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 short-term 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. ProstaglandinB. HistamineC. Leukotriene D. 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◦ Patient preparation◦ Procedure◦ Follow-up care

Oral food challenges

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 drug-induced 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. Anaphylactic reaction to an unknown allergenB. Sjögren’s syndromeC. Graves’ disease D. 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. Seasonal allergic rhinitisB. Acute respiratory infection C. Goodpasture’s syndromeD. Sjögren’s syndrome