The document discusses several connective tissue disorders and collagen disorders including osteoarthritis, rheumatoid arthritis, gout, systemic lupus erythematosus, and scleroderma. It covers the definition, etiology, risk factors, signs and symptoms, diagnostic tests, and management of each condition. Key points include that osteoarthritis is caused by mechanical stress on joints, rheumatoid arthritis is an autoimmune disorder, gout results from uric acid crystal deposition, SLE can affect multiple organ systems, and scleroderma causes hardening and tightening of the skin and connective tissues.

1. Connective Tissue and Collagen
Disorders
BY:
Mr. Rahul Ranjan
Tutor, Narayan Nursing College
Jamuhar, Rohtas, Bihar

2. INTRODUCTION
• The connective tissues include several types of
fibrous tissue that vary only in their density and
cellularity, as well as the more specialized and
recognizable variants—bone, ligaments, tendons,
cartilage, and adipose (fat) tissue.
• Collagen is one of the most plentiful proteins in
mammals.
• It is responsible for several biological functions, one
of which is to provide structural support in
connective tissue, muscle, and skin.
• Collagen is the protein responsible for skin elasticity.

5. HEALTH ASSESSMENT
Health History :
Health history includes the followings:
• Biographical and demographic data
• Health management pattern
• Chief complaints
• Family health history
• Nutritional-Metabolic pattern
• Psychosocial & Personal history

6. Cont’d…
Physical Examination:
• Posture (Kyphosis, lordosis, scoliosis)
• Gait (limping motion, unsteadiness, irregular
movements)
• Bone integrity (deformities, alignment)
• Joint function (ROM by Goniometer, dislocation)
• Muscle strength ( coordination, muscle thickness,
muscle tone)
• Neurovascular status (pain, pallor, pulse, paresthesia,
movement, temperature )

7. DIAGNOSTIC EVALUATION
Noninvasive test:
Radiography:
• X-ray – Establish the presence of musculoskeletal disorders
• Tomography – Show tissue at various planes to locate
bone destruction
• Fluoroscopy – Verify location of lumbar puncture, progress
of contrast dye
• DEXA- Methods to measure bone density
• CT Scan- Assess bone and soft tissue tumors and fractures
MRI: Facilitate the early diagnosis of many conditions that
affect tendon, ligaments, bone marrow

8. Cont’d…
Invasive test:
Radiography
• Arthrography – to examine soft tissue joint structures.
• Sinography and myelography –Sinography is used to
examine sinus tracts & myelography is used to examine
spinal cord
Laboratories studies
• Mineral metabolism- calcium, alkaline phosphatase,
phosphorus
• Muscle enzymes- Aldolase A, AST, LDH, creatine kinase
• ESR (Erythrocyte sedimentation rate)
• C-reactive protein
• Antinuclear Antibody (ANA)

9. Cont’d…
Radionuclide imaging
• Bone scan
• Gallium Scan
• Indium imaging
Other tests
• Biopsy

10. ARTHRITIS

11. ARTHRITIS
• Definition: Arthritis is an inflammation of the joints. It can
affect one joint or multiple joints

12. Types of Arthritis
Two of the most common types are-
• Osteoarthritis (OA)
• Rheumatoid arthritis (RA)

14. OSTEOARTHRITIS
• Definition: Osteoarthritis refers to a clinical syndrome
of joint pain accompanied by varying degrees of
functional limitation and reduced quality of life.

15. Risk Factors of Osteoarthritis
• Osteoarthritis usually happens gradually over time. Some
risk factors that might lead to it include:
– Being overweight
– Getting older
– Women than man
– Joint injury
– Joints that are not properly formed
– A genetic defect in joint cartilage
– Stresses on the joints from certain jobs and playing
sports

16. Classification
On the basis of risk factors and etiology osteoarthritis is classified
into:
Primary osteoarthritis Secondary osteoarthritis
 Idiopathic
 No history of joint
injury, joint disease
 Common in women
 Older age
 Genetic factor may
contribute
 Result from trauma,
 other inflammatory
joint disease
 avascular necrosis
 Common in man
 Neuropathic disorders

17. Pathophysiology
In OA , due to some etiological factors
Process of cartilage matrix degradation starts
Pathologic changes include a decrease in proteoglycan content
in the matrix
softening and lose of elasticity by the cartilage

18. Cont’d…
As collagen fibre rupture, cracking appears in cartilage
Cartilage become yellowed and worn over articular surfaces so
bone growth increases
Bone overgrowths (osteophytes) develops, further friction
cause inflammation and other symptoms result in OA

19. Clinical Manifestations
• The most common symptom of osteoarthritis is pain in the
affected joint(s) after repetitive use.
• Worsening pain and stiffness that increase with activity and
relieved by rest
• There can be swelling, warmth, and creaking of the affected
joints.
• Pain and stiffness of the joints can also occur after long periods
of inactivity (for example, sitting in a theater).

20. Cont’d…
• In severe osteoarthritis, complete loss
of the cartilage cushion causes friction
between bones, causing pain even at
rest or pain with limited motion.
• Deficit ROM, joint enlargement
• Heberden’s node (Bone growth in
Distal interphalangeal joint)
• Bouchard’s node (bone growth in
Proximal interphalangeal joints

21. Diagnostic test
Warning signs of osteoarthritis are:
• Stiffness in a joint after getting out of bed or
sitting for a long time.
• Swelling or tenderness in one or more joints.

22. Cont’d…
• Medical history and Physical examination
• X rays- Findings include loss of joint cartilage,
narrowing of the joint space between adjacent
bones, and bone spur formation
• Arthroscopy
• Blood tests or examination of joints fluid

23. Management of Osteoarthritis
Non pharmacological management:
• Exercises : Exercise is helpful for relief of symptoms of
osteoarthritis in several ways, including strengthening the
muscular support around the joints. Eg. Swimming, stationary
cycling, walking
• Physical therapies: can provide support devices, such as
splints, canes, walkers, and braces.
• Rest: Resting sore joints decreases stress on the joints and
relieves pain and swelling.
• Diet: Diet control for weight reduction

24. Cont’d…
Pharmacological management:
• Mild pain relievers such
as aspirin and acetaminophen (Tylenol) may be sufficient
treatment
• Pain-relieving creams Examples include capsaicin, salicin ,
methyl salicylate and menthol
• Topical treatments include an anti-inflammatory
lotion, diclofenac (Voltaren Gel, Pennsaid) and diclofenac
patch (Flector Patch)

25. Surgical management
• Osteotomy: It is a surgical fracture, a cut across a
bone to alter stresses on a joint
• Arthrodesis: It is a joint fusion procedure in which
surgical immobilization of a joint
• Total hip replacement/arthroplasty: It is performed
to restore joint motion by replacing arthritic bone with
metal components

27. RHEUMATOID ARTHRITIS (RA)
• Definition: RA is a systemic autoimmune, chronic disorder
characterized by joint inflammation, causing swelling, pain,
stiffness and loss of function.

29. Etiology & Risk Factors
• Idiopathic
• Family history: Some people who develop RA have genetic
risk factors.
• Hormones: The RA symptoms often improve during
pregnancy
• RA is less common among women who breastfeed.

30. Cont’d…
• Age: Anyone can get RA at any age, but the risk does
increase with age (commonly developing between ages 40
and 60).
• Environment: Infection can trigger RA in people who are
genetically predisposed to it. However, it’s important to
remember that RA is not an infectious disease, nor is it
contagious.
• Smoking: Studies have shown that of all environmental
factors contributing to RA, smoking most commonly linked

31. Pathophysiology

33. Clinical Manifestations
• Pain and stiffness in multiple joints, sometimes affecting the
same joints on both sides of body
• Stiff joints in the morning lasting 60 minutes or more
• Reduced ROM, such as difficulty making a fist
• Joint swelling, sometimes feeling hot to touch
• Fever, fatigue, weight loss or decreased appetite
• Nodules (growth that forms under your skin), most commonly
on the elbows, hands and feet

35. Diagnostic test
• Health History
• Physical examination
• Blood tests: rheumatoid factor (RF) or cyclic citrullinated
peptide (CCP) antibody, both of which can help confirm the
diagnosis.
• X-rays: to look for early damage to joints.
• C-reactive protein levels and
• ESR-erythrocyte sedimentation rate are often increased with
active RA

36. MANAGEMENT
Medical Management of RA:
• Corticosteroids: Cortisol
• Disease-Modifying Anti-Rheumatic Drugs (DMARDs):
– cyclophosphamide.
– gold injections.
– hydroxychloroquine
• Biologics:
– tocilizumab (Actemra)
– certolizumab (Cimzia)
– etanercept (Enbrel)
– adalimumab (Humira)
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs):

37. CONT..
Surgical management of RA:
• Joint replacement: Joint replacement is indicated when
there is severe joint damage and unsatisfactory control
of symptoms with medical management

38. Nursing management
• Acute and chronic pain related to inflammation and
increased disease activity, tissue damage, fatigue, or lowered
tolerance level.
• Fatigue related to increased disease activity, pain, inadequate
sleep/rest, deconditioning, inadequate nutrition, and
emotional stress/depression
• Impaired physical mobility related to decreased range of
motion, muscle weakness, pain on movement, limited
endurance, lack or improper use of ambulatory devices.
• Self-care deficit related to contractures, fatigue, or loss of
motion.
• Disturbed body image related to physical and psychological
changes and dependency imposed by chronic illness.
• Ineffective coping related to actual or perceived lifestyle or
role changes.

39. Nursing Interventions
• Provide a variety of comfort measures (eg, application of heat or
cold; massage, position changes, rest; foam mattress, supportive
pillow, splints; relaxation techniques, diversional activities).
• Provide instruction about fatigue: develop and encourage a sleep
routine (warm bath and relaxation techniques that promote
sleep); explain importance of rest for relieving systematic, articular,
and emotional stress.
• Encourage patient’s verbalization of feelings, perceptions, and
fears.

40. GOUT (GOUTY ARTHRITIS)
• Introduction: Gout is a type of arthritis that happens when
there is too much uric acid in blood and it forms sharp crystals
in one or more joints. This usually happens in big toe, but it
also can be in knee, ankle, foot, hand, wrist, or elbow.
• Definition: Gouty arthritis is usually an extremely painful
attack with a rapid onset of joint inflammation which is
precipitated by the deposition of uric acid crystals in the lining
of the joint (synovial lining) and the fluid within the joint.

42. Causes & Risk Factors
• Age and gender - Men produce more uric acid than
women, though women's levels of uric acid approach
those of men after the menopause.
• Genetics
• Lifestyle choices - Alcohol consumption interferes
with the removal of uric acid from the body.
• Medications - Include some diuretics and drugs
containing salicylate.

43. Cont’d…
• Weight - Being overweight increases the risk of gout as
there is more turnover of body tissue, which means more
production of uric acid as a metabolic waste product.
• Higher levels of body fat also increase levels of systemic
inflammation as fat cells produce pro-inflammatory cytokines.
• Recent trauma or surgery
• Other health problems - Renal insufficiency and other
kidney problems can reduce the body's ability to efficiently
remove waste products, leading to elevated uric acid levels.

44. CLASSIFICATION
• Acute gout: This stage occurs when the urate crystals that
have been deposited suddenly cause acute inflammation and
intense pain. This sudden attack is referred to as a "flare" and
will normally subside within 3-10 days. Flares can sometimes
be triggered by stressful events, alcohol and drugs, as well as
cold weather.
• Interval or intercritical gout: This stage is the period in
between attacks of acute gout. Subsequent flares may not
occur for months or years, though if not treated, over time,
they can last longer and occur more frequently. During this
interval, further urate crystals are being deposited in tissue.

45. Cont’d…
Chronic tophaceous gout:
Chronic tophaceous gout is the final stage
and the most debilitating form of gout.
Permanent damage may have occurred in
the joints and the kidneys.
The patient can suffer from chronic
arthritis and develop tophi - big lumps of
urate crystals - in cooler areas of the
body such as the joints of the fingers.
It takes a long time without treatment to
reach the stage of chronic tophaceous
gout - around 10 years.

46. Pathophysiology
• An elevated serum urate level, together with
local factors, can result in the deposition of urate
crystals into the joints.
• Once crystals are deposited into a joint, they can
be released into the joint space and initiate an
inflammatory cascade causing acute gouty
arthritis.

47. Clinical Manifestations
• Pain areas: in the joints, ankle, foot, knee, or toe
• Joints: lumps, stiffness, or swelling
• Also common: physical deformity or redness
• Limited range of motion

48. Diagnostic test
• History collection
• Physical examination
• Joint Fluid Analysis: Once joint fluid is obtained, it is
analyzed for uric acid crystals and infection.
• Blood test to measure the amount of uric acid in your blood.
• Uric acid urine test: Periodically test urine for uric acid, can
help predict and monitor the formation of kidney stones.
Kidney stones are a complication of gout in some people.

49. MANAGEMENT
Pharmacologic Management:
• NSAIDs are the usual first-line treatment for gout.
• Colchicine is an alternative for those unable to tolerate
NSAIDs.
• Glucocorticoids have been found to be as effective as
NSAIDs and may be used if contraindications exist for
NSAIDs.
• Allopurinol blocks uric acid production

50. Cont’d…
Non-Pharmacologic Management:
• Maintain a high fluid intake (2-4 liters a day)
• Avoid alcohol
• Maintain a healthy body weight
• Gout diet: the primary dietary goal for gout is to limit your
intake of foods with high amounts of purine in them. Limit fish,
meat, seafoods and poultry intake.

51. Nursing Management
• All patients should be encouraged to modify their lifestyle
including limiting alcohol intake, encouraging weight loss
where appropriate and decreasing food rich in purines.
Foods High in Purines:
– Very High – Some meats, turkey, alcoholic beverage
– Moderately High – mutton, veal, pea, mushroom, fish
• Co-morbid medical conditions should also be controlled
including hypertension, diabetes and hyperlipidemia.

52. Systemic Lupus Erythematosus
• Systemic lupus erythematosus (SLE) is a
progressive chronic autoimmune disease that
results in inflammation and tissue damage
• Can affect any part of the body: Often damages
skin, joints, heart, kidneys, lungs, nervous
system.

53. Signs and Symptoms
• Painful or swollen joints and muscle pain
• Unexplained fever
• Rashes, most common in sun exposed areas
• Chest pain upon deep breathing
• Unusual loss of hair
• Sensitivity to the sun
• Edema in legs or around eyes
• Extreme fatigue

56. Diagnostic Test

57. Treatment for SLE
• Anti-inflammatory medications for joint pain and
stiffness.
• Steroid creams for rashes.
• Corticosteroids to minimize the immune
response.

58. Self-care
• Sun Cream- Protects against the sun's UV rays,
which can damage the skin over time.
• Sun protective clothing- Reduces exposure to
the sun's UV rays, which can damage the skin.

59. Scleroderma (Systemic Sclerosis)
• Chronic hardening and tightening of the skin and
connective tissues.
Definition
• Systemic sclerosis (scleroderma) a multisystem
disorder characterized by
1) functional and structural abnormalities of
blood vessels
2) fibrosis of the skin and internal organs
3) immune system activation
4) autoimmunity

61. Etiology
Environmental factors
• silica dust
• organic solvents
• urea formaldehyde
• bleomycin
Genetic
Defective immunoregulation

62. Sign and Symptoms
• Hardened or thickened skin that looks shiny and
smooth.
• Cold fingers or toes that turn red, white, or blue.
• Ulcers or sores on fingertips.
• Small red spots on the face and chest.
• Puffy or swollen or painful fingers and/or toes.
• Painful or swollen joints.
• Muscle weakness.
• Other: facial pain due to trigeminal neuralgia, hand
paresthesias, headache, stroke, fatigue.

64. Diagnostic Evaluation
• Typical scleroderma is classically defined as
symmetrical skin thickening
• Antinuclear antibodies (ANA) – this test is
positive with a variety of connective tissue and
autoimmune disorders.
• Biopsy may be performed to evaluate fibrosis in
affected tissue.
• Complete blood count (CBC) – to evaluate red
and white blood cells

65. Treatment
• Treatment of scleroderma is focused on
managing symptoms, minimizing damage to
organs and tissues, and maintaining mobility in
affected joints
• Non-steroidal anti-inflammatory drugs (NSAIDs)
and other pain relievers as well as medications
to reduce inflammation
• Corticosteroids and other immune suppressants
• Physical and occupational therapy may be
indicated to maintain muscle strength and range
of motion.

66. Polymyositis
• Polymyositis is one of the inflammatory
myopathies, a group of muscle diseases that
involves inflammation of the muscles or
associated tissues, such as the blood vessels
that supply the muscles.
• A myopathy is a muscle disease, and
inflammation is response to cell damage

68. Signs and Symptoms
• Most affected are the muscles of the hips and
thighs, the upper arms, the top part of the back,
the shoulder area and the muscles that move
the neck.
• Many people with PM have pain or tenderness in
the affected areas.
• The person may have trouble extending the
knee, stepping down or climbing stairs.
• Lifting things, fixing the hair or putting things on
a high shelf may be difficult.

70. Causes
• Idiopathic.
• For some reason, the body’s immune system
turns against its own muscles and damages
muscle tissue in an autoimmune process.
• People with the HIV virus
• Some myositis cases have followed infection
with the Coxsackie B virus

71. Diagnosis
• History, family medical history
• Physical examination
• Muscle biopsy.
• Creatine kinase (CK),
• Electromyogram, a test in which tiny needles are
inserted into the muscles to test their electrical
activity both at rest and when the person tries to
contract the muscle

73. Treatment
• Immunosuppressants: These medications
include azathioprine, methotrexate,
cyclosporine, cyclophosphamide etc.
• Corticosteroid: such as prednisone.

74. ANKYLOSING SPONDYLITIS
• Ankylose: (of bones or a joint) be or become
stiffened.
• Spondylitis is an inflammation of the vertebra.
• Inflammatory disorder of unknown cause that
primarily affects the axial skeleton; peripheral
joints and extra-articular structures

76. Etiology
• Etiology is unknown, but probable etiologic
factors are:
• Genetic predisposition
• Bacterias - Klebsiella pneumoniae and some
other Enterobacterias.

77. Clinical Features
• Pain areas: in the ankle, eyes, heel, hip, joints,
lower back, middle back, neck, or shoulder
• Pain circumstances: can occur during rest
• Joints: back joint dysfunction or stiffness
• Eyes: inflammation of the eye's middle layer or
redness
• Visual: blurred vision or sensitivity to light

78. Diagnosis
• History
• Physical examination
• X-ray
• MRI
• CBC
• ESR

79. Treatment
• Exercise
• Immunosuppresant
• NSAIDs

80. Fibromyalgia
• Fibromyalgia is a disorder characterized by
widespread musculoskeletal pain accompanied
by fatigue, sleep, memory and mood issues.

81. Risk Factors
• Anxiety and depression.
• Physical abuse.
• A painful disease like arthritis
• Fibromyalgia is often triggered by a stressful
event, including physical stress or emotional
(psychological) stress.
• Genetics

82. Clinical Manifestations
• Pain areas: in the muscles, abdomen, back, or neck
• Pain types: can be chronic, diffuse, sharp, or
severe
• Pain circumstances: can occur at night
• Whole body: fatigue, feeling tired, or malaise
• Muscular: muscle tenderness, delayed onset
muscle soreness, or muscle spasms
• Gastrointestinal: constipation, nausea, or passing
excessive amounts of gas
• Mood: anxiety, mood swings, or nervousness
• Hand: sensation of coldness or tingling
• Cognitive: forgetfulness or lack of concentration
• Sleep: difficulty falling asleep or sleep disturbances

83. Diagnostic Evaluation
• History of widespread pain for more than 3
months, on both sides of the body, above and
below the waist
• X-rays, blood tests, specialized scans such as
nuclear medicine and CT, muscle biopsies
• Electromyography

84. Treatment
• NSAIDs
• Antidepprasant
• Exercise
• Yoga
• Massage therapy
• Acupuncture.