Chapter 65: Nursing Management: Arthritis and Connective Tissue Diseases

ARTHRITIS
• Arthritis is inflammation of a joint.

• The most prevalent types of arthritis are osteoarthritis, rheumatoid arthritis, and gout.

OSTEOARTHRITIS
• Osteoarthritis (OA), the most common form of joint (articular) disease in North
America, is a slowly progressive noninflammatory disorder of the diarthrodial (synovial)
joints.

• Factors linked to OA include increasing age, genetics, obesity, occupations with

frequent kneeling, and lack of exercise.

• OA results from cartilage damage, leading to fissuring, fibrillation, and erosion of

articular surfaces.

• Systemic manifestations (fatigue, fever) are not present in OA, whereas they are
present in inflammatory joint disorders such as rheumatoid arthritis.

• Manifestations range from mild discomfort to significant disability, with joint pain
being the major symptom.

• As OA progresses, increasing pain contributes significantly to disability and loss of

function.

• Care focuses on managing pain and inflammation, preventing disability, and

maintaining and improving joint function.

• Symptoms are initially managed conservatively through medication, joint rest, heat
and cold, nutrition, and exercise.

• Arthroscopy to repair cartilage or remove bone bits or cartilage may be

recommended with OA progression.

• Teaching should include information about nature and treatment of OA, pain
management, posture and body mechanics, use of assistive devices, principles of joint
protection and energy conservation.

RHEUMATOID ARTHRITIS
• Rheumatoid arthritis (RA) is a chronic, systemic disease with inflammation in
connective tissue of the diarthrodial (synovial) joints, often remission and exacerbations.

• The etiology of RA is unknown; it is probably due to autoimmune and genetic

factors.

• Onset is typically insidious with fatigue, weight loss, and generalized stiffness.

• Articular signs include pain, stiffness, limitation of motion, and inflammation (e.g.,
heat, swelling, tenderness). Joint stiffness after periods of inactivity is common.
 • As RA progresses, muscle atrophy and destruction of tendons around joint cause one
articular surface to slip past the other (subluxation).

• RA can affect nearly every body system. Most common extraarticular signs are
rheumatoid nodules and Sjögren’s and Felty syndromes.
o Treatment goals include reduction of inflammation, management of pain,
maintenance of joint function, and prevention/correction of joint deformity
o Initial care usually involves drug therapy and education.

ANKYLOSING SPONDYLITIS
• Ankylosing spondylitis (AS) is a chronic inflammatory disease
primarily affecting the axial skeleton (sacroiliac joints, intervertebral disk spaces, and
costovertebral articulations).

• Most persons are positive for HLA-B27 antigen.

• Extraarticular inflammation can affect eyes, lungs, heart, kidneys, and peripheral
nervous system.

• Signs of AS are low back pain, stiffness, and limitation of motion.

• Care is aimed at maintaining maximal skeletal mobility while decreasing pain and
inflammation. Heat applications, exercise, and medications are often recommended.

• Surgery may be done for severe deformity and mobility impairment.

PSORIASIS
• Psoriasis is a common benign, inflammatory skin disorder with a possible genetic
predisposition.

• Approximately 10% of people with psoriasis for reasons unknown develop psoriatic
arthritis, a progressive inflammatory disease.

• Psoriasis can occur in different forms, all having a degree of arthritis.

• Treatment includes splinting, joint protection, drugs, and physical therapy.

REACTIVE ARTHRITIS
• Reactive arthritis (Reiter’s syndrome) occurs more commonly in young men and is
associated with a symptom complex that includes urethritis (cervicitis in women),
conjunctivitis, and mucocutaneous lesions.

• The etiology is unknown, but it appears to occur after genitourinary

or gastrointestinal tract infection.

• The prognosis is favorable; most patients have a complete recovery

after 2 to 16 weeks.

• Since reactive arthritis is associated with C. trachomatis infection,

patients and their sexual partners are often treated with antibiotics.
SEPTIC ARTHRITIS
• Septic arthritis (infectious or bacterial arthritis) is caused by invasion of joint cavity with
microorganisms.

• Large joints (knee and hip) are frequently involved, causing severe pain, erythema,
and swelling.

• This condition requires prompt treatment with antibiotics to prevent joint destruction.

• Nursing care includes assessment and monitoring of joint inflammation, pain, and
fever.

LYME DISEASE
• Lyme disease is a spirochetal infection transmitted by bite of an infected deer tick.

• A characteristic symptom of the early localized disease is erythema

migrans, a skin lesion occurring at site of tick bite 2 to 30 days after exposure.

• Viral-like symptoms, such as fever, chills, headache, swollen lymph

nodes, and migratory joint and muscle pain, also occur.

• In late disease, arthritis pain and swelling may occur in large joints.

• Antibiotics are used for active disease and to prevent late disease.

• Reducing exposure to ticks is the best way to prevent Lyme disease.

GOUT
• Gout is caused by an increase in uric acid production, underexcretion of uric acid, or
increased intake of foods containing purines, which are metabolized to uric acid by the body.

• Deposits of sodium urate crystals occur in articular, periarticular, and

subcutaneous tissues. This leads to recurrent attacks of acute arthritis.

• Risk factors are obesity (in men), hypertension, diuretic use, and excessive
alcohol consumption.

• Affected joints may appear dusky or cyanotic and are extremely tender.
Inflammation of great toe (podagra) is a common initial problem.

• Chronic gout is characterized by multiple joint involvement and visible deposits

of sodium urate crystals (tophi).

• Treatment includes drug therapy for pain management and to terminate an acute attack.

• Future attacks are prevented by drugs, weight reduction as needed, and possible
avoidance of alcohol and food high in purine (red and organ meats).

• Nursing interventions include supportive care of inflamed joints.

SYSTEMIC LUPUS ERYTHEMATOSUS
• Systemic lupus erythematosus (SLE) is a chronic multisystem inflammatory
disease with immune system abnormalities.

• The etiology of abnormal immune response is unknown; a genetic influence is

suspected.

• Extremely variable in its severity, ranging from a relatively mild disorder to rapidly
progressive and affecting many organ systems.

• Commonly affected are the skin (butterfly rash over nose, cheeks), muscles
(polyarthralgia with morning stiffness), lungs (tachypnea), heart (dysrhythmias), nervous
tissue (seizures), and kidneys (nephritis).

• Other signs include anemia, mild leukopenia, and thrombocytopenia. Infection is a

major cause of death.

• A major treatment challenge is to manage active disease while preventing treatment

complications that cause long-term tissue damage.

• Patients with mild polyarthralgias or polyarthritis are treated with NSAIDs.

Corticosteroids are given for severe cutaneous SLE. Antimalarial agents and
immunosuppressive drugs may also be used.

• Nursing care emphasizes health teaching and importance of patient cooperation for
successful home management.

SYSTEMIC SCLEROSIS
• Systemic sclerosis (SS), or scleroderma, is a connective tissue disorder with fibrotic,
degenerative, and occasionally inflammatory changes in the skin, blood vessels,
synovium, skeletal muscle, and internal organs.

• The cause of SS is unknown. Immunologic dysfunction and vascular abnormalities

may play a role in systemic disease.

• In this disorder, collagen is overproduced. Disruption of cell is followed by platelet

aggregation and fibrosis. Proliferation of collagen disrupts normal functioning of internal
organs.

• Manifestations range from diffuse cutaneous thickening with rapidly progressive and
fatal visceral involvement, to the more benign variant of limited cutaneous SS.

• Clinical manifestations are described by the acronym CREST, including calcinosis,

Raynaud’s phenomenon, esophageal dysfunction, sclerodactyly, and telangiectasia.

• No specific drug(s) have been proven effective for treating SS. However many drugs can be
used in treating the various manifestations of SS.

• Physical and occupational therapy maintains joint mobility, preserves muscle strength, and
assists in maintaining functional abilities.
POLYMYOSITIS AND DERMATOMYOSITIS
• Polymyositis (PM) and dermatomyositis (DM) are diffuse, idiopathic,
inflammatory myopathies of striated muscle that produce bilateral weakness, usually most
severe in proximal or limb-girdle muscles.

• The exact cause of PM and DM is unknown; theories include infectious agent, neoplasms,
drugs or vaccinations, and stress.

• Patients with DM and PM experience weight loss and increasing fatigue, with gradual
weakness of muscles that leads to difficulty in performing routine activities.

• DM skin changes include classic violet-colored (heliotrope), cyanotic, or erythematous

symmetric rash with edema around eyelids.

• DM and PM diagnosis is confirmed by EMG findings, muscle biopsy, and serum enzyme
levels.

• PM and DM are initially treated with high-dose corticosteroids. If corticosteroids are

ineffective and/or organ involvement is occurring, immunosuppressive drugs may be given.

• The nurse should assist the patient to organize activities and use pacing techniques to
conserve energy.

SJÖGREN’S SYNDROME
• Sjögren’s syndrome is an autoimmune disease that targets moisture-producing
glands, leading to xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes).

• It appears to be caused by genetic and environmental factors.

• Lymphocytes attack and damage the lacrimal and salivary glands in this syndrome.

• Treatment is symptomatic, including instillation of preservative-free artificial tears for

hydration and lubrication, surgical punctual occlusion, and increased fluids with meals.

MYOFASCIAL PAIN SYNDROME

• Myofascial pain syndrome is characterized by
musculoskeletal pain and tenderness in one anatomic region of the body.

• Regions of pain are often within taut bands and fascia of skeletal muscles. With pressure,
trigger points are thought to activate a pattern of pain.

• Treatment can include massage, physical therapy, acupuncture, and biofeedback.

FIBROMYALGIA SYNDROME
• Fibromyalgia syndrome (FMS)
is a chronic disorder characterized by widespread, nonarticular musculoskeletal pain and
fatigue with multiple tender points.

• Nonrestorative sleep, morning stiffness, irritable bowel syndrome, and anxiety may also be
noted.
 • The cause and pathology of FMS are being studied. It is known to be a disorder of central
processing with neuroendocrine/neurotransmitter dysregulation.

• Treatment is symptomatic and requires a high level of patient motivation, including rest,
medication, relaxation strategies, and massage.

CHRONIC FATIGUE SYNDROME

• Chronic fatigue syndrome (CFS), also called chronic fatigue and immune
dysfunction syndrome, is a disorder characterized by debilitating fatigue.

• The etiology and pathology are largely unknown.

• It is often difficult to distinguish between CFS and FMS, as many of the clinical features are
similar.

• There is no definitive treatment. Supportive management is essential.

• This condition does not appear to progress. Most patients recover or at least gradually
improve over time.