Lesson 10
Rheumatoid Arthritis, Osteoarthritis, and Gout

CONNECTIVE TISSUE DISORDERS

The musculoskeletal system consists of bones, muscles, joints, tendons, ligaments, cartilage, and bursae. These connective tissue structures are responsible for movement, storing calcium, producing blood cells, and protection and support of many organs. Arthritis, gout, and other related diseases can be collectively referred to as connective tissue disorders. Inflammation and subsequent destruction of these tissues result in joint dysfunction, secondary to pain with movement, and possible joint deformity. Any organ or body system may be affected by connective tissue disorder; for example, lungs, heart, and blood vessels.

RHEUMATOID ARTHRITIS

a. Rheumatoid arthritis is a chronic, progressive disease that affects the cartilage surface of the joints and other collagen tissues throughout the body. It is characterized by recurrent inflammation of the lining of joints (synovitis). This leads to formation of a tissue that adheres to the opposite joint surface, inhibiting motion (fibrous ankylosis). The restricting band of tissue becomes calcified, causing destruction of the joint (osseous ankylosis). See figure 1-21.

Figure 1-21. Pathological changes in rheumatoid arthritis.

b. Signs and symptoms of early stage rheumatoid arthritis are:

(1) Paresthesia (burning, prickling sensation).

(2) Anorexia.

(3) Night sweats.

(4) Generalized weakness.

(5) Warm, swollen, and painful joints.

(6) Mild to moderate pain.

c. Signs and symptoms of late stage rheumatoid arthritis are:

(1) Joint stiffness, especially in the morning.

(2) Muscular atrophy around the affected joint, leading to deformity.

(3) Chronic pain.

(4) Multiple organ involvement (pericarditis, osteoporosis, anemia, subcutaneous nodules, vasculitis, neuropathy, fibrotic lung disease).

d. Buffered or enteric coated aspirin and nonsteroidal anti-inflammatory drugs are given to decrease the inflammation that is causing the pain and destruction of the joint. If conservative treatment fails, adrenocortico-steroid drugs are given. Treatment will not reverse the structural damage incurred.

e. Nursing care implications include administering anti-inflammatory drugs as prescribed, providing hot or cold applications as ordered, assisting the patient with exercises, properly positioning the patient with pillows or sandbags to prevent and correct contracture deformities, and educating the patient regarding the disease.

OSTEOARTHRITIS

a. Osteoarthritis is the most common of all joint diseases. It is also known as degenerative joint disease. It is a slow, progressive thinning of the joint cartilage that exposes underlying bone to pressure, abrasion and erosion. Unlike rheumatoid arthritis, degenerative joint disease has no remissions and no systemic symptoms such as malaise and fever. Although the exact cause is not known, there appears to be an underlying metabolic abnormality of cartilage. The following predisposing factors are known:

(1) Aging (usually, late middle life and older).

(2) Joint injury.

(3) Obesity or excessive joint use.

(4) Genetic influences.

(5) Systemic diseases (hemophilia or due to organ transplantation.

(6) Poor posture.

b. Pathological changes include thinning cartilage, which exposes bone to articulating surfaces, and thickened synovial membrane. The fibrous tissue around the joint ossifies. Ankylosis does not occur. Signs and symptoms of osteoarthritis are:

(1) Pain in one or more joints, particularly after exercise and long periods of inactivity.

(2) Stiffness in the morning or at night.

(3) Joint enlargement.

(4) Limitation of joint motion.

c. The goal of patient care is relief of pain and discomfort. Rest of the affected joints and short periods of moderate exercise are helpful. Heat to the affected part may afford some relief of pain. Obese patients should lose weight. Analgesics are given for pain control. Anti-inflammatory agents are prescribed when synovial inflammation is present. Assistive devices such as splints, braces, cervical collars, or corsets are provided as necessary. Surgical procedures are used to repair or replace painful, nonfunctioning joints.

d. Nursing care implications include administering medications as prescribed, application of heat as ordered, assessing and reporting the postoperative patient's status, and educating the patient regarding the disease.

GOUT

Gout is a disease manifested by an acute inflammation of a joint. It occurs most often in men over 40. Primary gout is a metabolic disorder in which the body is unable to properly metabolize purines. Purines are end products of the digestion of certain proteins. This inability results in deposit of urate crystals (a salt of uric acid) in the joint and connective tissues. Secondary gout is an acquired disease resulting in underexcretion of uric acid. It occurs because of impaired renal function precipitated by trauma or prolonged use of diuretic agents, aspirin, or alcohol.

Pathological changes include elevated serum uric acid levels and uric acid crystals in the synovial fluid. Signs and symptoms of acute gout are sudden onset of severe joint pain, accompanied by intense inflammation, swelling, and tenderness. The first joint of the great toe is usually affected; and later, other joints of the foot become affected. Attacks involving the same joints tend to recur. In chronic gout, there may be development of renal calculi and deformity of the joints.

Patient care is directed toward decreasing the amount of sodium urate in the extracellular fluid so that deposits do not form. This is done by modifying the diet to decrease the amount of purine ingested and drug therapy to promote renal excretion of urates. Drug therapy must be continued after the acute phase to decrease the possibility of future attacks. Foods that should be limited are:

(1) Liver, kidney, and brains.

(2) Anchovies, sardines, and herring.

(3) Bacon, goose, and mutton.

(4) Salmon, turkey, and veal.

(5) Yeast, beer, and meat broth.

Nursing care implications include administering medication as ordered, documenting the patient's response, and observing the patient for side effects related to the medication.

End of Lesson 10

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