Connective Tissue Diseases

Question 1

Arthritis, or inflammation of the joints, has many etiologies

Most prevalent are -
* Osteoarthritis (OA)
* Rheumatoid arthritis (RA)
* Gout/gouty arthritis

Answer 1

Differential features of RA & OA

Question 2

RA

• inflammatory, autoimmune, genetic component, younger onset; women to men 3:1
• Inc RF factor, ESR, ANA
• Meds: NSAIDs, methotrexate, corticosteroids, biologic response modifiers, other immunosuppressants

Question 3

OA

• degenerative, possibly genetic component; older age of onset, obesity; traumatic event; 55-60 y.o.; after 55 yrs women to men is 2:1
• Normal to sl elevated ESR
• Meds: Tylenol, analgesics, NSAIDs usually short-term & later in the dz process

Question 4

OA is classified as idiopathic or secondary

Answer 4

Note, RA can lead to OA

Question 5

?

Caused from another dz process (DM, Paget’s, hemophilia, sickle cell, RA)

Probably prev trauma or infection; infection can cause joint sepsis

Answer 5

Secondary

Question 6

?

No known cause; seen more in the hips, knees, & spine
More in women than in men; people older than 65 yrs probably genetic link

Answer 6

idiopathic/primary

Question 7

Risk factors - primary OA

• Middle-aged & older adults
• Obesity
• Repetitive joint injuries/trauma
• Genetic component
• Smoking

Answer 7

Age is the biggest risk factor

Question 8

OA - Pathophysiology

• Articular cartilage degeneration & uneven surfaces
• Thickening of subchondral bone
• Osteophyte formation
• Narrowing of joint space
• Decline in synovial fluid protection

Answer 8

• Central cartilage loss & peripheral growth of cartilage & bone causes uneven surfaces that have a grating sound (crepitus) upon movement
• Dec in synovial fluid causes less lubrication & circulation of nutrients to the joint; these in turn cause pain, limited ROM & loss of function
• Late in the dz process → 2° synovitis (inflammation) & joint effusions; bone cysts lead to bone deformations & atrophy of skeletal muscle (from guarding & not using) may be seen

Question 9

S/S - OA

• Localized pain & stiffness
• Pain relieved w/rest, not systemic pain
• Stiffness possible; atrophy of skeletal muscle that may effect ambulation
• Crepitus - grating sensation w/movement
• Asymmetrical - joint enlargement; monoarticular or polyarticular; usually r/t bony hypertrophy; not usually an inflammatory process
• Possible mild swelling
• not usually warm; may have joint effusions esp in knees from inc synovial fluid

Answer 9

• Pain w/activity, improves w/rest
• pain early on; pain dec w/rest & gets worse w/activity; late phase, pain can occur @ rest
• Joint enlargement incl Heberden’s & Bouchard’s nodules
• Possible “locking” or “giving way” of joints

Question 10

Bouchard’s & Heberden’s Nodes in OA

• Heberden in the DIP joint (distal interphalangeal joints)
• Bouchard in the PIP joints (proximal interphalangeal joints)

Answer 10

• Can appear in both hands; may be red & painful

Question 11

Diagnostic testing (OA findings)

• Arthroscopy for visualization of articular surfaces - degeneration
• MRI
• X-ray films - narrowing of joint space & osteophyte formation

Answer 11

• Serological studies to look @ uric acid (gout), rheumatoid factor (RF), lyme titre, ESR for systemic sx’s [poss slightly elevated]
• Synovial fluid for color & consistency; signs of infection; crystals

Question 12

Medications

• Analgesic: acetaminophen - Tylenol
  > For mild to mod pain w/o inflammation - 1st choice
  > Monitor LFT’s @ beginning of therapy and q6-12 mos
  ! Not for persons w/liver dz or increased ETOH intake

! No greater than 3g max/day incl additive effects of Percocet & Darvocet, etc.

Answer 12

NSAIDs (nonselective):

• Ibuprofen - Motrin
• Naproxen - Naprosyn
• Indomethacin - Indocin

COX-2 selective inhibitor: Celecoxib [Celebrex]

Question 13

NSAIDs

• analgesic & anti-inflammatory; prevent prostaglandin formation
• caution w/cardiac dz - inc fluid overload & BP
• caution for GI bleeding - misoprostol (Cytotec) can be given w/NSAID; Cytotec produces prostaglandins for mucosal protection
• Monitor renal & liver fxn tests
• Avoid use w/other NSAIDs, steroids, anticoagulants, & ETOH - inc bleeding

Answer 13

• Celecoxib is less of an issue w/dec GI prostaglandins
• NSAIDs may actually disrupt articular cartilage metabolism
• COX-2 inhibitors - not used as much r/t evidence of cardiovascular disorders like MI

Question 14

Opioid analgesics
- codeine
- oxycodone - Percodan, Percocet
- Propoxyphene - Darvon, Darvocet [taken off market for cardiac arrhythmias]

Steroid injection - Kenalog, Depo-Medrol

Viscosupplementation
- Synvisc - Hylan G-F 20
- Orthovisc - Hyaluranon/hyaluronic acid

Answer 14

Opioids

• Monitor for CNS & respiratory depression
• s/e: nausea, constipation, dizziness
• Monitor for renal/hepatic toxicity; safety precautions; drug dependence
• Hyaluronan is a polysaccharide similar to synovial fluid & promotes independent articular production of synovial fluid for several mos

Question 15

Dietary supplements

?

This improves elasticity of cartilage; ! monitor for bleeding

Answer 15

condroitin

Question 16

SAM-e (5-adenosylmethionine)

Repairs cartilage by improving proteoglycans

Question 17

?

Used to make & repair cartilage; s/e - inc blood glucose lvls & INR; diarrhea, HA

Answer 17

glucosamine

Question 18

Topical Agents

• Capsaicin - may produce a cutaneous burning sensation that resolves w/time
• Icy Hot
• Aspercreme
• Lidocaine 5% patch [! can slow cardiac electrical activity]

Question 19

For inflammation, should we treat with cold or heat?

Answer 19

Cold

Question 20

Non-Medication Interventions

• Weight loss
• Smoke cessation
• Rest
• Repositioning
• Heat/cold
• Protect joints from trauma/stress

Answer 20

! Heat inc circulation & dec muscle tension; can create edema

! Cold numbs nerve endings; also vasoconstricts

• Protect & cover skin - thermo source not directly on skin; 20 min on/off & check skin following protocol

Question 21

Surgical Management

• Joint debridement or abrasion
  > Abrasion chondroplasty performed w/arthroscopy stimulates growth
• Cartilage transplant
  > w/graft or chondrocyte inj
• Osteotomy - surgical incision in bone to redistribute the load-bearing surface of a joint

Answer 21

• Arthrodesis - fusion of the bones of a joint usually of cervical & lumbar spine, finger, wrist, & ankle
• Arthroplasty - joint replacement usually of the hip & knee but can be performed on shoulder, fingers, ankle, & elbow
  ! preserves ROM

Question 22

Varus deformity - knee osteotomy

• Tibial osteotomy may delay knee replacement for 10 yrs

Answer 22

Arthrodesis

• Joint fusion w/allograft, cadaver bone or hardware
  > bone graft in hardware [photo]

Question 23

Arthroplasty

• Joint replacement w/hardware maintains ROM as compared to arthrodesis

Answer 23

Total knee replacement (TKR)

• Gen anesthesia w/opiates or continuous femoral nerve block (CFNB) into the femoral or sciatic nerve
• Less opiates req’d >surgery so faster rehab
• Knee brace, CMS checks, plantar & dorsiflexion but no pain is normal

! systemic warning of infusion -
slurred speech, hypotension, dec resp, metallic taste, tinnitus

Question 24

Continuous passive motion (CPM) machine

• Leg is placed slightly abducted
• Pt’s leg is started at 0° of flexion & over a period of days inc the ° of flexion to the hcp’s orders; HOB no more than 15° off CPM to elevate HOB & eat
• Can be very uncomfortable; there’s conflicting research on the efficacy on the use of CPM

Answer 24

Key Points - CPM

↣ Lining up the knee joint w/the joint in the CPM for flexion
↣ Making sure that the pt has the controller to stop the machine
↣ Shut off when the leg is in extension
↣ Check the skin for any reddened areas & instruct the pt to notify you if any discomfort noted
↣ Pre-medicate for pain; straight leg raises & isometrics to inc extremity muscle strength
↣ MD may order a knee brace for knee extension
↣ CryoPad, ConstaVac
↣ ! No hyperextension of knee - usually no pillow under the popliteal space - can contribute to contracture
↣ May lock the bottom of the bed so the knee will not flex

Question 25

OA of hip e.g., hardware - hemiarthroplasty prosthesis Anterior approach - more muscle damage but dec risk of dislocation

Answer 25

Posterior approach - less muscle damage but inc risk for dislocation & sciatic nerve injury

Question 26

Complications of TKR & THR ! Infection ! Blood vessel injury/blood loss/hypotension ! Nerve injury ! Fat embolism ! DVT/PE ! Dislocation or instability of joint ! Loosening of prosthesis ! Compartment syndrome

Answer 26

- Prosthesis can be cemented or non-cemented - Non-cemented has a rough coat on the prosthesis so that the bone grows into the prosthetic - Cemented joints usually able to be PWB to FWB as tolerated - Non-cemented-PWB for a few wks until bone grows in - Start w/walker or crutches & advance to single cane 4-6 wks >surgery - Collaboration w/PT for early ambulation & leg exercises to strengthen muscles, improve balance, dec risk of clots

Question 27

Nursing Interventions ↣ No adduction beyond midline; abduction splint/wedge (hip) ↣ No flexion of hip beyond 90° ↣ No extreme external/internal rotation (hip) ↣ No lying on operated side (hip)

Answer 27

↣ Report acute pain, rotation, & extremity shortening ↣ Maintain drain(s) - JP/Hemovac - make sure they're compressed - ConstaVac - able to autologously re-transfuse blood; empty q4h & prn ↣ Prevent thrombus formation - anticoag's, dorsiflexion/plantar flexion - Heels off bed - risk for decubitus ! prevent infection ↣ Regular pulmonary toilette

Question 28

↣ Do not put pillow under knee for TKR, keep knee @ 180° ↣ Weight-bearing activities as ordered w/inc activities as tol/assistive devices ↣ Pain control/PCA/CFNB - check CMS q2-4 hrs - alt sensation, alt amb r/t nerve block ↣ CPM machine - knee brace to help stabilize ↣ Prophylactic abx (for dental work hardware) ↣ Metal may activate metal detectors/MRI

Answer 28

↣ If getting into systemic circulation = restlessness, metallic taste, hypotension, bradycardia, dec resp, slurred speech ↣ Pillow placement less bulky ↣ Fracture bed pan vs regular pan

Question 29

↣ Observe dressing for drainage & reinforce/aseptic dressing change >1st MD change ↣ CMS checks (compared to unoperated extrem) - monitor for DVT, ! compartment synd ↣ Keep incision dry, no tub baths/shower seat - no showers for about 3 days; then cover with Tegaderm - shower seat d/t instability created from incision ↣ Rehab; PT/OT

Answer 29

* Pt may be d/c'd home (usually about 4-5 days post-op) if can transfer independently to & from the bed, walk alone 150 ft on a flat surface, & safely negotiate stairs - If not, then may go to a SNF or rehab center * OT & PT will need to work w/pt to strengthen the muscles that had been severed during surgery * Pt unable to drive for until muscles heal & strength & stability return ! Hip dislocation - shortening of LE; inc pain; leg rotation adduction

Question 30

? Chronic, inflammatory dz of connective tissue throughout the body Systemic manifestations incl anorexia, wt loss, fatigue, muscle aching & stiffness, joint pain & stiffness Is **autoimmune** & **has a genetic component** (allele of the MHC on the short arm of chromosome 6) Inflamed synovial membrane & bone erosions Periarticular osteopenia in hand or wrist joints is common

Answer 30

Rheumatoid Arthritis

Question 31

* Usually dx'd @ a younger age & more prevalent among women * Subchondral cysts, inflamed synovial membrane, eroded cartilage

Answer 31

Pathophysiology ↣ Inflammation w/an unk etiology - most likely autoimmune etiology ↣ Proliferation of the synovial membrane ↣ Erosion of articular cartilage & subchondral bone ↣ Can extend beyond joint into soft tissue - **can become systemic**

Question 32

S/S - RA * Painful, stiff, red, warm, swollen joints * Bilateral & symmetrical * Mostly hands, knees, elbows, feet, wrist, ankle * Systemic involvement * Muscle atrophy * Joint fusion/dislocation

Answer 32

* Inflammatory response (systemic sx's) - low-grade fever, fatigue, weakness, anorexia, paresthesias * Mod to severe pain w/morning stiffness * Ulnar deviation * Systemic involvement - fatigue, anemia, wt loss, fever, vasculitis, SC nodules over bony prominences, bone erosions

Question 33

RA - late stage * Tenosynovitis (inflammation of the tendon sheath) on the wrist is common & carpal tunnel can result * Boutonniere deformity (of thumb) * Ulnar deviation (of metacarpophalangeal joints) * Swan-neck deformity (of fingers)

Answer 33

* Nodules over extensor surfaces * Not painful in themselves but expose a person to integument issues if traumatized & skin breaks * Other systemic sx's may incl osteoporosis, peripheral neuropathy, vasculitis, pericarditis, fibrotic lung dz, Sjogren's dz, renal dz

Question 34

Systemic complications * Vasculitis * Pulmonary - pleurisy, pneumonitis, diffuse interstitial fibrosis, Caplan's syndrome * Cardiac - pericarditis, myocarditis * Eyes - iritis, scleritis

Answer 34

Sjogren's syndrome - **dry eyes** - **dry mouth (xerostomia)** - dry vagina

Question 35

* Felty's syndrome - hepatosplenomegaly, leukopenia

Question 36

Diagnostics * xray bone erosion in hand or wrist joints; narrowing joint space * (+) serum rheumatoid factor (RF) test * elevated ESR & C-reactive protein (CRP) > indicators of inflammation

Answer 36

- inc synovial fluid - inc WBC, cloudy, volume, rf - ice & rest for 24h; monitor for bleeding or synovial leakage - RF is an antibody to IgG - anti-CCP, cyclic citrullinated protein, antibodies are more specific for RA * Elevated WBC, anemia, thrombocytosis * Elevated ANA

Question 37

Medications * NSAIDs DMARDs: disease-modifying anti-rheumatic drugs - methotrexate (Rheumatrex) - sulfasalazine (Azulfidine) - penicillamine (Depen) - azathioprine (Imuran) - gold compounds - hydroxychloroquine (Plaquenil)

Answer 37

- NSAIDs + steroids + DMARDs for complete treatment - GI s/e's controlled w/H2 blocker, PPI's, or sucralfate - Steroid-induced osteoporosis counteracted w/calcium (1200-1500 mg/day) & vit D - Do not stop meds abruptly - Monitor for F&E balance, glucose lvls, HTN, dec healing, thinning skin, purpura

Question 38

- Methotrexate + folic acid 1 mg/day dec toxicity > Inhibits DNA synthesis of inflammatory cells s/e's > GI complaints, liver, bone marrow suppression > incl pneumonitis, leukopenia, thrombocytopenia, anemia, n/d, stomatitis - check kidney & liver function before & w/liver q4-8wks - avoid sunlight

Answer 38

penicillamine (Azulfidine) > GI upset, liver dysfunction, bone marrow suppression

Question 39

hydroxychloroquine (Plaquenil) > suppresses formation of antigens responsible for hypersensitivity rxns s/e's > HA, GI/visual disturbances, pruritus (esp palms, soles, scalp), impaired hearing > Retinopathy can progress even after med d/c'd ! Monitor CBC & liver function 400-600 mg/daily for 5-10 days, gradually inc to optimum response

Answer 39

Maintenance in 4-12 wks - dec dose 50% then maintain @ 200-400 mg/day

Question 40

Tumor Necrosis Factor (TNF) blockers leflunomide (Arava) adalimumab (Humira) infliximab (Remicade) etanercept (Enbrel)

Answer 40

↣ Neutralize the biologic activity of TNF to dec immune responses ↣ BRMs (biologic response modifiers) are a branch of DMARDs - do not give to pt w/serious infection, TB, or MS > Mantoux prior to starting drugs ↣ May take wks to mos to reach therapeutic effect so NSAIDs & steroids stay on board until that time ↣ All DMARDs are toxic to multiple body organs incl the liver, kidneys, GI, lungs, bone marrow, & eyes > They suppress bone marrow & place pt @ risk for infection, anemia, & bleeding

Question 41

Tumor necrosis factor A member of a super family of proteins, each w/157 amino acids, which induce necrosis (death) of tumor cells & possess a wide range of pro-inflammatory actions

Answer 41

TNF-alpha antagonists s/e ! flu-like sx's ! infections ! injection site irritation ! fatal pulmonary response

Question 42

* Blocking the action of TNF has been shown to be beneficial in reducing the inflammation in inflammatory cases such as Crohn's dz & RA * Remicade - infusion rxn = CP, tachy, dyspnea, light-headed, check CBC

Answer 42

Surgical treatment * Tendon transfer & osteotomy > Tendon transfers w/osteotomy & arthrodesis (fusions) are used commonly in the fingers to give them more function * Synovectomy - is removal of the synovia in the elbows, wrists, fingers, or knees b/c the dz process starts in the synovial membrane & destruction cont to other local tissues * Arthrodesis * Arthroplasty = joint replacement

Question 43

Other Interventions * Low impact exercises/wt loss/diet - yoga, walking, bike riding, tai chi all inc muscle tone to keep off wt * Heat & cold application > heat to inc circulation & elasticity of joint > cold to dec inflammation * Utilization of assistive devices * Steps for joint protection

Answer 43

* 1st line of attack is through meds, PT w/poss assistive devices, exercise, wt loss; if interventions fail, then surgery may be considered

Question 44

Gouty arthritis * Overproduction or under-excretion of uric acid - collects in joints * S/S: acute pain, redness, edema in 1 joint last approx 1 wk - primary s/s may incl systemic findings like fever, malaise * Chronic collection in kidneys (calculi), soft tissues (tophi), & arteries (atherosclerosis) - purine crystals

Answer 44

* Joints usually incl the great toe, fingers, wrist, ankle, knees

Question 45

Tophi Collection of uric acid crystals in the soft tissue

Answer 45

Question 46

Diagnostics * Inc serum ESR * Inc serum uric acid * 24 hr urine * Joint aspirate positive for uric acid crystals * Painful, swollen joints * Tophi, renal stones w/chronic gout - check renal function

Answer 46

Serum > 8.5 mg/dL = abn Urine >750 mg/24hr Aspirate is definitive

Question 47

Treatment * Ice (to dec inflammation), bedrest * Increase fluid intake (2L H2O/day), weight reduction * Lower purine diet, avoid physical/emotional stress & alcohol (is dehydrating & will inc conc of uric acid crystals) * Medications - **avoid aspirin & diuretics**

Answer 47

* Incr pH of urine w/alkaline ash foods - milk, citrus juices * Proper fitting shoes * Use of bed cradle (to keep sheets off skin) ! Foods high in purines - > fish/seafood: anchovies, herring, mackerel > meats: brains, organ meats, wild game > veggies: asparagus, cauliflower, green peas, mushrooms, spinach > grains: legumes, oatmeal, wheat bran, whole grains