Practice nursing care for Clients with Connective Tissue Disease and Other Type of Arthritis I

Connective tissue disease (CTD) is the major focus of rheumatology, the study of rheumatic disease. A rheumatic disease is any disease or condition involving the muscu-loskeletal system. In this text, CTDs are discussed separately from other musculoskeletal conditions because most CTDs are classified as probably autoimmune.

More than 38 million people in the United States (1 in 7) have at least one of more than 100 CTDs. The primary clinical manifestation of many of these diseases is arthritis, the inflammation of one or more joints. In clinical practice, however, arthritis usually refers to either degenerative arthritis or rheumatoid arthritis.

Most common CTDs are characterized by chronic pain and progressive joint deterioration, which results in decreased function. Some of these disorders have additional localized clinical manifestations, whereas others are systemic. The economic and social costs of these diseases are staggering and will increase steadily as "baby boomers" continue to age. Client management requires an interdisciplinary approach, including medicine, surgery, nursing, and physical and occupational therapy.

A connective tissue disease is any disease that has the connective tissues of the body as a target of pathology. Connective tissue is any type of biological tissue with an extensive extracellular matrix that supports, binds together, and protects organs. These tissues form a framework, or matrix, for the body, and are composed of two major structural protein molecules: collagen and elastin. There are many different types of collagen protein in each of the body's tissues. Elastin has the capability of stretching and returning to its original length—like a spring or rubber band. Elastin is the major component of ligaments (tissues that attach bone to bone) and skin. In patients with connective tissue disease, it is common for collagen and elastin to become injured by inflammation. Many connective tissue diseases feature abnormal immune system activity with inflammation in tissues as a result of an immune system that is directed against one's own body tissues (autoimmunity).

The autoimmune CTDs may have both genetic and environmental causes. Genetic factors may create a predisposition towards developing these autoimmune diseases. They are characterized as a group by the presence of spontaneous overactivity of the immune system that results in the production of extra antibodies into the circulation. The classic collagen vascular diseases have a "classic" presentation with typical findings that doctors can recognize during an examination. Each also has "classic" blood test abnormalities and abnormal antibody patterns. However, each of these diseases can evolve slowly or rapidly from very subtle abnormalities before demonstrating the classic features that help in the diagnosis. The classic collagen vascular diseases include:

· Rheumatoid arthritis – Rheumatoid arthritis is a systemic disorder in which immune cells attack and inflame the membrane around joints. It also can affect the heart, lungs, and eyes. Of the estimated 2.1 million Americans with rheumatoid arthritis, approximately 1.5 million (71 percent) are women.

· Systemic lupus erythematosus (SLE) – An inflammation of the connective tissues, SLE can afflict every organ system. It is up to nine times more common in women than men and strikes black women three times as often as white women. The condition is aggravated by sunlight.

· Scleroderma – an activation of immune cells that produces scar tissue in the skin, internal organs, and small blood vessels. It affects women three times more often than men overall, but increases to a rate 15 times greater for women during childbearing years, and appears to be more common among black women.

· Sjögren's syndrome – also called Sjögren's disease, is a chronic, slowly progressing inability to secrete saliva and tears. It can occur alone or with rheumatoid arthritis, scleroderma, or systemic lupus erythematosus. Nine out of 10 cases occur in women, most often at or around mid-life.

· Mixed connective tissue disease – Mixed connective-tissue disease (MCTD) is a disorder in which features of various connective-tissue diseases (CTDs) such as systemic lupus erythematosus (SLE); systemic sclerosis (SSc); dermatomyositis (DM); polymyositis (PM); and, occasionally, Sjögren syndrome can coexist and overlap. The course of the disease is chronic and usually milder than other CTDs. In most cases, MCTD is considered an intermediate stage of a disease that eventually becomes either SLE or Scleroderma.

DEGENERATIVE JOINT DISEASE (OSTEOARTHRITIS)

Several terms describe degenerative joint disease (DJD), the most common connective tissue disease and the second most common cause of disability among adults in the United States. It is the eighth most common cause of disability worldwide (Kee, 2000). Osteoarthritis (OA) is used interchangeably with DJD; however, this condition is not a primary inflammatory disease, and thus osteoarthritis may not be the most accurate term.

Pathophysiology

DJD is characterized by the progressive deterioration of and loss of cartilage in the joints. Weight-bearing joints (hips and knees), the vertebral column, and the hands are primarily affected because they are used most often and, except for the hands, bear the mechanical stress of body weight. Therefore DJD is sometimes called the "wear and tear disease."

Figure 21-1 • Joint changes in degenerative joint disease.

Most clients have the primary (idiopathic) form of the disease; secondary DJD can result from other musculoskeletal conditions or from trauma. DJD can also be classified as nodal (with hand involvement) or non-nodal (without hand involvement) (Kee, 2000).

In affected joints, the normal bluish-white, translucent cartilage becomes soft, opaque, and yellow. Fissures, pitting, and ul-cerations develop, and the cartilage thins. As cartilage and the bone beneath the cartilage begin to erode, the joint space narrows and osteophytes (bone spurs) form (Figure 21-1). Inflammatory enzymes enhance tissue deterioration as a result of altered cartilage metabolism. As a result, the repair process is unable to overcome the rapid process of degeneration. Bone cysts and secondary synovitis are common in advanced disease. Subluxation and joint deformities eventually cause marked immobility, pain, muscle spasm and, possibly, inflammation.

Etiology

Although the causative mechanisms of primary DJD at the cellular level have not been well identified, the disease may be initiated by developmental, genetic, metabolic, and traumatic factors. Age is the strongest risk factor, but research does not support that aging is the only cause of DJD (Mankin & Brandt, 1997). Some clients report a family history of DJD, which supports a possible genetic cause, especially for women who have the nodal type. Obesity also contributes to the likelihood of degeneration, particularly in the knees. Recent research has found that postmenopausal women who are not on hormone replacement therapy (HRT) are prone to nodal DJD. This finding suggests that estrogen reduction may be a contributing factor to the disease (Kee, 2000).

Trauma to the joints from excessive use or abuse predisposes a person to DJD. Certain heavy manual occupations (e.g., carpet installation, construction, and farming) cause high intensity or repetitive stress to the joints. The risk of hip and knee DJD is significantly increased in professional athletes, especially football and soccer players, runners, and gymnasts.

Lack of exercise can also contribute to DJD, causing sar-copenia (muscle loss). Muscle tissue helps to support joints, particularly those that bear weight (e.g., hips and knees).

In a small percentage of people, congenital anomalies, trauma, and joint sepsis can result in secondary DJD. For example, injuries from motor vehicle accidents can cause DJD in later years. Certain metabolic diseases (e.g., diabetes mel-litus, Paget's disease) and blood disorders (e.g., hemophilia, sickle cell disease) can also cause joint degeneration. Inflammatory joint diseases, such as rheumatoid arthritis, often lead to secondary DJD.

Incidence/Prevalence

The prevalence of DJD varies among different populations but is a universal problem. Approximately 70% to 85% of people over 55 years of age have x-ray changes associated with the disease.

CONSIDERATIONS FOR OLDER ADULTS

The prevalence of DJD increases with age; almost everyone older than 60 years of age has some degree of symptomatic joint degeneration. DJD of the hands is especially common among older adults, affecting more than 70% of individuals older than 70 years of age (Solomon, 1997).

WOMEN'S HEALTH CONSIDERATIONS Before 50 years of age, more men than women have DJD. The disease is much more common in women, especially African-American women, after 50 years of age. Women are more prone to hand involvement, especially in the distal and proximal interphalangeal joints of the fingers, which often produces painful, bony nodes. Women also have a greater number of affected joints when compared with men, but men have more hip involvement.

CULTURAL CONSIDERATIONS

Native Americans, especially Pima and Blackfoot Indians, African Americans, and South African blacks, are affected more often than Caucasians in the United States. Alaskan Eskimos have a lower prevalence of DJD when compared with Caucasians.

DJD of the hip occurs less often in Asians when compared with other ethnic groups. African Americans have more knee involvement but less hand involvement than other groups (Kee, 2000).

COLLABORATIVE

At the initial interview, the nurse collects information specifically related to degenerative joint disease (DJD). Because this disease is observed more often in older women, age, gender, and ethnicity are important factors for the nursing history. Women should also be asked whether they are currently taking or have taken estrogen or hormone replacement therapy (ERT or HRT). The nurse asks all clients about their occupation, nature of work, history of trauma, weight history, exercise, and current or previous involvement in sports. A history of obesity is significant, even for clients currently within the ideal range for body weight. A family history of arthritis is also noted

PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

In the early stage of the disease, the clinical manifestations of DJD may appear similar to those of rheumatoid arthritis (RA). The distinction between DJD and RA becomes more evident as the disease progresses. Table 21-1 differentiates the major characteristics of both diseases and their treatments.

JOINT PAIN. The typical client with DJD is a middle-aged or older woman who complains of joint pain and stiffness. Early in the course of the disease, the pain diminishes after rest and intensifies after activity. Later the pain occurs with slight motion or even when the client is at rest. Because cartilage has no nerve supply, the pain is probably due to joint and soft-tissue involvement and to spasms of the surrounding muscles. During examination of the joints, the nurse can often elicit pain or tenderness by palpation or by putting the joint through range of motion. Crepitus, a continuous grating sensation caused by irregular cartilage, may be felt or heard as the joint is put through passive range of motion. One or more joints are affected. The client may also complain of joint stiffness that usually lasts less than 30 minutes after a period of inactivity.

JOINT CHANGES. On inspection, the nurse notes that the joint is often enlarged because of bony hypertrophy; rarely does a joint appear to be hot and inflamed. The presence of inflammation in clients with DJD usually indicates a secondary synovitis. Approximately 50% of clients with hand involvement display the characteristic Heberden's nodes (at the distal interphalangeal joints) and Bouchard's nodes (at the proximal interphalangeal joints). Although DJD is not a bilateral, symmetric disease, these large bony nodes appear in that pattern, especially in women. The nodes may be painful and red, but some clients do not experience discomfort from their presence. They have a familial tendency and are usually a cosmetic concern to clients. The nodes feel hard when the nurse palpates them, and clients may complain of tenderness on palpation.

OTHER CLINICAL MANIFESTATIONS Joint effusions are common when the knees are involved. When trying to differentiate the presence of fluid from subcutaneous tissue, the nurse may be able to move fluid from the infrapatellar notch (the area directly below the knee) into the suprapatellar notch (the area directly above the knee). Subcutaneous tissue cannot be relocated.

The nurse may also observe atrophy of skeletal muscle from disuse. The vicious pain cycle of the disease discourages the movement of painful joints, which then results in contrac-tures, muscle atrophy, and further pain. Loss of function may result depending on which joints are involved. Hip or knee pain may cause the client to limp and restrict walking distance.

DJD can often affect the spine, especially the lumbar region at the L3-4 level or the cervical region at C4-6. Compression of spinal nerve roots may occur as a result of vertebral facet bone spurs. The client typically complains of radiating pain, stiffness, and muscle spasms in one or both extremities. Spinal and vertebral arteries may also become compressed.

Severe pain and deformity interfere with ambulation and self-care. In addition to performing a musculoskeletal assessment, the nurse performs a functional assessment of the client with DJD to determine mobility and the ability to perform activities of daily living (ADLs). Chapter 10 describes ADLs and functional assessment in depth.

PSYCHOSOCIAL ASSESSMENT

DJD is a chronic condition that may cause permanent changes in lifestyle. An inability to care for oneself in advanced disease prevents socialization and results in role changes and other losses. Therefore the client may exhibit a variety of behaviors indicative of the grieving process, such as anger and depression. The client may experience a role change in the family, workplace, or both. To identify changes that have been or need to be made, the nurse asks the client about his or her roles before the disease developed. Coping strategies to help in living with the disease are also identified. Kee (1998) found four themes that help people cope with DJD (see the Evidence-Based Practice for Nursing box at right):

Refusal to give up

Pragmatism toward treatment strategies

Staying in charge

Tangible caring by others

In addition to role changes, joint deformities and bony nodules often cause an alteration in body image and self-esteem. The nurse observes the client's response to body changes. Does the client ignore them or seem overly occupied with them? How does he or she refer to the changes—with anger, degradation, or humor? These clues help the nurse assess the client's acceptance of body alterations.

The purpose of this qualitative study was to explore the daily experiences of older adults with symptomatic osteoarthritis (OA), or degenerative joint disease, and to determine if older adults with varying socioeconomic status have different coping strategies. A semistructured interview was used for all 20 subjects.

Some differences in understanding the cause and treatment of OA were found. For example, less advantaged subjects used rubbing alcohol on their joints, whereas the more advantaged group used more expensive creams and ointments. Overall coping strategies were similar for both groups.

Four themes emerged regarding living with OA: (1) refusing to give up, (2) pragmatism toward treatment strategies, (3) staying in charge, and (4) tangible caring by others.

Critique. Although the sample size was small, this study is important in beginning to understand the ways in which people live with a chronic disease such as OA on a day-to-day basis. Open-ended questions on the interview allowed subjects to express their real experiences.

Implications for Nursing. Support and caring for the person with OA was a valuable asset for all subjects. Nurses can help to identify support systems or organizations that provide interaction for clients with OA. In addition, they can be encouraged to view their illness as something they can live with and control.

OTHER DIAGNOSTIC ASSESSMENT

The health care provider may order magnetic resonance imaging (MRI) studies of the vertebral column to detect degenerative bony changes in the spine. A bone scan using tech-netium (Tc^99m) can often show early DJD—years before typical changes appear on x-ray film.

Analysis

COMMON NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

The following are priority nursing diagnoses for clients with degenerative joint disease (DJD):

1. Chronic Pain related to muscle spasm, cartilage deterioration, or joint inflammation

2. Impaired Physical Mobility related to pain and muscle atrophy

LABORATORY ASSESSMENT

The health care provider uses the history and physical examination to make the diagnosis of DJD. The results of routine laboratory tests are usually normal but can be helpful in screening for associated conditions. The erythrocyte sedimentation rate (ESR) may be slightly elevated when secondary synovitis (synovial inflammation) occurs. ESR also tends to rise with age and infection.

RADIOGRAPHIC ASSESSMENT

Routine x-ray examinations are useful in determining structural joint changes. Specialized views are obtained when the disease cannot be visualized on standard x-ray film but is suspected. A computed tomography (CT) scan may be used to determine vertebral involvement.

ADDITIONAL NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS

In addition to the common nursing diagnoses, clients may have secondary problems caused by the pain and immobility common in DJD, including one or more of the following:

• Activity Intolerance related to pain and fatigue

■ Self-Care Deficit (Partial) related to pain, fatigue, and immobility

• Disturbed Body Image related to the effects of loss of body function

• Impaired Walking related to joint pain

■' Ineffective Coping related to chronic pain and decreased function

• Imbalanced Nutrition: More than Body Requirements related to decreased activity and mobility

CHRONIC PAIN

PLANNING: EXPECTED OUTCOMES. The major concern of the client with DJD is pain control. Therefore the client is expected to state that chronic pain is reduced or relieved.

INTERVENTIONS. Pain control may be accomplished at home with drug and nondrug measures. If these measures become ineffective, surgery may be performed to reduce pain. The nurse performs a comprehensive pain assessment before and after implementing interventions.

NONSURGICAL MANAGEMENT. Management of chronic joint pain is difficult for both the client and the health care professional. A combination of modalities is often used, including analgesics, rest, positioning, thermal modalities, weight control, and integrative therapies.

INTERVENTION ACTIVITIES for The Client with Degenerative Joint Disease

Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain

• Determine pain location, characteristics, quality, and severity before medicating client.

• Check medical order for drug, dose, and frequency of analgesic prescribed.

• Attend to comfort needs and other activities that assist relaxation to facilitate response to analgesia.

• Administer analgesics around-the-clock to prevent the peaks and troughs of analgesia, especially with severe pain.

• Set positive expectations regarding the effectiveness of analgesics to optimize client response.

• Document response to analgesic and any untoward effects.

Pain Management: Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the client

• Observe for nonverbal cues of discomfort, especially in clients who are unable to communicate effectively.

• Consider cultural influences on pain response.

• Determine the impact of the pain experience on quality of life (e.g., sleep, appetite, activity, cognition, mood, relationships, performance of job, and role responsibilities).

• Evaluate, with the client and the health care team, the effectiveness of past pain control measures that have been used.

• Consider the client's willingness to participate, ability to participate, preference, support of significant others for method, and contraindications when selecting a pain relief strategy.

• Teach the use of nonpharmacologic techniques (e.g., biofeedback, TENS, hypnosis, relaxation, guided imagery, music therapy, distraction, activity therapy, hot/cold application, and massage) before, after and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures.

• Promote adequate rest/sleep to facilitate pain relief.

• Utilize a multidisciplinary approach to pain management, when appropriate.

• Consider referrals for client, family, and significant others to support groups and other resources, as appropriate.

ANALGESIC ADMINISTRATION. The purpose of drug therapy is to reduce pain and secondary joint inflammation if present. Acetaminophen (Tylenol, Atasol⁴*") is the primary drug of choice for pain relief. Clients are at risk for liver damage if they take more than 4000 mg/day, have concurrent alcoholism, or have pre-existing liver disease.

Topical salicylates, such as over-the-counter (OTC) As-percreme, are useful for some clients as a temporary pain reliever. The Food and Drug Administration (FDA) has recently approved topical capsaicin products for DJD. This expensive OTC drug works by blocking substance P, a neu-rotransmitter for pain (Kee, 2000). The nurse teaches the client to expect a burning sensation for a short time after applying capsaicin.

If acetaminophen or topical agents are not successful in relieving pain, the analgesic drug class of choice is usually non-steroidal anti-inflammatory drugs (NSAIDs) (Chart 21-2). Most NSAIDs work by inhibiting both forms of the enzyme cyclooxygenase, COX-1 and COX-2. COX-1 produces pros-taglandins that help regulate normal cell activity, including protecting the lining of the gastrointestinal (GI) tract. COX-2 produces prostaglandins mainly at the sites of inflammation. A subgroup of NSAIDs has been developed to inhibit only the COX-2 enzyme. These new COX-2-inhibiting medications, such as celecoxib (Celebrex) and rofecoxib (Vioxx), appear to manage pain and inflammation without the adverse side effects of GI distress or bleeding.

For temporary relief of pain in a single joint, the health care provider may inject an individual joint with cortisone. Frequently injected joints include the knee, base of the thumb, shoulder, and hip.

Newer agents, such as hyaluronate (Hyalgan) and hylan GF 20 (Synvisc), are used for DJD of the knee. These synthetic joint fluid implants replace or supplement the body's natural hyaluronic acid, which is broken down by inflammation. Muscle relaxants, such as cyclobenzaprine hydrochlo-ride (Flexeril), are sometimes given for painful muscle spasms, especially those occurring in the back. Potent analgesics are not usually appropriate for the client with DJD because of the chronic nature of the pain.

PAIN MANAGEMENT. In addition to analgesics, many nondrug measures can be used for clients with DJD.

Rest. Several types of rest are used to treat clients with DJD:

'' Local rest involves immobilizing a joint with a splint or brace. If a joint becomes acutely inflamed, the joint is rested until inflammation subsides. The nurse consults with the occupational therapist (ОТ), who fits the client for the appropriate device and explains its use. Systemic rest refers to immobilizing the entire body, such as during a nap. The nurse teaches the client about the importance of sleeping approximately 10 hours and, if possible, resting an additional 1 to 2 hours each day.

Psychologic rest is equally important because it allows relief from the daily stresses that can enhance pain.

Positioning. Joints should be placed in their functional position, which may not be the position of comfort. When the client is in a supine position (recumbent), he or she should use a small pillow under the head or neck but avoid the use of other pillows. The use of large pillows under the knees or head may quickly result in flexion contractures. If needed, the legs may be elevated 8 to 12 inches (20.3 to 30.5 cm) to reduce back discomfort. Lying in the prone position twice a day is recommended if tolerated. The nurse also reminds the client to use proper posture when standing and sitting to reduce undue strain on the vertebral column.

Thermal Modalities. In general, the client with DJD uses heat instead of cold to reduce pain. The application of cold is usually reserved for acutely inflamed joints. In collaboration with the physical therapist, the nurse suggests hot showers and baths, hot packs or compresses, and moist heating pads. Regardless of treatment, the nurse teaches the client to check that the heat source is not too heavy or so hot that it causes

	DRUG THERAPY/or Connective	Tissue Disease—cont'd
Drug		Usual Dosage	Nursing Interventions	Rationale
	Aurothioglucose	Same as for gold sodium	Instruct client to expect	Proper, frequent mouth care
	(oil-based gold)	thiomalate. If total of	metallic taste in mouth;	reduces risk of stomatitis
	(Solganal)	1000 mg is used and no	teach importance of	and metallic taste.
		clinical change is seen,	proper mouth care.
		gold is discontinued.	Monitor urine for protein	These changes indicate se-
			and serum for CBC. If	rious toxic effects, and
			CBC is markedly de-	the drug needs to be dis-
			creased or if proteinuria	continued.
			is present, discontinue
			drug. Give deep IM administra-	Drug is locally irritating to
			tion, preferably by Z-	soft tissue.
			track technique.
			After IM administration,	Flushing, dyspnea, and anx-
			observe for nitroid crisis,	iety may occur shortly af-
			a form of anaphylactic	ter drug administration.
			reaction.
	Hydroxychloroquine	Dosage is 200 mg PO	Instruct client to have fre-	Drug can cause retinal
	sulfate (Plaquenil)	each day.	quent (every 3-6 mo)	damage.
			ophthalmologic exami-
			nation.
	Penicillamine (Cuprimine)	Dosage is 125-250 mg	Same as for IM gold, ex-	Same as for IM gold.
		PO each day (may be	cept no nitroid crisis
		given in two divided	occurs.
		doses).
	Immunosuppressive	Dosage varies depending	Observe for side effects	The side effects and toxic
	agents, e.g.,	on disease activity and	and toxic effects, includ-	effects of these drugs can
	azathioprine (Imuran),	route of drug adminis-	ing but not limited to	be devastating. Drugs are
	cyclophosphamide	tration.	nausea/vomiting, bone	reserved for severe forms
	(Cytoxan, Procytox*),		marrow suppression,	of CTDs in which organ
	methotrexate (Mexate)		alopecia, and increased	involvement is potentially
			liver enzymes.	life threatening.
			Take medications with
			meals.
			Instruct client to avoid	Bone marrow suppression
			crowds and people with	or immune suppression
			infections such as	increases the risk of
			influenza.	infection.
	Prednisone	Dosage is 10-150 mg PO	Observe for cushiongoid	These changes are expected
	(Deltasone,	each day. For mainte-	changes, such as moon-	and tend to be dose re-
	Apo-Prednisone*)	nance, attempt to give	face, buffalo hump,	lated. Changes diminish
		dose every other day	striae, acne, thin skin,	as dose decreases.
		(to allow client's adrenal	bruising, fluid retention,
		glands to function).	and increased blood r\fOCC| |I*O
			|JI CooUl С Monitor electrolyte and	Chronic steroid therapy can
			glucose levels.	cause sodium or fluid re-
				tention, potassium deple-
				tion, and elevated glu-
				cose level.
			Observe for long-term ef-	These complications may
			fects of chronic steroid	need to be treated with
			therapy, such as osteo-	Other drugs or modalities.
			porosis, cataracts, hy-
			pertension, diabetes,
			and impaired healing.
			Instruct client to avoid	Drug suppresses immune
			crowds and individuals	system (lymphocytes) and
			with infections such as	increases risk of infection
			influenza.	or decreased healing.

burns. A temperature just above body temperature is adequate to promote comfort.

A physical therapist may provide special heat treatments, such as paraffin dips, diathermy (electrical current), and ultrasonography (sound waves). A 15- to 20-minute heat application usually is sufficient to temporarily reduce pain, spasm, and stiffness.

Weight Control. Contrary to what has been proposed by the media and uninformed authors, there is no "arthritis diet." In collaboration with the dietitian, the nurse explains which foods are high in protein and vitamin С to promote tissue healing. People who consume adequate amounts of antioxi-dants, such as vitamins С and D, have a lower incidence of DJD (Kee, 2000). In addition, the nurse encourages clients who are obese to lose weight to lessen the stress on weight-bearing joints. Less weight reduces pain and slows the disease process in affected joints. If needed, the nurse collaborates with the dietitian to provide more in-depth teaching about nutrition and meal planning.

Complementary and Alternative Therapies. Additional measures may be used for pain reduction. Transcutaneous electrical nerve stimulation (TENS) may be particularly helpful for vertebral involvement. The health care provider collaborates with the nurse and physical therapist to determine whether this pain management modality would be beneficial. The client must be able to control the TENS unit for pain relief.

Clients may also use acupuncture, acupressure, tai chi, therapeutic touch, hypnosis, magnets, music therapy, and imagery for pain relief (see Chapters 4 and 7). In a study by Berman et al. (1999), acupuncture was found to be an effective and safe adjunct to conventional pain management for clients with DJD of the knee. After using therapeutic touch, Gordon et al. (1998) and Evanoff et al. (1999) observed decreased pain and improved function in clients with DJD in one or both knees.

Cayenne pepper (the source of capsaicin products) and other dietary supplements, gamma linolenic acid (GLA), glu-cosamine, and chondroitin are the most recent additions to complement traditional therapies. GLA can be found in evening primrose oil, borage seed oil, and currant seed oil. Many clients have reported positive results from these dietary supplements and topical analgesics, especially decreased pain and inflammation. However, scientific data are lacking (Kee, 2000).

SURGICAL MANAGEMENT. Surgery may be indicated when all other measures are inadequate to provide pain control for clients with degenerative joint disease (DJD). The most common surgical procedure performed for these clients is total joint replacement (TJR). A surgical arthroscopy may be used to remove damaged cartilage (see Chapter 50). An osteotomy may be performed to correct joint deformity, but this procedure is less common because of the success rate of TJR.

Almost any synovial joint of the body can be replaced with a prosthetic system that consists of at least two parts, one for each joint surface. A TJR is the major type of arthroplasty (surgical creation of a joint) performed.

INDICATIONS. TJR is a procedure of last resort for pain management; it is used when all other methods of pain relief have been unsuccessful. The hips and knees are the joints most commonly replaced, but replacements of finger and wrist joints, elbows, shoulders, toe joints, and ankles have become more popular in the past 20 years.

Although TJRs are performed most often for clients with DJD, other conditions causing joint damage may also require surgery. These disorders include rheumatoid arthritis (RA), congenital anomalies, trauma, and avascular necrosis (bony necrosis secondary to lack of blood flow, usually from trauma or chronic steroid therapy).

CONTRAINDICATIONS. The primary contraindications for TJR are infection anywhere in the body, advanced osteoporosis, and severe inflammation. An infection elsewhere in the body or from the joint being replaced can result in an infected TJR and subsequent prosthetic failure. Therefore if a client has a urinary tract infection, for example, the physician treats the infection before surgery. Advanced osteoporosis can cause bone shattering during insertion of the prosthetic device. Acute joint inflammation is treated before surgery because the mechanical stress of the procedure may promote further inflammation and prosthetic failure.

As a group, TJRs are quite successful. Many clients who have lived with chronic, unbearable pain for years and could not function independently at home or in the workplace no longer experience pain in the diseased joint. The pain relief and psychologic benefit may outweigh the perioperative risks and costs, but the surgeon and client must make that decision with the case manager. When the client is of advanced age, this decision may become an ethical issue in addition to a physical risk and cost-versus-benefit decision (see the Legal/Ethical Issues in Health Care box on p. 336).

TOTAL HIP REPLACEMENT. The most commonly replaced joint is the hip. Although clients of any age can undergo total hip replacement (THR), the procedure is performed most often in clients over 60 years of age. The special needs and normal physiologic changes of older clients often complicate the perioperative period and may result in additional postoperative complications. (See Chapters 17 to 19 for routine perioperative care and the special considerations needed for care of the older client.)

PREOPERATIVE CARE. Most managed care companies assign TJR candidates to case managers (CMs) before surgery. During the assessment process, the CM determines whether the client will have postoperative support and care-giving services.

QUALITY OF LIFE FOR CLIENTS HAVING TOTAL JOINT REPLACEMENT

Quality of life (QOL) or quality of well-being (QWB) is a difficult concept to define. In general, it is determined by the client's opinion about the importance of certain elements of his or her life and satisfaction with those elements. Few studies have compared the high cost of surgery with QOL following total joint replacement. This utilitarian ethical approach is based on the belief that a person deserves resources based on the real or potential productivity that he or she offers to society.

Health economists consider a resource or intervention a bargain for society if it costs less than $30,000 per quality of well year. Lavernia, Guzman, and Gachupin-Garcia (1999) calculated the cost per quality of well year for 100 clients undergoing a total knee replacement. The clients completed the QWB Index before surgery and at 3 months, 6 months, 1 year, and 2 years after surgery. The differences in the scores before and after surgery were multiplied by the client's life expectancy to obtain the cost per quality of well year. The calculated costs were about $30,700 at 3 months but steadily decreased to about $6,600 by 2 years postsurgery. Based on this study, total knee replacement meets the utilitarian approach to ethical decision making and should be considered an appropriate investment by society.

As with any surgical procedure, preoperative care begins with assessing the client's level of understanding about the impending replacement. The surgeon explains the procedure and realistic postoperative care expectations during the office visit, but this education may have occurred weeks or months before the scheduled surgery. Older clients in particular may forget some of the information or may not know what questions to ask. Many orthopedic surgeons employ nurses who follow up and address client concerns. An interdisciplinary clinical pathway that outlines expectations during preadmission, hospital-ization, and posthospitalization phases of care should be reviewed with the client and family or significant other.

In addition, nurse educators or orthopedic nurses may lead formal classes in the hospital or clinic several weeks before surgery to answer questions and clarify information. Preadmission sessions are an excellent way for nurses to provide education and support and to improve customer satisfaction. During the class, the client sees the prosthesis or a picture of the device and receives written instructions or a teaching booklet to reinforce the information.

In some hospitals or orthopedic office practices, the physical therapist may meet the client before surgery to explain transfers, precautions, ambulation, and postoperative exercises. An occupational therapist may be available to demonstrate assistive/adaptive devices that facilitate independent activities of daily living (ADLs).

Preadmission programs are beginning to include outcomes measurement using a quality-of-life assessment tool, such as the Health Status Profile (SF-36). (See Chapter 1 for discussion of quality-of-life assessments.) This widely used form is typically completed by the client during preadmission, 6 months after surgery, and every year thereafter to compare measurable outcomes such as ability to perform ADLs and mobility skills.

Clients are admitted to the hospital on the morning of surgery and are transferred to the orthopedic, surgical, or medical-surgical unit after surgery.

OPERATIVE PROCEDURES. Before the start of the procedure, the operating room may be specially cleaned to reduce the risk of infection. Laminar airflow surgical suites and body exhaust systems ("spacesuits") may be used. The surgery is usually scheduled early in the morning, if possible, and movement into and out of the room is kept to a minimum. The client is given a dose of intravenous (IV) antibiotics, usually a cephalosporin such as cefazolin (Ancef), at least 1 hour before the initial surgical incision is made. Vancomycin (Van-cocin) or clindamycin (Cleocin) may be used for clients who are allergic to cephalosporins.

The anesthesiologist or nurse anesthetist places the client under general or epidural anesthesia. Epidural induction reduces blood loss and the incidence of deep vein thrombosis. Intraoperative blood loss with hypotensive epidural anesthesia is usually less than 300 mL, which decreases the need for postoperative blood transfusions (Ranawat et al., 1997).

The 8- to 10-inch (20.3 to 24.5 cm) incision is usually longitudinal on the anterolateral thigh. A posterior incision may be used instead to preserve muscle, depending on the surgeon's preference.

If the prosthesis is cemented, polymethyl methacrylate (an acrylic fixating substance) is used. During the surgical procedure, the operative area is irrigated with a cool solution. To help prevent infection, the surgeon may mix an antibiotic with the cement or may plant antibiotic-impregnated beads deep into the wound. The surgeon also inserts one or two wound drains to remove exudate from the tissues, which might serve as a medium for pathogenic growth and cause wound infection.

A major advance in joint replacement surgery is the increased use of noncemented prostheses, especially for hip replacements. Although polymethyl methacrylate is an excellent initial fixator, it has a finite life span and deteriorates over time, which loosens the implant and causes pain. The average life span of a cemented hip is 10 years. When a prosthesis eventually loosens and causes pain, it is replaced in a procedure called a revision arthroplasty. To prevent repeated replacements, several devices that do not require a fixating substance have been designed. Clients who are older than 75 years or age or who do not have sufficient bone mass are often not candidates for a noncemented hip.

The most common mechanism used to avoid polymethyl methacrylate is a porous metal coating on the shaft of the femoral component and the back of the acetabular cap. By using a tight fit, known as a "press fit," the surgeon places the implant (prosthesis) snugly against the client's bone tissue. Most of the prostheses used today are custom designed by computers to match the size of the prosthesis with the size of the joint. Figure 21-2 illustrates a typical noncemented hip replacement system.

New bone tissue grows between the pores of the prosthesis and "grafts" to the device within 6 to 12 weeks. The older the client, the longer the bone grafting may take. This bony ingrowth serves as the fixating mechanism and, ideally, lasts a lifetime. The earliest noncemented total joint systems, which were inserted in the 1970s and 1980s, have needed revisions, primarily because of undersizing of the prosthesis. These older devices have loosened and have been replaced with a new noncemented device.

Figure 21-2 Noncemented, porous-coated hip replacement system.

Freeze-dried bone grafts (allo-grafts) are used to fill in the bony defects that result from removing the old prosthesis. During the healing process, the essentially dead bone revascularizes and grafts with the client's own bone.

POSTOPERATIVE CARE. In addition to providing the routine postoperative care discussed in Chapter 19, the nurse assesses for and assists in the prevention of possible postoperative complications following a joint replacement.

Prevention of Dislocation. A common complication of total hip replacement is subluxation (partial dislocation) or total dislocation. Therefore correct positioning is maintained at all times. When the client returns from the postanesthesia care unit (PACU), the nurse places him or her in a supine position with the head slightly elevated. The nurse may place a trapezoid-shaped abduction pillow, wedge, sling, or splint (with or without straps) between the client's legs to prevent adduction beyond the midline of the body. In some hospitals this device is no longer used because it is uncomfortable and unnecessary in most cases. Abduction devices are usually reserved for clients who are very restless or are unable to follow instructions, especially older adults. One or two regular bed pillows are used in most cases.

The nurse also monitors the surgical incision and vital signs carefully—every 4 hours for the first several days and every 8 hours thereafter. The nurse observes for signs of infection, such as an elevated temperature and excessive or foul-smelling drainage from the incision. An older client may not have a fever with infection but instead may experience an altered mental state. The nurse obtains a sample of the drainage for culture and sensitivity to determine the offending organisms and the antibiotics that may be needed for treatment.

An infection that occurs within 1 year of surgery is referred to as an early infection. It is most often due to contamination during surgery. In addition to antibiotics, laminar airflow operating rooms, body exhaust systems, ultraviolet light, and double gloving help reduce the incidence of infection. If an early infection occurs, the surgeon usually prescribes IV antibiotic therapy. Late infection can occur anytime after 1 year following surgery. If the late infection does not resolve with treatment, the surgeon may replace the prosthesis.

The clinical manifestations of infection are variable. The erythrocyte sedimentation rate (ESR) is elevated, and the client typically complains of incisional pain, swelling, erythema, and wound drainage.

Assessment of Bleeding and Prevention of Anemia.

The nurse observes the surgical hip dressing for bleeding or other type of drainage at least every 4 hours or when vital signs are taken. The nurse or assistive nursing personnel empties and measures the bloody fluid in the drain every shift. The total amount of drainage is usually less than 50 mL every 8 hours (possibly more if the client has received a plasma expander such as dextran). The surgeon removes the drains and operative dressing 48 to 72 hours after surgery. Care must be taken to prevent tape burns when the surgical dressing is removed, especially in older adults.

The surgeon also orders periodic hemoglobin and hema-tocrit assessments to determine whether the client is anemic and requires blood transfusions. Although some clients receive several units of blood during surgery, the hematocrit and hemoglobin may fall below the normal level, in which case additional blood is needed 2 or 3 days after surgery. Blood pressure may be lower than usual because of blood loss during surgery or because cement was used during surgery. (Cement tends to dilate blood vessels and cause hypotension.)

Because total joint replacements (TJRs) are elective procedures, autologous blood transfusions are appropriate. The client may donate blood before surgery to be used as needed during and after surgery. This predeposit autologous blood donation is a cost-effective blood replacement alternative for clients who are undergoing elective surgeries.

Another method for blood replacement is intraoperative or postoperative blood salvage. The shed blood is collected in-traoperatively via aspiration from the surgical site. Using a cell saver, approximately 50% of the red blood cells are saved for reinfusion. This procedure is used most commonly for bilateral joint replacements or revision surgeries. Blood can be replaced postoperatively by collecting shed blood via suction into a reservoir, filtering the blood, and reinfusing it within a few hours.

Postoperative blood replacement has been standard practice until recently. A preventive alternative is the use of Epo-etin alfa (Epogen, Procrit, Eprex^), an approved treatment for anemia that may prevent the necessity of postoperative blood transfusion when given to clients undergoing TJR (Geier, 1998).

Assessment for Neurovascular Compromise. As with other bone surgery, frequent neurovascular assessments are necessary to monitor for a possible compromise in circulation to the distal extremity. Such assessments are performed at the same time the vital signs are checked.

Management of Incisional Pain. Although hip replacement is performed to relieve joint pain, the client does experience pain related to the surgical procedure. Many clients state that they have pain after surgery but that it is of a different type and is less excruciating than the pain before surgery. Pain control may be achieved by epidural analgesia, patient-controlled analgesia (PCA), intramuscular opioid analgesia, or a combination of techniques. Chapter 7 contains a chart of commonly used opioid analgesics and related nursing interventions.

A new device for pain control after TJR (hip or knee) is a small pump called the PainBuster. This pump continuously infuses a local anesthetic, such as bupivacaine, directly into the surgical site. The local infusion decreases the amount of opioids that the client needs (e.g., morphine), thus reducing the risk of adverse drug reactions. The device is also ideal for ambulatory surgical clients, who may go home with the device (Kettelman, 2000). After the catheter is removed in 48 to 72 hours, the entire device is discarded and the site is covered with a sterile dressing.

The nurse anticipates the older client's need for pain medication if he or she cannot verbalize the need. Many older adults experience several days of increased disorientation or delirium as a result of surgery and anesthesia.

Regardless of the pain management method used, most clients do not require parenteral analgesia after the first 2 days. Oral opioids, such as oxycodone (Supeudol^) or oxy-codone plus acetaminophen (Percocet, Tylox), are then commonly prescribed until the pain can be controlled by NSAIDs such as ketorolac (Toradol, Acular) or ibuprofen (Motrin, Apo-Ibuprofen+O.

Progression of Activity. The client with a total hip replacement is usually allowed to get out of bed the day after surgery, and physical therapy is initiated. Permitted activities differ among surgeons and hospitals, but prolonged bedrest can cause numerous complications (e.g., atelectasis and pneumonia), especially in the older adults. When getting the client out of bed, the nurse stands on the same side of the bed as the affected leg. After achieving a sitting position, the client stands on the unaffected leg and pivots to the chair with assistance. To prevent hip dislocation, the nurse at all times ensures that the client does not flex the hips beyond 90 degrees (Figure 21-3).

Figure 21-3 Correct and incorrect (more than 90⁰) hip flexion after a total hip replacement.

Raised toilet seats, straight-back chairs, and reclining wheelchairs help prevent hyperflexion.

The surgeon, the type of prosthesis, and the surgical approach determine the resumption of weight bearing on the affected leg. A client with a cemented implant is usually allowed immediate partial weight bearing (PWB) or full weight bearing (FWB) to tolerance. A client with an uncemented prosthesis cannot tolerate FWB until bony ingrowth occurs. Typically, only PWB is permitted for the first 6 weeks or until there is x-ray evidence of bony ingrowth.

The physical therapist (PT) teaches the client how to follow these weight-bearing restrictions and helps the client progress to FWB status, if possible. Most clients use a walker, but young clients may use crutches. Clients are usually advanced to a single cane or crutch if they can walk without a severe limp 1 month after surgery. When the limp disappears, they no longer need an ambulatory/assistive device and are permitted to sit in chairs of normal height, use regular toilets, and drive a car.

Prevention of Thromboembolic Complications. The risk of developing deep venous thrombosis (DVT) postopera-tively is high. Fatal pulmonary embolism syndrome occurs in 0.5% to 2% of cases (Ranawat et al., 1997). Older clients are especially at increased risk for thrombi because of age and compromised circulation before surgery. Obese clients and those with a history of DVT are also at high risk for thrombi. In clients with total hip replacement, thrombi usually develop in the thigh; these thrombi become life-threatening emboli more readily than thrombi in the calf and other areas. For this reason, thigh-high stockings, elastic bandages, and sequential compression devices (SCDs) are used during the hospital stay (see Chapter 17).

Anticoagulants, such as aspirin (Ecotrin, buffered aspirin), warfarin (Coumadin, Warfilone^), or a subcutaneous low-molecular-weight (LMW) heparin (Lovenox), are prescribed. Studies indicate that LMW heparins are superior and decrease the risk of DVT in clients undergoing total hip and knee replacement (Morris et al., 1998). If the client takes warfarin, the dosage is usually adjusted to maintain an International Normalized Ratio (INR) of 2.0 to 3.0.

The PT teaches leg exercises, which are begun in the immediate postoperative period and continue until the client is fully ambulatory. These exercises include plantar flexion and dorsiflexion (heel pumping), circumduction (circles) of the feet, gluteal and quadriceps muscle setting, and straight-leg raises (SLRs). The client performs gluteal exercises by pushing the heels into the bed and achieves quadriceps-setting exercises ("quad sets") by straightening the legs and pushing the back of the knees into the bed. In addition to preventing clots, these exercises improve muscle tone, which aids restoring the function of the extremity.

Promotion of Self-Care. The hospital's occupational therapy department often supplies assistive/adaptive devices to help with activities of daily living (ADLs). Particularly important for clients are devices designed for reaching to prevent them from bending or stooping and flexing at the hips more than 90 degrees. Extended handles on shoehorns and dressing sticks are particularly useful for helping clients achieve independence in ADLs.

The length of stay in the acute care hospital is typically 3 days, but older clients or those experiencing postoperative complications may stay longer. Discharge may be to the home, a rehabilitation unit, transitional care unit (subacute unit), or long-term care facility for rehabilitation or custodial care. The interdisciplinary team provides written instructions for posthospital care and reviews them with clients and their family members (Chart 21-4). A copy of the posthospital instructions is sent with clients who are transferred to a facility.

CRITICAL THINKING CHALLENGE

Your client is unable to obtain pain control for degenerative joint disease (DJD) of the hip and knee and therefore undergoes a left cemented total hip replacement. She returns to the assisted living facility for rehabilitation following a 3-day hospital stay. She is able to ambulate with a walker in her room and wears thigh-high elastic stockings. Her medication orders include Coumadin and Tylox for pain.

• What teaching should you reinforce with her related to Coumadin?

• What weight-bearing allowance will she most likely have?

• What surgical complications is she still at risk for, and how can you help prevent them?

• Do not sit or stand for prolonged periods.

• Do not cross your legs beyond the midline of your body.

• Do not bend your hips more than 90 degrees.

• Use an ambulatory aid, such as a walker, when walking.

• Use assistive/adaptive devices for dressing, such as for putting on shoes and socks.

• You can resume sexual intercourse as usual, but use the hip precautions learned in the hospital.

Pain Management

• Report increased hip pain to the physician immediately.

• Take oral analgesics as prescribed and only as needed.

• Do not overexert yourself; take frequent rests.

Incisional Care

» Inspect your hip incision every day for redness, heat, or drainage; if any of these are present, call your physician immediately.

• Cleanse your hip incision with a mild soap and water every day; be sure to dry it thoroughly.

Other Care

• Continue walking and performing the leg exercises as you learned in the hospital.

• Report pain, redness, or swelling in your legs to your physician immediately.

• Report chest pain and/or shortness of breath to your physician immediately.

• If you are taking an anticoagulant for 4 to 6 weeks, follow the precautions learned in the hospital to prevent bleeding: avoid using a straight razor, avoid injuries, and report bleeding or excessive bruising to your physician immediately.

Before 1980, attempts at knee replacement were not successful, and most of the prostheses inserted before then have been removed. The knee is not a simple, hinged joint; it is a condylar joint that rotates slightly when flexed and extended. As seen in Figure 21-4, the typical total knee prosthesis is a three-part system: a femoral component, a tibial plate, and a patellar button. With some clients, only one surface is replaced.

PREOPERATIVE CARE.

Only severe symptoms and disability justify TKR in clients with DJD. TKRs are typically avoided in people younger than 60 years of age (Windsor & Insall, 1997). The preoperative care for clients undergoing a TKR is similar to that for total hip replacement. The major difference is the teaching, which depends on the postoperative protocol used by the orthopedic surgeon.

OPERATIVE PROCEDURES.

As with the hip, the knee can be replaced with the client under general or epidural anesthesia. The surgeon typically makes a central longitudinal incision approximately 8 inches (20.3 cm) long. Osteotomies of the femoral and tibial condyles and of the posterior patella are performed, and the surfaces are prepared for the prosthesis. Noncemented implants, once popular in the 1980s, are used less for the knee than they are for the hip. The surgeon inserts one or two surgical drains and applies a pressure dressing to prevent bleeding. Some clients have bilateral knee replacements as part of one surgery.

POSTOPERATIVE CARE.

Postoperative nursing care of the client with a TKR is similar to that for the client with a total hip replacement; however, maintaining abduction is not necessary. The surgeon usually orders the use of a continuous passive motion (CPM) machine, which can be applied in the postanesthesia care unit (PACU) or not used until 1 to 2 days after surgery (Figure 21-5). The CPM keeps the prosthetic knee in motion and prevents the formation of scar tissue, which could impede mobility of the knee and exacerbate postoperative pain. In the immediate postoperative period, the surgeon may also order ice packs or a Hot/Ice Machine to decrease swelling at the surgical site.

Figure 21-5 • A continuous passive motion machine in use.

BEST PRACTICE for The Client Using a Continuous Passive Motion (CPM) Machine

• Ensure that the machine is well padded with sheepskin or other similar material.

• Check the cycle and range-of-motion settings at least once per shift (every 8 hours).

• Ensure that the joint being moved is properly positioned on the machine.

• If the client is confused, place the controls to the machine
out of his or her reach.

• Assess the client's response to the machine.

• Turn off the machine while the client is having a meal in bed.

• When the machine is not in use, do not store it on the floor.

The surgeon, physical therapist, or technician presets the CPM machine for the appropriate range of motion and cycles per minute. A typical initial setting is 20 to 30 degrees of flexion and full extension (0 degrees) at 2 cycles/min, but this setting varies according to surgeon preference. The CPM machine is generally used for 8 to 12 hours per day, with the range of motion increased gradually. The current trend is intermittent use for several hours at a time. Each day the nurse notes the client's response to the device.

Some machines do not allow the leg to achieve full extension, thus promoting flexion contractures. One solution is for the client to use the CPM machine during the day and sleep in a knee immobilizer at night to achieve the desired extension. Chart 21-5 outlines the nurse's responsibility when caring for a client using the CPM machine.

In general, pain control measures for clients with TKR are similar to clients with total hip replacement. Ritter et al. (1999) found that intra-articular morphine for the first 24 hours after surgery is a safe and effective alternative for pain management.

Because dislocation is a rare problem for a client with TKR, special positioning is not required. Other complications that affect clients with total hip replacement may also affect clients with TKR. The preventive measures described earlier for total hip replacement are used for TKR.

The goal for discharge from the hospital is that the client should walk independently with a cane or walker and have 90 degrees of flexion in the operative knee. The use of a stationary bicycle can help gain flexion. After discharge from the hospital, the client should not hyperflex the knee or kneel for prolonged periods.

TOTAL SHOULDER REPLACEMENT. Shoulder replacements have not been performed as often as other types of replacement techniques. Because the joint is complex and has many articulations, subluxation (or dislocation) is a major complication. A Neer-type prosthesis is commonly used, with or without cement.

The client's affected arm is typically placed in a CPM machine shortly after surgery (see Chart 21-5). During the first few postoperative days, frequent neurovascular assessments are important. The hospital stay is shorter than for a total hip replacement or total knee replacement.

TOTAL ELBOW REPLACEMENT. Total elbow replacement is performed most commonly for clients with rheumatoid arthritis. It is usually successful in increasing range of motion, but infection is fairly common because of extensive tissue cutting during surgery. A Mayo prosthesis is commonly inserted, and the CPM device is often used postoperatively. In general, elbow motion is allowed as tolerated. Physical therapy is not usually necessary. Generalized swelling usually resolves in 3 to 6 months.

FINGER AND WRIST REPLACEMENTS. Any joint of the hand can be replaced, often for clients with rheumatoid arthritis. Flexible, silicone prostheses are implanted without the use of polymethyl methacrylate because no weight bearing is required.

A bulky dressing is used temporarily after surgery and is then replaced with a dynamic splint, brace, cast, or very small CPM machine. Edema formation is controlled if the client elevates the arm as much as possible. The rehabilitation program for finger arthroplasties may last for weeks, until normal function and strength return. These procedures are typically performed in specialized hand centers.

Any bone of" the wrist can be replaced, including the heads of the radius and ulna. The postoperative pressure dressing is removed in 2 to 3 days, and a splint or short arm cast is applied. The client usually regains full function within 6 to 12 weeks, but lifting may be restricted for a longer period. Occupational therapists are usually involved with upper extremity rehabilitation.

ANKLE AND TOE REPLACEMENTS. Because the ankles support approximately 25% of the body's weight, developing an implant that is both small enough and strong enough has been difficult. When the ankle is replaced, an arthrodesis (bone fusion) is usually performed for added stability. Replacing the ankle is not a common procedure because of implant failures. The long-term results of newer-designed pros-theses are not yet known.

Metatarsal implants are made of silicone and cannot bear excessive weight. Typically the client has one or more osteotomies and fusions, which are immobilized by wires and a cast while healing occurs. Chapter 51 discusses foot osteotomies and their associated nursing care.

IMPAIRED PHYSICAL MOBILITY

PLANNING: EXPECTED OUTCOMES. The client with degenerative joint disease (DJD) is expected to function independently in performing activities of daily living (ADLs) and ambulation.

INTERVENTIONS. Management of the client with DJD is an interdisciplinary effort. The nurse collaborates with physical and occupational therapists to meet the goal of independent function. Major interventions include therapeutic exercise and the promotion of ADLs and ambulation by teaching about health and the use of assistive/adaptive devices.

EXERCISE. Two types of exercise are recommended for the client with DJD: recreational and therapeutic. Recreational exercise includes hobbies and sports, with no planned purpose other than relaxation. Therapeutic exercise includes carefully planned activities that are designed to improve muscle strength, muscle tone, and joint range of motion. Thera peutic exercise can also reduce pain and improve the client's psychologic health.

Certain recreational activities may also be therapeutic, such as doing the breaststroke during swimming to enhance chest and arm muscles. Aerobic exercises (e.g., walking, biking, swimming, and aerobic dance) are recommended. Usually the physical therapist prescribes exercises for the client with DJD, but the nurse reinforces their techniques and principles. The ideal time for exercise is immediately after the application of heat.

DEGENERATIVE JOINT DISEASE

Cost of Care

• The cost of medical care for older clients with degenerative joint disease (DJD) is approximately twice that of older clients with no symptomatic DJD.

• The average individual cost of arthritis-related care for clients with rheumatoid arthritis (RA) is approximately $2200 per year. Medications account for almost two thirds of the cost, and hospital care accounts for 16%. By contrast, the average individual cost for clients with DJD is approximately $550 per year. Medications account for approximately one third of the cost, and hospital care accounts for close to one half of the cost (most due to total joint replacement).

• Although the individual cost of care for clients with DJD is approximately one fourth of that for clients with RA, the total cost for DJD is about seven times greater because the higher prevalence of DJD.

• One half of the costs for DJD is due to sick days from work—$15.5 billion in the United States.

• Clinical pathways for total hip replacement reduce the length of stay and hospital costs.

Implications for Nursing

Because of the high cost of medications for DJD and RA, nurses need to become more familiar with the use of integra-tive therapies for pain management. Research has shown that some modalities are as effective as analgesics, and others serve as excellent adjuncts for pain control. For clients undergoing total joint replacement, extensive staff and client education is needed to follow clinical pathways and ensure positive clinical and cost outcomes.

USE OF ASSISTIVE/ADAPTIVE DEVICES. The physical therapist evaluates the client's need for ambulatory aids such as canes, walkers, or platform crutches. Although many clients do not like to use these aids or may forget how to use them, they do help prevent further joint deterioration and pain. An occupational therapist evaluates the client's ability to perform ADLs and can provide ideas and devices for assistance.

Community-Based Care

The client with DJD is not usually hospitalized for the disease itself but for surgical management. The cost of medical and surgical care for clients with DJD has been evaluated (see the Cost of Care box above).

HOME CARE MANAGEMENT

If weight-bearing joints are markedly involved, the client may have difficulty going up or down stairs. Making arrangements to live on one floor with accessibility to all rooms is often the best solution. A home care nurse, physical therapist, or occupational therapist assesses the need for structural alterations to the home to accommodate ambulatory aids and enable the client to perform activities. For example, a kitchen counter may need to be lowered, or a seat and handrails may need to be installed in the shower. If the client has undergone a total hip replacement, an elevated toilet seat is necessary for several weeks postoperatively to prevent excessive hip flexion.

HEALTH TEACHING

Learning how to protect the joint is the most important feature of client education. Preventing further damage to joints slows the progression of DJD and minimizes pain.

As with other diseases in which drugs and diet therapy are used, the nurse teaches the drug protocol, side effects, and toxic effects to the client and family. The nurse also emphasizes the importance of reducing weight and eating a well-balanced diet to promote tissue healing.

Many clients with "arthritis" look for a cure after becoming frustrated and desperate about the course of the disease and treatment. Unfortunately, there is no cure for these joint diseases, even though tabloids, books, and the media often cite "curative" remedies. People spend billions of dollars each year on quackery, including liniments, special diets, and copper bracelets. More hazardous substances, such as snake venom and industrial cleaners, are also advertised as remedies. The nurse instructs the client always to check with The Arthritis Foundation about new "cures."

For example, if a client believes it is helpful to wear a copper bracelet or to eat more foods with a high vitamin С content, the nurse may encourage continuation of the practice as long as it is not harmful. If there is a potential for harm, the nurse instructs the client to avoid the modality and provides the rationale for doing so.

With most types of connective tissue disease (CTD), clients must live with a chronic, unpredictable, and painful disorder. Their roles, self-esteem, and body image may be affected by these diseases. Body image is often not as devastating in DJD as in the inflammatory arthritic diseases, such as rheumatoid arthritis.

CLIENT EDUCATION GUIDE

Evidence-Based Instructions for Joint Protection

Use large joints instead of small ones; for example, place your purse strap over your shoulder instead of grasping the purse with your hand.

• Do not turn a doorknob clockwise. Turn it counterclockwise to avoid twisting your arm and promoting ulnar deviation.

• Use two hands instead of one to hold objects.

• Sit in a chair that has a high, straight back.

• When getting out of bed, do not push off with your fingers; use the entire palm of both hands.

• Do not bend at your waist; instead bend your knees while keeping your back straight.

• Use long-handled devices, such as a hairbrush with an extended handle.

• Use assistive/adaptive devices, such as Velcro closures and built-up utensil handles, to protect your joints.

• Do not use pillows in bed, except a small one under your head.

• Avoid twisting or wringing your hands.

HEALTH CARE RESOURCES

The client who has undergone surgery is most likely to need help from community resources. After a joint replacement, he or she needs extensive assistance with mobility. He or she may be discharged to home, a long-term care facility, a subacute unit (transitional care unit), or a rehabilitation unit. The nurse collaborates with the case manager and physician to find the best placement. If the client is discharged to home, home care nurses may be approved for several visits, depending on the concurrent systemic diseases. A nursing assistant may visit the home to help with hygiene-related needs, and a physical therapist may work with ambulatory and mobility skills. A client who has undergone a total hip or knee replacement should not be discharged to home alone. A family member or significant other must be in the home at all times for at least the first 4 to 6 weeks—when the client needs the most assistance.

The nurse provides written instructions about the required care, regardless of whether the client goes home or to another inpatient facility. Communication with the new care provider is essential for seamless continuity of care. Arrangements are made for the client to return to the same acute care hospital if needed.

The Arthritis Foundation is an important community resource for all clients with CTD. This organization provides information to lay people and health care professionals and refers clients and their families to other resources as needed.

Evaluation: Outcomes

The nurse evaluates the care of the client with DJD on the basis of the identified nursing diagnoses. The expected outcomes are that the client:

• States that chronic pain is reduced as a result of interdisciplinary interventions for pain control

• Ambulates without personal assistance (although a mechanical aid such as a walker may be used)

• Is independent in ADLs (may use assistive/adaptive devices)

LABORATORY PROFILE Connective Tissue Disease

Test	Normal Range for Adults	Significance of Abnormal Findings
Rheumatoid factor
Rose-Waaler	Negative	Elevations of either titer (increase in number at right
		of colon) indicative of possible CTD
		Increased Rose's titer indicative of RA (seropositive);
		not a sensitive test
Latex agglutination	<1:16	Latex titer not as specific to one disease, but quite a
		sensitive test
ANA (total)	Negative (if positive, types of ANA	Elevations common in SLE, PSS, RA, and other in-
	identified [e.g., anti-DNA, anti-DNP,	flammatory CTDs (5% of healthy adults have posi-
	anti-RNA] to indicate what part of	tive ANA results)
	cells are involved)
Serum complement	Varies greatly among laboratories	Decreased value indicative of active autoimmune dis-
(C or CH50)		ease such as SLE
LE preparation	Negative	A type of ANA (anti-DNP); not reliable because nega-
		tive result does not rule out SLE; can be used as
SPEP		screening test
Albumin	3.5-5.0 g/dL	Increased levels of gamma globulins indicative of
Globulin		CTD (inflammatory type)
Alpha, globulin	0.1-0.3 g/dL	Increased level of alpha globulins possible in RA
Alpha2 globulin	0.6-1.0 g/dL
Beta globulin	0.7-1.1 g/dL
Gamma globulin	0.8-1.6 g/dL
HLA testing (HLA-B27)	None	Presence of HLA-B27 indicative of Reiter's syndrome
		or ankylosing spondylitis

ANA, Antinuclear antibody; CTD, connective tissue disease; DNP, dinitrophenol; SLE, systemic lupus erythematosus; PSS, progressive systemic sclerosis; LE, lupus erythematosus; SPEP, serum protein electrophoresis; RA, rheumatoid arthritis; HLA, human leukocyte antigen; ESR, erythrocyte sedimentation rate.values than men. In general, a value of 20 to 40 mm/hr indicates mild inflammation; 40 to 70 mm/hr, moderate inflammation; and 70 to 150 mm/hr, severe inflammation.

COMPLEMENTARY AND ALTERNATIVE THERAPIES.

As for any client with arthritis, other nonpharmacologic pain relief techniques are available for rheumatoid arthritis (RA). Some clients may achieve relief with transcutaneous electrical nerve stimulation (TENS), hypnosis, acupuncture, magnet therapy, imagery, or music therapy. Stress management is also becoming more popular as a pain relief intervention. Chapters 4 and 7 discuss these therapies in detail.

Good nutrition is an important part of the management of RA, and special attention is given to certain types of foods (Yen, 1999):

• Omega 3 fatty acids (found in coldwater fish such as salmon and tuna) to decrease inflammation; Eskimos eat whale blubber and have a low incidence of RA

• Fish oil capsules at 2.5 to 5.0 g/day (should not be taken if the client is taking anticoagulant therapy)

• Antioxidant vitamins A, C, and E

EXPERIMENTAL THERAPIES.

In addition to the drag regimens described earlier, two techniques—pulse therapy and plasmapheresis—have been tried and evaluated in the treatment of severe RA. In pulse therapy, the client receives rapid infusions of high-dose steroids or chemotherapeutic agents, usually over a period of several days. Plasmapheresis (sometimes called plasma exchange) is a procedure in which the client's plasma is treated to remove the antibodies causing the disease. This procedure may be combined with pulse therapy for clients with severe, life-threatening disease.

PROMOTION OF SELF-CARE.

Although the physical appearance of a client with severe RA may lead the nurse to believe that independence in activities of daily living (ADLs) is not possible, a number of alternative methods can be used to perform these activities. The nurse should not automatically perform these activities; clients with RA do not want to be dependent. For example, hand deformities often prevent a client from opening packages of food, such as a box of crackers. However, he or she may prefer to use his or her teeth to open the crackers rather than depend on someone else.

In the hospital or long-term care facility, a client may not eat because of the barriers of heavy plate covers, milk cartons, small packages of condiments, and heavy containers. Styro-foam or paper cups may bend and collapse as the client attempts to hold them. A china or heavy plastic cup with handles may be easier to manipulate. The nurse and client collaborate with the dietitian to allow access to food and total independence in eating.

When fine motor activities (e.g., squeezing a tube of toothpaste) become impossible, larger joints or body surfaces can substitute for smaller ones. For example, the nurse teaches the client to use the palm of the hand to press the paste onto the brash. Devices such as long-handled brushes can allow clients to brush their hair; dressing sticks can facilitate putting on pants. These examples illustrate the need for the nurse to assess the problem area, suggest alternative methods, and refer the client to an occupational or physical therapist for special assistive and adaptive devices if necessary.

Figure 21-7 • Heating units used to keep hot packs warm. (Courtesy Whitehall Manufacturing, City of Industry, CA.)

MANAGEMENT OF FATIGUE. Nursing interventions depend in part on identifying the factors contributing to fatigue. For example, increases in pain, sleep disturbances, and weakness are positively associated with increased fatigue. Anemia may also be a contributing factor and may be treated with iron (if an iron deficiency anemia is present), folic acid, or supplements prescribed by the health care provider. Chronic normochromic or chronic hypochromic anemia often occurs in most chronic, systemic diseases. The nurse also assesses for drug-related blood loss, such as that caused by salicylate therapy or other NSAIDs, by checking the stool for gross or occult blood. Older Caucasian women are the most likely clients to experience gastrointestinal bleeding as a result of taking these medications.

When fatigue results from muscle atrophy, the physician prescribes an aggressive physical therapy program to strengthen muscles and prevent further atrophy. Clients experience increased fatigue when pain prevents them from getting adequate rest and sleep. Measures to facilitate sleep include promoting a quiet environment, giving warm beverages, and administering hypnotics or relaxants as prescribed, if necessary. Pain relief measures were discussed earlier in this chapter under Chronic Pain.

In addition to identifying and managing specific reasons for fatigue, the nurse assesses the client's daily activities and teaches principles of energy conservation, including:

• Pacing activities

• Allowing rest periods

• Setting priorities

• Obtaining assistance when needed

ENHANCEMENT OF BODY IMAGE.

Body image may be affected by both the disease process and drug therapy. Steroids can cause a moon-faced appearance, acne, striae, "buffalo humps," and weight gain. The nurse determines the client's perception of these changes and the impact of the reactions of family and significant others. The most important intervention for the nurse is communicating acceptance of the client. When a trusting relationship is established, the nurse encourages the client to express his or her feelings.

Another way to improve body image while in the hospital or nursing home is to use personal items. A hospital gown reinforces the sick role. The nurse encourages clients to wear their own clothes, to brush their hair, and to use makeup if desired. The nurse assists in making the client as presentable as possible. The use of colored hair bows, nail polish, and perfume may improve a female client's image and self-concept.

As a reaction to body image disturbance and the presence of a chronic, painful disease, clients may display behaviors indicative of loss. They may use coping strategies that range from denial or fear to anger or depression. In an attempt to regain control over the effects of the disease process, they may appear to be manipulative and demanding and may sometimes be referred to as having an "arthritis personality." This personality, which has negative connotations, is a myth. Clients are trying to cope with the effects of their illness and should be treated with patience and understanding. The nurse continually assesses and accepts these behaviors but remains realistic in discussing goals to improve self-esteem. Clients' strengths are emphasized, and previously successful coping strategies are identified.

Nurses need to assess and intervene appropriately if clients are in pain and are suffering. A qualitative nursing study by Dildy (1996) found that clients with RA benefit from nurses who are empathetic, gentle, caring, and cheerful. In addition,

CLIENT EDUCATION GUIDE

Energy Conservation for the Client with Arthritis

· Balance activity with rest. Take one or two naps each day. Pace yourself; do not plan too much for one day. Set priorities. Determine which activities are most important, and do them first.

· Delegate responsibility and tasks to your family and friends.

· Plan ahead to prevent last-minute rushing and stress. Learn your own activity tolerance and do not exceed it.

Community-Based Care

Clients with rheumatoid arthritis (RA) are usually managed at home but may be institutionalized in a long-term care setting if they become restricted to bed or a wheelchair. Some clients may be discharged to a rehabilitation facility for several weeks to aid in developing strategies, techniques, and skills for independent living at home.

HOME CARE MANAGEMENT

The amount of home care preparation depends on the severity of the disease. Structural changes may be necessary if there are deficits in activities of daily living (ADLs) or mobility. Doors must be wide enough to accommodate a wheelchair or walker if one is used. Ramps are needed to prevent the client in a wheelchair from being homebound. If the client cannot negotiate stairs, he or she must have access to facilities for all ADLs on one floor. Handrails should be available in the bathroom and halls.

To promote continued homemaking functions, countertops and appliances may require structural changes. The client may also require handrails and elevated chairs and toilet seats, which facilitate transfers (Figure 21-8).

HEALTH TEACHING

Health teaching is a vital role for nurses in the diagnosis and management of arthritis. Many people have signs and symptoms of joint inflammation but do not seek medical attention.

Figure 21-8 Handrails and an elevated toilet seat make transfers easier for the client.

The nurse teaches about the need to seek professional health care to reduce pain and disability (see the Meeting Healthy People 2010 Objectives box at right).

Health teaching is also important for promoting compliance with a treatment plan. The nurse should take precautions regarding myths and quackery to protect the client from harm. Information about drug therapy, joint protection, energy conservation, rest, and exercise is reviewed with the client, family, and significant others.

The client with RA often complains of being on an "emotional roller coaster" from coping with a chronic illness every day. Control over one's life is an important human need. The client with an unpredictable chronic disease may lose this control, and this lowers self-esteem. Health care providers must allow the client to make decisions about care. Families and significant others must also include the client in decision making. Although the client's behavior may be perceived as demanding or manipulative, his or her self-esteem cannot be improved without this important aspect of interpersonal relationships.

Increased dependency also affects a sense of control and self-esteem. Some clients ignore their health needs and portray a tough image for others by insisting that they need no assistance. The nurse emphasizes to the client and family that asking for help may be the best decision at times to prevent further joint damage and disease progression.

Social and work roles are dramatically affected by RA. The client may find new friends among others who have the same problem; such friends provide a support system in coping with these changes. Becoming an active member of and volunteering for The Arthritis Foundation can help the client to meet his or her social and work needs. Loss of income from an inability to be gainfully employed can also be a major source of stress. The client may qualify for disability benefits through the federal Social Security program. If possible, he or she can learn new skills for a less stressful career.

In addition to the interventions just described for self-esteem disturbance, the nurse may need to refer the client to a counselor or religious or spiritual leader for emotional support and guidance during times of crisis. The nurse should

LUPUS ERYTHEMATOSUS

OVERVIEW

The word lupus is the Latin term for "wolf." In the mid-nineteenth century, the facial rash accompanying this disease was thought to look like bites caused by a wolf. The rash was usually red, and thus the term erythematosus, a Latin word meaning "reddened," was added to describe the disease.

There are two main classifications of lupus: discoid lupus erythematosus (DLE) and systemic lupus erythematosus (SLE). A small percentage of clients with lupus have the DLE type, which affects only the skin.

SLE is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. It is characterized by spontaneous remissions and exacerbations, and the onset may be acute or insidious. The condition is potentially fatal, but the survival rate has dramatically over the past 20 years. Today more than 85% of clients with SLE are alive 5 years after diagnosis (Hahn, 1997). Improvements in determining the cause, diagnosis, and treatment of lupus account for the prolonged survival of these clients.

Lupus is thought to be an autoimmune process; that is, abnormal antibodies are produced and react with the client's tissues. These antinuclear antibodies (ANAs) primarily affect the deoxyribonucleic acid (DNA) within the cell nuclei. As a result, immune complexes form in the serum and organ tissues, which causes inflammation and damage. These complexes invade organs directly or cause vasculitis (vessel inflammation), which deprives the organs of arterial blood and oxygen.

Many clients with SLE have some degree of kidney involvement—the leading cause of death. Other causes of death from SLE are cardiac and central nervous system involvement.

In kidney disease, renal biopsies show the following progressive changes within the glomeruli:

• In minimal lupus nephritis, the glomeruli are slightly irregular; immunoglobulins and complement are seen by electron microscopy.

• Focal, or mild, lupus nephritis is characterized by further glomerular changes, and immune complex deposits are common. In this type of lupus, the client begins to show clinical signs of renal impairment.

• In diffuse, severe proliferative nephritis, more than 50% of the glomeruli are affected, and the client is in renal failure.

Lupus affects women between the ages of 15 and 40 years at a rate 8 to 10 times more often than men. The onset of the disease occurs most often during the childbearing years, but it has been reported in young children and older adults.

COLLABORATIVE MANAGEMENT

Assessment

It is impossible to describe a typical textbook picture of a client with lupus because of the extreme variability of symptoms. When the disease is in remission, the client may appear healthy and have no activity limitations. When the disease flares, the client may be so ill that admission to a critical care unit is required.

PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

SKIN INVOLVEMENT. The major and usually only manifestation of DLE is a dry, scaly, raised rash on the face ("butterfly" rash) or upper body or individual round lesions that are sometimes referred to as discoid (coinlike) lesions. The lesions are especially evident when the client is exposed to sunlight or ultraviolet light. Alopecia is CNS, Central nervous system.

MUSCULOSKELETAL CHANGES. In addition to skin changes, polyarthritis occurs in 90% of clients with SLE. The initial joint changes are similar to those seen in rheumatoid arthritis (RA), but severe deformities are not common. Small joints and the knees are most commonly involved. Avascular necrosis (bone necrosis from lack of oxygen) is often seen in clients with SLE who have been treated for at least 5 years, usually with steroids. Chronic steroid therapy may cause the constriction of small blood vessels supplying the joint, which causes the tissue to die. The hip is most commonly affected, and complaints of pain and decreased mobility result.

The nurse observes for muscle atrophy, which can result from disuse or from skeletal muscle invasion by the immune complexes (myositis). Myalgia (muscle pain) may also occur. The nurse inspects and palpates the major muscles, especially those in the extremities.

SYSTEMIC MANIFESTATIONS. Because SLE is an inflammatory condition, fever and fatigue are common findings. Fever is the classic sign of a flare, or exacerbation. Various degrees of generalized weakness, fatigue, anorexia, and weight loss occur. These signs may be the only evidence of impending disease, which makes diagnosis by the health care provider difficult. Consequently, some clients have a diagnosis of "probable SLE."

Any or all body systems may be affected by SLE. Because lupus nephritis is the leading cause of death, the nurse carefully assesses for signs of renal involvement (e.g., changes in urinary output, proteinuria, hematuria, and fluid retention). Approximately 50% of clients with SLE have some type of nephritis.

Pleural effusions or pneumonia are found in almost half of all cases of SLE, but this complication is usually not life threatening. Pulmonary restrictive or obstructive changes may not result in overt clinical signs. However, progressive involvement can lead to dyspnea and arterial blood gas abnormalities. The nurse performs a complete respiratory assessment to determine any abnormalities in respiratory pattern or breath sounds.

Pericarditis is the most common cardiovascular manifestation and causes tachycardia, chest pain, and myocardial ischemia. The nurse monitors the vital signs at least every 4 hours while the client is in the hospital and reports chest pain immediately to the physician.

Raynaud's phenomenon is noted in 15% of cases of lupus. On exposure to cold or extreme stress, the client with Raynaud's phenomenon complains of the characteristic red, white, and blue color changes and severe pain in the digits; these changes are caused by arteriolar vasospasm. The nurse may not observe these episodes but should ask clients whether color changes occur when their hands or feet are exposed to cold or when they are extremely stressed.

Neurologic manifestations are varied. Central nervous system effects include psychoses, paresis, seizures, migraine headaches, and cranial nerve palsies. Peripheral neuropathies are also common.

The nurse monitors for reports of abdominal pain, which most often result from serositis (peritoneal involvement). Mesenteric arteritis, pancreatitis from arteritis of the pancreatic artery, and colonic ulcers also can cause abdominal pain with lupus. The nurse may note liver enlargement on assessment of the abdomen, but jaundice is rare. More than 50% of clients have lymph enlargement, and 10% have splenomegaly. The nurse palpates the lymph nodes and documents the findings. Vasculitis affecting any major or small vessels can lead to organ failure.

Figure 21-9 The characteristic "butterfly" rash of systemic lupus erythematosus

PSYCHOSOCIAL ASSESSMENT

The psychosocial results of lupus can be devastating. With either DLE or SLE, the rash can be disfiguring and embarrassing. Young adult women who never had a blemish are confronted with a rash that cannot be completely covered with makeup. If chronic steroid therapy is used, side effects such as acne, striae, fat pads, and weight gain intensify the problem of an already altered body image.

Chronic fatigue and generalized weakness may prevent the client from being as active as in the past. He or she may avoid social gatherings and may withdraw from family activities. The unpredictability and chronicity of SLE can cause fear and anxiety. Fear may increase if the client knows another person with the disease, particularly if the other person has more advanced, severe disease. The myth that lupus is always fatal is still common.

The nurse assesses the client's feelings about the illness to identify areas requiring intervention. The nurse should assess the usual coping mechanisms and support systems before developing a plan of care. See Psychosocial Assessment (Rheumatoid Arthritis), p. 346, for additional information about the psychosocial assessment of clients with chronic illness.

LABORATORY ASSESSMENT

Because DLE is not a systemic condition, the only significant test is a skin biopsy. The physician gently scrapes skin cells from the rash for microscopic evaluation. The characteristic lupus cell and a number of inflammatory cells confirm the diagnosis.

Some of the immunologic-based laboratory tests used to diagnose SLE are the same as those performed for rheumatoid arthritis (RA): positive rheumatoid factor, antinuclear antibody, erythrocyte sedimentation rate, serum protein elec-trophoresis, serum complement (especially C₃ and C₄), and immunoglobulins (see Chart 21-9). The lupus cell preparation (LE cell prep) may also be performed, but this assay is a poor indicator of disease; it is best used for screening. A false-positive VDRL (syphilis) test is common with lupus. Newer and more specific immunologic tests, such as anti-Rho (SSA), anti-La (SSB), anti-RNP, anti-Smith (anti-Sm), Anti-DNA, and antiphospholipid antibodies (AP) are also performed. High titers of these antibodies are associated with lupus (Kuper & Failla, 2000).

In addition to immunologic testing, several tests are performed to evaluate the possible involvement of major organs and body systems. A complete blood count (CBC) commonly shows pancytopenia (a decrease of all cell types), probably caused by direct attack of the blood cells or bone marrow by immune complexes. Serum electrolyte levels, renal function,cardiac and liver enzymes, and clotting factors are also routinely assessed to determine other body system functioning. APs prolong the partial thromboplastin time, causing clots.

Interventions

The health care provider often prescribes potent drugs that are used topically and systemically. In addition, precautions are taken to prevent further skin impairment and exacerbations (flare-ups). Many of the skin lesions do not disappear, even with treatment, but they usually fade when the disease is in remission.

DRUG THERAPY. With discoid lupus erythematosus (DLE), the client's major concern is the rash or discoid lesions. Clients with systemic lupus erythematosus (SLE) may also be concerned about skin changes. Topical cortisone preparations help to reduce inflammation and promote fading of the skin lesions. In addition, the health care provider may prescribe the antimalarial hydroxychloro-quine (Plaquenil) for some clients to decrease the inflammatory response; other systemic medications are usually not used (see Chart 21-2).

The aim of management of SLE is to treat the disease aggressively until remission. In addition to medications for skin lesions, the health care provider often prescribes chronic steroid therapy to treat the systemic disease process. For renal or central nervous system lupus, the health care provider may also order immunosuppressive agents (e.g., azathioprine [Imuran]), which are sometimes used for clients with RA (see Chart 21-2). Although clinical manifestations improve during remission, maintenance doses of these drags are usually continued to prevent further exacerbations of the disease. The nurse observes for side effects and toxic effects of these medications and reports their occurrence to the physician.

For severe renal involvement, azathioprine or cyclophos-phamide (Cytoxan) may be given in combination with steroids. For clients who do not respond to this regimen, IV pulse (high dose) cyclophosphamide and plasmapheresis may be tried (see Experimental Therapies [Rheumatoid Arthritis], p. 350). Renal transplantation has been successful for some clients. Recent advances in allogenic stem cell transplantation have improved symptoms in clients who respond poorly to steroids or immunosuppressive drags (Kuper & Failla, 2000).

SKIN PROTECTION. Clients with lupus should avoid prolonged exposure to sunlight and other forms of ultraviolet lighting, including certain types of fluorescent light. The nurse instructs clients that they may need to wear long sleeves and a large-brimmed hat when outdoors. They should use sunblocking agents with an SPF (sun protection factor) of 30 or higher on exposed skin surfaces.

In addition, the nurse teaches the client to clean the skin with mild soap (e.g., Ivory) and to avoid harsh, perfumed substances. The skin is rinsed and dried well, and lotion is applied. Excess powder and other drying substances are avoided. Cosmetics are carefully selected and should include moisturizers and sun protectors. The nurse may refer the client to a medical cosmetologist who specializes in applying makeup for skin lesions of all types.

The hair should receive special attention because alopecia (hair loss) is common. The nurse recommends the use of mild protein shampoos and the avoidance of harsh treatments

CLIENT EDUCATION GUIDE

Evidence-Based Practice for Skin Protection in Clients with Lupus Erythematosus

• Cleanse your skin with a mild soap, such as Ivory.

• Dry your skin thoroughly by patting rather than rubbing.

• Apply lotion liberally to dry skin areas.

• Avoid powder and other drying agents, such as rubbing alcohol.

• Use cosmetics that contain moisturizers.

• Avoid direct sunlight and any other type of ultraviolet lighting, including tanning beds.

• Wear a large-brimmed hat, long sleeves, and long pants when in the sun.

• Use a sun-blocking agent with a sun protection factor (SPF) of at least 30.

• Inspect your skin daily for open areas and rashes.

Community-Based Care

Community-based care for the client with lupus is similar to that for rheumatoid arthritis. In general, the client is managed at home but may need repeated hospitalizations during exacerbations of disease. The client usually does not need rehabilitation or a long-term care facility, because severe joint deformity and prolonged immobility are not common.

Two major differences exist between SLE and rheumatoid arthritis in terms of education of the client and family or significant others. First, the nurse teaches the client with SLE how to protect the skin (Chart 21-12). Second, body temperature is monitored carefully with SLE. Fever is the major sign of an exacerbation, during which the client can become seriously ill. The nurse teaches the client to report any other unusual or new clinical manifestations to the health care provider immediately.

Many clients become frustrated that family members, significant others, and laypeople do not have a good understanding of lupus. When lupus is in complete remission, the client appears to be healthy. However, an exacerbation can necessitate rapid admission to a critical care unit. This unpredictability disrupts the client's life and can cause fear and anxiety. The nurse helps the client identify coping strategies and support systems that can help with functioning in the community.

The nurse teaches about possible effects of the disease on lifestyle, including fatigue. Women of childbearing age need to know that pregnancy can be a stressor and cause an exacerbation of the disease, either during pregnancy or after delivery. The pregnant client also has an increased risk of miscarriage, stillbirth, or premature birth. Pregnancy is not recommended for those with cardiac, renal, or central nervous system involvement. Sexual counseling regarding contraception options may be necessary.

Although The Arthritis Foundation is a general resource for all clients with connective tissue disease, the Lupus Foundation is a national organization and has chapters in every state to provide information and assistance for clients with lupus. Local support groups and services are offered free of charge.

PROGRESSIVE SYSTEMIC SCLEROSIS

OVERVIEW

Progressive systemic sclerosis (PSS), one of a family of diseases, is often referred to as systemic scleroderma. "Sclero-derma" means hardening of the skin, which is only one clinical manifestation of PSS. As the name implies, PSS is a systemic disease. It is less common than systemic lupus ery-thematosus (SLE) but is associated with a higher mortality rate.

Figure 21-10 • Late-stage skin changes seen in clients with progressive systemic sclerosis. (From the Arthritis Teaching Slide Collection, copyright 1980. Used by permission of the Arthritis Foundation.)

PSS is a chronic connective tissue disease characterized by inflammation, fibrosis, and sclerosis of the skin and vital organs. The inflammatory process is so similar to that of lupus that clients are often diagnosed as having probable SLE until the disease progresses. The inflamed tissue undergoes fibrotic and then sclerotic changes. The tissue most obviously affected is the skin, but renal involvement is the leading cause of death. Unfortunately, clients with PSS do not respond well to the steroids and immunosuppressants used for lupus, and therefore the mortality rate is higher.

The prognosis seems to be worse when the client presents with a group of manifestations that occur at the same time (the CREST syndrome):

• Calcinosis (calcium deposits)

•esophageal dysmotility

• Sclerodactyly (scleroderma of the digits)

• Telangiectasia (spiderlike hemangiomas)

The disease tends to progress rapidly, but spontaneous remissions and exacerbations can occur.

Little is known about the cause of PSS, but autoimmunity is suspected. The occurrence of more than one case per family is uncommon, but other connective tissue diseases may be noted in the family history.

PSS has been described in people of all races and in all geographic areas. Women are affected three to four times more often than men. The onset of the disease is usually between 30 and 50 years of age. The incidence is higher in coal miners, who have a high incidence of silicosis, a possible predisposing or contributing factor to PSS. Prolonged exposure to other toxins, such as vinyl chloride and epoxy resins, may also predispose an individual to PSS.

COLLABORATIVE MANAGEMENT

• Assessment

PHYSICAL ASSESSMENT/CLINICAL MANIFESTATIONS

Arthralgia (joint pain) and stiffness are common manifestations that the nurse can elicit during the musculoskeletal examination. The acute inflammation that occurs with rheumatoid arthritis (RA) is not common, and deformities are rare.

Findings on inspection of the skin depend on the stage of the scleroderma. Typically there is a painless, symmetric, pitting edema of the hands and fingers; this edema may progress to include the entire upper and lower extremities and face. In this edematous phase, the fingers are described as sausage-like. The skin is taut, shiny, and free of wrinkles. If diffuse scleroderma occurs, swelling is replaced by tightening, hardening, and thickening of skin tissue; this phase is sometimes called the indurative phase. The skin loses its elasticity, and range of motion is markedly decreased; ulcera-tions may occur. Joint contractures may develop, and the client may be unable to perform activities of daily living (ADLs) independently.

Major organ damage is likely to develop with diffuse scleroderma, and it specifically affects the following areas:

Gastrointestinal tract

• Cardiovascular system

• Pulmonary system

• Renal system

Involvement of the gastrointestinal tract, particularly the esophagus, is common. The esophagus loses its motility, resulting in dysphagia and esophageal reflux. A small, sliding hi-atal hernia may be present, and swallowing may be difficult. Reflux of the gastric contents can cause esophagitis and subsequent ulceration, particularly in the lower two thirds of the esophagus. Intestinal changes are similar to those of the esophagus. Peristalsis is diminished, which causes clinical manifestations similar to a partial bowel obstruction. Malabsorption is a common complication, causing malodorous diarrheal stoolsIn addition to assessing problems of the digestive tract, the nurse observes for cardiovascular manifestations. Raynaud's phenomenon occurs in various degrees in most clients with PSS. On exposure to cold or emotional stress, the small arteri-oles in the digits of both hands and feet rapidly constrict, which causes decreased blood flow. In severe cases, the client experiences digit necrosis, excruciating pain, and autoamputation of the distal digits (the tips of the digits fall off spontaneously). (See Chapter 36 for a complete discussion of this disorder.) In many clients the nurse notes vasculitic lesions, often around the nail beds (periungual lesions). Myocardial fibrosis, another common problem, is evidenced by electrocardiographic (ECG) changes, cardiac dysrhythmias, and chest pain.

Lung involvement in the client with PSS may go undetected until autopsy. Fibrosis of the alveoli and interstitial tissues is present in almost all cases of the disease, but clinical manifestations may not be present.

Renal involvement is an important aspect of the overall disease process and often causes malignant hypertension and death. The nurse assesses for signs of impending organ failure, such as changes in urinary output.

LABORATORY ASSESSMENT

The laboratory findings for PSS are similar to those for SLE. Clinical findings and the client's response to drug therapy help the health care provider differentiate between the two diseases. Additional tests depend on which organs seem to be affected. Upper and lower gastrointestinal series are commonly performed because of the frequency of gastrointestinal clinical manifestations.

BEST PRACTICE for

The Client with Progressive Systemic Sclerosis and Esophagitis

· Keep the client's head elevated at least 60 degrees during meals and for at least 1 hour after each meal.

· Provide small, frequent meals rather than three large meals each day.

· Give the client small amounts of food for each bite, and explain the importance of chewing each bite carefully before swallowing.

· Provide semisoft foods, such as mashed potatoes and pudding or custard; liquids are most likely to cause choking.

· Collaborate with the dietitian about the client's diet.

· Teach the client to avoid foods that increase gastric secretion, such as caffeine, pepper, and other spices.

· Give antacids if the health care provider prescribes them.

Community-Based Care

Community-based care for the client with PSS is similar to that for the client with lupus. The client is treated at home but may need frequent hospitalizations if major organ involvement occurs during exacerbations.

Interventions

The medical management of progressive systemic sclerosis (PSS) aims to force the disease into remission and thus slow disease progression. The health care provider uses drug therapy primarily for this purpose, but it is often unsuccessful. Systemic steroids and immunosuppressants are used in large doses and often in combination.

Local skin protective measures can help to maintain skin integrity. The nurse teaches the client to use mild soap and lotions and gentle cleaning techniques. The skin should be inspected daily for further changes or open lesions. Skin ulcers are treated according to their type and location.

In addition to drug therapy to control the overall disease process, specific measures can provide comfort. The client with PSS not only experiences chronic joint pain but also has severe, acute pain during episodes of Raynaud's phenomenon. A bed cradle and footboard keep bed covers away from the skin in severe cases. The nurse adjusts the room temperature to prevent chilling, which can precipitate digit vasospasm. The client who can tolerate touching of the affected areas can wear gloves and socks to increase warmth. Because cigarette smoking and extreme emotional stress can also cause symptoms to recur, the client should try to avoid or minimize these factors as much as possible. Chapter 36 describes the management of clients with Raynaud's phenomenon in more detail.

The client with esophageal involvement may need small, frequent meals rather than the traditional three meals daily. He or she should minimize the intake of foods and liquids that stimulate gastric secretion (e.g., spicy foods, caffeine, and alcohol). The nurse instructs the client to keep his or her head elevated for 1 to 2 hours after meals. The client may need to be in this position continuously. Histamine antagonists and antacids help to reduce and neutralize gastric acid. To help prevent choking, the nurse collaborates with the dietitian for dietary changes. Nursing care for the client with joint pain and decreased mobility is very similar to that for the client with rheumatoid arthritis.

GOUT

OVERVIEW

Gout, or gouty arthritis, is a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation.

The cause and treatment of gout have been firmly established. The classic case of well-advanced disease is seldom seen today unless the client does not comply with the therapeutic regimen. There are two major types of gout: primary and secondary.

Primary gout is the most common type and results from one of several inborn errors of purine metabolism. An end product of purine metabolism is uric acid, which is usually excreted by the kidneys. In primary gout, the production of uric acid exceeds the excretion capability of the kidneys; sodium urate is deposited in synovium and other tissues, resulting in inflammation. Primary gout is inherited as an X-linked trait; males are affected through female carriers. Approximately 25% of clients have a family history of gout. Primary gout affects middle-aged and older men (85% to 90% of clients with gout) and postmenopausal women. The peak time of onset is during a person's 30s and 40s.

Secondary gout involves hyperuricemia (excessive uric acid in the blood) caused by another disease. Secondary gout affects people of all ages. Renal insufficiency, diuretic therapy, and certain chemotherapeutic agents decrease the normal excretion of uric acid and other waste products. Disorders such as multiple myeloma and certain carcinomas result in in-creased production of uric acid because of a greater turnover of cellular nucleic acids. Treatment involves management of the underlying disorder.

There are four phases of the primary disease process: asymptomatic hyperuricemic, acute, intercritical (intercur-rent), and chronic. The client is usually unaware of the asymptomatic hyperuricemic phase unless he or she has had a serum uric acid level determination. The serum level is elevated, but no overt signs of the disease are present.

The first "attack" of gouty arthritis begins the acute phase. The client experiences excruciating pain and inflammation in one or more small joints, usually the metatarsophalangeal joint of the great toe. Of all clients with gout, 75% experience inflammation of this joint (podagra) as the initial manifestation. The erythrocyte sedimentation rate (ESR) and white blood cell count are increased as a result of the inflammatory process.

Months or perhaps years can pass before additional attacks occur; this is the intercritical, or intercurrent, phase of the disease. The client is asymptomatic, and no abnormalities are found during examination of the joints.

After repeated episodes of acute gout, deposits of urate crystals develop under the skin and within the major organs, particularly in the renal system. The client is then classified as having chronic tophaceous gout. In chronic gout, urate kidney stone formation is more common than renal insufficiency.

COLLABORATIVE MANAGEMENT

Assessment

The nurse collects historical data, including age, sex, and a family history of gout. Gout affects more men than women, particularly men who have relatives with gout. A complete medical history is needed to determine whether gout has been caused by another problem. There is a tendency to overuse diuretics, especially among women, which can lead to secondary gout.

ACUTE GOUT

Overt manifestations are present in the acute and chronic phases of gout. The nurse most often encounters a client with acute gout; chronic gout is not common in the United States today. Joint inflammation is the most common finding and is usually so painful that the client seeks medical care. The nurse uses inspection skills only; the inflamed area is usually too painful and swollen to be touched or moved.

CHRONIC GOUT

With chronic gout, the nurse inspects the skin for tophi, or deposits of sodium urate crystals (Figure 21-11). Although tophi may occur anywhere, they commonly appear on the outer ear. Other common sites for tophi are the arms and fingers near the joints. The tophi are hard on palpation and are irregular in shape. When the skin over the tophi is irritated, it may break open, and a yellow, gritty substance is discharged. Infection may result.

Other manifestations of chronic gout include signs of renal calculi (stones) or renal dysfunction. Stones develop in approximately 20% of clients with gout. In some cases, urate kidney stones occur before the arthritis is present.

The health care provider orders determinations of serum uric acid levels to validate hyperuricemia. Because the serum uric acid level can be altered by food intake, serial measurements are usually obtained. A consistent level of more than 8 mg/100 mL is generally considered abnormal. Urinary uric acid levels are also measured; an overproduction of uric acid is confirmed by an excretion of more than 600 mg/24 hr after a 5-day restriction of purine intake.

The health care provider may order renal function tests, such as blood urea nitrogen (BUN) and serum creatinine level, to monitor possible kidney involvement. A definitive diagnostic test for the disease is synovial fluid aspiration (arthrocentesis) to detect the needle-like crystals that are characteristic of the disorder.

• Interventions

Gout is one of the easiest diseases for the health care provider to diagnose and treat in its early phases. If the client receives treatment and complies with drug therapy, he or she should experience no further symptoms and no change in body image or lifestyle. The client with gout is usually treated on an outpatient basis.

Figure 21-11 • Typical appearance of tophi, which may occur in chronic gout, on an index finger.

DRUG THERAPY. Drug therapy is the primary component of management for clients with gout. In acute gouty "attacks," the inflammation subsides spontaneously within 3 to 5 days; however, most clients cannot tolerate the pain for that long. The drugs used for acute gout are different from those used chronic gout. The health care provider typically prescribes a combination of colchicine (Colsalide, Novocolchicine^) and a nonsteroidal anti-inflammatory drug such as indomethacin (Indocin, Novomethacin¹*') or ibuprofen (Motrin, Amersol¹*¹), for acute gout. IV colchicine works within 12 hours. The client takes oral medications until the inflammation subsides, usually for 4 to 7 days.

For clients with chronic gout, the health care provider prescribes drugs to promote uric acid excretion or to reduce its production on a continuous, maintenance basis. Allopurinol (Zyloprim) is the drag of choice. As a xanthine oxidase inhibitor, it prevents the conversion of xanthine to uric acid. Probenecid (Benemid, Benuryl<#>) is also effective as a urico-suric drug in gout because it promotes the excretion of excess uric acid. Combination drugs that contain probenecid and colchicine (e.g., ColBenemid) are also available. The health care provider and nurse monitor serum uric acid levels to determine the effectiveness of these medications. Aspirin should be avoided because it inactivates the effects of the drug.

DIET THERAPY. Whether or not to recommend special dietary restrictions for clients with gout is controversial. Some physicians advocate a strict low-purine diet and advise clients to avoid foods such as organ meats, shellfish, and oily fish with bones (e.g., sardines). Some health care providers and dietitians believe that limiting protein foods, especially red and organ meats, is sufficient. Still others do not believe that diet restrictions affect treatment. It is well known, however, that excessive alcohol intake and fad "starvation" diets can cause a gouty attack. The nurse helps clients determine which foods may precipitate such an attack.

In addition to food and beverage restrictions, clients with gout should avoid all forms of aspirin and diuretics because they may precipitate an attack. Likewise, excessive physical or emotional stress can exacerbate the disease. The nurse may need to teach stress management techniques.

Having the client drink more fluids is one of the best measures to prevent the formation of urinary stones. Such a measure helps to dilute urine and prevent sediment formation. Uric acid is more soluble in urine with a high pH and therefore is less likely to form urinary stones in that environment. The client's urinary pH can be increased with an intake of alkaline ash foods, such as citrus fruits and juices, milk, and certain dairy products. However, the value of adhering to a strict diet rich in these foods is questionable.

The client with a diagnosis of gout is seldom hospitalized unless renal complications develop. If the client follows the prescribed interventions, chronic tophaceous gout should not develop.

OTHER CONNECTIVE TISSUE DISEASES

The care of clients with connective tissue diseases (CTDs) is often similar regardless of the specific diagnosis. This section describes other fairly common diseases that are classified as CTDs.

Polymyositis/Dermatomyositis

Polymyositis is a diffuse, inflammatory disease of striated muscle that causes symmetric weakness and atrophy. When a rash accompanies polymyositis, the disease is called dermatomyositis. Both diseases vary in their mode of onset and progression and are characterized by spontaneous remissions and exacerbations. Women are affected twice as often as men, and men and women between 30 and 60 years of age are most susceptible to either disease.

In addition to proximal muscle and possible skin involvement, clients typically have polyarthritis, polyarthralgia (pain around multiple joints), and Raynaud's phenomenon (see Chapter 36). Clients with dermatomyositis have the characteristic heliotrope (lilac) rash and periorbital edema. Malignant neoplasms are more common in these clients than in the rest of the population; as many as 30% of clients older than 55 have internal malignancies. Many clients have difficulty swallowing or talking because of severe muscle weakness.

This condition is treated with high-dose steroids, immuno-suppressive agents, and supportive care, and particular attention is given to nutrition.

Systemic Necrotizing Vasculitis

Necrotizing vasculitis is a term for a group of diseases whose primary manifestation is arteritis (inflammation of arterial walls), which causes ischemia in the tissues usually supplied by the involved vessels. The drug of choice for most types of vasculitis is chronic steroid therapy.

Polyarteritis nodosa affects middle-aged men and involves every body system. Treatment is similar to that for systemic lupus, but the prognosis is not as promising. Renal disorders and cardiac involvement are the most common causes of death. Hypersensitivity vasculitis is the most common form of vasculitis and primarily causes skin lesions as an allergic response to drugs, infections, or tumors. Takayasu's arteritis, or the aortic arch syndrome, is also called the "pulseless" disease. Women in their 20s, particularly those of Japanese descent, are affected most often. Cerebral ischemia is manifested by visual changes, syncope, and vertigo.

Polymyalgia Rheumatica and Temporal Arteritis

Polymyalgia rheumatica (PMR) is a clinical syndrome characterized by stiffness, weakness, and aching of the proximal musculature (i.e., the shoulder and pelvic girdles).

CULTURAL CONSIDERATIONS

The incidence of PMR is greater among people in the northern regions of the United States and Europe. It is very uncommon in the African-American population.

Systemic manifestations such as low-grade fever, arthral-gias (pain around joints), and weight loss occur in the majority of cases. Most clients have an increased erythrocyte sedimentation rate (ESR) and a normochromic, normocytic anemia (see Chart 21-9). The disease commonly occurs in women over 50 years of age and typically responds to low-dose steroid therapy in 1 to 3 days (Mikanowicz & Leslie, 2000).

Giant cell, or temporal arteritis (ТА) occurs in as many as 20% of people with PMR. ТА is a systemic vasculitis that affects large and midsized arteries.

The cause of both PMR and ТА is unknown, but a genetic predisposition related to HLA-DRBI is likely. The disorder is easy to miss because most clients are older women who complain of declining vision (also an age-related change). ТА is treated with high doses of corticosteroids, often as high as 40 to 80 mg/day (Mikanowicz & Leslie, 2000).

ANKYLOSING SPONDYLITIS

Ankylosing spondylitis is also known as Marie-Striimpell disease and, more recently, as rheumatoid spondylitis.

As shown in Figure 21-12, the disease affects the vertebral column and causes spinal deformities. Although this disorder is present in both sexes at any age in adulthood, young Caucasian males under age 40 are most commonly affected. Other features include iritis (inflammation of the iris), arthritis or arthralgia, and nonspecific systemic manifestations such as malaise and weight loss.

Although the exact cause is unknown, ankylosing spondylitis is associated with the HLA-B27 antigen. Compromised respiratory function caused by a rigid chest wall is the major threat to health. Most clients function normally but live with chronic discomfort. Anti-inflammatory drugs and physical therapy are the key components of management.

Figure 21-12 • Spinal deformity and posture often seen in clients with advanced spondylitis. (From the Arthritis Teaching Slide Collection, copyright 1980. Used by permission of the Arthritis Foundation.)

Sjogren's Syndrome

With Sjogren's syndrome, inflammatory cells and immune complexes obstruct secretory ducts and glands. As a result, the client has dry eyes (sicca syndrome), a dry mouth (xerostomia), and a dry vagina. Severe cases involve swelling of the parotid and lacrimal areas and systemic manifestations (e.g., fever, fatigue). Of clients with the syndrome, 50% have an associated disease, such as rheumatoid arthritis (RA).

Local management includes meticulous care of the mouth, eyes, and perineal areas and the use of artificial tears and saliva. Systemic steroids may also be administered. Without treatment, the client can lose vision, and oral ulcerations, dental caries, and difficulty in swallowing or talking may ensue.

Reiter's Syndrome

As with ankylosing spondylitis, Reiter's syndrome is associated with the HLA-B27 antigen. This disease most often affects young Caucasian males. The complete syndrome is a triad of arthritis, conjunctivitis, and urethritis (inflammation of the urethra) resulting from exposure to sexually transmitted disease or dysentery (infectious diarrhea). Urethritis is often the first clinical manifestation.

Although the disease is characterized by this triad of manifestations, other conditions such as balanitis circinata (ring-like inflammation of the glans penis) and skin lesions are equally significant for confirmation of the diagnosis.

Management is symptomatic and may be complex if there is organ involvement. Nonsteroidal anti-inflammatory drugs and physical therapy are generally prescribed.