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Inflammatory Diseases

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ObjectivesIdentify the S/S of inflammatory disease.

Classify the common disease modifying drugs used to treat inflammatory disease.

Develop a nursing plan of care for individuals with inflammatory disease.

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Inflammatory Arthritis

An inflammatory process with the target organ being the synovial membrane leading to pannus formation (inflammatory exudate in the lining of the synovial cells).

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Inflammatory Disorders

RA/JRASLEScleradermaSjogren’s SyndromePolymyositis/Giant Cell ArteritisPsoriatric Arthritis

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Inflammatory Disorders con’t

Ankylosing SpondylitisReiter’s SyndromeFibromyalgiaBursitisArthritic InfectionsGout

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Rheumatoid ArthritisOsteopenia - demineralization of the bone

Early on in the inflammatory process,only the periarticular portion of the bones are affected.Over time, the inflammatory pain causes disuse of affected joints leading to generalized osteopenia of whole bones.

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Question #1A common hand deformity in rheumatoid arthritis is:

a. Radial deviation.b. Supination deformity.c. Ulnar deviation. d. Flexion contracture.

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Answer #1

A common hand deformity in rheumatoid arthritis is:Ulnar deviation occurs when the MCP joints are affected by RA

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Rheumatoid Arthritis

Uniform joint space narrowing

Marginal erosions at bare areas where synovium lies on bone

Subluxation

RA of the Hands

RA of the Hands

RA of the Hips

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RA-Epidemiology

Develops most often between ages 20 & 502 million Americans have RA Roughly twice as many women as menGenetic predisposition

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RA-Etiology

TheoriesAutoimmuneInfectious

GeneticsFamily history of RA

StressExacerbations

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RA-PathophysiologyRheumatoid Factor develops in synoviumAntibody/antigen complexes inflammationSynovitis developsSynovial lining thickens & invades surrounding tissueGranulation forms (Pannus)

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Answer #2

Which of the following symptoms would you expect a patient with RA to have?Morning stiffness usually lasts about 4 hours

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RA-SymptomsPain & swelling in hands & feetMorning stiffness & stiffness after restLoss of ROMFatigue (severe during a flare-up)Rheumatoid NodulesFlares & Remissions

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RA Complications

Flexion contracturesJoint InstabilityTendon RuptureSeptic ArthritisCord CompressionSensory/motor loss

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RA ComplicationsTMJCricoarytenoid joint involvementCarpal TunnelSjogren’s Still’sDepression

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Answer #3

Which of the following is a therapeutic modality used for symptom management in RA?

Exercise to promote ROM & flexibility

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RA - Treatment ModalitiesDrug therapy (pyramid)NSAIDs, DMARDs, Steroid, Exp.Avara, Remicaide (IV)

***See handouts for lists of drugs used

Exercise/ PTROM, strength, endurance, splints

Use of heat & coldJoint Replacement

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RA Nursing InterventionsPt & Family Education!!!!!Joint protection/work simplificationRespect painBalance work/restReduce effort on joint/avoid positionsUse larger/stronger/stable jointsAvoid remaining in one positionAvoid activities that don’t allow stopping/break

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Amyotrophic Lateral Sclerosis

ALS (Lou Gehrig Disease) - chronic progressive degeneration of motor neurons - muscle weakness and atrophyM 3x>F, age 35-6550% die in 3 yearsRx: symptomatic

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GoutMonosodium urate crystalsDeposited into soft tissue Activate inflammatory process and inflammatory cytokines (IgG, IL-1, IL-2, free radicals)

Etiology/DemographicsSeen mostly in males 40-60 years / women after MenopauseRenal dysfunctionAlcohol useDefect in purine metabolism

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GoutClinical PresentationSudden onsetGenerally involves one joint – Lower extremity

Physical examinationRed swollen joint, usually first MTPExtremely painful pointFever 103°F / tachycardia / headachesUrate acid crystal nodules (tophi) noted on helix of ears

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GoutDiagnosticsSerum uric acid levels – ↑WBC –↑ during acute episodeSED rate – ↑Joint Aspiration – Synovial fluid

Crystals of sodium urate noted under special light → glow red under light

X-RaysNon-specific soft tissue swellingErosive changes occur with disease progression

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GoutClinical ManagementWeight bearing activity restriction until after acute episode subsidesNSAIDs – indomethacin preferableColchicine- narrow window of toxicityUricosuricsAllopurinol-never use for acute episode- For chronic Rx

Interferes with uric acid productionDiet

Protein Restriction ???-controversial

Alcohol / Purine RestrictionWeight Loss if Obese

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Gout

ComplicationsMajor concern is renal disease from recurrent renal calculiOften form large calculi called staghorn calculi that fill renal calyx and causes renal dysfunctionStones cause interstitial inflammation and can result in chronic renal failure

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Reiter’s Syndrome

Classic presentation is a young male with a triad of : Urethritis, Conjunctivitis Oligoarticular arthritis.

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SLEIs an autoimmune disease that can

involve the skin, kidneys, blood vessels, joints, nervous system, heart, and other internal organs

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SLE - SymptomsSkin rashArthritisFeverAnemia

Hair lossUlcers in the mouth

Kidney damage

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SLE - EpidemiologyInherited tendencyAffects women about 9 to 10 times as often as men

3x more common in African-American women

All ages, average age 30

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Lyme DiseaseSpirochete B. Burgdorferi transmitted from a tick bite

Erythema Migrans-”target lesion”Unexplained fever, sweats, chills, flushing, swollen glands, sore throat, fever, HA, stiff neck, body aches & fatigue.

Treated with Doxycycline, Amoxicillin or Cephalosporins

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Giant Cell ArteritisEarly symptoms of giant cell arteritis also may resemble the flu. People are likely to experience headaches, pain in the temples, and blurred or double vision. Pain may also affect the jaw and tongue.

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Polymyalgia Rheumatica

Primary symptoms of polymyalgia rheumatica are moderate to severe stiffness and muscle pain near the neck, shoulders, or hips. The stiffness is more severe upon waking or after a period of inactivity, and typically lasts longer than 30 minutes. People with this condition also may have flu-like symptoms, including fever, weakness, and weight loss.

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Sjogren's Syndrome Affects an estimated 2 million to 4 million people in the United States•Dry eyes Dry mouth•Dental cavities•Fatigue•Low-grade fever•Enlarged parotid glands •Difficulty swallowing or chewing

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Sjogren's Syndrome con’tOral yeast infectionsNosebleedsBruisingSkin rashes or dry skinVaginal drynessShortness of breath

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Sjogren's Syndrome-risk factors Having a rheumatic disease. Approximately half of the people who have Sjogren's syndrome also have a rheumatic disease

Being female. Women are nine times more likely than men to have Sjogren's syndrome.

Being a certain age. Sjogren's syndrome is usually diagnosed in people between the ages of 45 and 55. It rarely occurs in children or teenagers.

Having a family history. Sjogren's syndrome sometimes runs in families.

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Psoriatic Arthropathy Affects about 7% of patients with psoriasis

Enteropathic ArthritisAbout 10-20% of Crohn’s disease and ulcerative colitis patients can develop peripheral joint arthritis.

Tuberculous Arthritis• Seen in undiagnosed TB and affects spine (Potts dz) and lower extremities

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FibromyalgiaA condition with generalized muscular pain, fatigue, and poor sleep

Affects nearly 4 million people

Fibromyalgia means pain in the muscles, ligaments and tendons

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Scleroderma

Causes thickening and hardening of the skin

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Multiple Sclerosis MSChronically progressive degenerative disease caused by sporadic plaques, demyelination slowly stops impulse conduction of a nerve

Etiol: unknown - illness, trauma F>M

75% prolonged remissions4 stages

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Multiple SclerosisDx: MRIRx: Low fat diet, Linoleic acid Plasmapheresis during exacerbations

Drugs to autoimmunityNursing - Safety sensationSupport: Physical 2˚ weaknessEmotional - Financial

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Myasthenia GravisChronic autoimmune deficit in neuro-transmission to motor end plates of voluntary muscles

F 2x > M, age 20-30 F, > 40yrs M Thymus 80%, weak shoulder girdle

Dx & Rx: Anti-cholinesterase (tensilon) with improve symptoms.

Thymectomy

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Question #1 A common hand deformity in

rheumatoid arthritis is:a. Radial deviation.b. Supination deformity.c. Ulnar deviation. d. Flexion contracture.

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Question #2Which of the following symptoms would you expect a patient with RA to have?a. Morning stiffness.b. High energy level.c. Bouchard’s nodes.d. Increased flexibility.

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Question #3

Which of the following is a therapeutic modality used for symptom management in RA?a. Avoid periods of rest throughout the day.

b. Exercise to promote ROM & flexibility.

c. Acetaminophen as 1st line drug.d. Raisins soaked in apple cider vinegar.

Question #4 Which of the following inflammatory disorders classically presents in young men along with urethritis, conjunctivitis, and oligoarticular arthritis?

A) Amyotrophic Lateral Sclerosis B) Gout C) Reiter’s Syndrome D) SLE

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Question #5Which of the following does NOT usually present with flu-like symptoms?

Lyme DiseaseGiant Cell ArteritisPolymyalgia RheumaticaSjorgen’s Syndrome

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Patients with which of the following conditions sometimes develop arthritis:

Psoriasis Chrohn’s DiseaseTuberculosisAll of the aboveNone of the above

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Queston #6

Question #7Which pair of conditions BOTH affect nerves

A) Fibromyalgia and SclerodermaB) Multiple Sclerosis and Fibromyalgia

C) Myesthenia Gravis and Multiple Sclerosis

D) Scleroderma and Myesthenia Gravis

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