Immunology Diseases (RA - SEL)

  1. What are type IV autoimmune diseases?
    • Develop when the immune system destroys normal body tissues or provokes abnormal growth of an organ or abnormal changes in organ function
    • Mechanism is unknown
  2. What is Reumatoid Arthritis?
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    • Triggered by a combination of genetics and environment.
    • Produces a measurable reumatoid factor (RF)
  3. Four stages of RA development
    • Infiltration by lymphocytes, macrophages, and neutrophils
    • WBCs and fibroblast-like synovial cells produce enzymes that help to degrade bone and cartilage
    • Pannus formation from thickened layers of granulation tissue, which destroys joint capsule and bone
    • Fibrous ankylosis from fibrous invasion of the pannus and scar formation that occludes the joint space
    • Bone atrophy and malignment cause visible deformities
    • Fibrous tissue calcifies, resulting in bony ankylosis and total immobility
  4. Diagnosis of RA
    • Morning joint stiffness lasting at least 1 hour
    • Swelling of three or more joints
    • Swelling of the wrist, PIP, or MCP joints
    • Symmetrical joint swelling
    • Rheumatoid nodules
    • Radiographic changes
    • Joint erosions on x-ray
    • Rheumatoid factor
    • Elevated RF levels take awhile to appear and may be found in people that do not have RA
    • labs:
    • --RA antibody (rheumatoid factor)
    • --HCT & Hgb
    • --Serum compliment
    • --C-reactive protein
    • X-rays may do MRI
  5. Tx for RA?
    • Goal low disease activity or remission accomplished through early diagnosis and aggressive tx to prevent/address joint and decreased mobility
    • Control of synovitis essential—pain control alone is not enough—ongoing presence of swollen joints implies ongoing disease activity and potential for destruction; 
    • --Relieve pain (regular non prn NSAIDs), reduce inflammation, protect articular surfaces, maintain function, and control systemic involvement
    • --Aggressive tx
    • ----Use of >  1 disease modifying anti rheumatoid drugs (DMARDS); combination therapy is increasingly common BUT
    • ----Aggressive treatment carries risk for immunosuppressive complications—balance must be struck between disease progression and treatment risks
  6. Rx Tx for RA?
    • Disease Modifying Anti rheumatic Drugs
    • Methotrexate is usually first line of therapy added to the NSAIDS
    • Other—(not used as much anymore) injectable gold, penicillamine, azathioprine, chloroquine, hydroxychloroquine, sulfasalazine, oral gold
    • Biologic Response Modifiers—directly modify the immune system by inhibiting cytokines. Etanercept, Infliximab, adalimumab and anakinra
    • Protein-A immuno adsorption Therapy—therapy that filters blood to remove antibodies and immune complexes
  7. Nursing care of RA?
    • Assess joints, looking for deformities, contractures, immobility, and inability to perform ADLs (consult PT and OT)
    • Monitor VS and note weight changes, sensory disturbances, and level of pain
    • Give meticulous skin care, checking for rheumatoid nodules and pressure ulcers
    • Monitor duration of morning stiffness (predictive)
    • Provide patient education about medications, rest, balanced diet, ADL aids, AF/support groups
    • Room arrangement for impaired mobility (de-clutter)
    • Apply cold packs to affect joints
  8. What is ankylosing spondylitis?
    • Rheumatic disease but inflammation is primarily at the enthesis (point at which ligaments, tendons and joint capsule are inserted into bone) → fibrosis, ossification, fusion of the joint Member of diseases called spondyloarthropathies
    • Inflammatory joint disease of the spine or sacroiliac joints causing stiffening and fusion of the joints
    • Cause unknown but there is a strong association with HLA-B27 antigen (genetic predisposition 
    • Begins with the inflammation of fibrocartilage, particularly in the vertebrae and sacroiliac joint inflammatory cells infiltrate and erode fibrocartilage
    • As repair begins, the scar tissue ossifies and calcifies; the joint eventually fuses
  9. What is Sjögren’s syndrome
    • Chronic arthritis accompanied by dry eyes and dry mouth (first described by Swedish physician Henrik Sjögren)
    • Dental carriers significant problem with dec. salvia
  10. What is fibromyalgia?
    • Chronic pain disorder of unknown etiology 
    • Possible factors/contributors?
    • --Flu like viral illness, chronic fatigue syndrome, HIV infection, Lyme disease, medications, physical or emotional trauma
    • Characterized by widespread musculoskeletal aches and pains, stiffness, and general fatigue.  
    • Swelling in soft tissues, tender points and muscle spasms or nodules
    • Associated with non-restorative sleep disorder
  11. Diagnosis of fibromyalgia?
    • Client hx of chronic widespread pain
    • Tender points at specific locations
    • Occipital, low cervical anterior aspects of inner-transverse spaces at C5-7, trapezius, supraspinatus, lateral epicondyle, gluteal, greater trochanter, knees
    • Labs --normal
    • R/O hypothyroidism, lupus, rheumatoid arthritis, infections
  12. SnSs of Fibromyalgia?
    • Diffuse, dull, aching pain that is typically concentrated across the neck, shoulders, lower back, and proximal limbs
    • Pain often worse in morning, sometimes accompanied by stiffness
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  13. Tx for fibromyalgia?
    • No cure
    • Treat symptomatic
    • Heat or cold application, massage, stretching, range-of-motion exercises
    • Relax muscles (amitriptyline, cyclobenzaprine, hypnotic agents, anxiolytic drugs, anti-depressant med
    • TREAT depression if present (often present)
    • Improve Sleep
  14. What is systemic Lupus?
    • Chronic, Multisystem, Inflammatory Disease
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    • Chronic, Multisystem, Inflammatory Disease
    • Potentially fatal autoimmune disease characterized by unpredictable exacerbations and remission
  15. Predisposing factors for systemic lupus?
    • 85 % are women (female to male ratio 9:1)
    • Hormones 
    • Most cases after menarche and before menopause
    • 1:1000 white women
    • 1:250 black women
    • Genetics
    • Morbidity
    • 5- year survival > 95%
    • 10 year survival rate is 85%-90%
  16. Clinical manifestations of SEL?
    • Vary by pt
    • Common presenting complaint is photosensitive rash with alopecia or arthralgias
    • May present with fever and single organ involvement 
    • Rare to present with severe, generalized acute lupus crisis with multi-organ involvement 
    • 90% experience fatigue
    • Persistent fever, anorexia, malaise, weight loss less common (but more serious)

    • Arthralgias
    • Rash: butterfly and discoid
    • Alopecia (50%)
    • Peripheral vascular 
    • Renal disease--> proteinurea, hematuria, ^BUN/creatinine
    • Hematologic abnormality (10%): clots
    • Ocular 
    • Cardiovascular:  Heart inflammation (pericarditis, endocarditis, myocarditis) leading to CP and dysrhythmias
    • Pulmonary: (pleurisy/pleural effusions) leading to CP and SOB
    • Neurologic: Seizures, psychosis, HA
    • GU (50%)
  17. Tx for SEL?
    • Wide range of disease from benign (requiring little treatment other than supportive care) to life-threatening
    • Supportive care/emotional support is extremely important for all 
    • Challenges belief of control over life
    • Feelings of helplessness may be more disabling than the disease
    • Like most autoimmune diseases SLE is characterized by frequent remissions and exacerbations
    • Can be very difficult to deal with
    • Promotion of healthy life style
    • Maintenance of proper nutrition
    • Preventive measures such as influenza and pneumococcal vaccination, TB testing, prudent diet, exercise improves health status
  18. Skin care for SEL?
    • Impaired skin integrity
    • Clean dry and moisturize intact skin
    • Use warm (not hot!) water, unscented lotion (Eucerin)
    • Nutrition and hydration
    • Prophylactic pressure-relieving devices
    • Avoid ultraviolet light
    • Maximum sun screen/protective clothing
    • Medication instructions
    • Availability of special makeup to cover rash (Covermark by Lydia O’Leary)
    • Oral care
    • Mouth ulcers
  19. Tx for alopecia in SEL?
    • Usually during exacerbation/ may regrow but may be different texture; will not regrow over scar tissue
    • May be caused by high dose prednisone (will usually regrow as doses decrease)
    • Use mild shampoo and decrease frequency of shampooing 
    • Evaluate emotional impact
  20. Tx for joint pain/stiffness, and fatigue in SEL
    • Pain:
    • relief techniques including medication (see NC for pain)
    • Anatomically correct position of joints to prevent contractures
    • Ambulation aids if pain related to withgt bearing
    • Bed cradle to relive pressure of bed covers
    • OT/PT consult as needed

    • Joint Stiffness:
    • 15 minute warm shower 
    • ROM
    • Time activities 
    • Anti-inflammatory medication as directed
    • Avoid prolonged inactivity
    • Fatigue:
    • History. Related to activity, sleep patterns, depression
    • Reinforce energy-conservation principles (pace, rest, organize, use assistive devices
    • Warm bath prior to sleep
    • Sleep in anatomically correct position
    • Change position frequently
    • Avoid stimulating foods
    • Progressive muscle-relaxation techniques
  21. Rx Tx for SEL?
    • Antimalarials (hydroxychloroquine {Plaquenil) and chloroquine (Aralen)} may be helpful for rashes and joints—takes weeks or months to work and not used for serious, systemic forms of SLE—(that affect the organs)
    • Corticosteroids used to control serious complications
    • 40-60 mg of prednisone initially with tapering to lowest effective dose—cannot be abruptly stopped if tx is greater than 3-4 weeks
    • CNS involvement may require higher doses
    • Immunosuppressive agents (cyclophosphamide [Cytoxan], Methotrexate [Rheumatrex] and cyclosporine improves renal survival)
    • Anticoagulation (INR > 3) for clotting or arterial or venous systems
Card Set
Immunology Diseases (RA - SEL)
Adult MedSurg 2