Rheumatic Disorders Part IV

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Fibromyalgia (FM), Spondyloarthropathies (Polymyositis, Dermatomyositis), Bursitis, Vasculitis, Polymyalgia rheumatica, Giant cell arteritis , Mixed connective tissue disease, Lyme disease …

Fibromyalgia (FM), Spondyloarthropathies (Polymyositis, Dermatomyositis), Bursitis, Vasculitis, Polymyalgia rheumatica, Giant cell arteritis , Mixed connective tissue disease, Lyme disease

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  • 1. Rheumatic Disorders Part IV: Fibromyalgia, Spondyloarthropathies (Polymyositis, Dermatomyositis), Bursitis,Vasculitis, Polymyalgia rheumatica, Giant cell arteritis , Mixed connective tissue disease, Lyme disease Maria Carmela L. Domocmat, RN, MSN Instructor, School of Nursing Northern Luzon Adventist College
  • 2. Fibromyalgia (FM)Idiopathic inflammatory myopathyBursitisVasculitisPolymyalgia rheumaticaGiant cell arteritisLyme diseaseSarcoidosis Maria Carmela L. Domocmat, RN, MSN
  • 3. 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
  • 4. 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
  • 5. Maria Carmela L. Domocmat, RN, MSN
  • 6. Algometer or dolorimeterA useful devicefor roughquantitation ofpain sensitivityis a pressurealgometer, ordolorimeter. Maria Carmela L. Domocmat, RN, MSN
  • 7. Tender points in fibromyalgia. Maria Carmela L. Domocmat, RN, MSN
  • 8. 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
  • 9. Maria Carmela L. Domocmat, RN, MSN
  • 10. 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
  • 11. Maria Carmela L. Domocmat, RN, MSN
  • 12. 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
  • 13. Other common symptomsSyncope or dizzinessShortness of breathUrinary frequency and urgency (female urethral syndrome,interstitial cystitis) Maria Carmela L. Domocmat, RN, MSN
  • 14. Maria Carmela L. Domocmat, RN, MSN
  • 15. 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
  • 16. Maria Carmela L. Domocmat, RN, MSN
  • 17. 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
  • 18. Laboratory StudiesThyroid-stimulating hormone: hypothyroidism 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
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. 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
  • 25. 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
  • 26. 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
  • 27. 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
  • 28. Anxiolytics/hypnotics Maria Carmela L. Domocmat, RN, MSN
  • 29. Tricyclic antidepressantAmitriptyline (Elavil)Desipramine (Norpramin)Doxepin (Sinequan)Imipramine (Tofranil)Trazodone (Desyrel)Nortriptyline (Pamelor) Maria Carmela L. Domocmat, RN, MSN
  • 30. Selective Serotonin-reuptake Inhibitors (SSRIs)Fluoxetine (Prozac)Sertraline (Zoloft)Paroxetine (Paxil)Fluvoxamine (Luvox)Citalopram (Celexa) Maria Carmela L. Domocmat, RN, MSN
  • 31. Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)Milnacipran (Savella)Duloxetine (Cymbalta) Maria Carmela L. Domocmat, RN, MSN
  • 32. Central Nervous System DepressantsZolpidem (Ambien)Zaleplon (Sonata)Sodium oxybate (Xyrem) Maria Carmela L. Domocmat, RN, MSN
  • 33. OpioidsMorphineOxycodone (OxyContin)Hydrocodone (Vicodin, Percocet)Hydromorphone (Dilaudid)Meperidine (Demerol) Maria Carmela L. Domocmat, RN, MSN
  • 34. AnticonvulsantsGabapentin (Neurontin)Pregabalin (Lyrica) Maria Carmela L. Domocmat, RN, MSN
  • 35. Pain RelieversAcetaminophen (Tylenol) Maria Carmela L. Domocmat, RN, MSN
  • 36. Nonsteroidal anti-inflammatory drugs (NSAIDs)AspirinIbuprofen (Advil)Naproxen (Aleve) Maria Carmela L. Domocmat, RN, MSN
  • 37. Sodium oxybate (Xyrem)a sedative hypnotic, prolongs stage III/IVrestorative sleep, which is essential to awakenrested and refreshed. Maria Carmela L. Domocmat, RN, MSN
  • 38. AnticonvulsantsPregabalin (Lyrica)Gabapentin (Neurontin)Clonidine (Catapres) Maria Carmela L. Domocmat, RN, MSN
  • 39. 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
  • 40. Polymyositiscan occur at any age,adults -30s, 40s or 50s.BlacksWomen Maria Carmela L. Domocmat, RN, MSN
  • 41. Polymyositissigns and symptoms usually develop gradually,over weeks or months.Remissions - rareRemissions: periods during which symptoms spontaneouslydisappear Maria Carmela L. Domocmat, RN, MSN
  • 42. Signs and symptomsappear gradually,Progressive muscle weaknessDifficulty swallowing (dysphagia)Difficulty speakingMild joint or muscle tendernessFatigueShortness of breath Maria Carmela L. Domocmat, RN, MSN
  • 43. 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
  • 44. 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
  • 45. 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
  • 46. 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
  • 47. 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
  • 48. 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
  • 49. Biological therapiesRituximab (Rituxan)Tumor necrosis factor (TNF) inhibitors etanercept (Enbrel) and infliximab (Remicade), Maria Carmela L. Domocmat, RN, MSN
  • 50. Other treatment approachesPhysical therapyDietetic assessmentSpeech therapy Maria Carmela L. Domocmat, RN, MSN
  • 51. Nursing managementCoping and supportEducate about the illnessBalance Rest and exercise Maria Carmela L. Domocmat, RN, MSN
  • 52. Sourceshttp://www.mayoclinic.com/health/polymyositis/DS00334/METHOD=print&DSECTION=allhttp://www.mayoclinic.com/health/polymyositis/DS00334 Maria Carmela L. Domocmat, RN, MSN
  • 53. 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
  • 54. SymptomsDysphagiaMuscle weakness, stiffness, or sorenessPurple or violet colored upper eyelidsPurple-red skin (violaceous) rashSOB Maria Carmela L. Domocmat, RN, MSN
  • 55. 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
  • 56. 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
  • 57. purple (violaceous) plaques The appearance of purple (violaceous) plaques on the knees may be associated with dermatomyositis. Maria Carmela L. Domocmat, RN, MSN
  • 58. Gottrons signRed, thickened, scaly skin over the knuckles Maria Carmela L. Domocmat, RN, MSN
  • 59. Heliotrope eyelidseyelids develop a brown(violaceous - rather thanred) color.Heliotrope eyelids andGottrons papules on theknuckles arecharacteristic findings indermatomyositis. Maria Carmela L. Domocmat, RN, MSN
  • 60. violet-colored inflammation (erythema) over theknuckles Maria Carmela L. Domocmat, RN, MSN
  • 61. periungual erythemaCandida paronychia produced periungualerythema, edema and nail fold maceration. Maria Carmela L. Domocmat, RN, MSN
  • 62. Dx ExamsCPK & aldolaseECGElectromyographyMagnetic resonance imaging (MRI)Muscle biopsy Maria Carmela L. Domocmat, RN, MSN
  • 63. 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
  • 64. 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
  • 65. Possible ComplicationsAcute renal failureCancer (malignancy)Inflammation of the heartJoint painLung disease Maria Carmela L. Domocmat, RN, MSN
  • 66. http://www.nlm.nih.gov/medlineplus/ency/article/000839.htmhttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001842/ Maria Carmela L. Domocmat, RN, MSN
  • 67. BursitisA painful inflammation of the bursae Maria Carmela L. Domocmat, RN, MSN
  • 68. 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
  • 69. Maria Carmela L. Domocmat, RN, MSN
  • 70. Maria Carmela L. Domocmat, RN, MSN
  • 71. 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
  • 72. Bursitispeaks – 40 to 50 yrsaffected areas – shoulder joints (mostcommon), elbow, knee, hip; dominant arm Maria Carmela L. Domocmat, RN, MSN
  • 73. 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
  • 74. 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
  • 75. Clinical manifestationsdifficulty walking (e.g., trochanteric bursitis,calcaneal bursitis)difficulty performing ADL (e.g., with subacromialor olecranon bursitis) Maria Carmela L. Domocmat, RN, MSN
  • 76. 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
  • 77. ManagementGoalsRests and immobilization of affected jointNon-opoiod analgesicsROM exercisesNSAIDs Maria Carmela L. Domocmat, RN, MSN
  • 78. 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
  • 79. Nursing DiagnosesAcute or Chronic PainImpaired Physical ImmobilityTemporary Self-Care Deficits Maria Carmela L. Domocmat, RN, MSN
  • 80. 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
  • 81. 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
  • 82. 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
  • 83. 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
  • 84. Clinical manifestationsvarydepending on organs affected Maria Carmela L. Domocmat, RN, MSN
  • 85. ManagementSteroids Maria Carmela L. Domocmat, RN, MSN
  • 86. Polymyalgia rheumaticaa clinical syndromemore common womendisease of aging, rarely occur before age 60years Maria Carmela L. Domocmat, RN, MSN
  • 87. 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
  • 88. DxElevated ESRmild anemiaelevated Ig Maria Carmela L. Domocmat, RN, MSN
  • 89. Managementsteroids Maria Carmela L. Domocmat, RN, MSN
  • 90. Giant cell arteritisAKA temporal or cranial arteritisdisease of aging Maria Carmela L. Domocmat, RN, MSN
  • 91. Giant cell arteritisa clinical syndromemore common womendisease of aging, rarely occur before age 60years Maria Carmela L. Domocmat, RN, MSN
  • 92. 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
  • 93. 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
  • 94. ManagementCorticosteroids Maria Carmela L. Domocmat, RN, MSN
  • 95. Mixed connective tissue disease a combination of several connective tissuediseasesfrequent combinations are SLE and SSc and RA Maria Carmela L. Domocmat, RN, MSN
  • 96. Mixed connective tissue diseaseclinical manifestations have manifestations that are not typical of any one disordermanagement according to manifestations Maria Carmela L. Domocmat, RN, MSN
  • 97. 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
  • 98. Etiology and risk factors cause: spirochete Borrelia burgdorferi Male tick Female tick Maria Carmela L. Domocmat, RN, MSN
  • 99. 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
  • 100. 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
  • 101. 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
  • 102. 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
  • 103. 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
  • 104. 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
  • 105. ManagementStage 1 Antibiotic therapy – PO, for 10-21 days Doxycycline Amoxicillin CefuroximeStage 2 IV Antibiotic therapy ceftriaxone, cefotaxime Maria Carmela L. Domocmat, RN, MSN
  • 106. ManagementIntra-articular steroids and NSAIDs To reduce inflammation and pain Maria Carmela L. Domocmat, RN, MSN
  • 107. 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
  • 108. 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
  • 109. 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
  • 110. Complicationslong-term joint inflammation (Lyme arthritis)ArrhythmiaBrain and nervous system (neurological)problems Maria Carmela L. Domocmat, RN, MSN
  • 111. 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
  • 112. CausesThe cause of the disease is unknown. Insarcoidosis, clumps of abnormal 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
  • 113. Possible causes of sarcoidosis include: Excess sensitivity to environmental factors Genetics Extreme immune response to infection Maria Carmela L. Domocmat, RN, MSN
  • 114. The condition is more common in AfricanAmericans than Caucasians.Females are usually affected more often thanmales.typically begins between the ages of 20 and 40.very rare in young children. Maria Carmela L. Domocmat, RN, MSN
  • 115. 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
  • 116. 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
  • 117. 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
  • 118. 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
  • 119. 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
  • 120. Exams and TestsOften the disease is found in patients with nosymptoms who have an abnormal chest x-ray.Different imaging tests Chest x-ray to see if the lungs are involved or lymph nodes are enlarged CT scan Lung gallium (Ga.) scan Maria Carmela L. Domocmat, RN, MSN
  • 121. 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
  • 122. lab testsCBCChem-7 or chem-20Quantitative immunoglobulins (nephelometryPTHSerum phosphorusImmunoelectrophoresis - serumCalcium - urineCalcium - ionizedCalcium - serumLiver function tests Maria Carmela L. Domocmat, RN, MSN
  • 123. TreatmentSarcoidosis symptoms often get better on theirown gradually without treatment.Severely affected patients corticosteroids (prednisone or methylprednisolone). This includes people who have involvement of the eyes, heart, nervous system, and some with lung involvement. Therapy may continue for 1 or 2 years. Some of the most severely affected patients may require life-long therapy. Maria Carmela L. Domocmat, RN, MSN
  • 124. TreatmentDrugs that suppress the immune system(immunosuppressive medicines), methotrexate, azathioprine, and cyclophosphamide are sometimes used in addition to corticosteroids. Rarely, some people with irreversible organ failure require an organ transplant.Although these treatments may temporarily improve thesymptoms of the disease, long-term treatment has notbeen proven to prevent sarcoidosis from slowly gettingworse. Maria Carmela L. Domocmat, RN, MSN
  • 125. Outlook (Prognosis)Many people are not seriously ill, and thedisease may get better without treatment.About 30 - 50% of cases get better withouttreatment in 3 years.About 20% of those whose lungs are involvedwill develop lung damage.The overall death rate from sarcoidosis is lessthan 5%. Maria Carmela L. Domocmat, RN, MSN
  • 126. Outlook (Prognosis)Causes of death include: Scarring of lung tissue (pulmonary fibrosis) Bleeding from the lung tissue Involvement of the heart (rarely) Maria Carmela L. Domocmat, RN, MSN
  • 127. Possible Complications Osteoporosis and other complications of taking corticosteroids for longer periods of time. Diffuse interstitial pulmonary fibrosis Pulmonary hypertension Fungal lung infections (aspergilloma Anterior uveitis Glaucoma and blindness (rare) Cardiac arrhythmias Cranial or peripheral nerve palsies High calcium levels (hypercalcemia Kidney stonesgan failure, leading to Carmela L. Domocmat, RN, MSN Maria the need for a transplant