NU 350 Autoimmune Disorders
Who is most affected by autoimmune disease?
Women more than men.
Autoimmune related diseases are considered to be:
Are autoimmune diseases a form of AIDS?
No. AIDS is caused by the HIV virus.
A person with an autoimmune disease is likely/unlikely to develop a 2nd autoimmune disease?
Fatality of most autoimmune diseases?
Quite often fatal.
How easily are most autoimmune disorders diagnosed?
With difficulty bc of varying symptoms.
Are autoimmune disease contagious?
Etiology of most autoimmune disease processes?
Body makes antibodies to kill antigens (bad guys). Autoimmune disease makes self-antibodies that live on cells get screwed up and decide that your tissue is the antigen. It attacks itself. Usually the body ignores itself, but every once in a while it messes up like this. In some cases, it may be due to a virus, but there’s no way to know. Certain environmental factors are usually present, but we don’t know enough as to why the immune response acts the way it does. Depends on what the antibodies attack as to what kind of disease you have.
Definition and examples of specific autoimmune disorders? How do these disorders attack, respectively?
Autoimmunity is an immune response against self.
Examples include Lupus, rheumatoid arthritis, scleroderma, mixed connective disease, multiple sclerosis.
RA attacks joints, lupus attacks skin, kidneys, eyes, connective tissue. MS attacks nerves and myelin sheaths.
How does humoral immunity work? What goes wrong to cause the autoimmune response?
In humoral immunity, the B-cell is the main player. Then antibodies (Ig G, M, A, D, E) attack the site. Then the complement cascade causes the inflammatory response which causes tissue damage at the site of the response.
What is the pathophysiology for rheumatoid arthritis?
Some kind of antigen causes the self-antibodies to attack the body. The abnormal IgG antibodies and the rheumatoid factor get in clumps specifically in the synovial joints and articular cartilage which is on the end of any bone. Also like to get in the cartilage in the knee. They get on the cartilage and the synovial space in the joints and destroy them. The complex response causes inflammation.
How does the complement cascade (inflammatory response) cause damage and eventual contracture in a joint?
Starts with synivitis (inflammation of the synovial space). Inflammatory response causes congestion and edema in the synovial membrane. Untreated, causes Pannus, a thickened synovial fluid. Layers of granulation tissue invade, the joint becomes stiff and hard. Fibrosis occurs and makes the joint immovable, causes contractures. Eventually, the person would become calcified and stuck in that position.
S/s of rheumatoid arthritis?
Painful, Swollen, Stiff Joints
Symmetrical response unlike regular arthritis
Morning Stiffness - Takes them at least more than an hour (up to several) to get going in the AM. Makes it hard to do things early in the morning.
Nodules - look like tissue bumps, get them on hands and joints, high rheumatoid factor in nodules
Fatigue - They physically cannot do ADLs or get out of bed. When you body tells you to take a nap, go take a nap. Don’t over do anything.
Sjogren syndrome - Decreased lacrimal and salivary gland secretion. They get dry eyes easily. Use artificial tears, increase oral fluid, do good oral care for lack of moisture.
Felty syndrome - RA jumps outside of the joints. Starts attacking other organs. Anemia, pulmonary disorders, attacks the heart, etc. RA goes outside of the normal pattern.
What characterizes each of the 4 stages of RA?
Early – no destructive changes on xray. Only complain about pain, stiffness, swelling.
Moderate – Maybe see a little damage xray. Maybe see some nodules.
Severe – Definitely see damage on xray.
Terminal – The joint is frozen.
What information is pertinent to suspected diagnosis of RA?
Start diagnosing RA in the 20s.
RA can have exacerbations and remissions. Makes it hard to diagnose.
Ask time related questions: Have you had this problem before? When did you notice it? Does anything relieve it or make it worse?
Want to look for swelling, ROM, strength, sensation.
What labs will be measured at in RA diagnosis, what specific levels are checked, and why?
CBC - Want to look at WBCs for infection, RBCs and H&H for anemia of chronic disease.
Rheumatoid Factor – antibody, RA factor measures the amount of the antibody present in the body.
Anti-citrullinated protein antibody (ACPA) - Predictor of severe errosive disease. Big indicator of severe RA. More common in those with RA, but alone does not confirm RA. RA factor is more telling than ACPA. But it is part of the picture.
ESR - Sed rate - General indicator of inflammation. We use it in many diseases and many diagnostic procedures to see if there’s an inflammatory response going on. Can go up if you have a MI. It’s a broad indicator
CRP - C Reactive Protein - Another general indicator for inflammation. ESR and CRP are similar. CRP can detect inflammation sooner, but is more expensive. The protein is produced by the liver when inflammation is present. Would draw this to see how effective medication regimen has been on inflammation.
ANA – Anti-nuclear Antibody - More specific for people with lupus than with RA. But it’s part of a RA panel.
Synovial fluid & biopsy - Rarely do this. Can get the diagnosis w/o sticking somebody. Usually, their getting synovial fluid out when you put steroids in.
X-Rays - Can’t see early stage RA on xray. It’s a late indicator. Start seeing osteoporosis first, then see degenerative changes of the bone after.
What are the categories of criteria for diagnosis of RA?
A. Joint Involvement
B. Serology (at least 1 test)
C. Acute Phase Reactants (At least 1 test)
D. Duration of symptoms
What is the goal of treatment in the RA patient?
Continue a lifestyle, not have pain, not have joint damage, not be disabled.
How do we treat RA? What is the purpose of early treatment?
Treat early! Used to treat with steroids, NSAIDs. Now, we treat early to lessen joint destruction.
For nurses, educate about disease and how it affects the joints. What are the risks of treatment? What’s the long-term plan? What should they do and not do ot preserve and protect joints?
What are the types of drug therapy used for RA treatment? For each type of drug, what are the benefits, why do we use it, and what are the main side effects?
Corticosteroid therapy - Intraarticular injections, Low-dose oral for limited time, cause weight gain, cushingoid syndrome, vision problems, glaucoma.
NSAID and salicylates - Antiinflammatory, analgesic, and antipyretic, May take 2 to 3 weeks for full effectiveness, cause bleeding and GI problems w/ long term use, Aspirin might cause bleeding.
DMARDs - (Methotrexate, Sulfasalazine, Hydroxychloroquine, Leflonamide) drug of choice. Specifically, methotrexate is the cornerstone of treatment. They decrease the permanent effects of RA. Watch the liver for hepatotoxicity, bone marrow suppression, and don’t have babies on the meds bc of teratogenic effects. Might reconsider if they’re trying to get pregnant or birth control for child-bearing age. Methotrexate can help within days. Hydroxychloroquine has a rare problem with retinal damage. They have to have an eye exam efore you start and one every 6 months.
Tumor necrosis factor (TNF) inhibitor - Etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab (Cimzia), and golimumab (Simponi)
Bind with TNF, inhibiting inflammation, TB test and chest x-ray before start of therapy, Monitor for infection, Avoid live vaccinations. Can be used in conjunction with methotrexate. Never use two at once!
Biologic/Targeted therapies: IL-1 receptor agonists like anakinra (Kineret), tocilizumab (Actemra), abatacept (Orencia), and rituximab (Rituxan) work in a variety of ways. Cannot use them with TNFs. Must use with methotrexate or by themselves.
Other used drug therapies:
Antibiotics (minocycline [Minocin])
Immunosuppressants (azathioprine [Imuran])
Gold preparations (auranofin [Ridaura])
What are some non-drug therapies used in the treatment of RA?
Surgery - replacements of destroyed joints
Nutrition - Balanced nutrition, especially if on steroids
Rest & Joint Protection
Heat & Cold Therapy
- Removed at regular intervals
- Perform ROM exercises
- Reapply as prescribed
Occupational therapist → additional self-help devices
Plan care around morning stiffness
To relieve joint stiffness and ↑ ability to perform ADLs
- Sit or stand in warm shower
- Sit in tub with warm towels around shoulders
- Soak hands in warm water
What is the importance of nutritional therapy in the RA patient?
Loss of appetite or inability to shop for and prepare food → weight loss
Corticosteroid therapy → weight gain
What acute interventions would a nurse consider with the RA patient?
Balance of rest and activity
Heat and cold applications
Patient and caregiver teaching
What are some non-drug pain relief interventions a nurse can implement or educate the patient about?
Therapeutic heat and cold
Transcutaneous electrical stimulation
What are some ways to modify ADLs and other tasks to protect the joints from damage?
- Work simplification techniques
- Pacing and organizing
- Use of carts
- Joint protective devices
- Assistive devices
What are the principles of rest in the RA patient?
Alternate rest periods with activity
Helps relieve pain and fatigue
Amount of rest varies with each patient
Avoid total bed rest
8–10 hours of sleep + daytime rest
Modify activities to avoid overexertion
Principles of heat and cold therapy in the RA patient?
Relieve pain, stiffness, and muscle spasm
- Especially beneficial during periods of disease exacerbation
- Application should not exceed 10–15 minutes at one time
- Heating pads, moist hot packs, paraffin baths, warm baths or showers
- Relieve stiffness
- Should not exceed 20 minutes at a time
- Be alert for burn potential
Principles of exercise in the RA patient?
Individualized exercise plan to
- Improve flexibility
- Increase strength
- Increase overall endurance
Reinforce program participation and ensure correct performance
Need both recreational and therapeutic exercise
What psychological problems do many RA patients encounter?
Patient is constantly challenged by problems of
- Limited function and fatigue
- Loss of self-esteem
- Altered body image
- Fear of disability or deformity
What are the characteristics of juvenile arthritis?
Some kids are diagnosed and it goes away with no further complications. 30% have chronic RA. Usually ages 1-3 is when they get diagnosed. That or ages 8-10. Ra factor usually is not positive. Joint pain, ESR rate, CRP will go up. Usually have eye problems too.
What are criteria for diagnosis and treatments for juvenile RA?
Criteria for Diagnosis
- Onset before 16 years
- Arthritis in 1 or more joints for 6 weeks or longer
- Exclusion of other etiologies
- DMARDS & Enbrel
What is the pathophysiology of lupus?
The cells attack other cells involved in the connective tissues. More often in women child bearing age than men.
Can involve the joints, the lining of the lungs, the sac around the heart, the kidneys, the blood vessels, the neurologic system.
Same patho as Ra except lupus is everywhere.
What are s/s of lupus?
No characteristic pattern
Photosensitivity, butterfly rash on the face over the cheeks and nose. Exacerbated by the sun.
Renal, Nerve, Heart problems
Mental health problems, many times depressed
Fever, Wt changes
Raynaud’s Phenomena - transient ischemia of distal part of the body, usually fingers.
What labs are used in the diagnosis of lupus?
Anti Nuclear Antibody (ANA)- particular for lupus more than RA factor. ANA will be positive in lupus.
Anti double-strand DNA antibody (dsDNA)- Rarely found in other diseases.
Anti-smith antigen is very specific to lupus
Urine casts or protein
What is the list of symptoms which classify diagnosis of lupus?
Nervous system problems
Must have at least 4 of these to be diagnosed.
What drugs are used in the treatment of lupus?
What other non-drug therapies are indicated in lupus?
Surgeries - lots of orthopedic surgeries
Avoid sun exposure - It can cause exacerbations of the disease itself.
What are some management options for fibromyalgia?
Reassurance that it does not cause harm
Need Cognitive behavioral therapy
Reasonable participation in physical activity or PT to avoid deconditioning
Muscle aches = massage, yoga, stretching
Referral to Specialist MD