med surg 2 chapter 38

diagnostic studies of rheumatic disease include

x-ray studies, CT, MRI, arthrography

testing OA

xray- only shows bones, not cartilage, decreased joint space, and bone spurs

Capsaicin (Zostrix)

Is a topical analgesic. Instruct the patient to apply sparingly, avoid areas of open skin, and avoid contact with eyes in mucous membranes. Wash hands carefully after application. Assess for local skin irritation.

Rhuematoid Factor positive titer

>1:80 and present in 80% of those with RA; may also suggest SLE, sjogrens syndrome, or mixed connective tissue disease. (The higher the number to the right of the semicolon, the greater the inflammation)

Nursing considerations for Nonsteroidal anti-inflammatory drugs

Increased risk of cardiovascular events, including myocardial infarction and stroke. Appropriate for older adults in patients who are at high risk for gastric ulcers.

Management of Fibromyalgia

-NSAIDs -TCAs, SSRIs, (for sleep) -anticonvulsants -muscle relaxants -cog behavoiral therapy -exercise

S/S of physiological Lupus

-fatigue/ weakness -loss of appetite -butterfly rash -pleura rash -pleura inflammation -pericardium inflammation -fingers and toes poor circulation -increased ESR + C-reactive protein -infection -stress ++NO LIVE VACCINES

S/S of systemic lupus

-low grade fever -photosensitivity -mouth and nose ulcers -muscle aches -arthritis of joints

Assessing and interventions for Lupus

-respiratory status -assess end organ function -plan rest periods -identify triggers, (sun, cold, infection) -dietician for dietary assistance MEDS: glucocorticoids (for inflammation) NSAIDs, cyclophosamine (immunosuppressive agents)

7 S's of RA

-sunrise stiffness greater than 30 min to hour -soft, tender, warm joint -swelling of joint -symmetrical -synovium inflammed -systemic -stages (synovitis, pannus, ankylosis)

normal value for creatinine

0.7-1.4 mg/dL

Uric acid normal levels

2.5-8 mg/dL

hematocrit level for women

35-47%

normal value for RBC in women

4,200,000-5,400,000 (4.2-5.4)

normal WBC count

4,500-11,000

normal value for RBC for men

4,600,000-6,200,000 (4.6-6.2)

Hematocrit level for men

42-52%

A total score of _____ or higher is required for the diagnosis of RA

6

Nursing interventions for the patient with rheumatic disorder of acute or chronic pain related to inflammation.

; Provide variety of comfort measures application of heat or cold, massage, position changes, rest.; Foam mattress, supportive pillow, splints, relaxation techniques, diversional activities, administer anti-inflammatory analgesics,

C-reactive protein normal levels

<1 mg/dL (<10 mg/L)

erythrocyte sedimentation rate for men

<15-20

erythrocyte sedimentation rate for women

<25-30

hyperuricemia

> 6.8 mg/dL

Nursing considerations for DMARDS (Plaquenil, Aralen)

Administer concurrently with nonsteroidal anti-inflammatory drugs, assess for visual changes, G.I. upset, skin rash, headaches, photosensitivity, bleaching of hair. Emphasize need for ophthalmology examinations every 6 to 12 months.

Nursing considerations for JAK inhibitors (Xeljanz)

Administer twice a day. Do not administer with biologic DMARDS or potent immuno suppressant. Monitor lipids 4 to 8 weeks following initiation of therapy. Monitor liver enzymes routinely.

Nursing considerations for aspirin

Administer with meals to prevent gastric irritation, assessed for tinnitus, gastric intolerance, G.I. bleeding, and purpura. monitor for possible confusion and the older adult.

Care of the patient with rheumatic disorder nursing diagnosis of impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack of or improper use of ambulatory devices

Allow ample time for activity. Provide rest after activity. Reinforce principles of pacing and work simplification. Initiate referral to community Health agency. Explain the use of safe footwear. Use individual appropriate positioning/posture. Assist to identify environmental barriers.

Psoriatic Arthritis

An inflammatory arthritis associated with psoriasis of the skin, then spreads to the joints. Can cause back pain that improves with activity, common at night systemic uveitits

Care of the patient with rheumatic disorder with a nursing diagnosis of readiness for enhanced self-care related to contractures, fatigue, or loss of motion

Assist patient to identify self-care deficits in factors that interfere with ability to perform self-care activities. Develop a plan based on the patient's perceptions and priorities on how to establish and achieve goals to meet self-care needs, incorporating energy can conservation and work simplification concepts.

CREST syndrome (scleroderma)

Calcinosis - calcium deposits in skin Raynauds -spasms of blood vessels in response to cold or stress. Esophageal dysfunction- acid reflux and decrease in motility Sclerodactyly- thickening and tightening of skin or fingers and hands Teleangiectasis- dilation of capillaries causing red marks on surface of skin

Including environmental factors such as the pollution and smoking, family history of first-degree relatives, and illness such as bacteria and viral illnesses. Cigarette smoking is one modifiable risk that has been shown to be highly related to RA.

Risk factors for the development of rheumatoid arthritis

Many subcutaneous lesions, butterfly shaped rash, a build up of antibodies and immune complexes that caused damage to the nephrons, psychosis cognitive impairment, seizures, peripheral and cranial nerve pathways, transverse Myelitis, and strokes. Joint pain and stiffness, arthritis. We also see cardiac symptoms such as Pericarditis.

Clinical manifestations of SLE

Antimalarial medications used in tx of SLE are targeted towards managing

Cutaneous, musculoskeletal, and mild systemic features

liver and kidney monitoring is recommended for most ________ therapy due to it causing elevation of liver enzymes and also effect kidneys

DMARD (disease modifying antirhuematic drugs)

medications for Gout

DONT GIVE ASPRIN FOR PAIN -diuretics -cyclosporin AVOID DEHYDRATION

Is based on a complete history, physical examination, and blood test.

Diagnosis of SLE

Nursing considerations for AZULFIDINE

Do not use in patients with allergy to sulfa medications or aspirin. Emphasize adequate fluid intake. Assessed for G.I. upset, skin rash, headache, liver abnormalities, and anemia.

diagnostic finding of Ruematoid Arthritis:

ESR and CRP significantly elevated

Type of arthritis due to build up of Uric acid in blood causes needle like crystals to form in joints particularly in the great toe because the kidneys are not excreting acid

Gout

Care of the patient with rheumatic disorder the nursing diagnosis of fatigue related to increased disease activity, pain in adequate sleep/rest, deconditioning, in adequate nutrition, and emotional stress/depression

Have the patient describe relationship of disease activity to fatigue. Describe comfort measures while providing them. Develop and encourage a sleep routine warm bath and relaxation techniques that promote sleep. Explain importance of rest for relieving systematic, articular, and emotional stress. Explain how to use energy conservation techniques such as pacing, delegating, setting priorities. Identify physical and emotional factors that can cause fatigue. Facilitate development of appropriate activity/rest schedule.

Care of the patient with rheumatic disorder nursing diagnosis of disturbed body image related to physical and psychological changes independency imposed by chronic illness

Help the patient identify elements of control of her disease symptoms and treatment. Encourage patients verbalization of feelings, perceptions, and fears. Hope to assess present situation and identify problems.

Aerobic exercise

Improve cardiovascular fitness and endurance. Perform 3 to 5 days per week for 20 to 30 minutes of moderate intensity. Progress slowly as activity and tolerance and fitness improve.

Isometric exercise

Improve muscle tone, static endurance, and strength; prepare for dynamic in weight-bearing exercises. Monitor blood pressure; isometric exercises may increase blood pressure and decreased blood flow to muscles.

a decrease WBC may be seen:

In SLE

Dynamic exercise

Maintain or increase dynamic strength and endurance; increase muscle power; enhance synovial blood flow; promote strength of bone and cartilage.

What is the first line agent for rheumatoid arthritis treatment?

Methotrexate. May be given orally or by intramuscular or subcutaneous injection. Assess for bone marrow suppression. Monitor CBC, liver enzymes, creatinine at six weeks after initiation, then every 2 to 3 months or accordingly.

Is an autoimmune, systemic disease that can affect any body system.

SLE

OSTEO

O-outgrowths bony S-sunrise stiffness T- tenderness on joint site -bone spurs E- experience crepitus O-only the joints affected

Nursing diagnoses of complications secondary to effects of medications

Perform periodic clinical assessment and laboratory evaluation. Provided education about correct self administration, potential side effects, and importance of monitoring. Counsel regarding methods to reduce side effects and manage symptoms. Administer medications in modified doses as prescribed if complications occur.

The goals of treatment for SLE include

Preventing progressive loss of organ function, reducing the likelihood of acute disease, minimizing disease related disabilities, and preventing complications from therapy.

decrease in RBC can indicate

RA, SLE

-stiffness of extremities with loss of mobility; mask like appearance -skin and subq tissue becomes hard; sweat secretion is suppressed -pulmonary HTN, scarred lungs, kidney failure -hardened esophagus, hard to swallow -CREST syndrome

Raynauds Phenomenon

spondyloarthropathies

Reiters syndrome Ankylosing spondyitis Psoriatic arthitis

Exercise is crucial for tx of ______ along with suppliments of Vit B12, folic acid, iron (to increase RBC)

Rhuematoid arthritis

a bony outgrowth or protuberance; bone spur

osteophyte

Is a complication of auto immune disease affecting the connective tissue of the skin, blood vessel walls, and internal organs.

Scleroderma

Cyclosporine (Neoral) is used for

Severe, progressive rheumatoid arthritis, unresponsive to other DMARDS and used in combination with methotrexate. Assess for toxic effects such as bleeding gums, fluid retention, hair growth, tremors. Monitor blood pressure and renal function every two weeks until stable.

A client with rheumatoid arthritis has infiltration of the lacrimal and salivary glands with lymphocytes as a result of the disease. What does the nurse understand that this clinical manifestation is?

Sicca syndrome

is a systemic autoimmune disease that progressively affects the lacrimal and salivary glands of the body. Most likely women between 35 and 50. (dry mouth and dry eyes)

Sjogren's syndrome

Clinical manifestations of scleroderma

Starts Insidiously with Raynauds phenomenon and swelling in the hands, the face is mask like, and mouth becomes rigid. Esophagus hardens which results in swallowing problems

The nurse is gathering objective data for a client at the clinic complaining of arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as?

Swan neck deformity

tx for for OA

ostotomy- realignment, lose weight (less pressure off joints), topical cream, EXERCISE IS CRUCIAL!!

Criteria for classifying systemic lupus erythematosus

The patient must meet four or more of the 11 criteria which include: -Malar rash -Discoid rash -Photosensitivity -Oral ulcers -Non-erosive arthritis -Pleuritis or Pericarditis -Kidney disease -Neurologic disease -Hematologic disorder -Immunologic disorder -Positive anti-nuclear antibody

Pool exercise

Water supports or resist movement; warm water may provide muscle relax station. Deep water to minimize joint compression; nonslip footwear for safety and comfort. Receive appropriate instructions in a program designed for people with arthritis

allpurinol (Zyloprim), febuxostat (Uloric)

Xanthine oxidase inhibitors; interrupt the breakdown of purines before uric acid is formed **Monitor for SE, including bone marrow suppression, vomiting, abdominal pain. Avoid starting med or increasing dose if active flare present.

Colchicine (Colcrys)

action- lowers the deposition of uric acid and interferes with leukocyte infiltration, thus reducing inflammation; does not alter serum urine levels of uric acid acute management: administer when attack begins; dosage increased until pain is relieved or diarrhea develops, then stop medication chronic management: causes gastrointestinal upset in most patients

Boswellia, ginger, green tea, and tumeric have helped with the inflammation by:

adding this to the nurtritonal therapy for RA

is where the body mistakenly recognizes its own tissue as a foreign antigen

autoimmunity

interventions for gout attacks

bed rest with extremity in a cradle cushion -cold/or hot compress if tolerated -stay hydrated -lose weight -no sodas -give colchine for decreased swelling (may cause GI upset and risk or neutropenia) TOXICITY: tingling, numbness of fingers and toes, gray lips, NO GRAPEFRUIT JUICE can cause increased toxicity.

The nurse is educating a client about the risks of stroke related to the new prescription for a COX-2 inhibitor and what symptoms to report. Which COX-2 inhibitor is the nurse educating the client about?

celecoxib (Celebrex) is associated with an increased risk of cardiovascular events, including myocardial infarction and stroke.

fibromyalgia

chronic condition with widespread aching and pain in the muscles and fibrous soft tissue

a decrease in hematocrit can be seen in:

chronic inflammation (anemia of chronic disease); also, blood loss through GI bleed.

proteins that can be produced by leukocytes that are vital to regulation of hematpooiesesis, apoptosis, and immune responses

cytokines

DMARD

disease-modifying antirheumatic drug; they have the ability to suppress the autoimmune response; alter disease progression; and stop or decrease further tissue damage on the joints, cartilage, and organs. This med has been known to halt the progression of bone loss and destruction and can induce remission

rheumatic diseases

encompass autoimmune, degenerative, inflammatory, and systemic conditions that affect the joints, muscles, and soft tissues of the body.

Because clients present with widespread symptoms that are often vague in nature, health care providers may misdiagnose them. Clients feel as though people are not listening to them. Nurses need to provide support and encouragement. Symptoms of disease vary from client to client and respond to different treatments.

fibromyalgia

ankylosis

fixation or immobility of a joint

s/s of fibromyalgia

generalized muscle aching, stiffness, sleep distrubances, functional impairment, chronic fatigue

Increase in uric acid levels indicate

gout, during acute flare ups, levels may be normal. After flare ups have subsided, levels will be elevated

these meds can be highly toxic and can produce bone marrow suppression, anemia, gastrointestinal disturbances disturbances, severe birth defects, and rashes for patients being treated for unremitting Rheumatoid Arthritis

high dose methotrexate, cyclophosphamide (cytotoxan), and azathioprine (Imuran)

chronic attacks of Gout

increased uric acid levels and repeated acute attacks -itching and peeling skin -kidney stones -tophi (white-yellowish nodules found on helix of ear, fingers, elbows, and toes)

an increase in ESR is usually seen in:

inflammatory connective tissue diseases, the higher the number, the greater the inflammatory activity

Probenecid (Benemid)

inhibits reabsorption of urates and increases the urinary excretion of uric acid; prevents tophi formation **BE ALERT FOR NAUSEA AND RASH

teach patients with Gout to avoid these foods:

internal organ meats such as liver, kidney, sweet breads, red meats. Seafood: anchovies, sardines, scallops, tuna ALCOHOL especially beer high fructose corn syrup

Osteoarthritis

is due to wear and tear of cartilage and usually appears 40 years or older, or repeated injuries, over weight, or genetics and occurs in the hands, hips, spine, knees, not systemic and only joints. *hard bony-bones rubbing together, bone spurs, stiffness in morning lasting <30 min

increase in creatinine indicates

kidney damage in SLE, scleroderma, and polyarteritis

S/S of acute gout attacks

may happen randomly or a few times that lasts 1-2 weeks -may have several months to years between attacks -no long term joint damage -tends to start out in big toe, fingers, elbows, wrist, knee, heel. -sudden swelling and redness in a joint awake at night with pain and warmth to the site. -can cause bone deformity, joint damage, tophi -pain intensifies 4-24 hours and stiffness, the site is VERY SENSITIVE TO ANY PRESSURE

CCBs, or other antihypertensives, PPI (reflux), vasoactive meds to prevent ulcers

meds associated in tx with Raynauds syndrome

Belimumab (Benlysta)

monoclonal antibody for treatment of systemic lupus erythematosus that halts the production of unnecessary antibodies and decreases disease activity.

normal Rhuematoid Factor is

negative and determines the presence of abnormal antibodies seen in connective tissue disease.

most common symptom of rheumatic diseases is:

pain, but other sx include: joint swelling, limited movement, stiffness, weakness, and fatigue

proliferation of newly formed synovial tissue infiltrated with inflammatory cells

pannus

insidious

proceeding in a gradual, subtle way, but with harmful effects

Ankylosing Spondylitis (AS)

rigid, decreased mobility of spine systemic effects: osteoporosis, AV defects, aortic insufficiency, pulmonary fibrosis, uvetitis (eye inflammation), WATCH FOR: Kyphosis (always assess respiratory)

symetrical

same on both sides

Heberden nodes

small, hard nodules formed in the cartilage of the distal finger joints in osteoarthritis

1)synovotis- thickened and inflammed 2) Pannus- extensive cartilage loss/exposed pitted bones 3) fibrous ankylosis- joint invaded by fibrous connective tissue 4) bony ankylosis- bones are fused together

stages for RA

bony plate that supports the articular cartilage

subchondral bone

annual eye exams are reccommended with the use of these meds with tx of early Rhuematoid Arthritis

sulfasalazine and hydroxychloroquine

Bouchard's nodes

swelling at the proximal interphalangeal joints (PIP) in osteoarthritis involving the hands

classical sx of Ruematoid Arthritis are:

symmetric joint pain, swelling, warmth, erythema, and lack of function

tx for dry mouth

systemic cholinergic agents such as cevimeline (Evoxac)

accumulation of crystaline deposits in articular surfaces, bones, soft tissue, and cartilage

tophi

Reiter's Syndrome

urethritis, conjunctivitis, arthritis non-infectious (but often follows infections), HLA-B27, polyarticular