CARE OF THE PATIENT WITH DEGENERATIVE DISORDERS

Course Information

Course Code: NUR308

Instructor: Erick Zarabozo, DNP, APRN, AGACNP-BC, FNP-C, PMHNP-BC

DISORDERS OF THE JOINTS: GOUT

Overview

Definition: Gout is characterized by urate crystal deposits in the joints.
Classification: Differentiated into Primary Gout (idiopathic hyperuricemia) versus Secondary Gout (resulting from other health conditions).
Risk Factors: Include obesity, excessive alcohol consumption, diet (high in purines), kidney disease, and certain medications.

Clinical Manifestations

Symptoms: Extreme pain, swelling, erythema (redness), and possible nephropathy.
Common Sites: Usually affects the big toe (first metatarsophalangeal joint), but can occur in other joints.
Kidney Involvement: Possible due to the formation of kidney stones.

GOUT: DIAGNOSIS

Diagnostic Criteria

Gold Standard: Identification of intracellular monosodium urate (MSU) crystals via polarizing light microscopy of an affected joint.
Serum Uric Acid Levels:
  - Women: ≥ 6 mg/dL
  - Men: ≥ [value missing]
  - Normal range: 3.5 to 7.0 mg/dL
Clinical Manifestations:
  - Recurrent flares of inflammatory arthritis (gout flare).
  - Chronic arthropathy due to accumulation of urate crystals in tophaceous deposits.
  - Uric acid nephrolithiasis leading to chronic nephropathy, commonly due to comorbid states.

GOUT: MANAGEMENT

Pain Management

Methods: Application of ice, resting the joint, cradle for foot/hand protection, and skin assessment.

Dietary Considerations

Limit: Alcohol (ETOH).
Grains: Such as rice, pasta, bread, and cereals are encouraged, but oats should be avoided.
Reduce purine intake:
- Foods to Avoid: Sardines, turkey, red meat, organ meats.
Increase Fluid Intake: Encourage consumption of milk, coffee, and water while avoiding soft drinks (fructose breaks down into uric acid).

Pharmacological Management

NSAIDs: Such as Acetaminophen, Indomethacin, and Naproxen.
Colchicine: Used to treat acute phases of gout.
Allopurinol (Zyloprim): For management/prevention of gout attacks.
Possible Steroids: May be used as adjunct therapy.

CLINICAL SCENARIO EXAMPLE

Patient with Type II Diabetes and Gout

Patient Management Instruction:
  - Expect a red rash while taking allopurinol.
  - Drink 2-3 liters of water daily.
  - Take the medication on an empty stomach before meals.
  - Be aware of needing to adjust oral diabetic medications while on allopurinol.

DISORDERS OF THE JOINTS: BACTERIAL/SEPTIC ARTHRITIS

Overview

Definition: Infection leading to inflammation of the synovial membrane.
Risk Factors: Include rheumatoid arthritis (RA), cancer, diabetes mellitus (DM).

Clinical Manifestations

Symptoms include acute pain, swelling, redness, decreased range of motion (ROM), fever, and chills.

Common Organisms

Pathogens commonly involved: Staphylococcus aureus, Neisseria gonorrhoeae, and Mycobacterium tuberculosis.

Diagnosis & Management

Diagnostic Method: Identification of the pathogen in stained smears of synovial fluid.
Management: Involves the use of antibiotics, anti-inflammatories, rest, and pain management.
Complications: Chronic complications such as osteomyelitis.

DISORDERS OF THE JOINT: LYME DISEASE

Overview

Transmission: Through tick bites from Borrelia burgdorferi (spirochete bacteria).
Risk Factors: Activities in wooded or grassy areas increase exposure.

Clinical Manifestations

Early Stage I (3-32 days post-bite):
- Erythema migrans (bull’s eye rash), fatigue, headache, lymphadenopathy.
Stage II: Cardiac involvement (Lyme carditis), possible neurological symptoms.
Stage III: Arthritis, potential neurological impairment.

LYME DISEASE: DIAGNOSIS & MANAGEMENT

Diagnosis

Assessment Methods: Serological testing like ELISA and Western Blot for antibody identification.

Management

Medication: Antibiotics such as:
- Doxycycline
- Amoxicillin
Comprehensive Assessment: Checking for cardiac involvement and neurological symptoms.

LYME DISEASE: PATIENT TEACHING

Preventative Measures:
  - Use protective clothing and insect repellents.
  - Stick to cleared paths while hiking.
  - Perform inspections and cleansing after potential exposure.
  - Follow-up with healthcare provider after returning from tick-prone areas.

CLINICAL SCENARIO EXAMPLE FOR LYME DISEASE

Patient Presentation

Expected Findings: After a tick bite and subsequent rash, the nurse should anticipate a bite mark with a circular border.

PATIENT TEACHING FOR LYME DISEASE PREVENTION

Interventions To Include:

Instruct patients to avoid shorts and T-shirts when outdoors due to tick exposure.
Use an adequate sunscreen (at least SPF 30).
Avoid dense undergrowth in wooded areas.
Correct myth: insect repellent is effective against Lyme disease.

AUTOIMMUNE CONNECTIVE TISSUE DISEASES: SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)

Overview

Definition: A chronic inflammatory disease affecting skin, joints, and kidneys with an autoimmune origin; primarily affects women of childbearing age.

CLINICAL MANIFESTATIONS OF SLE

Skin: Erythema with a butterfly-shaped rash (malar rash).
Musculoskeletal: Arthritis and arthralgias (joint pain).
Systemic Involvement: Fatigue, weakness, depression, and multi-system impacts including:
  - Neurological: Cognitive dysfunction, headaches, memory loss, optic neuritis, retinal vasculitis, seizures.
  - Renal: Lupus nephritis leading to potential complications.
  - Respiratory: Pleural effusion and pneumonia.
  - Gastrointestinal: Nausea, vomiting, diarrhea, elevated liver enzymes, and anemia.
Mortality: Lupus nephritis and infection are the leading causes of mortality within the first decade of diagnosis.

MANAGEMENT OF SLE

Diagnosis

Diagnostic Tools: An American College of Rheumatology Criteria for classification and identification of ANA antibodies.
Symptom Management:
  - Renal: Cytoxan (Cyclophosphamide)
  - Arthritis: NSAIDs (caution advised), corticosteroids, Methotrexate, Plaquenil (Hydroxychloroquine), Benlysta (Belimumab) for prolonged treatment and control.
  - Seizures: As indicated.

PATIENT TEACHING FOR SLE

Important Topics:
  - Signs and symptoms of infection and potential complications.
  - Skin care strategies.
  - Avoiding sun exposure to minimize flare-ups.
  - Stress reduction techniques.
  - Addressing body image issues.
  - In-depth medication teaching.
  - Awareness regarding high miscarriage risk in pregnancies.
  - Encouragement to join support groups for shared experiences.

CLINICAL SCENARIO EXAMPLE FOR SLE

Patient Inquiry

Potential Response by Nurse: "SLE is an autoimmune disorder that can have genetic or hormonal components, though its exact cause remains unclear."

FIBROMYALGIA (FM) SYNDROME

Overview

Definition: A generalized pain syndrome often associated with other conditions like RA and SLE.
Epidemiology: Affects approximately 2% of the population, with a higher prevalence in women (9:1 ratio).

Pathophysiology

Mechanism: Generalized pain intolerance due to central sensitization.

Diagnosis

Criteria: Per the American College of Rheumatology, pain must be present in 11 out of 18 identified tender points most days for at least 3 months.

CLINICAL MANIFESTATIONS OF FIBROMYALGIA

Symptoms:
  - Generalized chronic pain
  - Sleep disorders and poor sleep quality
  - Fatigue
  - Morning stiffness
  - Depression
  - Noise sensitivity
  - Functional loss without observable radiographic changes.

MANAGEMENT OF FIBROMYALGIA

Goals: Focus on restoring sleep and relieving pain.
Interventions Include:
  - Pain Management: Medications including Tramadol and Cyclobenzaprine.
  - Antidepressants: Elavil (Amitriptyline) or SSRIs.
  - Exercise Recommendations: Yoga, Tai Chi, aerobic exercise, and Pilates.
  - Dietary Management: Address caffeine consumption.
  - Relaxation Techniques: Meditation, acupuncture, hydrotherapy, and chiropractic care.
  - Support: Enhance coping skills and patient education.