Autoimmune Disorders That Affect the Musculoskeletal System

1. Autoimmune Disorders That Affect the Musculoskeletal System

2. Rheumatoid Arthritis

3. Rheumatoid Arthritis (RA) • Chronic, systemic autoimmune disease • Inflammation of connective tissue in diarthrodial (synovial) joints • Periods of remission and exacerbation • Frequently accompanied by extra-articular manifestations

4. Incidence • Occurs globally, affecting all ethnic groups • Occurs at any time of life • Incidence increases with age • Peaks between 30s and 50s • Nearly 2.1 million Americans affected • Women have incidences three times higher than men

5. Etiology • Cause of RA is unknown • No infectious agent found • Two etiologies • Autoimmune etiology • Most widely accepted • Genetic factor etiology

6. Pathophysiology • Chronic inflammation of the joints leads to: • Scar tissue (pannus) & joint cartilage destruction • Joint laxity, subluxation (dislocation), & contracture

7. Pathophysiology Fig. 65-3

8. As the synovitis expands inside and outside of the joint, it can damage the bone and cartilage of the joint and the surrounding tissues, such as ligaments, tendons, nerves, and blood vessels. • With articular cartilage destruction, vascular granulation tissue grows across the surface of the cartilage (pannas) with loss of cartilage beneath the expanding pannas

9. Etiology and Pathophysiology of Rheumatoid Arthritis • Inflammatory pannus causes destruction of bone. • This leads to joint deformities.

10. Pathophysiology • If unarrested, RA progresses in 4 stages • Stage 1: Early • No destructive changes on x-ray, possible x-ray evidence of osteoporosis • Stage 2: Moderate • X-ray evidence of osteoporosis, with or without slight bone or cartilage destruction • No joint deformities, adjacent muscle atrophy, possibly presence of extra-articular soft tissue lesions

11. Etiology and Pathophysiology • RA progresses in four stages (cont'd) • Stage 3: Severe • X-ray evidence of cartilage and bone destruction in addition to osteoporosis; joint deformity; extensive muscle atrophy; possible presence of extra-articular soft tissue lesions • Stage 4: Terminal • Fibrous or bony ankylosis, stage III criteria

12. Clinical ManifestationsOnset • Onset is typically insidious • Nonspecific manifestations may precede onset of arthritic complaints • Some report a history of precipitating events

13. Clinical ManifestationsJoints • Specific articular involvement • Symptoms occur symmetrically • Frequently affect small joints of hands and feet • Larger peripheral joints may also be involved

14. Typical Deformities of Rheumatoid Arthritis Fig. 65-4

15. Clinical ManifestationsJoints • Patient experiences joint stiffness after periods of __________ • Morning stiffness may last from 60 minutes to several hours or more • MCP and PIP joints typically swollen • Fingers may become spindle shaped from synovial hypertrophy and thickening of joint capsule

16. Clinical ManifestationsJoints • Joints become tender, painful, and warm • Joint pain • Increases with ______ • Varies in intensity • May not be proportional to degree of inflammation • Tenosynovitis frequently affects extensor and flexor tendons near wrists • RA progresses

17. Extraarticular Manifestations of Rheumatoid Arthritis Fig. 65-5

18. Clinical ManifestationsExtraarticular Manifestations • Three most common • Rheumatoid nodules develop in up to 25% of all patients with RA • Those affected usually have high RF titers

19. Clinical ManifestationsExtraarticular Manifestations • Sjögren’s syndrome • Seen in 10% to 15% of patients with RA • Can occur as a disease by itself or in conjunction with other arthritic disorders • RA and systemic lupus erythematosus (SLE) • Complaints of burning, gritty, itchy eyes • Decreased tearing, photosensitivity

20. Clinical ManifestationsExtraarticular Manifestations • Felty’s syndrome • Most commonly in patients with severe, nodule-forming RA • Characterized by • Inflammatory eye disorder • Splenomegaly • Lymphadenopathy • Pulmonary disease • Blood dyscrasias

21. Complications • Joint destruction begins as early as first year of disease without treatment • Flexion contractures and hand deformities • Cause diminished grasp strength • Affect patient’s ability to perform self-care tasks • Cataract development and loss of vision can result from scleral nodules

22. Complications Rheumatoid nodules On the skin can ulcerate, similar to pressure ulcers On vocal cords leads to progressive hoarseness In vertebral bodies can cause bone destruction

23. Complications • Cardiopulmonary effects may occur later in RA • Pleurisy, pleural effusion, pericarditis, pericardial effusion, cardiomyopathy • Carpal tunnel syndrome can result from swelling of synovial membrane

24. Diagnostic Studies • RA is defined as having at least 4 of the following seven criteria. Following must be present for at least 6 wks: • Morning stiffness that lasts ≥1 hour • Swelling in three or more joints • Swelling in hand joints • Symmetrical joint swelling • Erosions or decalcification seen on hand x-rays • Rheumatoid nodules • Presence of serum RF

25. Diagnostic Studies • Accurate diagnosis is essential to initiation of appropriate treatment and prevention of unnecessary disability • Diagnosis is often made • Based on history and physical findings • Some laboratory tests are useful for confirmation and to monitor disease progression

26. Diagnostic Studies • Positive RF • Titers rise during active disease • Antinuclear antibody (ANA) titers • Indicators of active inflammation • ESR • C-reactive protein (CRP)

27. Diagnostic Testing • 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 diagnosis – only show bone changes

28. Collaborative Care • Care begins with a comprehensive program of education and drug therapy • Education of drug therapy • Patient and family educated about disease process and home management strategies • NSAIDs are prescribed to provide comfort

29. Collaborative Care • Physical therapy helps maintain joint motion and muscle strength • Occupational therapy develops extremity function and encourages joint protection

30. Drug Therapy • Drugs remain cornerstone of treatment • DMARDs can lessen permanent effects of RA • Choice of drug is based on

31. Treatment and Nursing Care for Rheumatoid Arthritis • See Table 65-3 for meds used for arthritis p. 1698-1700. • Salicylates • NSAIDs • Antibiotics • Topical analgesics • Corticosteroids • DMARDs • Gold compounds • Antimalarials • Immunosupressants • Biologic/Targeted therapy

32. Drug TherapyDMARD • Many of the drugs used to treat RA are expensive • Methotrexate (Rheumatrex) is drug of choice • Rapid antiinflammatory effect decreases clinical symptoms in days to weeks • Inexpensive • Lower toxicity compared to other drugs

33. Drug Therapy • Effective DMARDs for mild to moderate disease • Sulfasalazine (Azulfidine) • Antimalarial drug hydroxychloroquine • Leflunomide (Arava) is a newer synthetic DMARD that blocks immune cell overproduction

34. Drug Therapy • Biologic/targeted drug therapies can also slow disease progression in RA • Can be used in patients with moderate to severe disease who have not responded to DMARDs or in combination therapy with an established DMARD

35. Drug Therapy • Corticosteroid therapy can aid in symptom control • Intraarticular injections may relieve pain and inflammation associated with flare-ups • Long-term use should not be a mainstay • Risk osteoporosis, avascular necrosis • Low-dose prednisone for a limited time to decrease disease activity until DMARD effect is seen

36. Drug Therapy • Various NSAIDs and salicylates to treat arthritis pain and inflammation • Aspirin is often used in high dosages of 4 to 6 g/day (10 to 18 tablets) • NSAIDs have antiinflammatory, analgesic, and antipyretic properties

37. Drug Therapy • NSAIDs • Do not alter natural history of RA • Full effectiveness may take 2 to 3 weeks • Some relief may be noted within days • May be used when patient cannot tolerate high doses of aspirin

38. Relieve Pain • NSAIDs • DMARDs • Non-Pharmacological • Heat or Cold applications • Rest • Relaxation techniques

39. Nursing ImplementationAcute Intervention • Usually treated on an outpatient basis • Hospitalization may be necessary for patients with extraarticular complications or advancing disease • Reconstructive surgery for disabling deformities • Nursing intervention begins with a careful physical assessment

40. Nursing ManagementAssessment • Nurse must also • Evaluate psychosocial needs and environmental concerns • After problem identification, coordinate a carefully planned program for rehabilitation and education for interdisciplinary health care team

41. Nursing ManagementProblems • Chronic pain • Impaired physical mobility • Activity intolerance • Self-care deficit • Ineffective therapeutic regimen management • Disturbed body image

42. Nursing ManagementPlanning • Overall goals • Satisfactory pain relief • Minimal loss of functional ability of affected joints • Perform self-care • Participate in planning and carrying out therapeutic regimen • Maintain a positive self-image

43. Nursing ManagementInterventions • Discuss with patient • Many patients take several different drugs so the nurse must make the drug regimen as understandable as possible • Careful attention to timing is critical to

44. Nursing ManagementInterventions • Nonpharmacologic relief of pain • Therapeutic heat and cold • Rest • Relaxation techniques • Joint protection • Biofeedback • Transcutaneous electrical stimulation • Hypnosis

45. Nursing ManagementInterventions • Lightweight splints may be prescribed to rest an inflamed joint and prevent deformity • Should be removed regularly to perform skin care and ROM exercises • Should be reapplied as prescribed • Occupational therapist may help identify additional self-help devices to assist in activities of daily living

46. Nursing ManagementInterventions • Morning care and procedures should be planned around morning stiffness • To relieve joint stiffness and increase comfort

47. Ambulatory and Home CareRest • Alternate scheduled rest periods with activity throughout day • Helps relieve pain and fatigue • Amount of rest varies • Total bed rest • Rarely necessary • Should be avoided to prevent stiffness and immobility

48. Ambulatory and Home CareRest • Good body alignment while resting can be maintained through use of a firm mattress or bed board • Encourage positions of extension • Avoid flexion positions • Splints and casts can help maintain proper alignment and promote rest

49. Ambulatory and Home CareHeat and Cold Therapy • Help relieve pain, stiffness, and muscle spasm • Ice • Superficial heat sources • Moist heat

50. Ambulatory and Home CareExercise • Inadequate joint movement can result in progressive joint immobility and muscle weakness • Overaggressive exercise can result in increased pain, inflammation, and joint damage • Gentle ROM exercises are usually done daily to keep joints functional