken, salmon, crab, veal, mutton, Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, hambacon, pork, beef, ham
Treatment and Nursing CareTreatment and Nursing Care Bedrest and position for comfortBedrest and position for comfort
Joint immobilization and protect joint from pressureJoint immobilization and protect joint from pressure
Local application of heat or coldLocal application of heat or cold
Assess for complications Assess for complications Formation of kidney stonesFormation of kidney stones HypertriglyceridemiaHypertriglyceridemia HypertensionHypertension
Collaborative CareCollaborative Care
Prevention of renal stonesPrevention of renal stones Increase fluid intake to maintain adequate Increase fluid intake to maintain adequate
urine outputurine output AllopurinolAllopurinol ACE inhibitor losartin (Cozaar) – promotes ACE inhibitor losartin (Cozaar) – promotes
urate diuresisurate diuresis
Nursing CareNursing Care
Acute gouty arthritis – pain controlAcute gouty arthritis – pain control Gentle, supportive care of affected jointsGentle, supportive care of affected joints Immobilize and rest affected joints – bed rest Immobilize and rest affected joints – bed rest
or NWBor NWB Cradle or footboard to prevent pressure from Cradle or footboard to prevent pressure from
bedcoversbedcovers Monitor ROM and degree of painMonitor ROM and degree of pain
Nursing CareNursing Care Patient/Family teachingPatient/Family teaching
Gout is a chronic diseaseGout is a chronic disease
Drug teachingDrug teaching
Need to monitor serum uric acid levelsNeed to monitor serum uric acid levels
Precipitating factorsPrecipitating factors
Systemic Lupus Systemic Lupus Erythematosus (SLE)Erythematosus (SLE)Chronic multisystem disease involving Chronic multisystem disease involving
vascular and connective tissuevascular and connective tissue
IncidenceIncidence SLE affects 2 to 8 persons per 100,000 in SLE affects 2 to 8 persons per 100,000 in
United StatesUnited States Most cases occur in women of Most cases occur in women of
childbearing yearschildbearing years African, Asian, Hispanic, and Native African, Asian, Hispanic, and Native
Americans three times more likely to Americans three times more likely to develop than Whitesdevelop than Whites
EtiologyEtiology
Etiology is unknownEtiology is unknown Most probable causesMost probable causes
Genetic influenceGenetic influence HormonesHormones Environmental factorsEnvironmental factors Certain medicationsCertain medications
SLESLEPathophysiologyPathophysiology
Chronic multisystem inflammatory diseaseChronic multisystem inflammatory disease Associated with abnormalities of immune Associated with abnormalities of immune
systemsystem Results from interactions among genetic, Results from interactions among genetic,
hormonal, environmental, and immunologic hormonal, environmental, and immunologic factors factors
Because the antibodies and accompanying Because the antibodies and accompanying cells of inflammation can affect tissues cells of inflammation can affect tissues anywhere in the body, lupus can affect a anywhere in the body, lupus can affect a variety of areasvariety of areas
Systemic Lupus ErythematosusSystemic Lupus Erythematosus
A variable diseaseA variable disease ChronicChronic UnpredictableUnpredictable Characterized by exacerbations & remissionsCharacterized by exacerbations & remissions
Clinical ManifestationsClinical Manifestations
Ranges from a relatively mild disorder to Ranges from a relatively mild disorder to rapidly progressing, affecting many body rapidly progressing, affecting many body systemssystems
Most commonly affects the skin/muscles, Most commonly affects the skin/muscles, lining of lungs, heart, nervous tissue, and lining of lungs, heart, nervous tissue, and kidneyskidneys
Systematic Lupus Systematic Lupus ErythematosusErythematosus
Affects theAffects the SkinSkin JointsJoints Serous membranes Serous membranes Renal systemRenal system Hematologic Hematologic
systemsystem Neurologic systemNeurologic system
Clinical ManifestationsClinical Manifestations
Dermatologic Dermatologic Cutaneous vascular lesionsCutaneous vascular lesions Butterfly rashButterfly rash Oral/nasopharyngeal ulcersOral/nasopharyngeal ulcers AlopeciaAlopecia
Clinical ManifestationsClinical Manifestations
MusculoskeletalMusculoskeletal Polyarthralgia with morning stiffnessPolyarthralgia with morning stiffness ArthritisArthritis
• Swan neck fingersSwan neck fingers• Ulnar deviationUlnar deviation• Subluxation with hyperlaxity of jointsSubluxation with hyperlaxity of joints
Clinical ManifestationsClinical Manifestations
CardiopulmonaryCardiopulmonary TachypneaTachypnea PleurisyPleurisy DysrhythmiasDysrhythmias Accelerated CADAccelerated CAD PericarditisPericarditis
Clinical ManifestationsClinical Manifestations
RenalRenal Lupus nephritisLupus nephritis
• Ranging from mild proteinuria to Ranging from mild proteinuria to glomerulonephritisglomerulonephritis
• Primary goal in treatment is slowing the Primary goal in treatment is slowing the progressionprogression
Clinical ManifestationsClinical Manifestations
Nervous systemNervous system Generalized/focal seizuresGeneralized/focal seizures Peripheral neuropathyPeripheral neuropathy Cognitive dysfunctionCognitive dysfunction
• DisorientationDisorientation• Memory deficitsMemory deficits• Psychiatric symptomsPsychiatric symptoms
Clinical ManifestationsClinical Manifestations
HematologicHematologic Formation of antibodies against blood cellsFormation of antibodies against blood cells AnemiaAnemia LeukopeniaLeukopenia ThrombocytopeniaThrombocytopenia CoagulopathyCoagulopathy Anti-phospholipid antibody syndromeAnti-phospholipid antibody syndrome
Clinical ManifestationsClinical Manifestations
InfectionInfection SSusceptibility to infectionsusceptibility to infections Fever should be considered seriousFever should be considered serious Infections such as pneumonia are a common Infections such as pneumonia are a common
cause of deathcause of death
Diagnostic StudiesDiagnostic Studies No specific testNo specific test SLE is diagnosed primarily on criteria relating to SLE is diagnosed primarily on criteria relating to
patient history, physical examination, and patient history, physical examination, and laboratory findingslaboratory findings
DiagnosisDiagnosisThese tests are not diagnostic for SLE, but These tests are not diagnostic for SLE, but
help in the diagnosis help in the diagnosis Autoantibody Testing:Autoantibody Testing:
Anti-DNA- specificAnti-DNA- specific Anti- Smith antibody (Anti-Sm) Anti- Smith antibody (Anti-Sm) These 2 tests ar emost specific to SLEThese 2 tests ar emost specific to SLE Anti nuclear antibody (ANA) – establishes Anti nuclear antibody (ANA) – establishes
presence of autoimmune diseasepresence of autoimmune disease
DiagnosisDiagnosis
Inflammatory Activity:Inflammatory Activity: * ESR * ESR * C-reactive protein * C-reactive protein These tests are helpful in monitoring the These tests are helpful in monitoring the
disease activity.disease activity.
Diagnostic TestsDiagnostic Tests
CBCCBC UAUA X-raysX-rays Chest x-rayChest x-ray ECGECG
Collaborative CareCollaborative Care
Prognosis is improved withPrognosis is improved with
Earlier diagnosisEarlier diagnosis Earlier and better treatment regimensEarlier and better treatment regimens Careful monitoring for organ Careful monitoring for organ
involvementinvolvement
Collaborative CareCollaborative Care
Drug therapyDrug therapy NSAIDs - for mild diseaseNSAIDs - for mild disease Antimalarial drugs – for fatigue/skin/joint Antimalarial drugs – for fatigue/skin/joint
problemsproblems Steroid-sparing drugs - Exs: MethotrexateSteroid-sparing drugs - Exs: Methotrexate Corticosteroidsdoes - for exacerbations and Corticosteroidsdoes - for exacerbations and
severe diseasesevere disease Immunosuppressive drugs – Exs: Cytoxan, Immunosuppressive drugs – Exs: Cytoxan,
Imuran; to reduce long term corticosteroid useImuran; to reduce long term corticosteroid use
Nursing ManagementNursing ManagementNursing AssessmentNursing Assessment
Assess patient’s physical, psychologic, Assess patient’s physical, psychologic, and sociocultural problems with long-term and sociocultural problems with long-term management of SLEmanagement of SLE
Assess pain and fatigue dailyAssess pain and fatigue daily Obtain subjective and objective dataObtain subjective and objective data Educate and counsel on expected issuesEducate and counsel on expected issues
Nursing ManagementNursing ManagementNursing DiagnosesNursing Diagnoses
FatigueFatigue Acute painAcute pain Impaired skin integrityImpaired skin integrity Ineffective therapeutic regimen Ineffective therapeutic regimen
managementmanagement Body image disturbance Body image disturbance
Nursing ManagementNursing ManagementNursing ImplementationNursing Implementation
Health promotionHealth promotion Promote early diagnosis and treatmentPromote early diagnosis and treatment
Relieve pain and discomfort and fatigueRelieve pain and discomfort and fatigue Application of heat and coldApplication of heat and cold Encourage to alternate rest and activityEncourage to alternate rest and activity Support devices – braces, splints, firm mattressSupport devices – braces, splints, firm mattress Analgesics and anti-inflammatory medicationsAnalgesics and anti-inflammatory medications
Nursing CareNursing Care
Maintain Skin IntegrityMaintain Skin Integrity Apply topical antiinflammatoryApply topical antiinflammatory Avoid direct sunlightAvoid direct sunlight
Increase MobilityIncrease Mobility ROMROM Assistive devices Assistive devices
Nursing ManagementNursing ManagementNursing ImplementationNursing Implementation
Acute interventionAcute intervention During exacerbation, patient will become During exacerbation, patient will become
abruptly, dramatically illabruptly, dramatically ill Record severity of symptoms and response to Record severity of symptoms and response to
therapy therapy Observe forObserve for
• Fever patternFever pattern• Joint inflammationJoint inflammation• Limitation of motionLimitation of motion• Location and degree of discomfortLocation and degree of discomfort• Fatigability Fatigability
Nursing ManagementNursing ManagementNursing ImplementationNursing Implementation
Acute intervention (cont’d)Acute intervention (cont’d) Monitor weight and I & O Monitor weight and I & O Collect 24-hour urine sample for protein and Collect 24-hour urine sample for protein and
creatinine clearance creatinine clearance Assess neurological statusAssess neurological status Explain nature of diseaseExplain nature of disease Provide supportProvide support
Nursing ManagementNursing ManagementNursing ImplementationNursing Implementation
Ambulatory and home careAmbulatory and home care Reiterate that adherence to treatment does not Reiterate that adherence to treatment does not
necessarily halt progressionnecessarily halt progression Minimize exposure to precipitating factors – Minimize exposure to precipitating factors – fatigue, sun, stress, infectionfatigue, sun, stress, infection Teach energy conservation and relaxation Teach energy conservation and relaxation
exercisesexercises For joint problems, all the teaching for RA related For joint problems, all the teaching for RA related
to joint protection, ROM, and positioning to to joint protection, ROM, and positioning to prevent contracturesprevent contractures
Treatment and Nursing CareTreatment and Nursing Care
Facilitate self careFacilitate self care Provide adaptive equipment for eating, bathing, Provide adaptive equipment for eating, bathing,
toileting, dressingtoileting, dressing Allow patient extra time to complete careAllow patient extra time to complete care
Improve body imageImprove body image Encourage patient to verbalize feelings, perceptions, Encourage patient to verbalize feelings, perceptions,
and fearsand fears Monitor for complicationsMonitor for complications
Assess for serious adverse effects of medications Assess for serious adverse effects of medications used in treatmentused in treatment
Nursing ManagementNursing ManagementNursing ImplementationNursing Implementation
Lupus and pregnancyLupus and pregnancy InfertilityInfertility
SLE is associated with complications of SLE is associated with complications of pregnancypregnancy
Pregnancy & post partumPregnancy & post partum
Women with serious SLEWomen with serious SLE
Nursing ManagementNursing ManagementNursing ImplementationNursing Implementation
Psychosocial issuesPsychosocial issues Counsel patient and family that SLE has good Counsel patient and family that SLE has good
prognosisprognosis Physical effects can lead to isolation, self-Physical effects can lead to isolation, self-
esteem, and body image disturbancesesteem, and body image disturbances Assist patient in developing goalsAssist patient in developing goals
Nursing ManagementNursing ManagementEvaluationEvaluation
Expected outcomesExpected outcomes Completion of priority activitiesCompletion of priority activities Verbalization of having more energyVerbalization of having more energy Expression of satisfaction with pain relief measuresExpression of satisfaction with pain relief measures Performance of activities of daily living without painPerformance of activities of daily living without pain Limitation of direct exposure to sunLimitation of direct exposure to sun No open skin lesionsNo open skin lesions Expression of satisfaction with activity levelExpression of satisfaction with activity level Pacing of activities to match level of tolerancePacing of activities to match level of tolerance Expression of confidence in ability to manage SLE over Expression of confidence in ability to manage SLE over
time and in home environmenttime and in home environment