Transcript Chapter 20
Lisa M. Dunn MSN/Ed, RN, CCRN, CNE Connective tissue disease (CTD) is a major focus of rheumatology. Rheumatic disease is any disease or condition involving the musculoskeletal system. Arthritis means inflammation of one or more joints. Noninflammatory arthritis (osteoarthritis) is not systemic. OA is not an autoimmune disease. Inflammatory arthritis: ◦ ◦ ◦ ◦ Rheumatoid arthritis Systemic lupus erythematosus Autoimmune disease Connective tissue disease that is inflammatory Most common type of arthritis Joint pain and loss of function characterized by progressive deterioration and loss of cartilage in the joints Osteophytes Synovitis Subluxation History Physical assessment and clinical manifestations: ◦ ◦ ◦ ◦ ◦ Joint involvement Heberden's nodes Bouchard’s nodes Joint effusions Atrophy of skeletal muscle Psychosocial Laboratory assessment of erythrocyte sedimentation rate and C-reactive protein (may be slightly elevated) Radiographic assessment Other diagnostic assessments: ◦ MR imaging ◦ CT studies Analgesics Rest Positioning Thermal modalities Weight control Integrative therapies Total joint arthroplasty (TJA) Total joint replacement (TJR) Arthroscopy Osteotomy Preoperative care Operative procedures Postoperative care: ◦ Prevention of dislocation, infection, and thromboembolic complications ◦ Assessment of bleeding ◦ Management of anemia Assessment for neurovascular compromise Management of pain Progression of activity Promotion of self-care Preoperative care Operative procedures Postoperative care: ◦ ◦ ◦ ◦ Continuous passive motion machine Hot/ice device Pain management Neurovascular assessment One of the most common connective tissue diseases and the most destructive to the joints Chronic, progressive, systemic inflammatory autoimmune disease affecting primarily the synovial joints Autoantibodies (rheumatoid factors) formed that attack healthy tissue, especially synovium, causing inflammation Affects synovial tissue of any organ or body system Assessment Physical assessment and clinical manifestations: ◦ Early disease manifestations—joint stiffness, swelling, pain, fatigue, and generalized weakness and morning stiffness ◦ Late disease manifestations—as the disease worsens, the joints become progressively inflamed and quite painful Weight loss, fever, and extreme fatigue Exacerbations Subcutaneous nodules Pulmonary complications Vasculitis Periungual lesions Paresthesias Cardiac complications Psychosocial assessment Laboratory assessment—rheumatoid factor, antinuclear antibody titer, erythrocyte sedimentation rate, serum complement, serum protein electrophoresis, serum immunoglobulins Other diagnostic assessments—x-ray, CT, arthrocentesis, bone scan Disease-modifying antirheumatic drugs NSAIDs Biologic response modifiers Other drugs: ◦ ◦ ◦ ◦ Glucocorticoids Immunosuppressive agents Gold therapy Analgesic drugs Adequate rest Proper positioning Ice and heat applications Plasmapheresis Gene therapy Complementary and alternative therapies Promotion of self-care Management of fatigue Enhancement of body image Community-based care: ◦ Home care management ◦ Health teaching ◦ Health care resources Chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Characterized by spontaneous remissions and exacerbations. Autoimmune process. Autoimmune complexes tend to be attracted to the glomeruli of the kidneys. Many patients with SLE have some degree of kidney involvement. Skin involvement Polyarthritis Osteonecrosis Muscle atrophy Fever and fatigue Renal involvement Pleural effusions Pericarditis Raynaud’s phenomenon Neurologic manifestation Serositis Psychosocial results can be devastating. Laboratory: ◦ Skin biopsy (only significant test to confirm diagnosis) ◦ Immunologic-based laboratory tests ◦ Complete blood count ◦ Body system function assessment Topical drugs Plaquenil Tylenol or NSAIDs Chronic steroid therapy Immunosuppressive agents Chronic, inflammatory, autoimmune connective tissue disease Not always progressive Hardening of the skin C—calcinosis R—Raynaud’s phenomenon E—esophageal dysmotility S—sclerodactyly T—telangiectasia Arthralgia GI tract Cardiovascular system Pulmonary system Renal system Drug therapy Identify early organ involvement Skin protective measures Comfort GI manifestation Mobility Also called gouty arthritis, a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation Primary gout Secondary gout—hyperuricemia Drug therapy Nutritional therapy Reportable systemic infectious disease caused by the spirochete Borrelia burgdorferi, resulting from the bite of an infected deer tick. Stages I and II. If not diagnosed and treated in early stages, chronic complications such as arthralgias, fatigue, and memory and thinking problems can result. For some patients, the first and only sign of Lyme disease is arthritis. Chronic pain syndrome, not an inflammatory disease Chronic illness in which patients have severe fatigue for 6 months or longer, usually following flu-like symptoms Sore throat; substantial impairment in shortterm memory or concentration; tender lymph nodes; muscle pain; multiple joint pain with redness or swelling; headaches of a new type, pattern, or severity; unrefreshing sleep; and postexertional malaise lasting more than 24 hours Care of Patients with Immune Function Excess: Hypersensitivity (Allergy) and Autoimmunity The chemical responsible for causing capillary leak, nasal and conjunctival mucus secretion, itching, and erythema during an allergic reaction is: A. B. C. D. Prostaglandin Histamine Leukotriene Immunoglobulin E (IgE) Increased or excessive response to the presence of an antigen to which the patient has been exposed Degree of reaction ranging from uncomfortable to life threatening Also called atopic allergy, this is the most common type of hypersensitivity. Some reactions occur just in the areas exposed to the antigen. Allergens can be contacted in these ways: ◦ Inhaled (plant pollens, fungal spores, animal dander, house dust, grass, ragweed) ◦ Ingested (foods, food additives, drugs) ◦ Injected (bee venom, drugs, biologic substances) ◦ Contacted (pollens, foods, environmental proteins) Other reactions may involve all blood vessels and bronchiolar smooth muscle, causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction, which is known as anaphylaxis History Laboratory assessment—increased eosinophils, immunoglobulin E (IgE), RAST Allergy testing Oral food challenges ◦ Patient preparation ◦ Procedure ◦ Follow-up care Avoidance therapy: ◦ Environmental changes: Air-conditioning and air-cleaning units Cloth drapes Upholstered furniture Carpeting ◦ Pet-induced allergies Decongestants Antihistamines Corticosteroids Mast cell stabilizers Leukotriene antagonists Complementary and alternative therapy Desensitization therapy First feelings of uneasiness, apprehension, weakness, and impending doom. Pruritus and urticaria. Erythema and sometimes angioedema of the eyes, lips, or tongue. Histamine causes capillary leak, bronchoconstriction, mucosal edema, and excess mucus secretion. Congestion, rhinorrhea, dyspnea, and increasing respiratory distress with audible wheezing result. Anaphylaxis can be fatal. First assess respiratory function; an airway must be established. CPR may be needed. Epinephrine (1:1000) 0.3 to 0.5 mL subcutaneous is given as soon as symptoms appear. Antihistamines treat angioedema and urticaria. Oxygen. Treat bronchospasm. IV fluids. The body makes special autoantibodies directed against self cells that have some form of foreign protein attached to them. Clinical examples include hemolytic anemias, thrombocytopenic purpura, hemolytic transfusion reactions, Goodpasture’s syndrome, and druginduced hemolytic anemia. Excess antigens cause immune complexes to form in the blood. These circulating complexes usually lodge in small blood vessels. Usual sites include the kidneys, skin, joints, and small blood vessels. Deposited complexes trigger inflammation, resulting in tissue or vessel damage. Rheumatoid arthritis, systemic lupus erythematosus, and serum sickness occur. In a type IV reaction, the reactive cell is the T-lymphocyte (T-cell). Antibodies and complement are not involved. Local collection of lymphocytes and macrophages causes edema, induration, ischemia, and tissue damage at the site. Other examples include positive purified protein derivative, contact dermatitis, poison ivy skin rashes, insect stings, tissue transplant rejection, and sarcoidosis. Excess stimulation of a normal cell surface receptor by an autoantibody, resulting in a continuous “turned-on” state for the cell. Graves’ disease. Autoimmunity is the process whereby a person develops an inappropriate immune response. Antibodies and/or lymphocytes are directed against healthy normal cells and tissues. For unknown reasons, the immune system fails to recognize certain body cells or tissues as self and triggers immune reactions. Group of problems that often appear with other autoimmune disorders Dry eyes, dry mucous membranes of the nose and mouth (xerostomia), and vaginal dryness Insufficient tears causing inflammation and ulceration of the cornea No cure; intensity and progression can be slowed by suppressing immune and inflammatory responses A 19-year-old man has been having trouble breathing for a week, along with occasional hemoptysis, decreased urine output, hypertension, and tachycardia. Further testing reveals that he has areas of consolidation over his lung fields (by chest x-ray) and glomerulonephritis with reduced kidney function. He is showing manifestations of which problem? A. B. C. D. Anaphylactic reaction to an unknown allergen Sjögren’s syndrome Graves’ disease Goodpasture’s syndrome Autoimmune disorder in which autoantibodies are made against the glomerular basement membrane and neutrophils Lungs and kidneys Shortness of breath, hemoptysis, decreased urine output, weight gain, edema, hypertension, and tachycardia Treatment—high-dose corticosteroids A patient with an elevated eosinophil count most likely has which condition? A. B. C. D. Seasonal allergic rhinitis Acute respiratory infection Goodpasture’s syndrome Sjögren’s syndrome