Rheumatic Disorders Part III

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Spondyloarthropathies: Ankylosing sponydilitis (AS)
Reactive arthritis (Reiter’s syndrome)
Psoriatic arthritis (PsA)

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Rheumatic Disorders Part III

  1. 1. Rheumatic Disorders Part III: Spondyloarthropathies (AS, Reiter’s, PsA) Maria Carmela L. Domocmat, RN, MSN Instructor, School of Nursing Northern Luzon Adventist College
  2. 2. Spondyloarthropathiesgroup of interrelated disorders including Ankylosing sponydilitis (AS) Reactive arthritis (Reiter’s syndrome) Psoriatic arthritis (PsA) Maria Carmela L. Domocmat, RN, MSN
  3. 3. Spondyloarthropathiesdistinguished from RA by the ff characteristics: (-) RF (-) rheumatoid nodules asymmetrical inflammatory peripheral arthritis Maria Carmela L. Domocmat, RN, MSN
  4. 4. Spondyloarthropathiesother characteristics inflammation occurs where ligament inserts into bone (enthesis) – rather at synovium there is overlap between various Spondyloarthropathies tendency toward familial aggregation Maria Carmela L. Domocmat, RN, MSN
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. hallmark feature the involvement of the sacroiliac (SI) joints (between pelvis and the spine) during the progression of the disease. Maria Carmela L. Domocmat, RN, MSN
  9. 9. Maria Carmela L. Domocmat, RN, MSN
  10. 10. S/SThe disease starts with low back pain thatcomes and goes.Pain and stiffness are worse at night, in themorning, or when not active. may wake patientfrom sleep.pain typically gets better with activity or exercise. Maria Carmela L. Domocmat, RN, MSN
  11. 11. 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
  12. 12. Ankylosing Spondylitis Maria Carmela L. Domocmat, RN, MSN
  13. 13. Ankylosing Spondylitis Maria Carmela L. Domocmat, RN, MSN
  14. 14. Ankylosing Spondylitis Maria Carmela L. Domocmat, RN, MSN
  15. 15. Ankylosing Spondylitis Maria Carmela L. Domocmat, RN, MSN
  16. 16. Ankylosing Spondylitis Maria Carmela L. Domocmat, RN, MSN
  17. 17. Maria Carmela L. Domocmat, RN, MSN
  18. 18. 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
  19. 19. Maintain mobilityexercise, engage in ADLgood postureswimmingsleep posture: emphasize spinal extension (flaton bed: no pillow, bed boards)furniture and work station ergonomics Maria Carmela L. Domocmat, RN, MSN
  20. 20. Decrease inflammation, control painNSAIDsheat therapy – relieve morning painsulfasalazine, MTX, TNF alpha-blockersCorticosteroid therapycytotoxic drugs etabercept, infliximab If do not respond well to corticosteroids or who are dependent on high doses of corticosteroids.Surgery Maria Carmela L. Domocmat, RN, MSN
  21. 21. Educationclothing that fitspromote effective breathing deep breathing exercise avoid smoking and respi depressants (+) dyspnea – pursed-lip breathing; pace activities Maria Carmela L. Domocmat, RN, MSN
  22. 22. Nursing managementProvide educationExercises can help improve posture andbreathing.Lying flat on the back at night can help maintainnormal posture. Maria Carmela L. Domocmat, RN, MSN
  23. 23. Promote effective breathing ongoing assessment of chest-wall expansion deep-breathing exercises avoid smoking and respi depressants for dyspnea – pursed-lip breathing and pacing of activities Maria Carmela L. Domocmat, RN, MSN
  24. 24. Reactive arthritisa group of inflammatory conditions that involvesthe joints, urethra, and eyes.A form of peripheral arthritisAppear shortly after certain infections of GUT orGITsometimes the first manifestation of humanimmunodeficiency virus infection. Maria Carmela L. Domocmat, RN, MSN
  25. 25. Causes, incidence, and risk factorsmen before the age of 40. may follow an infection withChlamydia,Campylobacter, Salmonella, or Yersinia.Genes – HLA-B27most frequently follows genitourinary infectionwith Chlamydia trachomatis, but other organismshave also been implicated. Maria Carmela L. Domocmat, RN, MSN
  26. 26. Triad of symptomsNongonococcal urethritisConjunctivitisArthritis Maria Carmela L. Domocmat, RN, MSN
  27. 27. SymptomsUrinary symptoms usually appear within days orweeks of an infection.Low-grade fever, Conjunctivitis, and arthritisdevelop over the next several weeks.arthritis may be mild or severe, and may affectonly one side of the body or more than one joint.Cervicitis Maria Carmela L. Domocmat, RN, MSN
  28. 28. Maria Carmela L. Domocmat, RN, MSN
  29. 29. Muscle and joint symptoms include: Achilles tendon pain Heel pain Joint pain in the large joints (hip pain, knee pain, and ankle pain are common) Low back pain Maria Carmela L. Domocmat, RN, MSN
  30. 30. 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
  31. 31. 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
  32. 32. Dx testsdiagnosis 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.HLA-B27 antigenIncreased ESRJoint x-raysUrinalysis Maria Carmela L. Domocmat, RN, MSN
  33. 33. TreatmentUsually self-limiting: 3-12 mosGoal - to relieve symptoms and treat anyunderlying infectionPharmacologic mgmt: same with AS NSAIDS and pain relievers DMARDs Maria Carmela L. Domocmat, RN, MSN
  34. 34. TreatmentOcular manifestations: steroid eye drops or subconjunctival preparationsantibiotics if have an infection. Maria Carmela L. Domocmat, RN, MSN
  35. 35. TreatmentJoint pain: Intraarticular corticosteroid PT Splinting Managed exercise and activity programmake adjustments if job requires heavy lifting orstrenuous use of the back. Maria Carmela L. Domocmat, RN, MSN
  36. 36. 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
  37. 37. Psoriasisis a common, chronic skin condition that causesred patches on the body. Maria Carmela L. Domocmat, RN, MSN
  38. 38. Maria Carmela L. Domocmat, RN, MSN
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. Scalp psoriasis Nail Psoriasis Maria Carmela L. Domocmat, RN, MSN
  48. 48. Plaque Psoriasis Pictures (Vulgaris/Circular) Maria Carmela L. Domocmat, RN, MSN
  49. 49. Guttate Psoriasis Maria Carmela L. Domocmat, RN, MSN
  50. 50. Pustular Psoriasis Maria Carmela L. Domocmat, RN, MSN
  51. 51. Inverse Psoriasis Maria Carmela L. Domocmat, RN, MSN
  52. 52. 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
  53. 53. Psoriatic Arthritis Maria Carmela L. Domocmat, RN, MSN
  54. 54. 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
  55. 55. TreatmentTopical medications such as lotions, ointments, creams, and shampoos Topical steroids Tar preparations UV Light therapy Maria Carmela L. Domocmat, RN, MSN
  56. 56. 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
  57. 57. 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
  58. 58. 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
  59. 59. 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
  60. 60. 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
  61. 61. 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
  62. 62. Topical medsCreams to remove the scaling (usually salicylicacid or lactic acid)Dandruff shampoos (over-the-counter orprescription)Moisturizers Maria Carmela L. Domocmat, RN, MSN
  63. 63. 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
  64. 64. UV light therapy Maria Carmela L. Domocmat, RN, MSN
  65. 65. 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
  66. 66. 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
  67. 67. Maria Carmela L. Domocmat, RN, MSN
  68. 68. 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
  69. 69. 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
  70. 70. PsoriasisMaintain skin integrityEnhance body imageProvide emotional support Maria Carmela L. Domocmat, RN, MSN
  71. 71. 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
  72. 72. 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
  73. 73. 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
  74. 74. 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
  75. 75. Psoriatic arthritis is an arthritis that is oftenassociated with psoriasis of the skin20-50 years oldWomen Maria Carmela L. Domocmat, RN, MSN
  76. 76. 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
  77. 77. 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
  78. 78. 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
  79. 79. http://images.emedicinehealth.com/images/4453/4453-13248-30912-31165.jpg Maria Carmela L. Domocmat, RN, MSN
  80. 80. Manage joint pain and inflammation Same with RAControl skin lesions Same with SLESlow progression of disease Maria Carmela L. Domocmat, RN, MSN
  81. 81. 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
  82. 82. 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
  83. 83. ComplicationsRepeated episodes may occur. Maria Carmela L. Domocmat, RN, MSN

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