Transcript Chapter 54 Assessment and Management of Patients With

Chapter 54
Assessment and Management
of Patients With Rheumatic
Disorders
Rheumatic Diseases
Arthritis”
 More than 100 different disorders
 Affect primary the joints, but also muscles,
bone, ligament, tendons, cartilage
 Classification
 Monoarticular or polyarticular
 Inflammatory or noninflammatory
 “
Characteristic Degenerative Changes—
“Degradation”
Joint space narrowing and osteophytes (bone spurs) are characteristic of
degenerative changes in joints.
Factors associated with degenerative
joint changes
 Mechanical Stress (The articular plate (subchondral bone)
thins, and its ability to absorb shock decreases)
 Altered Lubrication
 Immobility
Clinical Manifestations
 Pain
 Weakness
 Joint swelling
 Fatigue
 Limited movement
 Warmth,
 Stiffness
 Erythema
 Joint involvement begins in the small joints of the hands,
wrists, and feet. As the disease progresses, the knees,
shoulders, hips, elbows, ankles, and cervical spine joints
are affected.
 The onset of symptoms is usually acute. Symptoms are
usually bilateral and symmetric. In addition to joint pain
and swelling, another classic sign of RA is joint stiffness,
especially in the morning, lasting at least 30 to 45
minutes
Pathophysiology and Associated Physical
Signs of Rheumatoid Arthritis
Patient Assessment and Diagnostic
Findings
 Health history: include onset of and evolution of
symptoms, family history, past health history, and
contributing factors
 Functional assessment
 Arthrocentesis (to take fluid for sampling and to
relieve pain caused by pressure of increased fluid
volume. After procedure, observe the patient for
signs of infection and hemarthrosis)
 X-rays, bone scans, CTs, and MRIs
 Tissue biopsy
 Blood studies
Treatment
Nursing Process: The Care of the Patient
with a Rheumatic Disease—Assessment
 Health history and physical assessment focus on current and
past symptoms, and also include the patient's psychological
and mental status, social support systems, ability to
participate in daily activities, comply with treatment
regimen, and manage self-care
Nursing Process: The Care of the Patient
with a Rheumatic Disease—Diagnoses
 Acute and chronic pain
 Fatigue
 Disturbed sleep pattern
 Impaired physical mobility
 Self-care deficits
 Disturbed body image
 Ineffective coping
Collaborative Problems/Potential
Complications
 Adverse effects of medications
Nursing Process: The Care of the Patient
with a Rheumatic Disease—Planning
 Major goals may include:
 Relief of pain and discomfort
 Relief of fatigue
 Promotion of restorative sleep
 Increased mobility
 Maintenance of self-care
 Improved body image
 Effective coping
 Absence of complications
Systemic Lupus Erythematosus
 More common in women than men
 An autoimmune disease. The immunoregulatory
disturbance is brought about by some
combination of genetic factors, hormonal factors
(as evidenced by the usual onset during the
childbearing years), environmental factors (eg,
sunlight, thermal burns), and some medications
(hydralazine (Apresoline), isoniazid (INH),
chlorpromazine, and some antiseizure
medications).
Clinical Manifestations
 The onset of SLE may be insidious or
acute. For this reason, SLE may remain
undiagnosed for many years.
 It can affect any body system
(musculoskeletal system, with arthralgias
and arthritis (synovitis), skin (butter fly
rash), Oral ulcers, Pericarditis, renal
involvement (increased creatinine) which
leads to hypertension, CNS (subtle
changes in behavior patterns or cognitive
ability)
Gout
 Is a heterogeneous group of conditions related to a genetic
defect of purine metabolism that results in hyperuricemia.
 Occur as a result of uversecretion of uric acid or a renal
defect to excrete uric acid, or a combination of both.
 Primary hyperuricemia may be caused by severe dieting or
starvation, excessive intake of foods that are high in purines
(shellfish, organ meats), or heredity.
 Secondary hyperuricemia is due to conditions in which there
is an increase in cell turnover (leukemia, some types of
anemias, psoriasis) and an increase in cell breakdown.
Pathophysiology
 With hyperuricemia, accumulations of sodium urate crystals,
called tophi, are deposited in peripheral areas of the body,
such as the great toe, the hands, and the ear.
 Renal urate lithiasis (kidney stones), with chronic renal
disease secondary to urate deposition, may develop.
Clinical Manifestations
 Acute gouty arthritis (recurrent attacks of severe articular
and periarticular inflammation), tophi (crystalline deposits
accumulating in articular tissue, osseous tissue, soft tissue,
and cartilage)
 The metatarsophalangeal joint of the big toe is the most
commonly affected joint (90%). The ankle or knee may also
be affected. Less commonly, the wrists, fingers, and elbows.
 Severe pain, redness, swelling, & warmth of the affected joint
 Gouty nephropathy (renal impairment), and uric acid urinary
calculi.
Medical Management
 Pharmacology
 Diet