NUR 265 EXAM 4 STUDY GUIDE
18: ARTHRITIS AND COMMON TISSUE DISEASES
LUPUS ERYTHEMATOSUS (DLE/SLE)
>>> PATHO
• Lupus is probably caused by a complex
... [Show More] combo of genetic and environmental factors • 2 main classifications:
o Discoid lupus erythematosus (DLE) – effects only the skin o Systemic lupus erythematosus (SLE) – more common • Systemic lupus erythematosus (SLE):
o Chronic, progressive, inflammatory connective tissue disorder that can cause major body organs/systems to fail
o Spontaneous remissions and exacerbations o Onset may be acute or insidious (slow) o Potentially fatal, but most live many years
o Autoimmune process – invades organs or deprives them of blood and oxygen o Immune complexes invade organs directly or cause vasculitis (vessel inflammation), which deprives the organs of arterial blood and oxygen. o Autoimmune complexes tend to be attracted to glomeruli of the kidneys o Often some degree of kidney involvement (lupus nephritis) – this is the leading cause of death from this disease
o Onset at 20-40 years old
>>> ASSESSMENT
>> PHYSICAL ASSESSMENT
• When in remission pt. may appear fully healthy
• When disease flares up, pt. may need to be admitted to the hospital
• MT skin condition daily and at every home visit
>> PSYCHOSOCIAL ASSESSMENT
• Psychosocial results can be devastating
• Chronic weakness and fatigue may prevent pt. from being as active
• May avoid social gatherings
• Fear and anxiety from unpredictability
• Limit sun exposure to prevent exacerbations
>> LABS
• Skin biopsy – confirms diagnosis o MD scraps skin cells from rash to be looked at under a microscope
• Immunologic-based lab tests – same as rheumatoid arthritis
• CBC – often shows pancytopenia (a decrease of all cell types) • Electrolytes • Kidney fx.
• Cardiac and liver enzymes
• Clotting factors
>>> INTERVENTIONS
• The primary health care provider often prescribes potent drugs that are used topically and systemically
• Many of the skin lesions do not disappear with treatment, but will usually fade when in remission
>> DRUG THERAPY
• DLE major concern is the rash or discoid lesions
• Topical cortisone drugs – help reduce inflammation and promote fading of lesions
• Tylenol or NSAIDs – treat joint and muscle pain and inflammation
• Hydroxychloroquine – decreases the absorption of UV light by the skin, therefore decreasing the risk for skin lesions o Eye exams before starting drug and every 6 months while on it
• Chronic steroid therapy – treats the systemic disease process
• Immunosuppressive agents (methotrexate or azathioprine) – for renal of CNS lupus o Continue to take while in remission to help prevent more exacerbations
• Chronic lupus = low dose steroids forever
• DRUG ALERT!! – when taking steroids or immunosuppressants avoid large crowds and ill people. Report early S/S of infection to DR, take meds early in the morning before breakfast (time when the body’s natural corticosteroid level is lowest)
• For severe renal involvement, immunosuppressants may be given in combo with steroids
• New drugs:
o Lupozor o Belimumab (Benlysta)
Increases risk for infection
Do not receive live viruses for 30 days before tx.
>> PROTECTING THE SKIN
• PROTECT SKIN TO PREVENT AN EXACERBATION
• ACTION ALERT!! – Avoid prolonged exposure to sunlight and other forms of UV light, wear long sleeves and large-brimmed hat when outdoors, use sunblock SPF 30 or higher.
• CHART 18-12 SKIN PROTECTION FOR LUPUS ERYTHEMATOSUS o Wash with mild soap (Ivory) and dry skin thoroughly by patting NOT rubbing.
o Avoid harsh perfumed substances
o Cosmetics should include moisturizers and sun protectant o Use lotions o Avoid powders, rubbing alcohol, and drying agents.
o Use gentle shampoos and avoid harsh hair treatments (Alopecia/hair loss is common)
o Avoid direct sunlight and ultraviolet light including tanning beds o Wear long sleeves, wide-brimmed hats, long pants when in the sun o Use sunscreen – SPF 30 or higher o Inspect skin daily for rashes and lesions.
CARE MANAGEMENT
• 2 major differences exist between SLE and rheumatoid arthritis (RA) in terms of education of the pt. and family o 1. SLE – how to protect the skin o 2. SLE – MT body temp. (fever is a major S/S of exacerbation)
• Teach the importance of reporting any other unusual or new S/S to the primary MD immediately.
• Identify coping strategies and support systems for the unpredictability of this condition – fear and anxiety
• Pregnancy can be a stressor that causes an exacerbation (during and after birth) o Increased risk for stillbirth, miscarriage, and premature birth
o Pregnancy not recommended for those with renal, cardiac, and CNS involvement
SYSTEMIC SCLEROSIS – (SCLERODERMA)
>>> PATHO
• Systemic sclerosis (SSc): “scleroderma” is a chronic, inflammatory, autoimmune connective tissue disease
• Autoimmunity is the suspected cause
• More common in women • Usually 25-55 y.o.
• Most common are women in their 40’s
• Scleroderma: hardening of the skin
• SSc is less common than systemic lupus erythematosus (SLE) but has a higher mortality rate
• Patients with the limited form of the disease often have the CREST syndrome:
o Calcinosis (calcium deposits)
o Raynaud’s phenomenon (1st S/S that occurs) o Esophageal dysmotility
o Sclerodactyly (scleroderma of the digits) o Telangiectasia (spider-like hemangiomas)
>>> COLLABORATIVE CARE >>> ASSESSMENT
>> PHYSICAL ASSESSMENT
• Arthralgia: joint pain and stiffness – very common
• Inspection of the skin depends on the stage of the scleroderma o Painless, symmetric, pitting edema of the hands and fingers “sausage-like”
Skin is taut, shiny, and free of wrinkles o Edema may progress to
include the entire upper and lower extremities and face • If diffuse scleroderma occurs indurative phase:
o Swelling is replaced by tightening, hardening, and thickening of skin tissue o The skin loses its elasticity, and range of motion is markedly decreased o Joint contractures may develop leaving the pt. unable to perform ADLs independently
o Major organ damage is common – especially the renal and cardiopulmonary systems
o The initial GERD S/S progress into other problems
Esophagus loses its motility, resulting in dysphagia (difficulty swallowing)
• Assess for the pt. ability to swallow before allowing them to drink or eat food
o Peristalsis is diminished – S/S of a partial bowel obstruction o Malabsorption is common, causing malodorous diarrheal stool o Cardiac S/S:
Raynaud’s phenomenon
• From exposure to cold or emotional stress, the small arterioles in the fingers and toes rapidly constrict, causing decreased blood flow.
• Severe cases – digital necrosis, severe pain, and autoamputation of the distal digits (tips of the fingers fall off spontaneously)
• Periungual lesions: lesions around the nail beds. Myocardial fibrosis – seen in ECG (dysrhythmias and chest pain) o Lung S/S:
May be undetected until late in the disease or sometimes until autopsy
Fibrosis of the alveoli and interstitial tissue – present in most cases with no S/S o Renal S/S:
Often causes malignant HTN and death
Assess for S/S of impending organ failure – changes in urine output and increased BP
>> LABS
• Similar to SLE
• Clinical findings and the pt.’s response to drug therapy help the health care provider differentiate between the 2 diseases.
>>> INTERVENTIONS
Management aims to force the disease into remission and thus slow disease progression
Systemic steroids and immunosuppressants are used in large doses and often in combination
• Identify early organ involvement and treat it before it becomes severe and irreversible
• Use mild soap and lotions, and gentle cleaning techniques
• Inspect skin for changes and open lesions
• Bosentan (Tracleer) – endothelin receptor antagonists o Improves pt. breathing during exercise o MT for liver toxicity and birth defects
• Pain meds for chronic joint pain and severe, acute pain during episodes of Raynaud’s phenomenon
• Have PCA use a bed cradle and foot board to keep bed covers away from the skin in severe cases.
• Adjust room temp to prevent chilling – causes digit vasospasms o Recommend gloves and socks if skin can tolerate
• Avoid stress
• Avoid smoking
• Swallow study if esophageal is involved
• CHART 18-13 CARE FOR SSc AND ESOPHAGITIS o Keep HOB elevated at least 60* during meals and for 1 hr. after meals o Small, frequent meals, NO 3 large meals a day o Give small bites, chew each bite carefully before swallowing
o Semisoft foods (mashed potatoes, pudding, custard) liquids can cause choking o Dietician
o Avoid foods that increase GI secretions (caffeine, pepper, spices, spicy foods, alcohol)
o Give antacids or histamine antagonists as needed
LYME DISEASE
Lyme disease: systemic infectious disease caused by spirochete Borrelia burgdorferi and results from the bite of an infected deer tick (“black-legged tick”)
Most common vector-borne disease in the US and Europe o Most common in - New England, Maryland, Virginia, Wisconsin, Minnesota, and northern California
STAGE 1
• Early and localized stage
• S/S:
o Flu-like S/S
o Erythema migrans: round or oval, flat or slightly raised rash
o Pain and stiffness in the muscles and joints o Bull’s-eye lesion – a single lesion
• Symptoms begin within 3-30 days of the tick bit,
(usually 7-14 days)
• Antibiotic therapy (doxycycline or amoxicillin) is prescribed during this uncomplicated stage for 14-21 days o Erythromycin – used for pt. allergic to penicillin o w/o treatment, S/S will disappear in about 4-5 weeks
STAGE 2
• If not treated or treatment is not successful
• Early disseminated stage • Occurs 2-12 weeks after tick bite
• S/S:
o Carditis with dysrhythmias, dyspnea, dizziness, or palpitations
o CNS disorders – meningitis and facial paralysis (often misdiagnosed as Bell’s palsy), and peripheral neuritis
LATE STAGE 3
• If not diagnosed and treated in the earlier stages
• Chronic complications – arthritis, chronic fatigue, memory/thinking problems)
• Chronic persistent stage
• Occurs months to years after the tick bite
• For some pt. the 1st and only S/S of Lyme disease is arthritis
In some cases, the disease may not respond to ABX in any stage, and the pt. develops permanent damage to joints and the nervous system Prevention is the best strategy for Lyme disease
CHART 18-14 PREVENTION AND EARLY DETECTION OF LYME DISEASE
• Avoid heavily wooded areas or areas with think underbrush, especially during spring and summer
• Walk in the center of the trail
• Avoid dark clothing – lighter-colored clothing makes spotting ticks easier
• Use an insect repellent (DEET) on skin and clothes
• Wear long sleeves and pants, tuck your shirt and pants in
• Wear closed toed shoes and a hat
• Bathe immediately after and inspect your body for ticks
• Check your pets for ticks
• Gently remove with tweezers or fingers covered with tissue or gloves o Flush down toilet
o Burning could spread infection
• After removal, clean the tick area with an antiseptic (rubbing alcohol)
• Wait 4-6 weeks to be tested for Lyme disease – testing before this time is not reliable • Report S/S such as rash or flu-like illness immediately
FIBROMYALGIA SYNDROME (FMS)
• Chronic pain syndrome, no inflammation present
• Remissions and exacerbations
• Arthritis and other comorbidities are commonly present
Pain, stiffness, and tenderness located in specific sites: back of the upper neck, upper chest, trunk, lower back, and extremities NO CURE
• Symptomatic treatment
• Most common in women 30-50 years old
TRIGGER POINTS
• Can palpate to cause pain in a predictable pattern
• Pain described as burning and gnawing
• Increased muscle tenderness – from inability to tolerate pain, may be a dysfunction in the brain
• Pain and tenderness come and go but tend to worsen with stress, increased activity, and weather conditions. [Show Less]