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What are type IV autoimmune diseases?
- Develop when the immune system destroys normal body tissues or provokes abnormal growth of an organ or abnormal changes in organ function
- Mechanism is unknown
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What is Reumatoid Arthritis?
- Triggered by a combination of genetics and environment.
- Produces a measurable reumatoid factor (RF)
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Four stages of RA development
- Infiltration by lymphocytes, macrophages, and neutrophils
- WBCs and fibroblast-like synovial cells produce enzymes that help to degrade bone and cartilage
- Pannus formation from thickened layers of granulation tissue, which destroys joint capsule and bone
- Fibrous ankylosis from fibrous invasion of the pannus and scar formation that occludes the joint space
- Bone atrophy and malignment cause visible deformities
- Fibrous tissue calcifies, resulting in bony ankylosis and total immobility
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Diagnosis of RA
- Morning joint stiffness lasting at least 1 hour
- Swelling of three or more joints
- Swelling of the wrist, PIP, or MCP joints
- Symmetrical joint swelling
- Rheumatoid nodules
- Radiographic changes
- Joint erosions on x-ray
- Rheumatoid factor
- Elevated RF levels take awhile to appear and may be found in people that do not have RA
- labs:
- --RA antibody (rheumatoid factor)
- --HCT & Hgb
- --Serum compliment
- --C-reactive protein
- X-rays may do MRI
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Tx for RA?
- Goal low disease activity or remission accomplished through early diagnosis and aggressive tx to prevent/address joint and decreased mobility
- Control of synovitis essential—pain control alone is not enough—ongoing presence of swollen joints implies ongoing disease activity and potential for destruction;
- --Relieve pain (regular non prn NSAIDs), reduce inflammation, protect articular surfaces, maintain function, and control systemic involvement
- --Aggressive tx
- ----Use of > 1 disease modifying anti rheumatoid drugs (DMARDS); combination therapy is increasingly common BUT
- ----Aggressive treatment carries risk for immunosuppressive complications—balance must be struck between disease progression and treatment risks
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Rx Tx for RA?
- Disease Modifying Anti rheumatic Drugs
- Methotrexate is usually first line of therapy added to the NSAIDS
- Other—(not used as much anymore) injectable gold, penicillamine, azathioprine, chloroquine, hydroxychloroquine, sulfasalazine, oral gold
- Biologic Response Modifiers—directly modify the immune system by inhibiting cytokines. Etanercept, Infliximab, adalimumab and anakinra
- Protein-A immuno adsorption Therapy—therapy that filters blood to remove antibodies and immune complexes
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Nursing care of RA?
- Assess joints, looking for deformities, contractures, immobility, and inability to perform ADLs (consult PT and OT)
- Monitor VS and note weight changes, sensory disturbances, and level of pain
- Give meticulous skin care, checking for rheumatoid nodules and pressure ulcers
- Monitor duration of morning stiffness (predictive)
- Provide patient education about medications, rest, balanced diet, ADL aids, AF/support groups
- Room arrangement for impaired mobility (de-clutter)
- Apply cold packs to affect joints
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What is ankylosing spondylitis?
- Rheumatic disease but inflammation is primarily at the enthesis (point at which ligaments, tendons and joint capsule are inserted into bone) → fibrosis, ossification, fusion of the joint Member of diseases called spondyloarthropathies
- Inflammatory joint disease of the spine or sacroiliac joints causing stiffening and fusion of the joints
- Cause unknown but there is a strong association with HLA-B27 antigen (genetic predisposition
- Begins with the inflammation of fibrocartilage, particularly in the vertebrae and sacroiliac joint inflammatory cells infiltrate and erode fibrocartilage
- As repair begins, the scar tissue ossifies and calcifies; the joint eventually fuses
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What is Sjögren’s syndrome
- Chronic arthritis accompanied by dry eyes and dry mouth (first described by Swedish physician Henrik Sjögren)
- Dental carriers significant problem with dec. salvia
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What is fibromyalgia?
- Chronic pain disorder of unknown etiology
- Possible factors/contributors?
- --Flu like viral illness, chronic fatigue syndrome, HIV infection, Lyme disease, medications, physical or emotional trauma
- Characterized by widespread musculoskeletal aches and pains, stiffness, and general fatigue.
- Swelling in soft tissues, tender points and muscle spasms or nodules
- Associated with non-restorative sleep disorder
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Diagnosis of fibromyalgia?
- Client hx of chronic widespread pain
- Tender points at specific locations
- Occipital, low cervical anterior aspects of inner-transverse spaces at C5-7, trapezius, supraspinatus, lateral epicondyle, gluteal, greater trochanter, knees
- Labs --normal
- R/O hypothyroidism, lupus, rheumatoid arthritis, infections
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SnSs of Fibromyalgia?
- Diffuse, dull, aching pain that is typically concentrated across the neck, shoulders, lower back, and proximal limbs
- Pain often worse in morning, sometimes accompanied by stiffness
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Tx for fibromyalgia?
- No cure
- Treat symptomatic
- Heat or cold application, massage, stretching, range-of-motion exercises
- Relax muscles (amitriptyline, cyclobenzaprine, hypnotic agents, anxiolytic drugs, anti-depressant med
- TREAT depression if present (often present)
- Improve Sleep
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What is systemic Lupus?
- Chronic, Multisystem, Inflammatory Disease
- Chronic, Multisystem, Inflammatory Disease
- Potentially fatal autoimmune disease characterized by unpredictable exacerbations and remission
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Predisposing factors for systemic lupus?
- 85 % are women (female to male ratio 9:1)
- Hormones
- Most cases after menarche and before menopause
- 1:1000 white women
- 1:250 black women
- Genetics
- Morbidity
- 5- year survival > 95%
- 10 year survival rate is 85%-90%
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Clinical manifestations of SEL?
- Vary by pt
- Common presenting complaint is photosensitive rash with alopecia or arthralgias
- May present with fever and single organ involvement
- Rare to present with severe, generalized acute lupus crisis with multi-organ involvement
- 90% experience fatigue
- Persistent fever, anorexia, malaise, weight loss less common (but more serious)
- Arthralgias
- Rash: butterfly and discoid
- Alopecia (50%)
- Peripheral vascular
- Renal disease--> proteinurea, hematuria, ^BUN/creatinine
- Hematologic abnormality (10%): clots
- Ocular
- Cardiovascular: Heart inflammation (pericarditis, endocarditis, myocarditis) leading to CP and dysrhythmias
- Pulmonary: (pleurisy/pleural effusions) leading to CP and SOB
- Neurologic: Seizures, psychosis, HA
- GU (50%)
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Tx for SEL?
- Wide range of disease from benign (requiring little treatment other than supportive care) to life-threatening
- Supportive care/emotional support is extremely important for all
- Challenges belief of control over life
- Feelings of helplessness may be more disabling than the disease
- Like most autoimmune diseases SLE is characterized by frequent remissions and exacerbations
- Can be very difficult to deal with
- Promotion of healthy life style
- Maintenance of proper nutrition
- Preventive measures such as influenza and pneumococcal vaccination, TB testing, prudent diet, exercise improves health status
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Skin care for SEL?
- Impaired skin integrity
- Clean dry and moisturize intact skin
- Use warm (not hot!) water, unscented lotion (Eucerin)
- Nutrition and hydration
- Prophylactic pressure-relieving devices
- Avoid ultraviolet light
- Maximum sun screen/protective clothing
- Medication instructions
- Availability of special makeup to cover rash (Covermark by Lydia O’Leary)
- Oral care
- Mouth ulcers
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Tx for alopecia in SEL?
- Usually during exacerbation/ may regrow but may be different texture; will not regrow over scar tissue
- May be caused by high dose prednisone (will usually regrow as doses decrease)
- Use mild shampoo and decrease frequency of shampooing
- Evaluate emotional impact
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Tx for joint pain/stiffness, and fatigue in SEL
- Pain:
- relief techniques including medication (see NC for pain)
- Anatomically correct position of joints to prevent contractures
- Ambulation aids if pain related to withgt bearing
- Bed cradle to relive pressure of bed covers
- OT/PT consult as needed
- Joint Stiffness:
- 15 minute warm shower
- ROM
- Time activities
- Anti-inflammatory medication as directed
- Avoid prolonged inactivity
- Fatigue:
- History. Related to activity, sleep patterns, depression
- Reinforce energy-conservation principles (pace, rest, organize, use assistive devices
- Warm bath prior to sleep
- Sleep in anatomically correct position
- Change position frequently
- Avoid stimulating foods
- Progressive muscle-relaxation techniques
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Rx Tx for SEL?
- Antimalarials (hydroxychloroquine {Plaquenil) and chloroquine (Aralen)} may be helpful for rashes and joints—takes weeks or months to work and not used for serious, systemic forms of SLE—(that affect the organs)
- Corticosteroids used to control serious complications
- 40-60 mg of prednisone initially with tapering to lowest effective dose—cannot be abruptly stopped if tx is greater than 3-4 weeks
- CNS involvement may require higher doses
- Immunosuppressive agents (cyclophosphamide [Cytoxan], Methotrexate [Rheumatrex] and cyclosporine improves renal survival)
- Anticoagulation (INR > 3) for clotting or arterial or venous systems
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