Chapter 41

1. Chapter 41 Connective Tissue Disorders

2. Learning Objectives • Define connective tissue. • Describe the function of connective tissue. • Describe the characteristics and prevalence of connective tissue diseases. • Describe the diagnostic tests and procedures used for assessing connective tissue diseases. • Discuss the drugs used to treat connective tissue diseases. • Describe the pathophysiology and treatment of osteoarthritis (degenerative joint disease), rheumatoid arthritis, osteoporosis, gout, progressive systemic sclerosis, polymyositis, bursitis, carpal tunnel syndrome, ankylosing spondylitis, polymyalgia rheumatica, Reiter’s syndrome, Behçet’s syndrome, and Sjögren’s syndrome. • Identify the data to be collected in the nursing assessment of a patient with a connective tissue disorder. • Assist in developing a nursing care plan for a patient whose life has been affected by a connective tissue disease.

3. Anatomy and Physiology of Connective Tissues Bind structures together, providing support for individual organs and a framework for the body Store fat, transport substances, provide protection, and play a role in repair of damaged tissue

4. Anatomy and Physiology of Connective Tissues Types of connective tissue Loose (areolar, adipose, reticular) Dense (tendons, fascia, dermis, gastrointestinal tract submucosa, fibrous joint capsules) Elastic (aortic walls, vocal cords, parts of trachea and bronchi, some ligaments) Hematopoietic (blood) Strong supportive (cartilage, bone, ligaments)

5. Anatomy and Physiology of Connective Tissues Bone Hard tissue: makes up most of skeletal system Functions: support, protection, movement, storage of calcium and other ions, and manufacture of blood cells

6. Anatomy and Physiology of Connective Tissues Cartilage Specialized fibrous connective tissue Provides firm but flexible support for the embryonic skeleton and part of the adult skeleton Cartilage cells are called chondrocytes

7. Anatomy and Physiology of Connective Tissues Ligaments Strong and flexible fibrous bands of connective tissue that connect bones and cartilage and support muscles Yellow ligaments, located in the vertebral column, are elastic and allow for stretching White ligaments, found in the knee, do not stretch but provide stability

8. Anatomy and Physiology of Connective Tissues Tendons Composed of very strong and dense fibrous connective tissue They are in the shape of heavy cords and anchor muscles firmly to bones

9. Joint Structure and Function Connective tissue disorders: manifested as joint disorders since joint mobility depends on functional connective tissue Joint: site where two or more bones are joined; permit motion and flexibility of the rigid skeleton Classification Synarthroses (fixed joints) Amphiarthroses (slightly movable joints) Diarthroses (freely movable joints) Encased in a fibrous capsule made of strong cartilage and lined with synovial membrane

10. Age-Related Changes Loss of bone mass and bone strength Osteoporosis common in women but affects men Put the older patient at risk for fractures Cartilage gradually loses elasticity; becomes soft and frayed Water content decreases, and cartilage may ulcerate, leaving bony joint surfaces unprotected and promoting growth of osteophytes (bony spurs) Result in pain and limited mobility

11. Nursing Assessment of Connective Tissue Structures

12. Chief Complaint and History of Present Illness Complaints that suggest possible problems related to connective tissue disorders are aches, pain, joint swelling or stiffness, generalized weakness, a change in ability to work or to enjoy leisure activities, a change in appearance that is significant to the patient, and a change in ability to carry out activities of daily living

13. Past Medical History Major childhood and adult illnesses, operations, and current medications and allergies History of tuberculosis, poliomyelitis, diabetes mellitus, gout, arthritis, rickets, infection of bones or joints, autoimmune diseases, and neuromuscular disabilities Accidents and injuries Current medications

14. Family History Osteoporosis, osteoarthritis, rheumatoid arthritis, gout, or scoliosis may have some genetic basis Autoimmune diseases, e.g., thyroid disorders Review of systems General health status; determines patient’s perception of well-being Fatigue, malaise, anorexia, weight loss, pain, stiffness, dysphagia, or dyspnea

15. Physical Examination Vital signs, height, and weight Skin color, rashes, lesions, scars, or any signs of injuries Palpate skin for warmth, edema, and moisture Palpate lymph nodes for enlargement and tenderness Inspect joints for swelling and deformity, and palpate for warmth, swelling, and tenderness Joint pain and range of motion Measure limb length and muscle strength

16. Diagnostic Tests and Procedures Blood studies Complete blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein determination Venereal Disease Research Laboratory (VDRL), rheumatoid factor (RF), creatinine, and antinuclear antibody (ANA) tests Urine studies Creatinine and uric acid levels

17. Diagnostic Tests and Procedures Radiologic imaging studies Radiography, ultrasonography, arthrography, nuclear scintigraphy, magnetic resonance imaging, diskography, tomography, and computed tomography

18. Therapeutic Measures Physical and occupational therapy Physical therapy: exercise and positioning to help preserve functional capability and minimize disability Occupational therapy helps patient gain maximal function in work and personal life Education and support Education: how treatment plan will benefit the patient Patients and their families need information about community support groups that can offer encouragement, information, and resources

19. Therapeutic Measures Drug therapy Glucocorticoids Nonsteroidal anti-inflammatory drugs (NSAIDs) Biologic response modifiers (BRMs) Disease-modifying antirheumatic drugs (DMARDs) Cyclooxygenase-2 (COX-2) inhibitors Surgical treatment Indicated in some musculoskeletal disorders, such as degenerative joint disease and arthritis Continuous passive motion (CPM) machine

20. Disorders of Connective Tissue Structures

21. Osteoarthritis Pathophysiology Degeneration of articular cartilage with hypertrophy of the underlying and adjacent bone Normally, articular cartilage provides a smooth surface for one bone to glide over another Cartilage transfers the weight of one bone to another so the bones do not shatter Osteoarthritis: shock-absorbing protection lost New bone growth is stimulated by exposed bone surfaces, causing bone spurs

22. Figure 41-1

23. Osteoarthritis Signs and symptoms Pain in affected joint, stiffness, limitation of movement, mild tenderness, swelling, and deformity or enlargement of the joint Heberden nodes and Bouchard nodes Medical diagnosis Health history and radiographic studies Arthroscopy and MRI Synovial fluid aspiration

24. Figure 41-2

25. Osteoarthritis Medical treatment Drug therapy Acetaminophen, NSAIDs, DMARDs, COX-2 inhibitors, or low dose of salicylates (aspirin) Surgery Arthroscopic surgery and arthroplasty Physical therapy Improve range of motion; maintain muscle mass and strength Education

26. Figure 41-3

27. Osteoarthritis Assessment Joint pain or tenderness Examine joints for crepitus, enlargement, deformity, and decreased range of motion Compare affected and unaffected joints to detect abnormalities Determine how the disease affects the patient’s mobility and ability to perform activities of daily living

28. Osteoarthritis Interventions Chronic Pain Impaired Physical Mobility Ineffective Coping Ineffective Therapeutic Regimen Management

29. Osteoarthritis Care following total joint replacement Assessment Vital signs, level of consciousness, intake and output, respiratory and neurovascular status, urinary function, bowel elimination, wound condition, and comfort Circulation and sensation in the affected extremity

30. Osteoarthritis Interventions Acute Pain Risk for Injury Impaired Physical Mobility Impaired Tissue Perfusion Risk for Infection Anxiety or Fear Deficient Knowledge

31. Figure 41-4

32. Rheumatoid Arthritis Pathophysiology Chronic, progressive inflammatory disease Inflammation of the synovial tissue Synovium thickens; fluid accumulates in joint space Vascular granulation tissue (pannus) forms in the joint capsule and breaks down cartilage and bone Fibrous tissue invades pannus, converting it first to rigid scar tissue and finally to bony tissue These changes result inankylosis

33. Figure 41-6

34. Rheumatoid Arthritis Signs and symptoms Pain in affected joints aggravated by movement Morning stiffness lasting more than 1 hour Weakness, easy fatigability, anorexia, weight loss, muscle aches and tenderness, and warmth and swelling of the affected joints Joint changes are usually symmetric Rheumatoid nodules (subcutaneous, over bony prominences) Any organ may be affected Inflammation in tissues of heart, lungs, kidneys, eyes Clusters of symptoms Sjögren’s, Felty’s, or Caplan’s syndromes

35. Figure 41-7

36. Rheumatoid Arthritis Medical diagnosis Health history and physical examination Laboratory studies RF (rheumatoid factor), ESR (erythrocyte sedimentation rate), and CRP (C-reactive protein) MRI, bone scans, and DEXA scans

37. Rheumatoid Arthritis Medical treatment Drug therapy Aspirin and other NSAIDs for several months, with the addition of gold compounds, d-penicillamine, antimalarials, or sulfasalazine if needed Physical and occupational therapy Surgery Arthroplasty, synovectomy, tenosynovectomy, and arthrodesis

38. Figure 41-5

39. Rheumatoid Arthritis Assessment Pain, joint swelling, tenderness, joint deformities and limitation of movement, fatigue, and decreased ability to perform activities of daily living Interventions Chronic Pain Activity Intolerance Ineffective Coping Social Isolation Ineffective Therapeutic Regimen Management

40. Osteoporosis Pathophysiology Bone constantly formed and absorbed Until adolescence, bone formation exceeds bone absorption so that bones grow and strengthen Around age 30, bone absorption surpasses formation Loss of trabecular bone, innermost layer, occurs first Loss of cortical bone, hard outer shell, begins later Begins earlier and progresses faster in women than in men Result is loss of bone mass

41. Osteoporosis Risk factors Older women who have small frames, who are white or of northern European heritage, and who have fair skin and blond or red hair Estrogen deficiency; physical inactivity; low body weight; inadequate calcium, protein, or vitamin D intake; corticosteroid therapy over more than 6 months; and excessive use of cigarettes, caffeine, and alcohol

42. Osteoporosis Signs and symptoms Back pain, fractures, loss of height due to vertebral compression, and kyphosis Bone deterioration in the jaw can cause dentures to fit poorly Collapsed vertebrae can cause chronic pain

43. Osteoporosis Medical diagnosis Absorptiometry Radiographs Bone specimen Medical treatment Calcium supplementation and estrogen replacement Bisphosphonates and selective estrogen receptor modulators (SERMs) Regular exercise Percutaneous vertebroplasty

44. Osteoporosis Assessment Diet, calcium intake, and exercise plan Note whether the patient is menopausal or has had an oophorectomy Compare height with previous measurements Posture; note the presence and degree of deformity Interventions Risk for Trauma Chronic Pain Ineffective Therapeutic Regimen Management

45. Gout Pathophysiology Characterized by hyperuricemia Related to excessive uric acid production or decreased uric acid excretion by the kidneys Four stages Asymptomatic hyperuricemia Acute gouty arthritis Asymptomatic intercritical period Chronic tophaceous gout

46. Gout Signs and symptoms Asymptomatic hyperuricemia Blood uric acid level is elevated, but no other symptoms Many people with asymptomatic hyperuricemia never progress to the next stage

47. Gout Signs and symptoms Acute gouty arthritis Onset is abrupt, usually occurs at night The patient is suddenly afflicted with severe, crushing pain and cannot bear even the light touch of bed sheets on the affected joint Joint commonly affected is the great toe Symptoms usually disappear within a few days

48. Gout Signs and symptoms Asymptomatic intercritical period No symptoms Chronic tophaceous gout Advanced gout Tophi: deposits of sodium urate crystals that are visible as small white nodules under the skin

49. Figure 41-8

50. Gout Medical diagnosis History and physical examination Urate crystals in synovial fluid Urinary uric acid Blood uric acid