AUTOIMMUNE DISORDERS
RHEUMATIC DISEASES
Categories of Rheumatic Diseases:
Ankylosing spondylitis
Rheumatoid arthritis
Osteoarthritis
Bursitis
Carpal tunnel syndrome
Fibromyalgia
Gout
Crohn's disease
Juvenile arthritis
Lupus
Lyme disease
Marfan syndrome
Paget's disease
Raynaud's disease
Scleroderma
Myositis
RHEUMATOLOGIC DISEASES - GERONTOLOGY CONSIDERATIONS
Impact on Elderly:
Disability: Many rheumatologic diseases contribute to physical disability.
Cognitive Changes: Can lead to changes in mental status and cognitive function.
Co-morbid Conditions: Rheumatic diseases often coexist with other health issues, particularly musculoskeletal conditions, which are the most common in elderly patients.
RHEUMATOID ARTHRITIS (RA)
Characteristics:
Chronic, systemic, inflammatory disease.
Onset of symptoms may be sudden or gradual.
RA ANATOMY CHANGES
Musculoskeletal Changes due to RA:
Damage involves synovial membranes leading to inflammation, swelling, and pain in joints.
Pathophysiological Changes: Image Description:
Normal joint anatomy includes:
Muscle
Synovial fluid
Cartilage
Bone
Bursa
Synovial membrane
Joint capsule
In RA:
Synovial membrane becomes inflamed and thickened, causing joint damage:
Erosion of bones and cartilage.
Pannus formation, fibrous ankylosis, and bony ankylosis can occur.
RA RISK FACTORS
Factors Contributing to RA Development:
Sex: Higher prevalence in females.
Genetic predisposition.
Can develop at any age.
RA PATHOPHYSIOLOGY
Stages of Rheumatoid Arthritis:
Synovitis: Inflammation of synovial membrane.
Pannus Formation: Thickened synovial membrane invades and erodes cartilage and bone.
Fibrous Ankylosis: Replacement of cartilage with fibrous tissue.
Bony Ankylosis: Fusion of bones within the joint due to extensive cartilage loss.
RA SIGNS & SYMPTOMS
Characteristic Symptoms include:
Sunrise stiffness lasting longer than 1 hour.
Joint swelling.
Symptoms noted are usually symmetrical.
Presence of synovitis and a soft feeling in affected joints.
Systemic effects can occur, affecting overall health.
RA COMPLICATIONS & CO-MORBIDITIES
Common Complications:
Stroke
Sleep disorders
Eye problems
Lung problems
Mental health issues: depression and anxiety
Heart disease
Vasculitis
Diabetes
Blood disease
Osteoporosis
Arteritis
Anemia
Neuropathy
Pericarditis
Splenomegaly
Sjögren's syndrome
RA DIAGNOSTIC CRITERIA
Tests and Indicators:
Serological Tests:
Anti-CCP antibody (high specificity for RA)
Rheumatoid factor (often positive)
Complete Blood Count (CBC): Indicating anemia.
Erythrocyte Sedimentation Rate (ESR): Elevated during inflammation.
C-Reactive Protein (CRP): Elevated in inflammation.
Imaging: X-rays show joint damage;
Antinuclear Antibodies (ANA): Positive in some patients.
Joint Aspiration: To analyze synovial fluid.
RA MEDICAL MANAGEMENT
Goals of Management:
Early intervention to control inflammation.
Prevent joint damage.
Relieve pain and improve function.
Achieve disease remission.
RA Pharmacological Treatments:
NSAIDs:
Mechanism of Action (MOA): Inhibit enzymes that synthesize prostaglandins.
Examples: Ibuprofen (Motrin), Naproxen (Naprosyn).
DMARDs (Disease-Modifying Anti-Rheumatic Drugs):
MOA: Suppression of immune and inflammatory responses.
Examples: Methotrexate (Rheumatrex), Sulfasalazine (Azulfidine), Leflunomide (Arava), Hydroxychloroquine (Plaquenil).
Corticosteroids:
Use:
MOA: Suppress inflammation and normal immune response.
Examples: Dexamethasone (Decadron), Methylprednisolone (Solu-Medrol), Prednisone.
Biologic DMARDs:
Use:
MOA: Target immune system by inhibiting proteins and pathways involved in inflammation.
Examples: Etanercept (Enbrel), Infliximab (Remicade).
Immunosuppressive Therapies:
Examples:
Azathioprine (Imuran), Cyclophosphamide (Cytoxan).
Surgical Interventions:
Invasive Options for RA include:
Synovectomy: Excision of the synovial membrane.
Arthrodesis: Joint fusion.
Arthroplasty: Joint replacement procedure.
RA NURSING PRIORITIES & INTERVENTIONS
Key Nursing Responsibilities:
Monitor laboratory results: CBC (Hemoglobin, Creatinine).
Provide comfort measures: heat application, massage, position changes, rest.
Facilitate independence in activities of daily living (ADLs).
Assess for signs of depression.
Coordinate care with Physical Therapy (PT)/Occupational Therapy (OT).
RA PATIENT EDUCATION
Key Educational Points for Patients:
Understand the nature of their disease.
Familiarity with medication regimens: benefits and potential side effects.
Importance of rest and an appropriate exercise plan.
Management of flare-ups by recognizing early signs.
Creating a low-stress environment and reducing fatigue.
COLD TO TREAT PAIN
Guidelines for Cold Therapy:
Ice or cold application can reduce inflammation and pain.
Best used right after an injury.
Treatment duration: No longer than 20 minutes at a time.
Precautions: Avoid placing ice directly on the skin; check skin condition during application.
Minimum interval of 1 hour between treatments.
HEAT TO TREAT PAIN
Guidelines for Heat Therapy:
Heat can ease muscle and joint stiffness; prepares joints for activity.
Facilitates range of motion and muscle relaxation.
Treatment duration: No longer than 20 minutes at a time.
Precautions: Monitor skin condition and avoid direct contact; allow for 1 hour minimum between applications.
SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
Definition:
Complex autoimmune disease influenced by genetic, hormonal, environmental, and immunologic factors.
Onset can be insidious or acute.
Types of Lupus:
Systemic Lupus Erythematosus (SLE)
Discoid Lupus Erythematosus: Primarily affects the skin.
Drug-Induced Lupus: Caused by medications.
Neonatal Lupus: Affects infants born to mothers with lupus.
SLE RISK FACTORS
Can occur at any age.
Higher incidence in females and ethnic minorities.
SLE PATHOPHYSIOLOGY
Mechanism of Disease:
The immune system mistakenly targets the cell nucleus as an invader, leading to autoantibody production.
B cells produce antibodies that form immune complexes that can accumulate in capillaries, triggering inflammation and tissue damage through complement activation.
SLE COMPLICATIONS & CO-MORBIDITIES
Affected Organ Systems:
Skin: Malar rash, alopecia, photosensitivity.
CNS: Seizures, psychosis.
Renal: Glomerulonephritis.
Hematologic: Anemia, thrombocytopenia.
Cardiac: Pericarditis, myocarditis.
Musculoskeletal: Arthritis, arthralgia.
Gastrointestinal: Nausea, abdominal pain.
Lung: Inflammation; pulmonary hypertension.
SLE SIGNS & SYMPTOMS
Clinical Manifestations:
Butterfly rash across the face.
Persistent high fever (>100 degrees F).
Extreme fatigue.
Joint pain and stiffness.
Raynaud's syndrome.
Lesions on skin and mucous membranes.
Pleurisy and pericarditis.
WARNING SIGNS OF SLE FLARE
Increased fatigue.
New or elevated fever.
Worsened joint pain.
Emergence of new signs or symptoms.
SLE FLARE TRIGGERS
Common Triggers Include:
Overexertion and stress.
Exposure to sunlight.
Infections, injuries, or surgeries.
Pregnancy or postpartum changes.
Sudden cessation of medications.
Certain medications and immunizations.
SLE DIAGNOSTICS
Key Laboratory Tests:
Antinuclear antibody (ANA) – positive in >95% of cases.
Anti-DNA antibodies – highly specific for SLE.
Anti-Sm antibodies – specific for Sm proteins found in the nucleus.
SLE MEDICAL MANAGEMENT
Treatment Objectives:
Tailor treatment based on symptom severity.
Establish diagnosis and prognosis.
Management varies based on organ involvement:
No major organ involvement: Antimalarials, low-dose steroids, immunosuppressants like methotrexate/Azathioprine, lifestyle modifications (sun avoidance).
Major organ involvement: More aggressive treatments like Cyclophosphamide or biologics.
SLE NURSING PRIORITIES & INTERVENTIONS
Important Nursing Actions:
Regular health screenings and medication adherence.
Promotion of a healthy lifestyle.
Education on flare-up prevention and pacing daily activities.
Nutrition rich in antioxidants.
SCLERODERMA
Definition:
A chronic autoimmune disease characterized by skin hardening (sclerosis).
TYPES OF SCLERODERMA
Localized Scleroderma:
Affects the skin primarily (face, hands).
Systemic Scleroderma:
Can involve internal organs (e.g., heart, lungs, kidneys).
SCLERODERMA RISK FACTORS
Factors include sex and age.
Genetics (HLA gene) and environmental triggers contribute to disease onset.
There is currently no cure for scleroderma.
SCLERODERMA PATHOPHYSIOLOGY
Mechanism:
Excess collagen accumulation leads to tissue stiffness.
Initially manifests as edema, which eventually results in histological changes, loss of elasticity, and tissue degeneration.
Leading causes of mortality arise from lung, heart, or kidney involvement.
SCLERODERMA SIGNS & SYMPTOMS
Skin changes: beading and hardness.
Limited symptoms collectively called CREST:
Calcinotis: Calcium deposits in skin.
Raynaud's phenomenon: Blood vessel spasm.
Esophageal dysfunction: Acid reflux, decreased motility.
Sclerodactyly: Thickened skin on fingers.
Telangiectasias: Visible capillary dilation.
SCLERODERMA DIAGNOSTICS
Diagnostic Tests:
There is no definitive diagnostic test; assessment includes:
CT scans for pulmonary hypertension.
Echocardiograms for pericardial effusion.
Blood tests showing positive ANA results.
Esophageal motility studies.
SCLERODERMA MEDICAL MANAGEMENT
Treatment Approaches include:
Gastrointestinal: Proton Pump Inhibitors (e.g., Tums, Mylanta).
Cardiac: Calcium channel blockers (Amlodipine), vasodilators (Flolan, Sildenafil).
Immunosuppressants: Methotrexate.
UVA irradiation and other therapies to manage symptoms.
SCLERODERMA NURSING PRIORITIES & INTERVENTIONS
Nursing Responsibilities include:
Monitor fluid balance through intake/output tracking.
Assess swallowing and activity tolerance regularly.
Encourage moderate exercise to maintain mobility.
Focus on maintaining skin integrity and hydration.
SCLERODERMA PATIENT EDUCATION
Educational Focus for Patients:
Counseling regarding disease understanding and lifestyle accommodations.
Skin care to prevent dryness and prevent complications related to temperature sensitivity.
Suggestions for balanced nutrition and regular moderate exercise routines.