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RHEUMATIC DISORDERS

RHEUMATIC
DISEASES

 Arthritis or Inflammation of the joints

 Onset: acute or insidious, with possible periods of remission &
exacerbation
 Classification
 Monoarticular
 Polyarticular
 Inflammatory
 Non-inflammatory
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PATHOPHYSIOLOGY

SYNOVIAL SWELLING AND FLUID ACCUMULATION

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PANNUS, ERODED CARTILAGE AND MUSCLE ATROPHY

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CHARACTERISTIC DEGENERATIVE CHANGES –

DEGRADATION
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CLINICAL MANIFESTATIONS
 Pain – most common
 Joint swelling
 Limited movement
 Stiffness
 Weakness
 Fatigue

ASSESSMENT AND DIAGNOSTIC FINDINGS

General Health History
 onset of symptoms
Family history; Past Health history
- Thorough Physical Assessment and Functional assessment includes:
a. Inspection: General appearance (gait, posture, general musculoskeletal
size and structure)
b. Note gross deformities and abnormalities in movement
 symmetry, size and contour of other connective tissues such as the
skin and adipose tissue.

DIAGNOSTIC PROCEDURES
1. Erythrocyte Sedimentation Rate (ESR)– reflects inflammatory activity and,
indirectly, the progression or remission of the disease
N⁰ = M: up to 15 mm/hr
F: up to 20 mm/hr
2. Arthrocentesis – needle aspiration of synovial fluid
Purposes:
✓ sample for analysis (crystals=gout; bacteria=infectious arthritis
✓ relieve pain caused
Site: knee or shoulder
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- After procedure, monitor for infection and Hemarthrosis activity and

progression demonstrating the loss of cartilage

ARTHROCENTESIS

3. X-ray Studies – used to evaluate patients with rheumatic disease

▪ long-standing disease: severe joint degradation
▪ monitor disease activity and progression ➔ loss of cartilage and
narrowing of the joint space
▪ cartilage abnormalities, joint erosions, abnormal bony growth, and
osteopenia (decreased bone mineralization)
4. Bone Scans, Computed Tomography, MRI
 Bone scans - degree to which the crystal lattice of bone takes up or
absorbs a bone-seeking radioactive isotope
 An area demonstrating increased uptake, such as a joint, is
considered abnormal and indicative of inflammation due to infection
or nondisplaced fractures
 CT scan and MRI are techniques used to better visualize soft tissues.
5. Tissue Biopsies
 Muscle Biopsy – examine skeletal muscle useful in diagnosing myositis
 Arterial Biopsy – examines a specimen of an arterial wall, most frequently
the temporal artery to confirm inflammation of the vessel wall or arteritis, a
type of vasculitis
 Skin Biopsy – to confirm inflammatory connective tissue diseases such as
scleroderma or lupus erythematosus (a non-systemic form of lupus that is
limited to skin symptoms)
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6. Blood Tests
ESR
Serum Creatinine M: 0.6-1.2mg/dL F: 0.5-1.1mg/dL
HCT M: 42-52% F: 37-47%
RBC 4.9 – 6.1 M/cu mm
WBC 5,000-10,000 cu mm
Uric Acid M:2.5-8.5mg/dL F: 2.7 – 7.3 mg/dL
Anti-nuclear Antibody (ANA): Negative at 1:40 dilution
C-reactive Protein Test (CRP) <1.0mg/dL
Rheumatoid Factor: Negative (Normal) <60 units/Ml
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MEDICAL MANAGEMENT
PHARMACOLOGIC THERAPY – to manage symptoms, to control inflammation,
and, in some instances, to modify the disease
 Salicylates – eg. Aspirin; anti-inflammatory, analgesic
 NSAIDs – eg. diclofenac (Voltaren), COX 2 inhibitors; anti-inflammatory,
analgesic and platelet aggregation inhibitor
 DMARDs (Disease-modifying Antirheumatic Drugs) – gold containing
compounds which inhibit T- and B- cell activity, suppress synovitis during
active stage of RD;
 Penicillamine (Cuprimine, Depen) which inhibits T-cell function,
impairs antigen presentation, and an anti-inflammatory
 Immunosuppressives like methotrexate (Rheumatrex) for immune
suppression.
 Immunomodulators – eg. Pyrimidine synthesis inhibitor; Interleukin-1
receptor antagonist; Had anti-inflammatory and anti-proliferative effects.
 Corticosteroids – eg. prednisone, hydrocortisone; Has anti-inflammatory
effects
 Topical Analgesics – eg. capsaicin (Zostrix); Analgesic

SURGICAL MANAGEMENT
 Joint damage and deformity can be repaired by knee replacement
surgery, which can also reduce pain and restore function.
○ The knee cap is removed and the damaged portion (head) of
the femur and tibia are shaved off or resurfaced. The two-
part prosthesis (usually metal) is implanted.
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NURSING PROCESS
ASSESSMENT
 Assess patient’s perception of the disorder and situation, actions taken to
relieve symptoms, plans for treatment, and expectations.
 Assess current and past symptoms like fatigue, weakness, pain, stiffness,
fever, or anorexia and the effects of theses symptoms on the patient’s
lifestyle and self-image.
 Review history and physical assessment focusing on areas commonly
affected including the musculoskeletal system.
 Assess ability to comply with treatment regimen, and manage self-care.

DISGNOSIS
 Acute and Chronic Pain related to inflammation and increased disease
activity, tissue damage, fatigue, or lowered tolerance level
 Impaired Physical Mobility related to decreased range of motion, muscle
weakness, pain on movement, limited endurance
 Disturbed sleep pattern related to pain, depression, and medications
 Self-care Deficits related to contractures, fatigue, or loss of motion
 Ineffective coping related to actual or perceived lifestyle or role changes

PLANNING AND GOALS

 Major Goal: To relieve pain and discomfort, relief of fatigue, promotion of
restorative sleep, increased mobility, maintenance of self-care, effective
coping and absence of complications

INTERVENTIONS
 Relieving Pain and Discomfort
 Decreasing Fatigue
 Promoting restorative Sleep
 Increasing Mobility
 Facilitating Self-care
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 Improving body image and coping

 Monitoring and Managing Potential Complications

EVALUATION
The client:
 Experiences relief of pain or improved comfort level
 Experiences reduction in level of fatigue
 Improves sleep pattern
 Increases or maintains level of mobility
 Maintains self-care activities
 Experiences improved body image and coping
 Experiences absence of complications

DIFFUSE CONNECIVE TISSUE DISORDERS

 refers to a group of disorders that are chronic in nature and are
characterized by diffuse inflammation and degeneration in the connective
tissues

RHEUMATOID ARTHRITIS
 used as the prototype for inflammatory arthritis
 affects 0.5% to 1% of the general population worldwide, with a female-male
ratio between 2:1 and 4:1
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CLINICAL MANIFESTATIONS
(may vary, usually reflecting the stage and severity of the disease)
Classic symptoms include:
 Joint Pain
 Swelling
 Warmth
 Erythema
 Lack of function
 Joint stiffness
 Deformities of the hands and feet

RA is a systemic disease with multiple extra-articular features that includes:

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 Fever, weight loss, fatigue, anemia, lymph node enlargement and

Raynaud’s phenomenon (cold- and stress-induced vasospasm causing
episodes of digital blanching or cyanosis).
 Rheumatoid nodules – develop in advanced RA; appears over bony
prominences
 Arteritis, neuropathy, scleritis, pericarditis, splenomegaly, and Sjogren’s
syndrome (dry eyes and mucous membranes)

DIAGNOSTIC FINDINGS
 ESR: Significantly elevated
 RBC and C4 complement component: Decreased
C4 N⁰ = 20 – 50 mg/dL or 0.20 – 0.50 g/L
 C-reactive protein and antinuclear antibody (ANA) may be positive
 Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow and
contains numerous inflammatory components such as leukocytes and
complement.
 X-ray – helps diagnose and monitor the progression of the disease, show
characteristic bony erosions and narrowed joint spaces occurring later in
the disease.

MEDICAL MANAGEMENT
 Pharmacologic treatment mentioned in Rheumatic diseases is indicated
but varies according to the progress of the disease.

NURSING MANAGEMENT
 Nursing care follows the basic plan of care presented earlier in RD
 Assess and intervene in patient concerns and issues that occur with the
diagnosis of a chronic illness such as RA and its resulting disability