Rheumatic Disorders Part II:SLE, PA, SSc, Fibromyalgia,    Lyme disease, etc.      Maria Carmela L. Domocmat, RN, MSN  Ins...
Rheumatic DisordersComprise autoimmune and inflammatorydisorders‘the primary crippling disease”Inflammation of jointPrimar...
What causes autoimmune disease?                   http://www.medscape.com/content/2000/00/40/87/408750/art-mrc4856.lymp.fi...
Reaction to SelfOccurs when the immune system sees “self”antigens as “nonself”may be due to genetic factors, infectious ag...
Reaction to Self~ 3.5 % of people have autoimmune diseases  On average, women are 2.7 times more likely to  develop these ...
Why does the immune system attack the body thatit’s supposed to protect? failure to recognize some cells as “self”    in r...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Systemic Lupus Erythematosus (SLE)a chronic systemic autoimmune disease   Complexes of anti-self antibodies and antigen de...
Lupus sufferers develop IgG antibodies todouble stranded DNA and nuclear antigens.Antibodies to T cells may also be produc...
s/sPainful or swollen joints and muscle painUnexplained feverRed rashes, most commonly on the faceChest pain upon deep bre...
Diagnostic Tools for LupusMedical historyComplete physical examinationLaboratory tests:   Complete blood count (CBC)   Ery...
Systemic Lupus Erythematosus (SLE)                                         Damaged kidney (left) caused by                ...
Lupus, discoid - view of                      lesions on the chest: This                      close-up picture of the     ...
The round or disk shaped(discoid) rash of lupusproduces red, raised patcheswith scales. The pores (hairfollicles) may be p...
This is a picture of a                      systemic lupus                      erythematosis rash on the                 ...
The rash of lupis is round ordisk shaped (discoid) and ischaracterized by red, raisedpatches with adherent scales.The skin...
LupusMaria Carmela L. Domocmat, RN, MSN
LupusMaria Carmela L. Domocmat, RN, MSN
exact trigger - not knownresearch has shown that the environmentalfactors include  infectious agents  excess UV light  phy...
Managementno cure for SLE.goal of treatment - control symptoms             Maria Carmela L. Domocmat, RN, MSN
ManagementReduce inflammation and minimizecomplications  NSAIDs - Aspirin  Glucoccorticoids  HydroxychloroquineManage exac...
Treatment : Mild disease        Mild disease              NSAIDs - treat arthritis and pleurisy              Corticosteroi...
Treatment :severe        Treatment for more severe lupus may include:              Pulse Therapy –                   High-...
Other Agents  For SLE thrombocytopenia    Attenuated androgen danazol    IV Ig - Immune globulin intravenous (Gamimune,   ...
Maria Carmela L. Domocmat, RN, MSN
Drugs in clinical trialUseful for maintenance in lupus nephritis andother serious lupus cases; Inhibits antibodyproduction...
Maintain skin integrityAvoid prolonged exposure to sunlight and otherforms of UV lighting including tanning bedswear prote...
Maintain skin integrityAvoid excess powder and other dryingsubstancesDry skin thoroughly by patting rather thanrubbingAppl...
For alopecia  Recommend use of mild protein shampoos  Avoid harsh treatments (e.g., permanents or  highlights) until hair ...
Severe or life-threatening symptoms  (such as hemolytic anemia, extensive heart or lung  involvement, kidney disease, or c...
it is also important to have:  Preventive heart care  Up-to-date immunizations  Tests to screen for thinning of the bones ...
Outlook (Prognosis)How well a person does depends on the severityof the disease.The outcome for people with SLE has improv...
Outlook (Prognosis)Women with SLE who become pregnant areoften able to carry safely to term and deliver ahealthy infant, a...
Possible ComplicationsSome people with SLE have abnormal depositsin the kidney cells. This leads to a conditioncalled lupu...
Possible ComplicationsSLE causes damage to many different parts ofthe body, including:  DVT or pulmonary embolism  hemolyt...
Possible ComplicationsPregnancy complications, including miscarriageStrokethrombocytopeniaInflammation of the blood vessel...
Psoriasisis a common, chronic skin condition that causesred patches on the body.             Maria Carmela L. Domocmat, RN...
Maria Carmela L. Domocmat, RN, MSN
Skin cells grow deep in the skin and normallyrise to the surface about once a month. Inpersons with psoriasis, this proces...
Psoriasis on the knucklesThis is a picture of a typical case of psoriasis,with small lesions on the knuckles. Note thechan...
The following may trigger an attack of psoriasis or makethe condition more difficult to treat:  Bacteria or viral infectio...
In general, psoriasis may be severe in peoplewho have a weakened immune system. Thismay include persons who have:AIDSAutoi...
SymptomsPsoriasis can appear suddenly or slowly. Inmany cases, psoriasis goes away and thenflares up again repeatedly over...
The skin patches or dots may be:ItchyDry and covered with silver, flaky skin (scales)Pink-red in color (like the color of ...
Other symptoms may include:Genital lesions in malesJoint pain or aching (psoriatic arthritis)Nail changes, including nail ...
five main types of psoriasisPsoriasis may affect any or all parts of the skin.  Erythrodermic -- The skin redness is very ...
Scalp psoriasis                              Nail Psoriasis                  Maria Carmela L. Domocmat, RN, MSN
Plaque Psoriasis Pictures   (Vulgaris/Circular)      Maria Carmela L. Domocmat, RN, MSN
Guttate Psoriasis  Maria Carmela L. Domocmat, RN, MSN
Pustular Psoriasis             Maria Carmela L. Domocmat, RN, MSN
Inverse Psoriasis             Maria Carmela L. Domocmat, RN, MSN
Erythrodermic Psoriasis particularly inflammatory form of psoriasis thatoften affects most of the body surface.least commo...
Psoriatic Arthritis  Maria Carmela L. Domocmat, RN, MSN
TreatmentThe goal of treatment is to control symptomsand prevent infections.In general, three treatment options are used f...
TreatmentTopical medications  such as lotions, ointments, creams, and shampoos  Topical steroids  Tar preparations  UV Lig...
Topical medsCortisone creams and ointments  Suppress cell division when applied to psoriatic  lesions  More effective when...
Topical medsTar preparations  Creams ,ointments, solutions, lotions, gels, shampoos  that contain coal tar or anthralin  C...
Topical medsTar preparations  Anthralin (Anthraforte, Drithocreme, Lasan)    A hydrocarbon similar in action to tar    Rel...
Topical medsTar preparations  Anthralin (Anthraforte, Drithocreme, Lasan)    Not used to treat acute, spreading psoriasis ...
Topical medsPrescription medicines containing vitamin D orvitamin A (retinoids)  Cream, ointment, lotion  For mild to mode...
Topical medsCalcipotriene (Dovonex)  A synthetic form of vitamin D – regulates skin cell  divisionTazarotene (Tazorac)  Vi...
Topical medsCreams to remove the scaling (usually salicylicacid or lactic acid)Dandruff shampoos (over-the-counter orpresc...
UV light therapyOr Phototherapyuses light to treat psoriasisNote: must wear eye protection during treatmentTypes: UVA, UVB...
UV light therapy Maria Carmela L. Domocmat, RN, MSN
Observe for generalized redness with edemaand tendernessWear dark glasses during treatment and for theremainder of the day...
Systemic medications for severe           psoriasisImmunosuppressants   Retinoids (acitretin)   DMARDs - Cytotoxic agents ...
Maria Carmela L. Domocmat, RN, MSN
BRMs (Biologics)  Alefacept (Amevive) – IM weekly x 12 wks  Efalizumab (Raptiva) – subq once/week  Adalimumab (Humira)  Et...
Self-care at homeOatmeal baths  may be soothing and may help to loosen scales.  can use over-the-counter oatmeal bath prod...
PsoriasisMaintain skin integrityEnhance body imageProvide emotional support             Maria Carmela L. Domocmat, RN, MSN
Tar - not only look dirty but unpleasant odor;bed linens, pajamas become stained – furtherdiscouraging social interactionE...
Touch - more than any gesture communicatesacceptance of the person and their skin problem  Shake hands during introduction...
Expectations (prognosis)Psoriasis is a life-long condition that can becontrolled with treatment.may go away for a long tim...
Complications        Arthritis        Pain        Severe itching        Secondary skin infections        Side effects from...
Psoriatic arthritis is an arthritis that is oftenassociated with psoriasis of the skin20-50 years oldWomen               M...
Psoriatic arthritisThe cause of is not knownIn general, people who have psoriasis have ahigher rate of arthritis than the ...
Symptomsarthritis - may be mild and involve only a fewjoints, particularly those at the end of the fingersor toes.In some ...
SymptomsPeople who also have arthritis usually have theskin and nail changes of psoriasis. Often, theskin gets worse at th...
http://images.emedicinehealth.com/images/4453/4453-13248-30912-31165.jpg                   Maria Carmela L. Domocmat, RN, ...
Manage joint pain and inflammation  Same with RAControl skin lesions  Same with SLESlow progression of disease            ...
TreatmentNSAIDSMore severe arthritis - DMARDs, TNF inhibitorsRest and exercisePhysical therapy may help increase themoveme...
Expectations (prognosis)The course of the disease is often mild andaffects only a few joints.A few people will have severe...
ComplicationsRepeated episodes may occur.            Maria Carmela L. Domocmat, RN, MSN
http://t1.gstatic.com/images?q=tbn:ANd9GcSNZJeyTzNT2-n9x75SxwCiHpxGRsPy_cT_qqDvE5lc04P94kRW                     Maria Carm...
Cause is unknown.People with this condition have a buildup of asubstance called collagen in the skin and otherorgans. This...
30 to 50 years old.Womenhistory of being around silica dust and polyvinylchloridecan occur with other autoimmune diseases,...
ManifestationsTypes: localized and systemicLocalized scleroderma  affects only the skin on the hands and face.  develops s...
ManifestationsSystemic scleroderma, or sclerosis  may affect large areas of skin and organs  such as the heart, lungs, or ...
Skin symptomsFingers or toes that turn blue or white in response to hotand cold temperaturesHair lossSkin hardnessSkin tha...
Telangiectasiais the dilation of smallsuperficial vessels andcapillaries that causenumerous flat red markson the hands, fa...
Maria Carmela L. Domocmat, RN, MSN
Sclerodactyly                      The most classic symptom of                      scleroderma is a type of skin         ...
Raynauds phenomenonis characterized byfingers becoming whitedue to lack of blood flow,then blue due to oxygenconsumption, ...
Bone and muscle symptoms may include:Joint painNumbness and pain in the feetPain, stiffness, and swelling of fingers and j...
Breathing problems may result from scarring inthe lungs and can include:Dry coughShortness of breathWheezing             M...
Digestive tract problems may include:Bloating after mealsConstipationDiarrheaDifficulty swallowingEsophageal reflux or hea...
Maria Carmela L. Domocmat, RN, MSN
Dx testsBlood tests may include:  Antinuclear antibody (ANA) panel  Antibody testing  ESR (sed rate)  Rheumatoid factorOth...
Medical managementThere is no specific treatment for scleroderma.Reduce inflammation, sclerosis, vasospasmReduce renal com...
Other treatments for specific symptoms mayinclude:  Medicines for heartburn or swallowing problems  Blood pressure medicat...
Medicines used to treat scleroderma include:  Power anti-inflammatory medicines called  corticosteroids  Immune-suppressin...
Nursing managementFacilitate muscle and joint movementMaintain skin integrityProvide educationPromote adequate nutritionPr...
Outlook (Prognosis)Some people with scleroderma have symptomsthat develop quickly over the first few years andcontinue to ...
Possible ComplicationsThe most common cause of death in people withscleroderma is scarring of the lungs, called pulmonaryf...
Ankylosing Spondylitisa form of arthritis that primarily affects the spine,although other joints can become involved.It ca...
In the most advanced cases, this inflammation canlead to new bone formation on the spine, causingthe spine to fuse in a fi...
Causes and risk factors20 and 40, but may begin before age 10.Risk factors include:  Family history of ankylosing spondyli...
hallmark feature  the involvement of the sacroiliac (SI) joints during the  progression of the disease, which are the join...
S/SThe disease starts with low back pain thatcomes and goes.Pain and stiffness are worse at night, in themorning, or when ...
S/SFatigueless common symptoms include:  Eye inflammation or uveitis  Heel pain  Hip pain and stiffness  Joint pain and jo...
Ankylosing Spondylitis    Maria Carmela L. Domocmat, RN, MSN
Ankylosing Spondylitis    Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
ComplicationsRarely, people may have problems with theaortic heart valve (aortic insufficiency) and heartrhythm problems.S...
TreatmentNSAIDsCorticosteroid therapyTNF-inhibitorscytotoxic drugs  If do not respond well to corticosteroids or who are  ...
Nursing managementProvide educationPromote effective breathingExercises can help improve posture andbreathing.Lying flat o...
Reactive arthritisis a group of inflammatory conditions thatinvolves the joints, urethra, and eyes.             Maria Carm...
Triad of symptomsNongonococcal urethritisConjunctivitisArthritis             Maria Carmela L. Domocmat, RN, MSN
Causes, incidence, and risk            factorsmen before the age of 40.may follow an infection withChlamydia,Campylobacter...
SymptomsUrinary symptoms usually appear within days orweeks of an infection. Low-grade fever,inflammation of the conjuncti...
Maria Carmela L. Domocmat, RN, MSN
Muscle and joint symptoms include:Achilles tendon painHeel painJoint pain in the large joints (hip pain, knee pain,and ank...
Eye and skin symptoms include:  Eye discharge  Eye pain - burning  Eye redness  Skin lesions on the palms and soles that m...
Urinary and genital symptoms may include:  Genital lesions (male)  Incontinence  Penis pain  Skin redness or inflammation ...
Signs and testsThe diagnosis is based on symptoms.Since the symptoms may occur at differenttimes, the diagnosis may be del...
Treatmentgoal - to relieve symptoms and treat anyunderlying infection.Conjunctivitis and skin lesions associated withthe s...
ManagementSelf-limited course - 3 to12 monthsAdminister meds  Same with AS  Antibiotic therapy – still controversial  Ster...
PreventionPreventing sexually transmitted diseases andgastrointestinal infection may help prevent thisdisease.Wearing a co...
Fibromyalgia (FM)is a disorder of chronic widespread pain  with associated fatigue, poor sleep, stiffness, cognitive diffi...
Fibromyalgia (FM)Pain - radiates diffusely from the axial skeletonover large areas of the body,  predominantly involving m...
Algometer or dolorimeterA useful devicefor roughquantitation ofpain sensitivityis a pressurealgometer, ordolorimeter.     ...
Tender points in fibromyalgia.        Maria Carmela L. Domocmat, RN, MSN
Fibromyalgia (FM)Fatigue and poor sleep  Most patients with fibromyalgia also meet the classification criteria  for chroni...
Maria Carmela L. Domocmat, RN, MSN
Fibromyalgia (FM)Cognitive problems  (known as "fibrofog") - primary symptom of  fibromyalgia,  reflecting impairments in ...
Maria Carmela L. Domocmat, RN, MSN
Other common symptomsWeight fluctuationsAllergic symptoms (eg, nasal congestion) andhypersensitivity to environmental stim...
Other common symptomsSyncope or dizzinessShortness of breathUrinary frequency and urgency (female urethral syndrome,inters...
Maria Carmela L. Domocmat, RN, MSN
Causesmultifactorial.Engels biopsychosocial model of chronic illness(ie, health status and outcomes in chronic illnessare ...
Maria Carmela L. Domocmat, RN, MSN
Laboratory Studiesdo not have characteristic or consistent abnormalities asdetermined by laboratory test results.Laborator...
Laboratory StudiesThyroid-stimulating hormone: H  ypothyroidism shares many clinical features with fibromyalgia,  especial...
Laboratory StudiesAntinuclear antibodies (ANAs):  Many patients with SLE have comorbid fibromyalgia. A low-titer  ANA is c...
Treatmentvalidation of the patient’s illness  empathetic listening and acknowledgment that the  patient is indeed experien...
TreatmentAccurately assess possible causal or perpetuatingfactors,  including attention to psychologic and sociocultural  ...
Comments such as "it’s all in your mind" or "Icannot find anything wrong with you" only add tothe patients frustration.   ...
Psychologic and behavioral           approachesDepression must be treated aggressively.  Depression, anxiety, stress, slee...
Psychologic and behavioral           approachesCognitive-behavioral therapy (CBT) and operant-behavioral therapy (OBT)  bo...
Patient EducationEducation is an essential element in therapy forfibromyalgia.It begins with an empathetic manner on the p...
MedicationAnxiolytics/hypnoticsAntidepressants  Tricyclics antidepressants  Selective Serotonin-reuptake Inhibitors (SSRIs...
Anxiolytics/hypnoticsoften used in combination with antidepressantsand anticonvulsant drugs (both of which also haveeffica...
Anxiolytics/hypnotics     Maria Carmela L. Domocmat, RN, MSN
Tricyclic antidepressantAmitriptyline (Elavil)Desipramine (Norpramin)Doxepin (Sinequan)Imipramine (Tofranil)Trazodone (Des...
Selective Serotonin-reuptake       Inhibitors (SSRIs)Fluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)Fluvoxamine (...
Serotonin Norepinephrine   Reuptake Inhibitors (SNRIs)Milnacipran (Savella)Duloxetine (Cymbalta)            Maria Carmela ...
Central Nervous System          DepressantsZolpidem (Ambien)Zaleplon (Sonata)Sodium oxybate (Xyrem)            Maria Carme...
OpioidsMorphineOxycodone (OxyContin)Hydrocodone (Vicodin, Percocet)Hydromorphone (Dilaudid)Meperidine (Demerol)           ...
AnticonvulsantsGabapentin (Neurontin)Pregabalin (Lyrica)            Maria Carmela L. Domocmat, RN, MSN
Pain RelieversAcetaminophen (Tylenol)            Maria Carmela L. Domocmat, RN, MSN
Nonsteroidal anti-inflammatory       drugs (NSAIDs)AspirinIbuprofen (Advil)Naproxen (Aleve)             Maria Carmela L. D...
Sodium oxybate (Xyrem)a sedative hypnotic, prolongs stage III/IVrestorative sleep, which is essential to awakenrested and ...
AnticonvulsantsPregabalin (Lyrica)Gabapentin (Neurontin)Clonidine (Catapres)             Maria Carmela L. Domocmat, RN, MSN
Polymyositisa persistent inflammatory muscle disease thatcauses weakness of the skeletal muscles, whichcontrol movement.Me...
Polymyositiscan occur at any age,adults -30s, 40s or 50s.BlacksWomen               Maria Carmela L. Domocmat, RN, MSN
Polymyositissigns and symptoms usually develop gradually,over weeks or months.Remissions - rareRemissions: periods during ...
Signs and symptomsappear gradually,Progressive muscle weaknessDifficulty swallowing (dysphagia)Difficulty speakingMild joi...
Signs and symptomsaffects the muscles closest to the trunk,particularly hips, thighs, shoulders, upper armsand neck.weakne...
ComplicationsDysphagia  Which in turn may cause weight loss and malnutrition.Aspiration pneumoniaShortness of breath or re...
Associated conditionspolymyositis is often associated with otherconditions that may cause further complicationsof their ow...
Treatmentcorticosteroid  When muscle strength improves, usually in 4 to 6  weeks, the medication is slowly tapered off.  M...
TreatmentIntravenous gamma globulin  IVIG  is a purified blood product that contains healthy  antibodies from thousands of...
Other immunosuppressive            medicineTacrolimus (Prograf)  is a transplant-rejection drug that may work to inhibit  ...
Biological therapiesRituximab (Rituxan)Tumor necrosis factor (TNF) inhibitors  etanercept (Enbrel) and infliximab (Remicad...
Other treatment approachesPhysical therapyDietetic assessmentSpeech therapy           Maria Carmela L. Domocmat, RN, MSN
Nursing managementCoping and supportEducate about the illnessBalance Rest and exercise            Maria Carmela L. Domocma...
Sourceshttp://www.mayoclinic.com/health/polymyositis/DS00334/METHOD=print&DSECTION=allhttp://www.mayoclinic.com/health/pol...
Dermatomyositisa muscle disease characterized by inflammationand a skin rash. It is a type of inflammatorymyopathy.5 - 15 ...
SymptomsDysphagiaMuscle weakness, stiffness, or sorenessPurple or violet colored upper eyelidsPurple-red skin (violaceous)...
SymptomsThe muscle weakness may appear suddenly or developslowly over weeks or months. may have difficulty raisingarms ove...
reddish-purple (violaceous) rashreddish-purple(violaceous) rash.The rash is named afterthe tendency of plants togrow towar...
purple (violaceous) plaques                            The appearance of purple                            (violaceous) pl...
Gottrons signRed, thickened, scaly skin over the knuckles             Maria Carmela L. Domocmat, RN, MSN
Heliotrope eyelidseyelids develop a brown(violaceous - rather thanred) color.Heliotrope eyelids andGottrons papules on the...
violet-colored inflammation (erythema) over theknuckles             Maria Carmela L. Domocmat, RN, MSN
periungual erythemaCandida paronychia produced periungualerythema, edema and nail fold maceration.             Maria Carme...
Dx ExamsCPK & aldolaseECGElectromyographyMagnetic resonance imaging (MRI)Muscle biopsy            Maria Carmela L. Domocma...
TreatmentCorticosteroidsImmunosuppressantsWhen muscle strength gets better – taper offcorticosHowever, most people take pr...
Outlook (Prognosis)Some recover and have symptoms completelydisappear - especially in children.In adults, death may result...
Possible ComplicationsAcute renal failureCancer (malignancy)Inflammation of the heartJoint painLung disease            Mar...
http://www.nlm.nih.gov/medlineplus/ency/article/000839.htmhttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001842/            ...
BursitisA painful inflammation of the bursae             Maria Carmela L. Domocmat, RN, MSN
Bursitisbursae closed, minimally fluid-filled sacs that are lined with a synovium similar to the lining of joint spaces fu...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
BursitisBursae  there are 150 bursae in human body  cover bony prominences (e.g., olecranon, trochanter,  and patella)  or...
Bursitispeaks – 40 to 50 yrsaffected areas – shoulder joints (mostcommon), elbow, knee, hip; dominant arm            Maria...
Etiology and risk factorsacute or chronic trauma (mechanical, highlyrepetitive activities)arthritic conditions (e.g., RA),...
Clinical manifestationsexquisite localized pain in target areapoint tenderness (can specifically point the spotof greatest...
Clinical manifestationsdifficulty walking (e.g., trochanteric bursitis,calcaneal bursitis)difficulty performing ADL (e.g.,...
Dxdiagnosis is based on PE and historyradiographs – usually normal in acute bursitis;calcium deposits in chroniclab tests ...
ManagementGoalsRests and immobilization of affected jointNon-opoiod analgesicsROM exercisesNSAIDs              Maria Carme...
Nursing ManagementClient education  Focus on causes and prevention of additional attacks     by avoiding activities that c...
Nursing DiagnosesAcute or Chronic PainImpaired Physical ImmobilityTemporary Self-Care Deficits             Maria Carmela L...
Interventions Goal: pain reduction (without pain reduction –joint mobility is impaired thru guarding,protective measures) ...
Teach postinjection flare of intra-articularcortisoneSelf-care: oversized garment, especially thosewith long sleeves or wi...
Vasculitisa group of disorders leading to inflammation andnecrosis of blood vessel wallsincludes:  polyarteritis nodosa  s...
VasculitisPathophysiology  soluble immune complexes are deposited in blood  vessel walls in areas where capillaries have  ...
Clinical manifestationsvarydepending on organs affected            Maria Carmela L. Domocmat, RN, MSN
ManagementSteroids           Maria Carmela L. Domocmat, RN, MSN
Polymyalgia rheumaticaa clinical syndromemore common womendisease of aging, rarely occur before age 60years             Ma...
Clinical manifestationspain and stiffness in neck, shoulder, back, andpelvic girdle esp in the morningheadaches or painful...
DxElevated ESRmild anemiaelevated Ig           Maria Carmela L. Domocmat, RN, MSN
Managementsteroids           Maria Carmela L. Domocmat, RN, MSN
Giant cell arteritisAKA temporal or cranial arteritisdisease of aging              Maria Carmela L. Domocmat, RN, MSN
Giant cell arteritisa clinical syndromemore common womendisease of aging, rarely occur before age 60years             Mari...
Clinical manifestationspolymyalgia rheumatic for months, thensuddenly experiences severe headaches assocwith temporal arte...
Clinical manifestationshyperesthesia (unusual or pathologicalsensitivity of the skin or of a particular sense ofstimulatio...
ManagementCorticosteroids             Maria Carmela L. Domocmat, RN, MSN
Mixed connective tissue disease a combination of several connective tissuediseasesfrequent combinations are SLE and SSc an...
Mixed connective tissue diseaseclinical manifestations  have manifestations that are not typical of any one  disordermanag...
Complex multisystem diseaseOne of form of rheumatic joint disease with aknown causeIncluded as a connective tissue disorde...
Etiology and risk factors  cause: spirochete Borrelia burgdorferi                                                Male tick...
Risk factorsDoing activities that increase tick exposure (forexample, gardening, hunting, or hiking)Having a pet that may ...
Clinical manifestationsLarge “bull’s –eye” circular rash; red flat rashthat clears in the centersevere headachesevere mala...
3 stages of Lyme diseaseStage 1 : primary Lyme disease.Stage 2 : secondary Lyme disease and earlydisseminated Lyme disease...
3 stages of Lyme diseaseStage 1 :  primary Lyme disease.  Occurs 3 to 32 days after the bite  Flu-like symptoms , bull’s e...
3 stages of Lyme diseaseStage 2 :  secondary Lyme disease and early disseminated  Lyme disease.  Occurs 2-12 wks after bit...
Stage 3  tertiary Lyme disease and chronic persistent Lyme  disease   develop months or years after first develop Lyme  di...
ManagementStage 1  Antibiotic therapy – PO, for 10-21 days  Doxycycline  Amoxicillin  CefuroximeStage 2  IV Antibiotic the...
ManagementIntra-articular steroids and NSAIDs  To reduce inflammation and pain              Maria Carmela L. Domocmat, RN,...
Client Education guideAvoid heavily wooded areas or areas with thickunderbrushWalk in the center of the trailAvoid dark cl...
Client Education guideWear closed shoes and a hat or capBathe immediately after being in an infestedarea, and inspect your...
Client Education guideWait 4-6 weeks after being bitten by a tick b4being tested for Lyme disease (testing b4 thistime is ...
Complicationslong-term joint inflammation (Lyme arthritis)ArrhythmiaBrain and nervous system (neurological)problems       ...
Sarcoidosis is a disease in which swelling(inflammation) occurs in the lymph nodes, lungs,liver, eyes, skin, or other tiss...
CausesThe cause of the disease is unknown. Insarcoidosis, clumps of abnnormal tissue(granulomas) form in certain organs of...
Possible causes of sarcoidosis include:Excess sensitivity to environmental factorsGeneticsExtreme immune response to infec...
The condition is more common in AfricanAmericans than Caucasians. Females areusually affected more often than males. Thedi...
SymptomsThere may be no symptoms. When symptomsoccur, they can involve almost any part or organsystem in your body.Almost ...
Symptoms of general discomfort or uneasinessoften occur:malaiseFatigue (one of the most common symptoms inchildren)FeverWe...
Skin symptoms:  Skin rashes  Old scars become more raised  Raised, red, firm skin sores (erythema nodosum,  almost always ...
Nervous system (neurological) and visionchanges:HeadacheSeizuresWeakness or paralysis (palsy) on one side of thefaceEye bu...
Other symptoms of this disease:  Enlarged lymph glands - armpit lump  Enlarged liver  Enlarged spleen  Dry mouth  Noseblee...
Exams and TestsOften the disease is found in patients with nosymptoms who have an abnormal chest x-ray.Different imaging t...
Biopsies of different tissues may be done:  Lymph node biopsy  Skin lesion biopsy  Bronchoscopy to perform a biopsy  Open ...
This disease may also alter the results of the followinglab tests:CBCChem-7 or chem-20Quantitative immunoglobulins (nephel...
TreatmentSarcoidosis symptoms often get better on their own gradually withouttreatment.Severely affected patients may need...
Outlook (Prognosis)Many people are not seriously ill, and thedisease may get better without treatment. About30 - 50% of ca...
Possible ComplicationsOsteoporosis and other complications of takingcorticosteroids for longer periods of time.Diffuse int...
THANK YOU!!!Maria Carmela L. Domocmat, RN, MSN
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
Autoimmune disorders Part II
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Autoimmune disorders Part II

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A continuation of the autoimmune disorders discussing the following topics: SLE, psoriasis, lyme disease, fibromylagia, scleroderma, polymyositis, dermatomyositis, ankylosing spondylitis

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Autoimmune disorders Part II

  1. 1. Rheumatic Disorders Part II:SLE, PA, SSc, Fibromyalgia, Lyme disease, etc. Maria Carmela L. Domocmat, RN, MSN Instructor, Curative and Rehabilitative Nursing Care II School of Nursing Northern Luzon Adventist College
  2. 2. Rheumatic DisordersComprise autoimmune and inflammatorydisorders‘the primary crippling disease”Inflammation of jointPrimary reason for work-related disabilityLeading cause of disability among 65 yrs oldand above Maria Carmela L. Domocmat, RN, MSN
  3. 3. What causes autoimmune disease? http://www.medscape.com/content/2000/00/40/87/408750/art-mrc4856.lymp.fig2.gif Certain variants or mutations in the MHC genes may result in abnormal MHCDomocmat, RN, MSN Maria Carmela L. proteins
  4. 4. Reaction to SelfOccurs when the immune system sees “self”antigens as “nonself”may be due to genetic factors, infectious agents,gender, and agethe autoimmune response results in tissuedamage Some damage occurs in only one or a few organs, in other cases it may be body-wide (systemic) Maria Carmela L. Domocmat, RN, MSN
  5. 5. Reaction to Self~ 3.5 % of people have autoimmune diseases On average, women are 2.7 times more likely to develop these diseases than menmost have no known cause or curetreatment is aimed at controlling symptoms Maria Carmela L. Domocmat, RN, MSN
  6. 6. Why does the immune system attack the body thatit’s supposed to protect? failure to recognize some cells as “self” in rheumatic fever, the streptococcus antigen is very similar to a protein in heart tissue, so the body mistakenly identifies heart tissues as foreign cells seen as foreign are attacked and destroyed may be only a few select cells or organs (organ-specific) – e.g., multiple sclerosis, juvenile diabetes, rheumatic fever may be systemic - e.g., systemic lupus erythematosus, rheumatoid arthritis Maria Carmela L. Domocmat, RN, MSN
  7. 7. Maria Carmela L. Domocmat, RN, MSN
  8. 8. Maria Carmela L. Domocmat, RN, MSN
  9. 9. Maria Carmela L. Domocmat, RN, MSN
  10. 10. Systemic Lupus Erythematosus (SLE)a chronic systemic autoimmune disease Complexes of anti-self antibodies and antigen deposit in, and cause damage to, tissue1 million sufferers in the U.S. Strikes women nine times more often than mensymptoms may include butterfly-shaped rash on face,fatigue, headachestriggered by environmental effects in persons who aregenetically susceptible Maria Carmela L. Domocmat, RN, MSN
  11. 11. Lupus sufferers develop IgG antibodies todouble stranded DNA and nuclear antigens.Antibodies to T cells may also be produced.Immune complexes formed during the diseaseprocess may end up in the kidneys and thencause damage by initiating an inflammatoryresponse that starts with complement fixation.This may ultimately cause kidney failure.Blood vessels and skin may also be attacked byantibodies. Antibodies to erythrocytes aresometimes produced. Maria Carmela L. Domocmat, RN, MSN
  12. 12. s/sPainful or swollen joints and muscle painUnexplained feverRed rashes, most commonly on the faceChest pain upon deep breathingUnusual loss of hairPale or purple fingers or toes from cold or stress (Raynaudsphenomenon)Sensitivity to the sunSwelling (edema) in legs or around eyesMouth ulcersSwollen glandsExtreme fatigue Maria Carmela L. Domocmat, RN, MSN
  13. 13. Diagnostic Tools for LupusMedical historyComplete physical examinationLaboratory tests: Complete blood count (CBC) Erythrocyte sedimentation rate (ESR) Urinalysis Blood chemistries Complement levels Antinuclear antibody test (ANA) Other autoantibody tests (anti-DNA, anti-Sm, anti-RNP, anti-Ro [SSA], anti-La [SSB]) Anticardiolipin antibody testSkin biopsyKidney biopsy Maria Carmela L. Domocmat, RN, MSN
  14. 14. Systemic Lupus Erythematosus (SLE) Damaged kidney (left) caused by immunoglobulin deposits (right)Butterfly rash of lupus Maria Carmela L. Domocmat, RN, MSN
  15. 15. Lupus, discoid - view of lesions on the chest: This close-up picture of the neck clearly shows the typical rounded appearance of discoid lupus. The whitish appearance is caused by scaling. The two dark spots are biopsy sites and are not part of the disease.Maria Carmela L. Domocmat, RN, MSN
  16. 16. The round or disk shaped(discoid) rash of lupusproduces red, raised patcheswith scales. The pores (hairfollicles) may be plugged.Scarring often occurs in olderlesions. The majority(approximately 90%) ofindividuals with discoid lupushave only skin involvement ascompared to more generalizedinvolvement in systemic lupuserythematosis (SLE). Maria Carmela L. Domocmat, RN, MSN
  17. 17. This is a picture of a systemic lupus erythematosis rash on the face. Lupus erythematosis often produces a "butterfly rash" or malar rash. Typically, the rash also appears on the nose.Maria Carmela L. Domocmat, RN, MSN
  18. 18. The rash of lupis is round ordisk shaped (discoid) and ischaracterized by red, raisedpatches with adherent scales.The skin pores (follicles) maybe plugged, and scarring oftenoccurs in older lesions.Approximately 90% ofindividuals with discoid lupushave only skin involvement ascompared to more generalizedinvolvement in systemic lupuserythematosis (SLE). Maria Carmela L. Domocmat, RN, MSN
  19. 19. LupusMaria Carmela L. Domocmat, RN, MSN
  20. 20. LupusMaria Carmela L. Domocmat, RN, MSN
  21. 21. exact trigger - not knownresearch has shown that the environmentalfactors include infectious agents excess UV light physical trauma emotional stress and some drugs (anticonvulsants, some forms of penicillin, and drugs used in estrogen therapy) Maria Carmela L. Domocmat, RN, MSN
  22. 22. Managementno cure for SLE.goal of treatment - control symptoms Maria Carmela L. Domocmat, RN, MSN
  23. 23. ManagementReduce inflammation and minimizecomplications NSAIDs - Aspirin Glucoccorticoids HydroxychloroquineManage exacerbationsPromote orientation and decision-makingProvide seizure precautionMonitor fluid status Maria Carmela L. Domocmat, RN, MSN
  24. 24. Treatment : Mild disease Mild disease NSAIDs - treat arthritis and pleurisy Corticosteroid creams – to treat skin rashes antimalaria drug (hydroxychloroquine) and low-dose corticosteroids for skin and arthritis symptomshttp://www.nlm.nih.gov/medlineplus/ency/article/000435.htm Maria Carmela L. Domocmat, RN, MSN
  25. 25. Treatment :severe Treatment for more severe lupus may include: Pulse Therapy – High-dose corticosteroids or medications to decrease the immune system response Cytotoxic drugs (drugs that block cell growth) MTX Azathioprine (Imuran) Cyclophosphamide (Cytoxan)http://www.nlm.nih.gov/medlineplus/ency/article/000435.htm Maria Carmela L. Domocmat, RN, MSN
  26. 26. Other Agents For SLE thrombocytopenia Attenuated androgen danazol IV Ig - Immune globulin intravenous (Gamimune, Gammagard, Sandoglobulin) immunosuppression in serious SLE flares. Platelet increase rapidly within hours after administration Indication – control acute bleeding; rapidly increase platelet to allow for splenectomy or other surgery For cutaneous s/s Dapson Maria Carmela L. Domocmat, RN, MSN
  27. 27. Maria Carmela L. Domocmat, RN, MSN
  28. 28. Drugs in clinical trialUseful for maintenance in lupus nephritis andother serious lupus cases; Inhibits antibodyproduction Mycophenolate (CellCept) ToterogensDehydroepiandrosterone (DHEA)Stem cell transplant Maria Carmela L. Domocmat, RN, MSN
  29. 29. Maintain skin integrityAvoid prolonged exposure to sunlight and otherforms of UV lighting including tanning bedswear protective clothing (long sleeves, large-brimmed hat, long pants), sunglasses, andsunscreen (SPF 30 or higher) when in the sun.Clean skin with mild soap (e.g., ivory)avoid harsh, perfumed substancesSkin is rinsed and dried well, apply lotion Maria Carmela L. Domocmat, RN, MSN
  30. 30. Maintain skin integrityAvoid excess powder and other dryingsubstancesDry skin thoroughly by patting rather thanrubbingApply lotion liberally to dry skin areasAvoid powder or other drying agents (e.g.,rubbing alcohol)Use cosmetics that contain moisturizersInspect skin daily for open areas and rashes Maria Carmela L. Domocmat, RN, MSN
  31. 31. For alopecia Recommend use of mild protein shampoos Avoid harsh treatments (e.g., permanents or highlights) until hair regrows during remission Maria Carmela L. Domocmat, RN, MSN
  32. 32. Severe or life-threatening symptoms (such as hemolytic anemia, extensive heart or lung involvement, kidney disease, or central nervous system involvement) often require more aggressive treatment by doctor specialists. Maria Carmela L. Domocmat, RN, MSN
  33. 33. it is also important to have: Preventive heart care Up-to-date immunizations Tests to screen for thinning of the bones (osteoporosis) Talk therapy and support groups may help relieve depression and mood changes that may occur in patients with this disease. Maria Carmela L. Domocmat, RN, MSN
  34. 34. Outlook (Prognosis)How well a person does depends on the severityof the disease.The outcome for people with SLE has improvedin recent years. Many people with SLE have mildsymptoms. Maria Carmela L. Domocmat, RN, MSN
  35. 35. Outlook (Prognosis)Women with SLE who become pregnant areoften able to carry safely to term and deliver ahealthy infant, as long as they do not havesevere kidney or heart disease and the SLE isbeing treated appropriately. However, thepresence of SLE antibodies may increase therisk of pregnancy loss. Maria Carmela L. Domocmat, RN, MSN
  36. 36. Possible ComplicationsSome people with SLE have abnormal depositsin the kidney cells. This leads to a conditioncalled lupus nephritis. Patients with thiscondition may eventually develop kidneyfailure and need dialysis or a kidney transplant. Maria Carmela L. Domocmat, RN, MSN
  37. 37. Possible ComplicationsSLE causes damage to many different parts ofthe body, including: DVT or pulmonary embolism hemolytic anemia pericarditis, endocarditis, or myocarditis Fluid around the lungs (pleural effusions) and damage to lung tissue Maria Carmela L. Domocmat, RN, MSN
  38. 38. Possible ComplicationsPregnancy complications, including miscarriageStrokethrombocytopeniaInflammation of the blood vessels Maria Carmela L. Domocmat, RN, MSN
  39. 39. Psoriasisis a common, chronic skin condition that causesred patches on the body. Maria Carmela L. Domocmat, RN, MSN
  40. 40. Maria Carmela L. Domocmat, RN, MSN
  41. 41. Skin cells grow deep in the skin and normallyrise to the surface about once a month. Inpersons with psoriasis, this process is too fast(about 2 weeks instead of 4 weeks) and deadskin cells build up on the skins surface. Maria Carmela L. Domocmat, RN, MSN
  42. 42. Psoriasis on the knucklesThis is a picture of a typical case of psoriasis,with small lesions on the knuckles. Note thechanges in the fingernails. Maria Carmela L. Domocmat, RN, MSN
  43. 43. The following may trigger an attack of psoriasis or makethe condition more difficult to treat: Bacteria or viral infections, including strep throat and upper respiratory infections Dry air or dry skin Injury to the skin, including cuts, burns, and insect bites Some medicines, including antimalaria drugs, beta-blockers, and lithium Stress Too little sunlight Too much sunlight (sunburn) Too much alcohol Maria Carmela L. Domocmat, RN, MSN
  44. 44. In general, psoriasis may be severe in peoplewho have a weakened immune system. Thismay include persons who have:AIDSAutoimmune disorders (such as rheumatoidarthritis)Cancer chemotherapyUp to one-third of people with psoriasis may alsohave arthritis, a condition known as psoriaticarthritis. Maria Carmela L. Domocmat, RN, MSN
  45. 45. SymptomsPsoriasis can appear suddenly or slowly. Inmany cases, psoriasis goes away and thenflares up again repeatedly over time.People with psoriasis have irritated patches ofskin. The redness is most often seen on theelbows, knees, and trunk, but it can appearanywhere on the body. For example, there maybe flaky patches on the scalp. Maria Carmela L. Domocmat, RN, MSN
  46. 46. The skin patches or dots may be:ItchyDry and covered with silver, flaky skin (scales)Pink-red in color (like the color of salmon)Raised and thick Maria Carmela L. Domocmat, RN, MSN
  47. 47. Other symptoms may include:Genital lesions in malesJoint pain or aching (psoriatic arthritis)Nail changes, including nail thickening, yellow-brown spots, dents (pits) on the nail surface, andseparation of the nail from the baseSevere dandruff on the scalp Maria Carmela L. Domocmat, RN, MSN
  48. 48. five main types of psoriasisPsoriasis may affect any or all parts of the skin. Erythrodermic -- The skin redness is very intense and covers a large area. Guttate -- Small, pink-red spots appear on the skin. Inverse -- Skin redness and irritation occurs in the armpits, groin, and in between overlapping skin. Plaque -- Thick, red patches of skin are covered by flaky, silver-white scales. This is the most common type of psoriasis. Pustular -- White blisters are surrounded by red, irritated skin. Maria Carmela L. Domocmat, RN, MSN
  49. 49. Scalp psoriasis Nail Psoriasis Maria Carmela L. Domocmat, RN, MSN
  50. 50. Plaque Psoriasis Pictures (Vulgaris/Circular) Maria Carmela L. Domocmat, RN, MSN
  51. 51. Guttate Psoriasis Maria Carmela L. Domocmat, RN, MSN
  52. 52. Pustular Psoriasis Maria Carmela L. Domocmat, RN, MSN
  53. 53. Inverse Psoriasis Maria Carmela L. Domocmat, RN, MSN
  54. 54. Erythrodermic Psoriasis particularly inflammatory form of psoriasis thatoften affects most of the body surface.least common type of psoriasismay occur once or more during a lifetime in 1 to 2percent of people who develop psoriasis Maria Carmela L. Domocmat, RN, MSN
  55. 55. Psoriatic Arthritis Maria Carmela L. Domocmat, RN, MSN
  56. 56. TreatmentThe goal of treatment is to control symptomsand prevent infections.In general, three treatment options are used forpatients with psoriasis: Topical medications such as lotions, ointments, creams, and shampoos Body-wide (systemic) medications, which are pills or injections that affect the whole body, not just the skin Phototherapy, which uses light to treat psoriasis Maria Carmela L. Domocmat, RN, MSN
  57. 57. TreatmentTopical medications such as lotions, ointments, creams, and shampoos Topical steroids Tar preparations UV Light therapy Maria Carmela L. Domocmat, RN, MSN
  58. 58. Topical medsCortisone creams and ointments Suppress cell division when applied to psoriatic lesions More effective when penetrate the skin How to enhance absorption: apply to skin, wrap with warm, moist dressings and occlusive outer wrap of plastic (film, gloves, booties, or similar garments) Note: when large surface areas are involved – limit occlusive therapy to 12 hrs/day Bcoz increased risk of localand systemic S/E Maria Carmela L. Domocmat, RN, MSN
  59. 59. Topical medsTar preparations Creams ,ointments, solutions, lotions, gels, shampoos that contain coal tar or anthralin Coal tar – inpatient messy, cause staining, and have unpleasant odor Maria Carmela L. Domocmat, RN, MSN
  60. 60. Topical medsTar preparations Anthralin (Anthraforte, Drithocreme, Lasan) A hydrocarbon similar in action to tar Relieves chronic psoriasis Can be used alone or in combination with coal tar baths and UV light Apply to each lesion for short periods (not exceeeding 2 hrs) Maria Carmela L. Domocmat, RN, MSN
  61. 61. Topical medsTar preparations Anthralin (Anthraforte, Drithocreme, Lasan) Not used to treat acute, spreading psoriasis – bcoz tend to induce Koebner’s phenomenon Koebner’s phenomenon – are psoriasis plaques that form at the site of a skin injury. Occurs when trauma to the skin causes a skin lesion. The amount of trauma required can be very small -- sometimes just rubbing the skin can cause a lesion to develop. http://www.psoriasis.org/page.aspx?pid=1660 Maria Carmela L. Domocmat, RN, MSN
  62. 62. Topical medsPrescription medicines containing vitamin D orvitamin A (retinoids) Cream, ointment, lotion For mild to moderateCalcipotriene (Dovonex)Tazarotene (Tazorac) Maria Carmela L. Domocmat, RN, MSN
  63. 63. Topical medsCalcipotriene (Dovonex) A synthetic form of vitamin D – regulates skin cell divisionTazarotene (Tazorac) Vit A derivative Teratogenic - even when applied topically Maria Carmela L. Domocmat, RN, MSN
  64. 64. Topical medsCreams to remove the scaling (usually salicylicacid or lactic acid)Dandruff shampoos (over-the-counter orprescription)Moisturizers Maria Carmela L. Domocmat, RN, MSN
  65. 65. UV light therapyOr Phototherapyuses light to treat psoriasisNote: must wear eye protection during treatmentTypes: UVA, UVBPsoralen and UVA (PUVA) Common in OPD Client ingest psoralen – a photosensitizing agent- 2 hrs b4 exposure 2-3 times a week; not on consecutive days Maria Carmela L. Domocmat, RN, MSN
  66. 66. UV light therapy Maria Carmela L. Domocmat, RN, MSN
  67. 67. Observe for generalized redness with edemaand tendernessWear dark glasses during treatment and for theremainder of the day – bcoz of the strongphotosensitizing properties of psoralenLong term S/E of UVB and PUVA Premature aging of skin Actinic keratosis Increased risk skin Ca Maria Carmela L. Domocmat, RN, MSN
  68. 68. Systemic medications for severe psoriasisImmunosuppressants Retinoids (acitretin) DMARDs - Cytotoxic agents Methotrexate or cyclosporine (Folex, Mexate) C/I – liver damage, bone marrow supression, impaired function Azathioprine (Imuran) Cyclosporine (Neoral, Sandimmune) Maria Carmela L. Domocmat, RN, MSN
  69. 69. Maria Carmela L. Domocmat, RN, MSN
  70. 70. BRMs (Biologics) Alefacept (Amevive) – IM weekly x 12 wks Efalizumab (Raptiva) – subq once/week Adalimumab (Humira) Etanercept (Enbrel) Infliximab (Remicade) Stelara Maria Carmela L. Domocmat, RN, MSN
  71. 71. Self-care at homeOatmeal baths may be soothing and may help to loosen scales. can use over-the-counter oatmeal bath products. Or can mix 1 cup of oatmeal into a tub of warm water.Sunlight may help symptoms go away. Becareful not to get sunburned.Relaxation and antistress techniques may behelpful. Maria Carmela L. Domocmat, RN, MSN
  72. 72. PsoriasisMaintain skin integrityEnhance body imageProvide emotional support Maria Carmela L. Domocmat, RN, MSN
  73. 73. Tar - not only look dirty but unpleasant odor;bed linens, pajamas become stained – furtherdiscouraging social interactionEncourage contact with other client with similarproblemsGroup discussion with family members or SO –can increase socialization process Maria Carmela L. Domocmat, RN, MSN
  74. 74. Touch - more than any gesture communicatesacceptance of the person and their skin problem Shake hands during introduction Place hand on client’s shoulder when explaining procedure Do not wear gloves during social interactions Maria Carmela L. Domocmat, RN, MSN
  75. 75. Expectations (prognosis)Psoriasis is a life-long condition that can becontrolled with treatment.may go away for a long time and then return.With appropriate treatment - usually does notaffect general physical health. Maria Carmela L. Domocmat, RN, MSN
  76. 76. Complications Arthritis Pain Severe itching Secondary skin infections Side effects from medicines used to treat psoriasis Skin cancer from light therapyhttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001470/ Maria Carmela L. Domocmat, RN, MSN
  77. 77. Psoriatic arthritis is an arthritis that is oftenassociated with psoriasis of the skin20-50 years oldWomen Maria Carmela L. Domocmat, RN, MSN
  78. 78. Psoriatic arthritisThe cause of is not knownIn general, people who have psoriasis have ahigher rate of arthritis than the generalpopulation. Maria Carmela L. Domocmat, RN, MSN
  79. 79. Symptomsarthritis - may be mild and involve only a fewjoints, particularly those at the end of the fingersor toes.In some - may be severe and affect many joints,including the spine.When spine is affected, symptoms are stiffness, burning, and pain, most often in the lower spine and sacrum. Maria Carmela L. Domocmat, RN, MSN
  80. 80. SymptomsPeople who also have arthritis usually have theskin and nail changes of psoriasis. Often, theskin gets worse at the same time as the arthritis.Nail pitting in a patient withpsoriatic arthritis. Maria Carmela L. Domocmat, RN, MSN
  81. 81. http://images.emedicinehealth.com/images/4453/4453-13248-30912-31165.jpg Maria Carmela L. Domocmat, RN, MSN
  82. 82. Manage joint pain and inflammation Same with RAControl skin lesions Same with SLESlow progression of disease Maria Carmela L. Domocmat, RN, MSN
  83. 83. TreatmentNSAIDSMore severe arthritis - DMARDs, TNF inhibitorsRest and exercisePhysical therapy may help increase themovement of specific jointsheat and cold therapy Maria Carmela L. Domocmat, RN, MSN
  84. 84. Expectations (prognosis)The course of the disease is often mild andaffects only a few joints.A few people will have severe psoriatic arthritisin their hands, feet, and spine that causesdeformities.In those with severe arthritis, treatment can stillbe successful in relieving the pain. Maria Carmela L. Domocmat, RN, MSN
  85. 85. ComplicationsRepeated episodes may occur. Maria Carmela L. Domocmat, RN, MSN
  86. 86. http://t1.gstatic.com/images?q=tbn:ANd9GcSNZJeyTzNT2-n9x75SxwCiHpxGRsPy_cT_qqDvE5lc04P94kRW Maria Carmela L. Domocmat, RN, MSN
  87. 87. Cause is unknown.People with this condition have a buildup of asubstance called collagen in the skin and otherorgans. This buildup leads to the symptoms ofthe disease. Maria Carmela L. Domocmat, RN, MSN
  88. 88. 30 to 50 years old.Womenhistory of being around silica dust and polyvinylchloridecan occur with other autoimmune diseases,including systemic lupus erythematosusand polymyositis.In such cases, the disorder is referred to asmixed connective disease. Maria Carmela L. Domocmat, RN, MSN
  89. 89. ManifestationsTypes: localized and systemicLocalized scleroderma affects only the skin on the hands and face. develops slowly, and rarely, if ever, spreads throughout the body or causes serious complications. Maria Carmela L. Domocmat, RN, MSN
  90. 90. ManifestationsSystemic scleroderma, or sclerosis may affect large areas of skin and organs such as the heart, lungs, or kidneys. There are two main types of systemic scleroderma: Limited disease (CREST syndrome) diffuse disease. Maria Carmela L. Domocmat, RN, MSN
  91. 91. Skin symptomsFingers or toes that turn blue or white in response to hotand cold temperaturesHair lossSkin hardnessSkin that is abnormally dark or lightSkin thickening, stiffness, and tightness of fingers,hands, and forearmSmall white lumps beneath the skin, sometimes oozing awhite substance that looks like toothpasteSores (ulcers) on the fingertips or toesTight and mask-like skin on the face Maria Carmela L. Domocmat, RN, MSN
  92. 92. Telangiectasiais the dilation of smallsuperficial vessels andcapillaries that causenumerous flat red markson the hands, face andtongue. Telangiectasiacan be a symptom ofscleroderma or othersystemic diseases. Maria Carmela L. Domocmat, RN, MSN
  93. 93. Maria Carmela L. Domocmat, RN, MSN
  94. 94. Sclerodactyly The most classic symptom of scleroderma is a type of skin tightening called sclerodactyly. The initial stages of the disease involves swelling of the fingers. Later, as the connective tissue becomes fibrotic, skin on the fingers and toes becomes hard and shiny. The fingers can become difficult to bend and can form contractures due to the severe tightening of the skin.Maria Carmela L. Domocmat, RN, MSN
  95. 95. Raynauds phenomenonis characterized byfingers becoming whitedue to lack of blood flow,then blue due to oxygenconsumption, and finallyred as blood flow returns. Maria Carmela L. Domocmat, RN, MSN
  96. 96. Bone and muscle symptoms may include:Joint painNumbness and pain in the feetPain, stiffness, and swelling of fingers and jointsWrist pain Maria Carmela L. Domocmat, RN, MSN
  97. 97. Breathing problems may result from scarring inthe lungs and can include:Dry coughShortness of breathWheezing Maria Carmela L. Domocmat, RN, MSN
  98. 98. Digestive tract problems may include:Bloating after mealsConstipationDiarrheaDifficulty swallowingEsophageal reflux or heartburnProblems controlling stools (fecal incontinence) Maria Carmela L. Domocmat, RN, MSN
  99. 99. Maria Carmela L. Domocmat, RN, MSN
  100. 100. Dx testsBlood tests may include: Antinuclear antibody (ANA) panel Antibody testing ESR (sed rate) Rheumatoid factorOther tests may include:Chest x-rayCT scan of the lungsEchocardiogramUrinalysisTests to see how well your lungs and gastrointestinal(GI) tract are workingSkin biopsy Maria Carmela L. Domocmat, RN, MSN
  101. 101. Medical managementThere is no specific treatment for scleroderma.Reduce inflammation, sclerosis, vasospasmReduce renal complicationsTreat pulmonary arterial hypertension (PAH) Maria Carmela L. Domocmat, RN, MSN
  102. 102. Other treatments for specific symptoms mayinclude: Medicines for heartburn or swallowing problems Blood pressure medications (particularly ACE inhibitors) for high blood pressure or kidney problems Light therapy to relieve skin thickening Medicines to improve breathing Medications to treat Raynauds phenomenonTreatment usually also involves physicaltherapy. Maria Carmela L. Domocmat, RN, MSN
  103. 103. Medicines used to treat scleroderma include: Power anti-inflammatory medicines called corticosteroids Immune-suppressing medications such as methotrexate and Cytoxan Nonsteroidal anti-inflammatory drugs (NSAIDs) Maria Carmela L. Domocmat, RN, MSN
  104. 104. Nursing managementFacilitate muscle and joint movementMaintain skin integrityProvide educationPromote adequate nutritionPromote bowel eliminationMonitor for complications Maria Carmela L. Domocmat, RN, MSN
  105. 105. Outlook (Prognosis)Some people with scleroderma have symptomsthat develop quickly over the first few years andcontinue to get worse. However, in mostpatients, the disease slowly gets worse.People who only have skin symptoms have abetter outlook. Widespread (systemic)scleroderma can damage the heart, kidney,lungs, or GI tract, which may cause death.Lung problems are the most common cause ofdeath in patients with scleroderma. Maria Carmela L. Domocmat, RN, MSN
  106. 106. Possible ComplicationsThe most common cause of death in people withscleroderma is scarring of the lungs, called pulmonaryfibrosisOther complications of scleroderma include:CancerHeart failureHigh blood pressure in the lungs (pulmonaryhypertension)Kidney failureProblems absorbing nutrients from food (malabsorption http://www.nlm.nih.gov/medlineplus/ency/ar Maria Carmela L. Domocmat, RN, MSN ticle/000429.htm
  107. 107. Ankylosing Spondylitisa form of arthritis that primarily affects the spine,although other joints can become involved.It causes inflammation of the spinal joints(vertebrae) that can lead to severe, chronic painand discomfort. Maria Carmela L. Domocmat, RN, MSN
  108. 108. In the most advanced cases, this inflammation canlead to new bone formation on the spine, causingthe spine to fuse in a fixed, immobile position,sometimes creating a forward-stooped posture(Kyphosis) Maria Carmela L. Domocmat, RN, MSN
  109. 109. Causes and risk factors20 and 40, but may begin before age 10.Risk factors include: Family history of ankylosing spondylitis Male gender Maria Carmela L. Domocmat, RN, MSN
  110. 110. hallmark feature the involvement of the sacroiliac (SI) joints during the progression of the disease, which are the joints at the base of the spine, where the spine joins the pelvis. Maria Carmela L. Domocmat, RN, MSN
  111. 111. S/SThe disease starts with low back pain thatcomes and goes.Pain and stiffness are worse at night, in themorning, or when you are not active. It maywake you from your sleep.The pain typically gets better with activity orexercise.Back pain may begin in the sacroiliac joints(between the pelvis and the spine). Over time, itmay involve all or part of the spine. Maria Carmela L. Domocmat, RN, MSN
  112. 112. S/SFatigueless common symptoms include: Eye inflammation or uveitis Heel pain Hip pain and stiffness Joint pain and joint swelling in the shoulders, knees, and ankles Loss of appetite Slight fever Weight loss Maria Carmela L. Domocmat, RN, MSN
  113. 113. Ankylosing Spondylitis Maria Carmela L. Domocmat, RN, MSN
  114. 114. Ankylosing Spondylitis Maria Carmela L. Domocmat, RN, MSN
  115. 115. Maria Carmela L. Domocmat, RN, MSN
  116. 116. ComplicationsRarely, people may have problems with theaortic heart valve (aortic insufficiency) and heartrhythm problems.Some patients may have pulmonary fibrosis orrestrictive lung disease Maria Carmela L. Domocmat, RN, MSN
  117. 117. TreatmentNSAIDsCorticosteroid therapyTNF-inhibitorscytotoxic drugs If do not respond well to corticosteroids or who are dependent on high doses of corticosteroids.Surgery Maria Carmela L. Domocmat, RN, MSN
  118. 118. Nursing managementProvide educationPromote effective breathingExercises can help improve posture andbreathing.Lying flat on the back at night can help maintainnormal posture. Maria Carmela L. Domocmat, RN, MSN
  119. 119. Reactive arthritisis a group of inflammatory conditions thatinvolves the joints, urethra, and eyes. Maria Carmela L. Domocmat, RN, MSN
  120. 120. Triad of symptomsNongonococcal urethritisConjunctivitisArthritis Maria Carmela L. Domocmat, RN, MSN
  121. 121. Causes, incidence, and risk factorsmen before the age of 40.may follow an infection withChlamydia,Campylobacter, Salmonella, or Yersinia. Maria Carmela L. Domocmat, RN, MSN
  122. 122. SymptomsUrinary symptoms usually appear within days orweeks of an infection. Low-grade fever,inflammation of the conjunctiva of the eye(conjunctivitis), and arthritis develop over thenext several weeks. The arthritis may be mild orsevere, and may affect only one side of the bodyor more than one joint. Maria Carmela L. Domocmat, RN, MSN
  123. 123. Maria Carmela L. Domocmat, RN, MSN
  124. 124. Muscle and joint symptoms include:Achilles tendon painHeel painJoint pain in the large joints (hip pain, knee pain,and ankle pain are common)Low back pain Maria Carmela L. Domocmat, RN, MSN
  125. 125. Eye and skin symptoms include: Eye discharge Eye pain - burning Eye redness Skin lesions on the palms and soles that may resemble psoriasis Small, painless ulcers in the mouth, tongue, and glans penis Urinary and genital symptoms may include: Maria Carmela L. Domocmat, RN, MSN
  126. 126. Urinary and genital symptoms may include: Genital lesions (male) Incontinence Penis pain Skin redness or inflammation Urethral discharge Urinary hesitancy Urinary urgency Urination - burning or stinging Maria Carmela L. Domocmat, RN, MSN
  127. 127. Signs and testsThe diagnosis is based on symptoms.Since the symptoms may occur at differenttimes, the diagnosis may be delayed.A physical examination may reveal conjunctivitisor typical skin lesions.Tests that may be performed include: HLA-B27 antigen Joint x-rays Urinalysis Maria Carmela L. Domocmat, RN, MSN
  128. 128. Treatmentgoal - to relieve symptoms and treat anyunderlying infection.Conjunctivitis and skin lesions associated withthe syndrome – self-limiintgantibiotics if have an infection.NSAIDS and pain relieversIntraarticular corticosteroidDMARDs Maria Carmela L. Domocmat, RN, MSN
  129. 129. ManagementSelf-limited course - 3 to12 monthsAdminister meds Same with AS Antibiotic therapy – still controversial Steroid eyedrops or subconjunctival prepProvide PTmake adjustments if job requires heavy lifting orstrenuous use of the back. Maria Carmela L. Domocmat, RN, MSN
  130. 130. PreventionPreventing sexually transmitted diseases andgastrointestinal infection may help prevent thisdisease.Wearing a condom during intercourse canreduce the risks of sexually transmitted disease.Wash hands and surface areas thoroughlybefore and after preparing food. Maria Carmela L. Domocmat, RN, MSN
  131. 131. Fibromyalgia (FM)is a disorder of chronic widespread pain with associated fatigue, poor sleep, stiffness, cognitive difficulties, multiple somatic symptoms, and, not infrequently, anxiety and/or depression. Maria Carmela L. Domocmat, RN, MSN
  132. 132. Fibromyalgia (FM)Pain - radiates diffusely from the axial skeletonover large areas of the body, predominantly involving muscles and musculoskeletal junctions, but also in joints (arthralgia without actual synovitis) described as exhausting, burning, miserable, or unbearable. may also be multifocal and can wax and wane in a migratory fashion. Described as "pain all over." However, multifocal pain or recurrent episodes of regional pain are essentially equivalent to the classic "pain all over" description. Maria Carmela L. Domocmat, RN, MSN
  133. 133. Algometer or dolorimeterA useful devicefor roughquantitation ofpain sensitivityis a pressurealgometer, ordolorimeter. Maria Carmela L. Domocmat, RN, MSN
  134. 134. Tender points in fibromyalgia. Maria Carmela L. Domocmat, RN, MSN
  135. 135. Fibromyalgia (FM)Fatigue and poor sleep Most patients with fibromyalgia also meet the classification criteria for chronic fatigue syndrome. Maria Carmela L. Domocmat, RN, MSN
  136. 136. Maria Carmela L. Domocmat, RN, MSN
  137. 137. Fibromyalgia (FM)Cognitive problems (known as "fibrofog") - primary symptom of fibromyalgia, reflecting impairments in working, episodic, and semantic memory that are roughly equivalent to 20 years of aging.Cognitive symptoms associated withfibromyalgia are exacerbated by pain, moodand anxiety disorders, and poor sleep. Maria Carmela L. Domocmat, RN, MSN
  138. 138. Maria Carmela L. Domocmat, RN, MSN
  139. 139. Other common symptomsWeight fluctuationsAllergic symptoms (eg, nasal congestion) andhypersensitivity to environmental stimuli (eg, odors, brightlights, loud noises) and medicationsRegional pains, including noncardiac chest pain,dyspepsia, headache, abdominal cramping (irritable bowelsyndrome), temporomandibular pain, chronic pelvic pain,and others (Patients with fibromyalgia may meet criteria for3 or more central sensitivity syndromes.) Maria Carmela L. Domocmat, RN, MSN
  140. 140. Other common symptomsSyncope or dizzinessShortness of breathUrinary frequency and urgency (female urethral syndrome,interstitial cystitis) Maria Carmela L. Domocmat, RN, MSN
  141. 141. Maria Carmela L. Domocmat, RN, MSN
  142. 142. Causesmultifactorial.Engels biopsychosocial model of chronic illness(ie, health status and outcomes in chronic illnessare influenced by the interaction of biologic,psychologic, and sociologic factors) provides auseful way to conceptualize fibromyalgia Maria Carmela L. Domocmat, RN, MSN
  143. 143. Maria Carmela L. Domocmat, RN, MSN
  144. 144. Laboratory Studiesdo not have characteristic or consistent abnormalities asdetermined by laboratory test results.Laboratory studies - important to help rule out diseaseswith similar manifestations Maria Carmela L. Domocmat, RN, MSN
  145. 145. Laboratory StudiesThyroid-stimulating hormone: H ypothyroidism shares many clinical features with fibromyalgia, especially diffuse muscle pain and fatigue.Creatinine phosphokinase (CPK) to exclude inflammatory myopathiesErythrocyte sedimentation rate (ESR): The normal ESR in patients with fibromyalgia contrasts with the high ESR in elderly patients with polymyalgia rheumatica. Obtaining an ESR can assist in identifying an underlying inflammatory disorder or occult malignancy. Maria Carmela L. Domocmat, RN, MSN
  146. 146. Laboratory StudiesAntinuclear antibodies (ANAs): Many patients with SLE have comorbid fibromyalgia. A low-titer ANA is common in the general population and may be of no clinical significance if diagnostic features of SLE or related autoimmune disorders are absent.Rheumatoid factor: Many patients with RA have comorbid fibromyalgia. However, a positive result for rheumatoid factor does not support a diagnosis of RA in the absence of objective evidence of characteristic joint inflammation. A positive result for rheumatoid factor is diagnostically nonspecific in other clinical settings. Maria Carmela L. Domocmat, RN, MSN
  147. 147. Treatmentvalidation of the patient’s illness empathetic listening and acknowledgment that the patient is indeed experiencing pain first crucial element in the treatment of pain, fatigue, and other diverse symptomatology in patients with fibromyalgia (FM) I Maria Carmela L. Domocmat, RN, MSN
  148. 148. TreatmentAccurately assess possible causal or perpetuatingfactors, including attention to psychologic and sociocultural factors and identification of specific regional sources of ongoing nociceptive pain (eg, degenerative spondylosis, bursitis). Maria Carmela L. Domocmat, RN, MSN
  149. 149. Comments such as "it’s all in your mind" or "Icannot find anything wrong with you" only add tothe patients frustration. Maria Carmela L. Domocmat, RN, MSN
  150. 150. Psychologic and behavioral approachesDepression must be treated aggressively. Depression, anxiety, stress, sleep disturbance, pain beliefs and coping strategies, and self-efficacy all are central to the pain experience in many patients and frequently determine the outcome of chronic pain.Unless psychosocial and behavioral variables arerecognized and approached, strictlypharmacologic interventions are of limited benefit. Maria Carmela L. Domocmat, RN, MSN
  151. 151. Psychologic and behavioral approachesCognitive-behavioral therapy (CBT) and operant-behavioral therapy (OBT) both effect clinically meaningful improvements in pain intensity and physical impairment in approximately one third to on half of patients with fibromyalgia. Maria Carmela L. Domocmat, RN, MSN
  152. 152. Patient EducationEducation is an essential element in therapy forfibromyalgia.It begins with an empathetic manner on the part ofthe nurse/physician, who must affirm the patientspain, explore social and behavioral variables (bothin childhood and current) that influence thisillness, and explain to the patient how stress anddistress can amplify pain and fatigue. Maria Carmela L. Domocmat, RN, MSN
  153. 153. MedicationAnxiolytics/hypnoticsAntidepressants Tricyclics antidepressants Selective Serotonin-reuptake Inhibitors (SSRIs)Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)Central Nervous System DepressantsOpioidsAnticonvulsantsAnalgesicsNonsteroidal anti-inflammatory drugs (NSAIDs) Maria Carmela L. Domocmat, RN, MSN
  154. 154. Anxiolytics/hypnoticsoften used in combination with antidepressantsand anticonvulsant drugs (both of which also haveefficacy for anxiety and insomnia)Benzodiazepines alprazolam [Xanax] temazepam [Restoril clonazepam [Klonopin] buspirone [BuSpar] trazodone [Desyrel]) Maria Carmela L. Domocmat, RN, MSN
  155. 155. Anxiolytics/hypnotics Maria Carmela L. Domocmat, RN, MSN
  156. 156. Tricyclic antidepressantAmitriptyline (Elavil)Desipramine (Norpramin)Doxepin (Sinequan)Imipramine (Tofranil)Trazodone (Desyrel)Nortriptyline (Pamelor) Maria Carmela L. Domocmat, RN, MSN
  157. 157. Selective Serotonin-reuptake Inhibitors (SSRIs)Fluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)Fluvoxamine (Luvox)Citalopram (Celexa) Maria Carmela L. Domocmat, RN, MSN
  158. 158. Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)Milnacipran (Savella)Duloxetine (Cymbalta) Maria Carmela L. Domocmat, RN, MSN
  159. 159. Central Nervous System DepressantsZolpidem (Ambien)Zaleplon (Sonata)Sodium oxybate (Xyrem) Maria Carmela L. Domocmat, RN, MSN
  160. 160. OpioidsMorphineOxycodone (OxyContin)Hydrocodone (Vicodin, Percocet)Hydromorphone (Dilaudid)Meperidine (Demerol) Maria Carmela L. Domocmat, RN, MSN
  161. 161. AnticonvulsantsGabapentin (Neurontin)Pregabalin (Lyrica) Maria Carmela L. Domocmat, RN, MSN
  162. 162. Pain RelieversAcetaminophen (Tylenol) Maria Carmela L. Domocmat, RN, MSN
  163. 163. Nonsteroidal anti-inflammatory drugs (NSAIDs)AspirinIbuprofen (Advil)Naproxen (Aleve) Maria Carmela L. Domocmat, RN, MSN
  164. 164. Sodium oxybate (Xyrem)a sedative hypnotic, prolongs stage III/IVrestorative sleep, which is essential to awakenrested and refreshed. Maria Carmela L. Domocmat, RN, MSN
  165. 165. AnticonvulsantsPregabalin (Lyrica)Gabapentin (Neurontin)Clonidine (Catapres) Maria Carmela L. Domocmat, RN, MSN
  166. 166. Polymyositisa persistent inflammatory muscle disease thatcauses weakness of the skeletal muscles, whichcontrol movement.Medically, polymyositis is classified as a chronicinflammatory myopathy — one of only three suchdiseases. Maria Carmela L. Domocmat, RN, MSN
  167. 167. Polymyositiscan occur at any age,adults -30s, 40s or 50s.BlacksWomen Maria Carmela L. Domocmat, RN, MSN
  168. 168. Polymyositissigns and symptoms usually develop gradually,over weeks or months.Remissions - rareRemissions: periods during which symptoms spontaneouslydisappear Maria Carmela L. Domocmat, RN, MSN
  169. 169. Signs and symptomsappear gradually,Progressive muscle weaknessDifficulty swallowing (dysphagia)Difficulty speakingMild joint or muscle tendernessFatigueShortness of breath Maria Carmela L. Domocmat, RN, MSN
  170. 170. Signs and symptomsaffects the muscles closest to the trunk,particularly hips, thighs, shoulders, upper armsand neck.weakness is symmetricalworsens over time.As muscle weakness progresses, difficult to climb stairs, rise from a seated position, lift objects or reach overhead. Maria Carmela L. Domocmat, RN, MSN
  171. 171. ComplicationsDysphagia Which in turn may cause weight loss and malnutrition.Aspiration pneumoniaShortness of breath or respiratory failure.Calcinosis Calcium deposits in muscles, skin and connective tissues Maria Carmela L. Domocmat, RN, MSN
  172. 172. Associated conditionspolymyositis is often associated with otherconditions that may cause further complicationsof their own, or in combination with polymyositissymptoms. Associated conditions include:Raynauds phenomenon.Other connective tissue diseases.Cardiovascular disease.Lung disease. Maria Carmela L. Domocmat, RN, MSN
  173. 173. Treatmentcorticosteroid When muscle strength improves, usually in 4 to 6 weeks, the medication is slowly tapered off. Maintenance therapy with prednisone may be continued indefinitely.DMARDs - If unresponsive to corticosteroids methotrexate and azathioprine, Maria Carmela L. Domocmat, RN, MSN
  174. 174. TreatmentIntravenous gamma globulin IVIG is a purified blood product that contains healthy antibodies from thousands of blood donors. The healthy antibodies in IVIG can block the damaging antibodies that attack muscle in polymyositis. Repeat infusions q 6-8 weeks Maria Carmela L. Domocmat, RN, MSN
  175. 175. Other immunosuppressive medicineTacrolimus (Prograf) is a transplant-rejection drug that may work to inhibit the immune system.Immunosuppressants, cyclophosphamide (Cytoxan) and cyclosporine (Gengraf, Neoral, Sandimmune), Maria Carmela L. Domocmat, RN, MSN
  176. 176. Biological therapiesRituximab (Rituxan)Tumor necrosis factor (TNF) inhibitors etanercept (Enbrel) and infliximab (Remicade), Maria Carmela L. Domocmat, RN, MSN
  177. 177. Other treatment approachesPhysical therapyDietetic assessmentSpeech therapy Maria Carmela L. Domocmat, RN, MSN
  178. 178. Nursing managementCoping and supportEducate about the illnessBalance Rest and exercise Maria Carmela L. Domocmat, RN, MSN
  179. 179. Sourceshttp://www.mayoclinic.com/health/polymyositis/DS00334/METHOD=print&DSECTION=allhttp://www.mayoclinic.com/health/polymyositis/DS00334 Maria Carmela L. Domocmat, RN, MSN
  180. 180. Dermatomyositisa muscle disease characterized by inflammationand a skin rash. It is a type of inflammatorymyopathy.5 - 15 and adults age 40 - 60.WomenPolymyositis is a similar condition, but thesymptoms occur without a skin rash. Maria Carmela L. Domocmat, RN, MSN
  181. 181. SymptomsDysphagiaMuscle weakness, stiffness, or sorenessPurple or violet colored upper eyelidsPurple-red skin (violaceous) rashSOB Maria Carmela L. Domocmat, RN, MSN
  182. 182. SymptomsThe muscle weakness may appear suddenly or developslowly over weeks or months. may have difficulty raisingarms over head, rising from a sitting position, andclimbing stairs.The rash may appear over the face, knuckles, neck,shoulders, upper chest, and back. Maria Carmela L. Domocmat, RN, MSN
  183. 183. reddish-purple (violaceous) rashreddish-purple(violaceous) rash.The rash is named afterthe tendency of plants togrow toward the sun(heliotropic) and ischaracteristic ofdermatomyositis. Maria Carmela L. Domocmat, RN, MSN
  184. 184. purple (violaceous) plaques The appearance of purple (violaceous) plaques on the knees may be associated with dermatomyositis. Maria Carmela L. Domocmat, RN, MSN
  185. 185. Gottrons signRed, thickened, scaly skin over the knuckles Maria Carmela L. Domocmat, RN, MSN
  186. 186. Heliotrope eyelidseyelids develop a brown(violaceous - rather thanred) color.Heliotrope eyelids andGottrons papules on theknuckles arecharacteristic findings indermatomyositis. Maria Carmela L. Domocmat, RN, MSN
  187. 187. violet-colored inflammation (erythema) over theknuckles Maria Carmela L. Domocmat, RN, MSN
  188. 188. periungual erythemaCandida paronychia produced periungualerythema, edema and nail fold maceration. Maria Carmela L. Domocmat, RN, MSN
  189. 189. Dx ExamsCPK & aldolaseECGElectromyographyMagnetic resonance imaging (MRI)Muscle biopsy Maria Carmela L. Domocmat, RN, MSN
  190. 190. TreatmentCorticosteroidsImmunosuppressantsWhen muscle strength gets better – taper offcorticosHowever, most people take prednisoneindefinitely.If the condition is associated with a tumor, themuscle weakness and rash may improve whenthe tumor is removed. Maria Carmela L. Domocmat, RN, MSN
  191. 191. Outlook (Prognosis)Some recover and have symptoms completelydisappear - especially in children.In adults, death may result from severe andprolonged muscle weakness,malnutrition, pneumonia, or lung failure. Themajor causes of death are cancer (malignancy)and lung disease. Maria Carmela L. Domocmat, RN, MSN
  192. 192. Possible ComplicationsAcute renal failureCancer (malignancy)Inflammation of the heartJoint painLung disease Maria Carmela L. Domocmat, RN, MSN
  193. 193. http://www.nlm.nih.gov/medlineplus/ency/article/000839.htmhttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001842/ Maria Carmela L. Domocmat, RN, MSN
  194. 194. BursitisA painful inflammation of the bursae Maria Carmela L. Domocmat, RN, MSN
  195. 195. Bursitisbursae closed, minimally fluid-filled sacs that are lined with a synovium similar to the lining of joint spaces function: to reduce friction between adjacent tissues (tendon and bones or tendon and ligaments) by lubricating these enclosed structures with synovial fluid from bursal sac Maria Carmela L. Domocmat, RN, MSN
  196. 196. Maria Carmela L. Domocmat, RN, MSN
  197. 197. Maria Carmela L. Domocmat, RN, MSN
  198. 198. BursitisBursae there are 150 bursae in human body cover bony prominences (e.g., olecranon, trochanter, and patella) or provide protection between the skin and other structures (e.g., calcaneal bursa) usually thin, but with repeated stress – can become thickened and fluid-filled secondary to inflammation Maria Carmela L. Domocmat, RN, MSN
  199. 199. Bursitispeaks – 40 to 50 yrsaffected areas – shoulder joints (mostcommon), elbow, knee, hip; dominant arm Maria Carmela L. Domocmat, RN, MSN
  200. 200. Etiology and risk factorsacute or chronic trauma (mechanical, highlyrepetitive activities)arthritic conditions (e.g., RA), gout, tumors,degenerative changesoccupational or avocational activities (e.g., woodcarver – acute subacromial bursitis;businesswoman walking long distance on highheels – retrocalcaneal bursitis) Maria Carmela L. Domocmat, RN, MSN
  201. 201. Clinical manifestationsexquisite localized pain in target areapoint tenderness (can specifically point the spotof greatest discomfort)diffuse soreness radiating to the tendons at thesiteinterrupted sleep (e.g., with subacromial bursitis,calcaneal bursitis) Maria Carmela L. Domocmat, RN, MSN
  202. 202. Clinical manifestationsdifficulty walking (e.g., trochanteric bursitis,calcaneal bursitis)difficulty performing ADL (e.g., with subacromialor olecranon bursitis) Maria Carmela L. Domocmat, RN, MSN
  203. 203. Dxdiagnosis is based on PE and historyradiographs – usually normal in acute bursitis;calcium deposits in chroniclab tests and synovial fluid analysis – normalunless bursa become infected Maria Carmela L. Domocmat, RN, MSN
  204. 204. ManagementGoalsRests and immobilization of affected jointNon-opoiod analgesicsROM exercisesNSAIDs Maria Carmela L. Domocmat, RN, MSN
  205. 205. Nursing ManagementClient education Focus on causes and prevention of additional attacks by avoiding activities that cause constraint friction or pressure correct application of moist heat medication exercise instruction intra-articular injections of cortisone Maria Carmela L. Domocmat, RN, MSN
  206. 206. Nursing DiagnosesAcute or Chronic PainImpaired Physical ImmobilityTemporary Self-Care Deficits Maria Carmela L. Domocmat, RN, MSN
  207. 207. Interventions Goal: pain reduction (without pain reduction –joint mobility is impaired thru guarding,protective measures) Teach purpose, dose and side effects of anti- inflammatory meds Resting or immobilizing joint or elevating or compressing involved area to control edema Teach about correct application of ice ad heat Maria Carmela L. Domocmat, RN, MSN
  208. 208. Teach postinjection flare of intra-articularcortisoneSelf-care: oversized garment, especially thosewith long sleeves or wide pant legsMinimize shoulder or elbow pain – by puttingclothing on affected arm first and by taking it offthe affected arm last. Maria Carmela L. Domocmat, RN, MSN
  209. 209. Vasculitisa group of disorders leading to inflammation andnecrosis of blood vessel wallsincludes: polyarteritis nodosa systemic necrotizing vasculitis allergic granulomatous angitis Maria Carmela L. Domocmat, RN, MSN
  210. 210. VasculitisPathophysiology soluble immune complexes are deposited in blood vessel walls in areas where capillaries have increased permeability after deposition, the immune system is activated and the complex is destroyed along with the blood vessel wall inflammation and damage to large and small vessels result in end-stage organ damage Maria Carmela L. Domocmat, RN, MSN
  211. 211. Clinical manifestationsvarydepending on organs affected Maria Carmela L. Domocmat, RN, MSN
  212. 212. ManagementSteroids Maria Carmela L. Domocmat, RN, MSN
  213. 213. Polymyalgia rheumaticaa clinical syndromemore common womendisease of aging, rarely occur before age 60years Maria Carmela L. Domocmat, RN, MSN
  214. 214. Clinical manifestationspain and stiffness in neck, shoulder, back, andpelvic girdle esp in the morningheadaches or painful areas on headlow grade fevertemporal arteritis Maria Carmela L. Domocmat, RN, MSN
  215. 215. DxElevated ESRmild anemiaelevated Ig Maria Carmela L. Domocmat, RN, MSN
  216. 216. Managementsteroids Maria Carmela L. Domocmat, RN, MSN
  217. 217. Giant cell arteritisAKA temporal or cranial arteritisdisease of aging Maria Carmela L. Domocmat, RN, MSN
  218. 218. Giant cell arteritisa clinical syndromemore common womendisease of aging, rarely occur before age 60years Maria Carmela L. Domocmat, RN, MSN
  219. 219. Clinical manifestationspolymyalgia rheumatic for months, thensuddenly experiences severe headaches assocwith temporal arteritissudden onset with severe pain often appearingin temporal area (can also be in occipital area,face, or side of neck Maria Carmela L. Domocmat, RN, MSN
  220. 220. Clinical manifestationshyperesthesia (unusual or pathologicalsensitivity of the skin or of a particular sense ofstimulation) – makes any touch exquisitelypainfulvisual changes – blindness in one or both eyes Maria Carmela L. Domocmat, RN, MSN
  221. 221. ManagementCorticosteroids Maria Carmela L. Domocmat, RN, MSN
  222. 222. Mixed connective tissue disease a combination of several connective tissuediseasesfrequent combinations are SLE and SSc and RA Maria Carmela L. Domocmat, RN, MSN
  223. 223. Mixed connective tissue diseaseclinical manifestations have manifestations that are not typical of any one disordermanagement according to manifestations Maria Carmela L. Domocmat, RN, MSN
  224. 224. Complex multisystem diseaseOne of form of rheumatic joint disease with aknown causeIncluded as a connective tissue disorder bcozthe skin, joint, nervous system, and heart areinvolved Maria Carmela L. Domocmat, RN, MSN
  225. 225. Etiology and risk factors cause: spirochete Borrelia burgdorferi Male tick Female tick Maria Carmela L. Domocmat, RN, MSN
  226. 226. Risk factorsDoing activities that increase tick exposure (forexample, gardening, hunting, or hiking)Having a pet that may carry ticks homeWalking in high grasses Tick imbedded in the skin This is a close-up photograph of a tick embedded in the skin. Ticks are important because they can carry diseases such as Rocky Mountain spotted fever, tularemia, Colorado tick fever, Lyme disease, and others. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001690/bin/2060.jpg Maria Carmela L. Domocmat, RN, MSN
  227. 227. Clinical manifestationsLarge “bull’s –eye” circular rash; red flat rashthat clears in the centersevere headachesevere malaisestiff neckfever chillsmyalgiasjoint painfatigue Maria Carmela L. Domocmat, RN, MSN
  228. 228. 3 stages of Lyme diseaseStage 1 : primary Lyme disease.Stage 2 : secondary Lyme disease and earlydisseminated Lyme disease.Stage 3 : tertiary Lyme disease and chronicpersistent Lyme disease Maria Carmela L. Domocmat, RN, MSN
  229. 229. 3 stages of Lyme diseaseStage 1 : primary Lyme disease. Occurs 3 to 32 days after the bite Flu-like symptoms , bull’s eye rash, pain and stiffness in muscles and joints For some – arthritis is the first and only sign of the disease Maria Carmela L. Domocmat, RN, MSN
  230. 230. 3 stages of Lyme diseaseStage 2 : secondary Lyme disease and early disseminated Lyme disease. Occurs 2-12 wks after bite Carditis with dysrhtmia, dyspnea, dizziness, palpitations CNS disorders – meningitis, facial paralysis, peripheral neuritis Maria Carmela L. Domocmat, RN, MSN
  231. 231. Stage 3 tertiary Lyme disease and chronic persistent Lyme disease develop months or years after first develop Lyme disease infection Occurs when disease is not diagnosed and treated in earlier stages s/s - arthralgias, fatigue, memory/thinking problems Maria Carmela L. Domocmat, RN, MSN
  232. 232. ManagementStage 1 Antibiotic therapy – PO, for 10-21 days Doxycycline Amoxicillin CefuroximeStage 2 IV Antibiotic therapy ceftriaxone, cefotaxime Maria Carmela L. Domocmat, RN, MSN
  233. 233. ManagementIntra-articular steroids and NSAIDs To reduce inflammation and pain Maria Carmela L. Domocmat, RN, MSN
  234. 234. Client Education guideAvoid heavily wooded areas or areas with thickunderbrushWalk in the center of the trailAvoid dark clothing. Lighter-colored clothingmakes spotting ticks easierUse an insect repellent on your skin and clotheswhen in an area where ticks are likely to befoundWear long-sleeved tops and long pants Maria Carmela L. Domocmat, RN, MSN
  235. 235. Client Education guideWear closed shoes and a hat or capBathe immediately after being in an infestedarea, and inspect your body for ticks (abt thesize of a pinhead); pay special attention to arms,legs and hairlineGently remove with tweezers, or finger any tickthat you find. Dispose of the tick by flushing itdown the toilet (burning could spread infection) Maria Carmela L. Domocmat, RN, MSN
  236. 236. Client Education guideWait 4-6 weeks after being bitten by a tick b4being tested for Lyme disease (testing b4 thistime is not reliable)Report symptoms, such as rash or influenza-likeillness, to the physicianObtain a vaccine to prevent disease if you livein a high-risk area Maria Carmela L. Domocmat, RN, MSN
  237. 237. Complicationslong-term joint inflammation (Lyme arthritis)ArrhythmiaBrain and nervous system (neurological)problems Maria Carmela L. Domocmat, RN, MSN
  238. 238. Sarcoidosis is a disease in which swelling(inflammation) occurs in the lymph nodes, lungs,liver, eyes, skin, or other tissues. Maria Carmela L. Domocmat, RN, MSN
  239. 239. CausesThe cause of the disease is unknown. Insarcoidosis, clumps of abnnormal tissue(granulomas) form in certain organs of the body.Granulomas are clusters of immune cells.The disease can affect almost any organ of thebody, but it most commonly affects the lungs. Maria Carmela L. Domocmat, RN, MSN
  240. 240. Possible causes of sarcoidosis include:Excess sensitivity to environmental factorsGeneticsExtreme immune response to infection Maria Carmela L. Domocmat, RN, MSN
  241. 241. The condition is more common in AfricanAmericans than Caucasians. Females areusually affected more often than males. Thedisease typically begins between the ages of 20and 40. Sarcoidosis is very rare in youngchildren. Maria Carmela L. Domocmat, RN, MSN
  242. 242. SymptomsThere may be no symptoms. When symptomsoccur, they can involve almost any part or organsystem in your body.Almost all patients have lung or chestsymptoms:Dry coughShortness of breathDiscomfort behind your breast boneAbnormal breath sounds (such as rales) Maria Carmela L. Domocmat, RN, MSN
  243. 243. Symptoms of general discomfort or uneasinessoften occur:malaiseFatigue (one of the most common symptoms inchildren)FeverWeight loss (one of the most common symptomsin children)Joint achiness or pain (arthralgia) Maria Carmela L. Domocmat, RN, MSN
  244. 244. Skin symptoms: Skin rashes Old scars become more raised Raised, red, firm skin sores (erythema nodosum, almost always on the front part of the lower legs Skin lesions Hair loss Maria Carmela L. Domocmat, RN, MSN
  245. 245. Nervous system (neurological) and visionchanges:HeadacheSeizuresWeakness or paralysis (palsy) on one side of thefaceEye burning, itching, and dischargeSymptoms of uveitisDecreased tearing Maria Carmela L. Domocmat, RN, MSN
  246. 246. Other symptoms of this disease: Enlarged lymph glands - armpit lump Enlarged liver Enlarged spleen Dry mouth Nosebleed http://www.nlm.nih.gov/medlineplus/ency/ar ticle/000076.htm Maria Carmela L. Domocmat, RN, MSN
  247. 247. Exams and TestsOften the disease is found in patients with nosymptoms who have an abnormal chest x-ray.Different imaging tests may help diagnosesarcoidosis:Chest x-ray to see if the lungs are involved orlymph nodes are enlargedCT scanLung gallium (Ga.) scan Maria Carmela L. Domocmat, RN, MSN
  248. 248. Biopsies of different tissues may be done: Lymph node biopsy Skin lesion biopsy Bronchoscopy to perform a biopsy Open lung biopsy Mediastinoscopy with biopsy Liver biopsy Kidney biopsy Nerve biopsy Heart biopsy Maria Carmela L. Domocmat, RN, MSN
  249. 249. This disease may also alter the results of the followinglab tests:CBCChem-7 or chem-20Quantitative immunoglobulins (nephelometryPTHSerum phosphorusImmunoelectrophoresis - serumCalcium - urineCalcium - ionizedCalcium - serumLiver function tests Carmela L. Domocmat, RN, MSN Maria
  250. 250. TreatmentSarcoidosis symptoms often get better on their own gradually withouttreatment.Severely affected patients may need treatment with corticosteroids(prednisone or methylprednisolone). This includes people who haveinvolvement of the eyes, heart, nervous system, and some with lunginvolvement. Therapy may continue for 1 or 2 years. Some of the mostseverely affected patients may require life-long therapy.Drugs that suppress the immune system (immunosuppressive medicines),such as methotrexate, azathioprine, and cyclophosphamide, are sometimesused in addition to corticosteroids. Rarely, some people with irreversibleorgan failure require an organ transplant.Although these treatments may temporarily improve the symptoms of thedisease, long-term treatment has not been proven to prevent sarcoidosisfrom slowly getting worse. Maria Carmela L. Domocmat, RN, MSN
  251. 251. Outlook (Prognosis)Many people are not seriously ill, and thedisease may get better without treatment. About30 - 50% of cases get better without treatment in3 years. About 20% of those whose lungs areinvolved will develop lung damage.The overall death rate from sarcoidosis is lessthan 5%. Causes of death include:Scarring of lung tissue (pulmonary fibrosis)Bleeding from the lung tissueInvolvement of the heart (rarely) Maria Carmela L. Domocmat, RN, MSN
  252. 252. Possible ComplicationsOsteoporosis and other complications of takingcorticosteroids for longer periods of time.Diffuse interstitial pulmonary fibrosisPulmonary hypertensionFungal lung infections (aspergillomaAnterior uveitisGlaucoma and blindness (rare)Cardiac arrhythmiasCranial or peripheral nerve palsiesHigh calcium levels (hypercalcemiaKidney stonesOrgan failure, leading to the needRN, MSN transplant Maria Carmela L. Domocmat, for a
  253. 253. THANK YOU!!!Maria Carmela L. Domocmat, RN, MSN
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