Transcript Chapter 34

Chapter 41
Connective Tissue
Disorders
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Learning Objectives
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Define connective tissue.
Describe the function of connective tissue.
Describe the characteristics and prevalence of connective tissue diseases.
Describe the diagnostic tests and procedures used for
assessing connective tissue diseases.
Discuss the drugs used to treat connective tissue diseases.
Describe the pathophysiology and treatment of osteoarthritis (degenerative
joint disease), rheumatoid arthritis, osteoporosis, gout, progressive systemic
sclerosis, polymyositis, bursitis, carpal tunnel syndrome, ankylosing
spondylitis, polymyalgia rheumatica, Reiter’s syndrome, Behçet’s syndrome,
and Sjögren’s syndrome.
Identify the data to be collected in the nursing assessment
of a patient with a connective tissue disorder.
Assist in developing a nursing care plan for a patient
whose life has been affected by a connective tissue disease.
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Anatomy and Physiology of
Connective Tissues
• Bind structures together, providing support for
individual organs and a framework for the body
• Store fat, transport substances, provide
protection, and play a role in repair of damaged
tissue
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Anatomy and Physiology of
Connective Tissues
• Types of connective tissue
• Loose (areolar, adipose, reticular)
• Dense (tendons, fascia, dermis, gastrointestinal
tract submucosa, fibrous joint capsules)
• Elastic (aortic walls, vocal cords, parts of trachea
and bronchi, some ligaments)
• Hematopoietic (blood)
• Strong supportive (cartilage, bone, ligaments)
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Anatomy and Physiology of
Connective Tissues
• Bone
• Hard tissue: makes up most of skeletal system
• Functions: support, protection, movement, storage
of calcium and other ions, and manufacture of blood
cells
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Anatomy and Physiology of
Connective Tissues
• Cartilage
• Specialized fibrous connective tissue
• Provides firm but flexible support for the embryonic
skeleton and part of the adult skeleton
• Cartilage cells are called chondrocytes
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Anatomy and Physiology of
Connective Tissues
• Ligaments
• Strong and flexible fibrous bands of connective
tissue that connect bones and cartilage and support
muscles
• Yellow ligaments, located in the vertebral column,
are elastic and allow for stretching
• White ligaments, found in the knee, do not stretch
but provide stability
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Anatomy and Physiology of
Connective Tissues
• Tendons
• Composed of very strong and dense fibrous
connective tissue
• They are in the shape of heavy cords and anchor
muscles firmly to bones
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Joint Structure and Function
• Connective tissue disorders: manifested as joint
disorders since joint mobility depends on functional
connective tissue
• Joint: site where two or more bones are joined; permit
motion and flexibility of the rigid skeleton
• Classification
• Synarthroses (fixed joints)
• Amphiarthroses (slightly movable joints)
• Diarthroses (freely movable joints)
• Encased in a fibrous capsule made of strong cartilage
and lined with synovial membrane
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Age-Related Changes
• Loss of bone mass and bone strength
• Osteoporosis common in women but affects men
• Put the older patient at risk for fractures
• Cartilage gradually loses elasticity; becomes soft and
frayed
• Water content decreases, and cartilage may ulcerate, leaving
bony joint surfaces unprotected and promoting growth of
osteophytes (bony spurs)
• Result in pain and limited mobility
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Nursing Assessment of
Connective Tissue Structures
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Chief Complaint and History of
Present Illness
• Complaints that suggest possible problems
related to connective tissue disorders are
aches, pain, joint swelling or stiffness,
generalized weakness, a change in ability to
work or to enjoy leisure activities, a change in
appearance that is significant to the patient,
and a change in ability to carry out activities of
daily living
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Past Medical History
• Major childhood and adult illnesses, operations,
and current medications and allergies
• History of tuberculosis, poliomyelitis, diabetes
mellitus, gout, arthritis, rickets, infection of
bones or joints, autoimmune diseases, and
neuromuscular disabilities
• Accidents and injuries
• Current medications
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Family History
• Osteoporosis, osteoarthritis, rheumatoid
arthritis, gout, or scoliosis may have some
genetic basis
• Autoimmune diseases, e.g., thyroid disorders
• Review of systems
• General health status; determines patient’s
perception of well-being
• Fatigue, malaise, anorexia, weight loss, pain,
stiffness, dysphagia, or dyspnea
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Physical Examination
• Vital signs, height, and weight
• Skin color, rashes, lesions, scars, or any signs of
injuries
• Palpate skin for warmth, edema, and moisture
• Palpate lymph nodes for enlargement and tenderness
• Inspect joints for swelling and deformity, and palpate
for warmth, swelling, and tenderness
• Joint pain and range of motion
• Measure limb length and muscle strength
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Diagnostic Tests and Procedures
• Blood studies
• Complete blood cell count, erythrocyte
sedimentation rate (ESR), and C-reactive protein
determination
• Venereal Disease Research Laboratory (VDRL),
rheumatoid factor (RF), creatinine, and antinuclear
antibody (ANA) tests
• Urine studies
• Creatinine and uric acid levels
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Diagnostic Tests and Procedures
• Radiologic imaging studies
• Radiography, ultrasonography, arthrography,
nuclear scintigraphy, magnetic resonance imaging,
diskography, tomography, and computed
tomography
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Therapeutic Measures
• Physical and occupational therapy
• Physical therapy: exercise and positioning to help preserve
functional capability and minimize disability
• Occupational therapy helps patient gain maximal function in
work and personal life
• Education and support
• Education: how treatment plan will benefit the patient
• Patients and their families need information about community
support groups that can offer encouragement, information, and
resources
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Therapeutic Measures
• Drug therapy
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Glucocorticoids
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Biologic response modifiers (BRMs)
Disease-modifying antirheumatic drugs (DMARDs)
Cyclooxygenase-2 (COX-2) inhibitors
• Surgical treatment
• Indicated in some musculoskeletal disorders, such as
degenerative joint disease and arthritis
• Continuous passive motion (CPM) machine
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Disorders of
Connective Tissue Structures
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Osteoarthritis
• Pathophysiology
• Degeneration of articular cartilage with hypertrophy of the
underlying and adjacent bone
• Normally, articular cartilage provides a smooth surface for one
bone to glide over another
• Cartilage transfers the weight of one bone to another so the
bones do not shatter
• Osteoarthritis: shock-absorbing protection lost
• New bone growth is stimulated by exposed bone surfaces,
causing bone spurs
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Figure 41-1
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Osteoarthritis
• Signs and symptoms
• Pain in affected joint, stiffness, limitation of
movement, mild tenderness, swelling, and deformity
or enlargement of the joint
• Heberden nodes and Bouchard nodes
• Medical diagnosis
• Health history and radiographic studies
• Arthroscopy and MRI
• Synovial fluid aspiration
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Figure 41-2
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Osteoarthritis
• Medical treatment
• Drug therapy
• Acetaminophen, NSAIDs, DMARDs, COX-2 inhibitors, or
low dose of salicylates (aspirin)
• Surgery
• Arthroscopic surgery and arthroplasty
• Physical therapy
• Improve range of motion; maintain muscle mass and
strength
• Education
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Figure 41-3
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Osteoarthritis
• Assessment
• Joint pain or tenderness
• Examine joints for crepitus, enlargement, deformity,
and decreased range of motion
• Compare affected and unaffected joints to detect
abnormalities
• Determine how the disease affects the patient’s
mobility and ability to perform activities of daily living
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Osteoarthritis
• Interventions
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Chronic Pain
Impaired Physical Mobility
Ineffective Coping
Ineffective Therapeutic Regimen Management
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Osteoarthritis
• Care following total joint replacement
• Assessment
• Vital signs, level of consciousness, intake and output,
respiratory and neurovascular status, urinary function,
bowel elimination, wound condition, and comfort
• Circulation and sensation in the affected extremity
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Osteoarthritis
• Interventions
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Acute Pain
Risk for Injury
Impaired Physical Mobility
Impaired Tissue Perfusion
Risk for Infection
Anxiety or Fear
Deficient Knowledge
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Figure 41-4
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Rheumatoid Arthritis
• Pathophysiology
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Chronic, progressive inflammatory disease
Inflammation of the synovial tissue
Synovium thickens; fluid accumulates in joint space
Vascular granulation tissue (pannus) forms in the joint capsule
and breaks down cartilage and bone
• Fibrous tissue invades pannus, converting it first to rigid scar
tissue and finally to bony tissue
• These changes result in ankylosis
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Figure 41-6
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Rheumatoid Arthritis
• Signs and symptoms
• Pain in affected joints aggravated by movement
• Morning stiffness lasting more than 1 hour
• Weakness, easy fatigability, anorexia, weight loss, muscle aches and
tenderness, and warmth and swelling of the affected joints
• Joint changes are usually symmetric
• Rheumatoid nodules (subcutaneous, over bony prominences)
• Any organ may be affected
• Inflammation in tissues of heart, lungs, kidneys, eyes
• Clusters of symptoms
• Sjögren’s, Felty’s, or Caplan’s syndromes
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Figure 41-7
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Rheumatoid Arthritis
• Medical diagnosis
• Health history and physical examination
• Laboratory studies
• RF (rheumatoid factor), ESR (erythrocyte sedimentation
rate), and CRP (C-reactive protein)
• MRI, bone scans, and DEXA scans
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Rheumatoid Arthritis
• Medical treatment
• Drug therapy
• Aspirin and other NSAIDs for several months, with the
addition of gold compounds, d-penicillamine, antimalarials,
or sulfasalazine if needed
• Physical and occupational therapy
• Surgery
• Arthroplasty, synovectomy, tenosynovectomy, and
arthrodesis
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Figure 41-5
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Rheumatoid Arthritis
• Assessment
• Pain, joint swelling, tenderness, joint deformities and limitation
of movement, fatigue, and decreased ability to perform
activities of daily living
• Interventions
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Chronic Pain
Activity Intolerance
Ineffective Coping
Social Isolation
Ineffective Therapeutic Regimen Management
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Osteoporosis
• Pathophysiology
• Bone constantly formed and absorbed
• Until adolescence, bone formation exceeds bone absorption
so that bones grow and strengthen
• Around age 30, bone absorption surpasses formation
• Loss of trabecular bone, innermost layer, occurs first
• Loss of cortical bone, hard outer shell, begins later
• Begins earlier and progresses faster in women than in men
• Result is loss of bone mass
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Osteoporosis
• Risk factors
• Older women who have small frames, who are white or
of northern European heritage, and who have fair skin
and blond or red hair
• Estrogen deficiency; physical inactivity; low body
weight; inadequate calcium, protein, or vitamin D
intake; corticosteroid therapy over more than 6 months;
and excessive use of cigarettes, caffeine, and alcohol
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Osteoporosis
• Signs and symptoms
• Back pain, fractures, loss of height due to vertebral
compression, and kyphosis
• Bone deterioration in the jaw can cause dentures to
fit poorly
• Collapsed vertebrae can cause chronic pain
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Osteoporosis
• Medical diagnosis
• Absorptiometry
• Radiographs
• Bone specimen
• Medical treatment
• Calcium supplementation and estrogen replacement
• Bisphosphonates and selective estrogen receptor modulators
(SERMs)
• Regular exercise
• Percutaneous vertebroplasty
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Osteoporosis
• Assessment
• Diet, calcium intake, and exercise plan
• Note whether the patient is menopausal or has had an
oophorectomy
• Compare height with previous measurements
• Posture; note the presence and degree of deformity
• Interventions
• Risk for Trauma
• Chronic Pain
• Ineffective Therapeutic Regimen Management
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Gout
• Pathophysiology
• Characterized by hyperuricemia
• Related to excessive uric acid production or
decreased uric acid excretion by the kidneys
• Four stages
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Asymptomatic hyperuricemia
Acute gouty arthritis
Asymptomatic intercritical period
Chronic tophaceous gout
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Gout
• Signs and symptoms
• Asymptomatic hyperuricemia
• Blood uric acid level is elevated, but no other symptoms
• Many people with asymptomatic hyperuricemia never
progress to the next stage
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Gout
• Signs and symptoms
• Acute gouty arthritis
• Onset is abrupt, usually occurs at night
• The patient is suddenly afflicted with severe, crushing pain
and cannot bear even the light touch of bed sheets on the
affected joint
• Joint commonly affected is the great toe
• Symptoms usually disappear within a few days
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Gout
• Signs and symptoms
• Asymptomatic intercritical period
• No symptoms
• Chronic tophaceous gout
• Advanced gout
• Tophi: deposits of sodium urate crystals that are visible as
small white nodules under the skin
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Figure 41-8
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Gout
• Medical diagnosis
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History and physical examination
Urate crystals in synovial fluid
Urinary uric acid
Blood uric acid
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Gout
• Medical treatment
• Asymptomatic hyperuricemia requires no medical
treatment
• NSAID alone or with colchicine for acute gouty
arthritis
• For subsequent attacks: indomethacin,
corticosteroids, and corticotrophin
• Avoid foods high in purines
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Gout
• Assessment
• Pain, joint swelling, tophi, uric acid stones, fever,
and a history of trauma, injury, or surgery
• Interventions
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Acute Pain
Impaired Physical Mobility
Altered Urinary Elimination
Ineffective Therapeutic Regimen Management
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Progressive Systemic Sclerosis
• Pathophysiology
• Primary vessel injury/dysfunction of immune system
• Manifestations: from inflammation to degeneration of tissues,
that results in decreased elasticity, stenosis, and occlusion of
vessels
• Signs and symptoms
• Raynaud’s phenomenon, symmetric painless swelling or
thickening of the skin, taut and shiny skin, morning stiffness,
frequent reflux of gastric acid, difficulty swallowing, weight loss,
dyspnea, pericarditis, and renal insufficiency
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Figure 41-9
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Progressive Systemic Sclerosis
• Medical diagnosis
• History and physical examination may lead the
physician to suspect fibrotic changes typical of PSS
in the skin, lungs, heart, or esophagus
• Positive ANA assay result, elevated ESR, and
increased serum muscle enzyme levels
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Progressive Systemic Sclerosis
• Medical treatment
• No cure
• High doses of steroids or other
immunosuppressants may bring about remission
• Physical therapy
• d-Penicillamine; antihypertensives
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Progressive Systemic Sclerosis
• Assessment
• Pain and stiffness in the fingers; intolerance for cold
• Signs and symptoms suggestive of cardiovascular, respiratory,
renal, and gastrointestinal problems
• Skin rash, loss of wrinkles on the face, limitations of joint range
of motion, muscle weakness, and dry mucous membranes
• Examine the hands for contractures of the fingers and for color
changes or lesions on the fingertips
• Palpate the fingers to determine warmth
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Progressive Systemic Sclerosis
• Interventions
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Impaired Skin Integrity
Self-Care Deficit
Chronic Pain
Social Isolation
Imbalanced Nutrition: Less Than Body
Requirements
• Ineffective Therapeutic Regimen Management
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Dermatomyositis/Polymyositis
• Pathophysiology
• Polymyositis: infiltration of inflammatory cells, causing
destruction of muscle fibers
• Inflammation of tissues surrounding blood vessels is an
outstanding pathologic feature of the disease
• Condition is sometimes associated with malignancy
• Signs and symptoms
• Polymyositis: muscle weakness, Raynaud’s phenomenon, and
joint pain and inflammation
• Dermatomyositis: periorbital edema as well
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Dermatomyositis/Polymyositis
• Medical diagnosis
• Proximal muscle weakness, a muscle biopsy positive for
muscle degeneration, elevated muscle enzymes, and
myopathic electromyographic changes
• Medical treatment
• Drug therapy
• High-dose glucocorticoids, such as prednisone, and
chemotherapeutic agents, such as methotrexate
• Supportive treatment: balancing rest and exercise to prevent
contractures
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Other Connective Tissue Disorders
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Bursitis
Carpal tunnel syndrome
Ankylosing spondylitis
Polymyalgia rheumatica
Reiter’s syndrome
Behçet’s syndrome
Sjögren’s syndrome
Periarteritis nodosa
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