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Chapter 50: Disorders of Musculoskeletal Function: Rheumatic Disorders

Arthritis

Primary arthritis

Those affecting body systems in addition to the musculoskeletal system

Resulting from an immune response

Secondary arthritis

Rheumatoid conditions limited to a single or few diarthrodial joints

Resulting from a degenerative process and the resulting joint irregularities that occur as the bone attempts to remodel itself

Systemic Autoimmune Rheumatic Diseases

Rheumatoid arthritis

Systemic lupus erythematosus

Systemic sclerosis/scleroderma

Polymyositis

Dermatomyositis

Characteristics of Rheumatoid Arthritis

Associated with extra-articular as well as articular manifestations

Usually has an insidious onset marked by systemic manifestations such as fatigue, anorexia, weight loss, and generalized aching and stiffness.

Characterized by exacerbations and remissions

May involve only a few joints for brief durations, or it may become relentlessly progressive and debilitating

Systemic Autoimmune Rheumatic Diseases

A group of chronic disorders characterized by diffuse inflammatory lesions and degenerative changes in connective tissue

These disorders share similar clinical features and may affect many of the same organs

Treatment Goals for a Person with RA

Reduce pain

Minimize stiffness and swelling

Maintain mobility

Become an informed health care consumer

Criteria for Rheumatoid Arthritis

Morning stiffness at least 1 hour for at least 6 weeks

Swelling of three or more joints for at least 6 weeks

Swelling of wrist, metacarpophalangeal or proximal interphalangeal joints for 6 or more weeks

Systemic joint swelling

Hand roentgenogram changes typical of RA

Rheumatoid nodules

Serum rheumatoid factor

Results of Progressive Joint Destruction

May lead to subluxation (dislocation of the joint resulting in misalignment of the bone ends)

Instability of the joint

Limitation of movement

Symptoms of RA

Fatigue

Weakness

Anorexia

Weight loss

Low-grade fever

Anemia

Question #1

Is the following statement True or False?

Rheumatoid arthritis is a condition of individual joint deterioration and breakdown.

Answer to Question #1

False

Rationale: Usually has an insidious onset marked by systemic manifestations such as fatigue, anorexia, weight loss, and generalized aching and stiffness. It may involve joints sporadically or progressively.

Characteristics of Systemic Lupus Erythematosus (SLE) #1

Formation of autoantibodies and immune complexes

B-cell hyperreactivity

Increased production of antibodies against self- (autoantibodies) and nonself antigens

Characteristics of Systemic Lupus Erythematosus (SLE) #2

The autoantibodies can directly damage tissues or combine with corresponding antigens to form tissue-damaging immune complexes.

Autoantibodies

Antinuclear antibodies

Other antibodies

Platelets

Coagulation factors

Red blood cell surface antigens

Categories of Clinical Manifestations of SLE

Constitutional

Musculoskeletal

Dermatologic

Cardiovascular

Pulmonary

Renal

Neuropsychiatric

Systemic Sclerosis

Autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin and internal organs

Diffuse or generalized form

Skin changes involve the trunk and proximal extremities.

Limited or CREST variant

Hardening of the skin (scleroderma) is limited to the hands and face.

Manifestations of the CREST Syndrome

Calcinosis (calcium deposits in the subcutaneous tissue that erupt through the skin)

Raynaud phenomenon

Esophageal dysmobility

Sclerodactyly (localized scleroderma of the fingers)

Telangiectasia

Types of Seronegative Spondyloarthropathies

Inflammation and involvement of the peripheral joints with an absence of RF

Ankylosing spondylitis

Juvenile ankylosing spondylitis

Reactive arthritis, enteropathic arthritis (i.e., inflammatory bowel disease)

Psoriatic arthritis

Methods of Assessing Mobility and Detecting Sacroiliitis

Pressure on the sacroiliac joints with the person in a forward-bending position to elicit pain and muscle spasm

Measurement of the distance between the tips of fingers and the floor in a bent-over position with straight knees,

Modified Schöber test in which contralateral flexion of the back is measured

Measurement of chest expansion may be used as an indirect indicator of thoracic involvement.

Reiter Syndrome

Clinical manifestation of reactive arthritis

Accompanied by extra-articular symptoms such as uveitis, bowel inflammation, carditis

Develops in a genetically susceptible host after a bacterial infection due to Chlamydia trachomatis in the genitourinary tract

Salmonella, Shigella, Yersinia, or Campylobacter in the gastrointestinal tract

Subgroups of Psoriatic Arthritis

Oligoarticular or asymmetric (48%)

Spondyloarthropathy (24%)

Polyarticular or symmetric (18%)

Distal interphalangeal (8%)

Mutilans (2%)

Question #2

Which of the following conditions is caused by collagen deposition?

Rheumatoid arthritis

Systemic lupus erythematosus

Psoriatic arthritis

Systemic sclerosis

Answer to Question #2

D. Systemic sclerosis

Rationale: Autoimmune disease of connective tissue characterized by excessive collagen deposition in the skin and internal organs

Causes of Osteoarthritis

Postinflammatory diseases

Posttraumatic disorders

Anatomic or bony disorders

Metabolic disorders

Neuropathic arthritis

Hereditary disorders of collagen

Idiopathic or primary variants

Osteoarthritis

Degenerative joint disease

Primary variants of OA occur as localized or generalized syndromes

Secondary OA has a known underlying cause such as

congenital or acquired defects of joint structures, trauma, metabolic disorders, or inflammatory diseases.

Osteoarthritis-Induced Joint Changes

Progression

A progressive loss of articular cartilage

Synovitis

Osteophytes

Bone spurs

Manifestations

Joint pain

Stiffness

Limitation of motion

Joint instability

Deformity

Metabolic and Endocrine Diseases Associated with Joint Symptoms

Amyloidosis

Gout syndrome

Osteogenesis imperfecta

Diabetes mellitus

Hyperparathyroidism

Thyroid disease

AIDS

Hypermobility syndromes

Gout Syndrome

Acute gouty arthritis with recurrent attacks of severe articular and periarticular inflammation

Tophi or the accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage

Gouty nephropathy or renal impairment

Uric acid kidney stones

Types of Gout

Primary gout

Designate cases in which the cause of the disorder is unknown or an inborn error in metabolism

Characterized primarily by hyperuricemia and gout

Secondary gout

The cause of the hyperuricemia is known but the gout is not the main disorder

Objectives for Treatment of Gout

Termination and prevention of the acute attacks of gouty arthritis

Correction of hyperuricemia

Inhibition of further precipitation of sodium urate

Absorption of urate crystal deposits already in the tissues

Question #3

Uric acid accumulation is involved in which condition?

Amyloidosis

Gout syndrome

Osteogenesis imperfecta

Diabetes mellitus

Hyperparathyroidism

Answer to Question #3

B. Gout syndrome

Rationale: Gout Syndrome is the result of hyperuricemia.

Juvenile Idiopathic Arthritis

JIA categories of diseases with three principle types of onset:

(1) Systemic onset disease

(2) Pauciarticular arthritis

(3) Polyarticular disease

Symptoms

Synovitis

Stunted growth also may occur

Influence epiphyseal growth by stimulating growth of the affected

Juvenile Rheumatoid Arthritis (JRA)

Definition

A chronic disease characterized by synovitis

Manifestations

Can influence epiphyseal growth by stimulating growth of the affected side

Generalized stunted growth also may occur.

Manifestations of Children with SLE

Constitutional symptoms

Fever, malaise, anorexia, weight loss

Symptoms of the integumentary, musculoskeletal, central nervous, cardiac, pulmonary, and hematopoietic systems are similar to those of adults.

Endocrine abnormalities include

Cushing syndrome from long-term corticosteroid use

autoimmune thyroiditis

Signs and Symptoms of Giant Cell Arteritis

Constitutional symptoms

Malaise, fatigue, fever, weight loss, cough, sore throat

Polymyalgia rheumatica syndrome

Manifestations related to vascular involvement

Ischemic optic neuropathy

Claudication of jaw or arm