Inflammatory & Infectious Diseases

RHEUMATOID ARTHRITIS-Is
ARTHRITIS-Is a chronic disease of unknown etiology characterized by inflammation of the
lining of the synovial joints.Peripheral
joints.Peripheral joints are most often affected.
4 Main Stages:
1.) Synovitis
2.) Pannus formation
3.) Fibrous ankylosis- subluxation
4.) Bony ankylosis
Clinical Findings:
Findings:
Morning stiffness
Symmetric joint swelling: finger joint or wrist.
Subcutaneous nodules
Swan-neck deformity
Diagnostic test: X-ray,ESR
Management:
Management:
1.) Rest
2.) Splinting
3.) Heat or cold application: Cold-acute, heat-as it subsides
4.) Positioning-No pillow under the affected joint.
5.) Exercise
6.) Diet: High CHON, iron, vitamins
Medications:-NSAID’s,
Medications:-NSAID’s, Methotrexate,Hydrochloroquine,Gold salts: Sodium Thiomalate, Corticosteroids
Sulfasalazine,Minocycline
OSTEOARTHRITIS -Degenerative
-Degenerative joint disease, is classified as a non-inflammatory disorder, primarily of
weight-bearing joints.
Clinical Findings:
1. Asymmetrical inflammation of joints in the hips, knee, feet, and lumbosacral spines.
2. Joint pain after activity
3. Herberden’s node-
4. Bouchard’s node-
Management:DX
Management:DX TEST:
TEST: X-RAY
Treatment:
-NSAID’s (celecoxib, meloxicam) s/e: GI distress and bleeding
-ROM exercises
-rest, -heat and cold, splints, assistive devices, weight control
GOUTY ARTHRITIS -genetic
-genetic defects in purine metabolism that causes increased serum uric acid. Deposits
called “TOPHI” within the joints space produce and acute stage.Caused
stage.Caused by trauma, alcohol, dietary
proteins.
CLINICAL FINDINGS:
>Abrupt onset of swelling
>Joint of the big toe is usually affected (PODAGRA)
 >Elevation of Serum uric acid: 7.5mg/dl
MANAGEMENT:
MANAGEMENT:
1.) Medications:Allopurinol: used in chronic gout, Colchicine: for acute attack.,Uricosurics:
attack.,Uricosurics: Probenecid &
Sulfinpyrazone, Analgesics, Steroids
2.) bed rest & extremities elevated.
3.) cold or heat application
Gouty Arthritis...Mgt.
Hydration
Diet: purine restriction
SURGICAL MANAGEMENT
1. HIP REPLACEMENT
Nursing Management: Maintain good body alignment by positioning with pillows between the legs when turned.
-Use draw sheet to aid in turning patient.
-Elastic stocking
-ROM, lifting the upper body with trapeze, or isometrics.
-Maintain the affected hip in position abduction and prevent adduction, flexion and internal rotation.
2.Total Knee Replacement -Aka: Knee Arthroplasty
The distal femur, proximal tibia and articulating surfaces of the patella are replaced with a femoral component
and metal-backed polyethylene tibial and sometimes patellar components.
Nursing Management
-Immobilized following surgery
-CPM (continuous passive motion) using mechanical device that flexes and extends the knee at a set
range of flexion and rate.
− ice
− Neurovascular check
− Monitor for drainage: 200-400ml/24 hours.
Bursitis
located Inflammation
between of bursae ( small sacs lined with synovial membrane and filled w/ synovial fluid that are
skin overlying thetendons,
bursae muscles and bony prominences. May be caused by repeated trauma or infection of the
Ankylosing Spondylitis - Chronic, inflammatory joint disease characterized by stiffening and fusion ( ankylosis)
of the spine and sacroiliac joints.
Site: enthesis( point at which ligaments, tendons and joint capsule are inserted into bone)- fibrosis, ossification
and fusion of the joint
Cause: - Unknown but may be genetic ( HLA-B27)
Clinical Manifestations
1. low back pain and stiffness
2. spinal deformities (lumbar lordosis and kyphosis)
3. pleuritic chest pain and restricted muscle movement
Lupus Erythemotosus
Chronic, multisystem, inflammatory disease
Causes:Unknown, Autoimmune, Drugs, Viral,Genetic
Females/ 15-40 years of age
Diagnostic Tests:
Cbc ,Elevated ESR, Anti- DNA (most specific)
Assessment
Weakness, Anorexia, Malaise, Fatigue, Joint pains, Fever, oral/nasopharyngeal ulcerations
 Alopecia
Photosensitivity
Butterfly rash
Perineuropathy
Seizures
Psychoses
renal/CNS/ Cardiopulmonary involvement
With remissions/exacerbations
10 yr. Survival (50%)
Collaborative Mgt:
Rest
ROM exercises
Prevent infection
Avoid exposure to sunlight (sunblock, long sleeved clothing, hats,sunglasses)
↑Ca., ↑CHON diet
Pharmacotherapy
ASA, Steroids, NSAID, anti-malarial, cytotoxic agent
Osteomyelitis - Infection of the bone by direct or indirect invasion usually caused by bacteria.
Types of Osteomyelitis:
1.Endogenous(Hematogenous)
1.Endogenous(Hematogenous) Osteomyelitis
Originates with infectious organisms that reach the bone through the blood stream
Common in infants, children and elderly persons
2. Exogenous osteomyelitis
Enters from outside the body
( open fractures, penetrating wounds, surgical procedures)
Clinical Manifestations:
1. pain, headache and malaise
2. tenderness of bone
3. fever
4. edema and erythema of the bone
Clinical Findings:
1. positive culture from bone biopsy
2. positive radionucleide bone scan
3. CBC
4. ESR
Collaborative Management
Analgesics
Antibiotics
Dressing change – sterile techique
Maintain proper body alignment and change position frequently
Immobilization of affected part
Psychologic support
 Surgery if needed
Incision and drainageof bone abscess
Sequestrectomy
Bone grafting
Lyme Disease - Infection caused by the bacterium Borrelia burgdorferi.Transmitted
burgdorferi.Transmitted by the bite of certain species
of ticks. often starts as a skin rash and can progress to more serious stages involving joint, nerve, or heart
tissue.Most
tissue.Most common vector borne disease in the United States.
Pathophysiology- caused by a coiled bacterium – a spirochete called Borrelia burgdorferi.The
burgdorferi.The bacterium enters
the skin at the site of a tick bite and may spread in lymph, producing regional adenopathy, or disseminate in blood
to organs or other skin sites.
Animal Reservoirs
Immature ticks become infected by feeding on small rodents such as mice and also on other mammals: deer,
birds, horses, dogs and cats that are infected with the bacterium Borrelia burgdorferi.In
burgdorferi.In later stages, these
ticks then transmit the Lyme disease bacterium to humans and other mammals during the feeding
process.Lyme
process.Lyme disease bacteria are maintained in the blood systems and tissues of small rodents.
Tick Bite- Begins as a red macule or papule.Usually on the proximal portion of an extremity or on the trunk
(thigh, buttock, or axilla) between 3 and 32 days after a tick bite.The
bite.The area expands, often with central
clearing to a diameter of up to 50 cm.
Objective Findings
Secondary Lesions - Soon after onset, some patients develop multiple, lesions without indurated centers.Cultures
centers.Cultures
of biopsies of these secondary lesions have been positive, indicating dissemination of infection.
Lyme Disease: Late Stage
Over time the central portion of the rash may become necrotic or vesicular.During
vesicular.During this stage, patients may
complain of flu-like symptoms, such as fatigue, chills, fever, headache, muscle and joint pain.Other
pain.Other symptoms
may include regional lymphadenopathy, facial nerve paralysis and irregularities of heart rhythm.
Laboratory and Radiology Findings
-Erythema Migrans in patients living in an endemic area
-ELISA Titers of specific antispirochetal antibodies-IgM, then IgG are preferably determined.
-Western blot: confirmation of positive titers is needed.
-In Skin Biopsy: all layers of the dermis are heavily infiltrated with mononuclear cells around blood vessels and
skin appendages.
-CSF: elevated titers
-ESR: elevated
-AST and LDH: slightly elevated
-X-ray findings usually are limited to soft tissue swelling, but a few patients have had erosion of cartilage and
bone.
-Hematocrit and WBC and differential counts usually are normal.
Structural Disorders
OSTEOPOROSIS - Is a metabolic disease in which bone demineralization results in decreased density and
subsequent fracture. Commonly affected: wrist, hip and vertebral column.
Types of Osteoporosis
1.) PRIMARY- No known cause
2.) SECONDARY
− Hyperthyroidism

− Cushing’s syndrome

− Hyperparathyroidism

− Prolonged use of certain meds.

Other Factors: Prolonged steroid use, Coffee, soft drinks and salt.
CLINICAL MANIFESTATION: Asymptomatic, Back pain,kyphosis
Diagnostic Test:
1. (DEXA).-measures bone mineral density in the hip, wrist or vertebrae.
Assess for allergy to radioisotope
Increase OFI
Empty the bladder.
2. Qualitative ultrasound (QUS)- of the heel or calcaneous.
MANAGEMENT:
1.) Exogenous calcium, Calcium carbonate ,Calcium citrate, Milk
2.) Vit. D supplements
3.) Biphosphonates: Alendronate (Fosamax)
4.) Selective Estrogen Receptor Modulators, Raloxifene (Evista)
5.) Calcitonin
Osteomalacia - Metabolic bone disease characterized by inadequate mineralization of bone resulting in softening
and weakening of bone
Etiologic Factors:
1. Vitamin D deficiency (calcitriol), calcium and phosphorus
2. G.I disorders ( chronic biliary tract obstruction, celiac disease, small bowel resection and chronic pancreatitis)
3. hyperparathyroidism
4. Renal insufficiency (chronic glumerolunephritis)
5. Prolonged used of antiseizure medication (phenytoin, phenobarbital)
Clinical manifestations:
1. pain 5. anorexia
2. limping gait 6. weakness
3. pathologic fracture
4. skeletal deformities (kyphosis & bowed legs)
Laboratory findings:
1. demineralization of bone on xray examination
2. Low serum Calcium (<8.5 to 10.5 mg/dl)
3. Low serum Phosphorus (<125 to 300 mg/dl)
Collaborative mgt:
1. Vit. D and Ca therapy(egg, cereals, chicken liver,milk)
2. Adequate exposure to sunlight
3. pain medication
4. sugery ( osteotomy)- correct deformity
Paget's Disease ( Osteitis Deformans) -Increased
-Increased rate of bone tissue breakdown by osteoclasts followed by
excessive bone formation by the osteoblasts.Bone
osteoblasts.Bone is weak and prone to fracture ( femur, tibia, lower spine, pelvis
and cranium)
Cause: Unknown
Predisposing Factors :Heredity, More common in males, over 40
Diagnostic Tests
>Elevated Se Ca
>Increased alkaline phosphatase
>Increased hydroxyproline
>Xray (confirm the disease) local demineralization and bone overgrowth
>Bone scan (extent of the disease)
Collaborative Mgt:
>Analgesic/Anti-inflammatory agents (ASA/NSAIDS)
>Calcitonin/Etidronate – retars bone absorption
ytotoxic Antibiotic (Mithracin) – to decrease Se Ca, hydroxyproline, S alkaline Phosphatase
Osteogenic Sarcoma- Malignant bone tumor that usually begins in long bone especially around the knee
Metastasis to the lung very common & occurs early (poor prognosis)
Highest incidence between 20-30 yrs old
Clinical findings:
1. pain
2. local swelling
3. body malaise
4. anemia and weight loss
Laboratory findings:

1. elevated Se alkaline phosphatase & neoplastic cells

Medical Mgt:
1. Surgery: wide excision of tumor, reconstructive and amputation of limb
3. Radiation
2. Chemotherapy
Nursing Management:
1. Maintain safe environment
2. Help control pain (imagery, relaxation, distraction, & medications)
3. Be available for the family & client to discuss fears, concern and treatment
4. encourage diet rich in immune stimulating nutrients
(selenium, proteins and Vit A,C,E)
5. Administer care based on therapeutic interventions
6. Refer client and family to cancer support groups
Scoliosis - lateral curving deviation of the spine
Clinical manifestations:
1. curve in the vertebral spinous process alignment
2. prominence of one hip
3. prominence of one scapula, difference in shoulder or scapula height
4. deformity of the rib cage, breast appear unequal in size
Classification:
1. Nonstructural – curve is flexible and correct by bending
2. Structural – curve fails to straighten on side – bending, characterized by changes in the spine and its
supporting structures
Clinical manifestations:
1. curve in the vertebral spinous process alignment
2. prominence of one hip
3. prominence of one scapula, difference in shoulder or scapula height
4. deformity of the rib cage, breast appear unequal in size
Medical Mgt
Exercise (Nonstructural)
Surgery (arthrodesis, harrington rods, luque segmental instrumentation, TSRH System)
Kyphosis - Increased forward curvature of the thoracic spine.Common in elderly clients with osteoporosis & in
some neurovascular disease
Lordosis - Swayback,An exaggerated curvature of the lumbar spine, Common in pregnant woman
Spinal Stenosis - Spinal stenosis is a narrowing of the lumbar or cervical spinal canal. The narrowing can cause
compression on nerve roots resulting in pain or weakness of the legs. Medications or steroid injections are
often administered to reduce inflammation. If the pain is persistent and does not respond to these
conservative measures, surgery is considered to relieve the pressure on the nerves.