DIFFUSE CONNECTIVE TISSUE

DISEASES
CONNECTIVE TISSUE DISEASES
• A group of diseases that are chronic in nature and characterized by diffuse inflammation
and degeneration in the connective tissues. (you have connective tissue about
everywhere)
• These disorders share similar clinical features and may affect some of the same organs.
• The characteristic clinical course is one of exacerbations and remissions.
• Some CTD can become systemic and affect organs
• May be a result of an autoimmune abnormality
o The body is attacking itself; thus beginning the autoimmune action
Include: RA, Systemic Lupus Erythamatosus, Scleraderma, Polymyositis, Polymyalgia

RHEUMATOID ARTHRITIS
RHEUMATOID ARTHRITIS
• Chronic, systemic disease with periods of exacerbations and remission
• Progressively deteriorating connective tissue disease that is characterized by inflammation of the
synovial membrane of the Diarthrodial Joint (freely moveable)
• A systemic disease that can affect all connective tissue including nonarticular connective tissue.
• It attacks the collagen; which is the protein in the connective tissue that is found in the lungs,
heart, muscles, blood vessels, and tendon.
o May also cause lesions of vasculature, nervous system, and other major organs of the
body.
• Progressive in nature
• OA has interactions in the joint capsule that lead to inflammation and RA the inflammation
occurs first**

ETIOLOGY AND INCIDENCE

• Could be an autoimmune disorder
• Could be a metabolic factor that causes an abnormal function in the production of the collagen.
• Usually diagnosed at 35-45 (family and careers)
• May be a genetic predisposition

PATHOPHYSIOLOGY
• Synovium becomes inflamed
o Edema with vascular congestion increases production of synovial fluid
o Continued inflammation with thickening of the synovium and granulation tissue (pannus)
begins to form over cartilage which results in necrosis of the cartilage
o If areas of cartilage are lost this will result in formation of adhesions, ankylosis, and
weakening of tendons and ligaments
o Destruction leads to dislocation of joints and deformities
• Joint involvement is usually bilateral and symmetrical.
• Process often starts in fingers and toes, however all joints can become involved (hips, knees,
wrists, elbows, shoulders, jaws)
 o Cartilage – Absorbs the load (cushion) of weight bearing
o Nourished by the synovial fluid; if there is a problem with the synovial membrane it cannot
nourish the joint capsule.

CLINICAL MANIFESTATIONS
• Local
o Inflammation Heat
o Swelling Erythema - Redness
o Pain Decreased ROM
• Systemic
o Fever Weight loss
o Fatigue Generalized aching
o Edema
o Lymph node enlargement
 You have a problem
o Joint tissue becomes spongy
o Presents bilaterally and symmetrically
o Onset may be acute (OA slowly)
o Hands, hips, and feet are involved and can progress to shoulders, knees, elbows,
spine, and also temporal mandibular joint
o Joint stiffness in the a.m. lasting longer than 30 minutes (OA Feel stiff at first but can
work the pain out)
• Complications – Structural Deformities
o Z-thumb deformity
 Overflex or hyperextention of the thumb
o Ulnar deviations
 Fingers deviate toward the ulnar side of hand (pinky)
 Metacarpal phalengeal joints are swollen – Spongy moveable nodules (OA are hard)
o Genu Valgun
 Knock knees
 May tend to sublux (dislocate)
o Hallux melleus
 Hammertoes with lower arch
 Some cannot walk – wide toed shoes
These people are on prednisone and things that mask infection and lot of times they can get infection from attempting surgery.
o Swan-neck deformity
 Hyperextension of the PIP joint and flexion of the distal joint
o Boutonniere’s deformity
 Hyperflexion of the PIP joint and extension of the distal joint

DIAGNOSTIC EVALUATION
• Full History and Physical
• Increase in Sed rate – ESR
o Only looking for inflammation
• C-Reactive Protein – Shows abnormal glycoprotein due to inflammatory process and active
inflammation. Coming in periodically to see if this is beginning to rise the MD may increase
medication to combat the inflammation
• ANA – Anti nuclear antibodies – Measuring antibodies that react to nuclear antigens
• Rheumatoid Factor Test (RF) or Latex Fixation
o Specifically for RA; Positive indicates RA; keep in mind you may get a false positive so
assess all the other manifestations
 • Decreased in RBC’s - RA can cause anemia
• C3 and C4 Complement Components
• Athrocentesis
o Fluid should be clear, viscous, straw colored, that would be normal
o RA the fluid would be cloudy, milky, or dark yellow
• X-Ray - Will show narrowing of joint space; could help diagnose what stage of disease
• Physical assessment
MEDICAL MANAGEMENT
Relief of Inflammation with Medications
• If you decrease inflammation you will decrease pain; then you would have possible
functioning of the joint for that individual.
• Every thing you do revolves around joint protection
• There are 3 stages of RA: Early, Moderate, Persistent or Erosive RA
o Now they begin with large doses of medications while they still have the
opportunity to combat the autoimmune process and prevent deformities

DRUG THERAPY
• DMARD’s – Disease Modifying Anti Rheumatic Drug
o Plaquenil – Anti-malarial
-Have a lot of side effects;Have pretty bad side
 Reduces the inflammation effects, so need to be monitored
o Gold Salts -Can be toxic and need to be followed
 Myochrysine, Solganal, Radura -Will not be prescribed if appointments are
kept up with.
 Decrease breakdown -DMARD’s given with an NSAID or
o Penicillamine – Cuprimine, Depen Corticosteriods
 Inhibits T-Cell function
 Decreases inflammation
• NSAID’s – Non Steroidal Anti Inflammatory Drug
• Corticosteroids
o Prednisone
o Reduce inflammation and slow joint damage; given short term
o Carry side effects: Weight gain, retaining fluid, cushings, Increase BP, Increase
blood glucose, causes sodium retention, can lead to Osteoporosis by
reducing bone mass, Masks S/S of infection, slows down healing.
• Immunosuppressive
o Because it is an autoimmune process; they tame the immune system
o Methotrexate, Imuran, Sandimmune, Neoral, Cytoxan, Arava
• Antidepressant - Depressed, change in alteration of lifestyle

Relief of Pain
• Pain, decreased ROM, Fatigue, and sleep disturbances are the most common problems
associated with RA.
• Traditional Methods of Pain Management
o Medications
o Splinting
 To decrease inflammation. Support optimal position of function
o Exercise, keep mobile
o Positioning
 o Heat / Ice
o Emotional Support
o Rest body – “systemic disease”
Fatigue
o Make sure they rest
o Don’t over do it
Sleep Disturbance
o Medication – sleep aids
Maintenance of Optimal Function
o Good posture
o Exercise
o Splinting
 Some will have splints made specifically for them.
 To rest and support the joint in its most optimal position
o Joint protection
o Energy conservation
o Assistive devices
 Cane
o Surgeries

Education of Patient
o Sitting in firm chair with arm rest and help with getting up
o Good posture
o Isometric / Isotonic exercise
o Therapy for daily routine
o Balance activity with rest
o Plan ahead, Set priorities, Pace activity, Learn activity
o Assistive devices
 Increase independence
 Simplify task
 Utilize available function in pain free and atraumatic manner
o Shoe low heel with wide toe (may have shoes fitted)
o Develop realistic acceptance of disease
o Help client strive for independence

NURSING DIAGNOSIS
• Altered Comfort: pain R2 inflamed joints
• Impaired Physical Mobility R2 pain and deformity
• Self care Deficit R2 fatigue, pain or deformity
• Body image disturbance R2 deformities
• Powerlessness R2 loss of independence and change in life-style
• Knowledge deficit