16 Chapter 43Connective Tissue Disorders _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
50-Minute Lesson Plan
Lecture Outline 20 minutes
5
Slide 22
Therapeutic Measures (cont.)
• Drug therapy
• Glucocorticoids
• Nonsteroidal antiinflammatory drugs (NSAIDs)
• Biologic response modifiers (BRMs)
6
Slide 23
Osteoarthritis
• Pathophysiology
• Degeneration of articular cartilage with hypertrophy of the underlying and adjacent
bone
• Normally, articular cartilage provides a smooth surface for one bone to glide over
another
TALKING POINTS:
• Osteoarthritis may be classified as primary or secondary, depending on the cause.
• Osteoarthritis that occurs with aging is generally considered to be primary and may have
a genetic basis.
• Secondary osteoarthritis may be associated with trauma, infection, congenital deformities,
or corticosteroid therapy.
• What type of joints does osteoarthritis generally affect?
Slide 24
Osteoarthritis (cont.)
• Signs and symptoms
• Pain in affected joint, stiffness, limitation of movement, mild tenderness, swelling, and
deformity or enlargement of the joint
• Medical diagnosis
• Health history and radiographic studies
• Arthroscopy and MRI
• Synovial fluid aspiration
TALKING POINTS:
• Many people with osteoarthritis have no symptoms, but others have pain that ranges from
mild to severe.
• What is the pain of osteoarthritis usually associated with?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
Slide 25
Osteoarthritis (cont.)
• Medical treatment
• Drug therapy
• Acetaminophen, NSAIDs, DMARDs, COX-2 inhibitors, or low-dose salicylates
(aspirin)
• Surgery
TALKING POINTS:
• What are the goals of patient therapy?
• Moist heat and occasionally cold can be used to help relieve pain.
• Transcutaneous electrical nerve stimulation (TENS) devices are especially effective for
treating back pain.
8
Slide 26
Osteoarthritis (cont.)
• Assessment
• Joint pain or tenderness
• Examine joints for crepitus, enlargement, deformity, and decreased range of motion
• Compare affected and unaffected joints to detect abnormalities
• Determine how the disease affects the patient’s mobility and ability to perform
activities of daily living
Osteoarthritis (cont.)
• Interventions
Slide 28
Osteoarthritis (cont.)
• Care following total joint replacement
• Assessment
• Vital signs, level of consciousness, intake and output, respiratory and
Slide 29
Osteoarthritis (cont.)
• Interventions
• Acute pain
• Risk for injury
• Impaired physical mobility
• Impaired tissue perfusion
18 Chapter 43Connective Tissue Disorders _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
6
Slide 30
Rheumatoid Arthritis (RA)
• Pathophysiology
• Chronic, progressive inflammatory disease
• Inflammation of the synovial tissue
• Synovium thickens; fluid accumulates in joint space
TALKING POINTS:
• In what population is rheumatoid arthritis (RA) commonly seen?
Slide 31
Rheumatoid Arthritis (cont.)
• Signs and symptoms
• Pain in affected joints aggravated by movement
• Morning stiffness lasting more than 1 hour
• Weakness, easy fatigability, anorexia, weight loss, muscle aches and tenderness, and
warmth and swelling of the affected joints
• Joint changes are usually symmetric
TALKING POINTS:
• What is vasculitis?
• Sjögren syndrome is characterized by dryness of the mouth, eyes, and vagina.
• Felty syndrome, characterized by liver and spleen enlargement and neutropenia, is less
common.
• Caplan syndrome, which is marked by rheumatoid nodules in the lungs, occurs most often
in coal miners and asbestos workers.
Slide 32
Rheumatoid Arthritis (cont.)
• Medical diagnosis
• Health history and physical examination
• Laboratory studies
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
Slide 33
deformities.
Rheumatoid Arthritis (cont.)
• Medical treatment
• Drug therapy
• Combinations of NSAIDs, glucocorticoids, and DMARDs
TALKING POINTS:
• What is the goal of drug therapy?
• In addition to drug therapy, supportive treatments may be used—including rest, splinting
8
Slide 34
Rheumatoid Arthritis (cont.)
• Assessment
• Pain, joint swelling, tenderness, joint deformities and limitation of movement, fatigue,
and decreased ability to perform activities of daily living
• Interventions
• Chronic pain
• Activity intolerance
• Ineffective coping
• Social isolation
• Ineffective self-health management
6
Slide 35
Osteoporosis
• Pathophysiology
• Bone constantly formed and absorbed
• Until adolescence, bone formation exceeds bone absorption so that bones grow and
TALKING POINTS:
• What sites are commonly fractured as a result of osteoporosis?
• Age-related loss of bone mass without apparent underlying medical causes is called
primary osteoporosis.
• Secondary osteoporosis is the loss of bone mass due to factors other than age, such as
hyperparathyroidism or long-term therapy with corticosteroids or heparin.
20 Chapter 43Connective Tissue Disorders _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
Slide 36
Osteoporosis (cont.)
• Risk factors
• Older women who have small frames, who are white or of northern European
heritage, and who have fair skin and blond or red hair
• Estrogen deficiency; physical inactivity; low body weight; inadequate calcium, protein,
or vitamin D intake; corticosteroid therapy over more than 6 months; and excessive
use of cigarettes, caffeine, and alcohol
Osteoporosis (cont.)
Slide 38
Osteoporosis (cont.)
• Medical diagnosis
• Absorptiometry
• Radiographs
• Bone specimen
• Medical treatment
• Calcium supplementation and estrogen replacement
• Bisphosphonates and selective estrogen receptor modulators (SERMs)
• Regular exercise
• Percutaneous vertebroplasty
TALKING POINTS:
• Absorptiometry is a quick, painless radiologic procedure that measures the amount of
bone tissue in the hip and spine.
• When will radiographs show decreased bone density?
8
Osteoporosis (cont.)
• Assessment
• Diet, calcium intake, and exercise plan
TALKING POINTS:
• What advice can the nurse provide to promote patient safety?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
6
Slide 40
Gout
• Pathophysiology
• Characterized by hyperuricemia
• Related to excessive uric acid production or decreased uric acid excretion by the
kidneys
• Three stages
• Asymptomatic hyperuricemia
• Acute gouty arthritis
• Chronic tophaceous gout
TALKING POINTS:
• There are two forms of gout: primary gout, in which uric acid is elevated because of a
Slide 41
Gout (cont.)
• Signs and symptoms
• Asymptomatic hyperuricemia
• Blood uric acid level is elevated, but no other symptoms
• Many people with asymptomatic hyperuricemia never progress to the next stage
Slide 42
Gout (cont.)
• Signs and symptoms
• Acute gouty arthritis
• Onset is abrupt, usually occurs at night
• The patient is suddenly afflicted with severe, crushing pain and cannot bear even
Slide 43
Gout (cont.)
• Signs and symptoms
• Asymptomatic intercritical period
• No symptoms
• Chronic tophaceous gout
Slide 44
Gout (cont.)
• Medical diagnosis
• History and physical examination
• Urate crystals in synovial fluid
22 Chapter 43Connective Tissue Disorders _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
Slide 45
Gout (cont.)
• Medical treatment
• Asymptomatic hyperuricemia requires no medical treatment
• NSAID alone or with colchicine for acute gouty arthritis
• For subsequent attacks: indomethacin, corticosteroids, and corticotrophin
• Avoid foods high in purines; limit animal-derived foods, alcohol, and fructose
TALKING POINTS:
• If the patient does not respond to colchicine or NSAIDs, parenteral glucocorticoids or
adrenocorticotropin may be prescribed.
• What drugs are used to inhibit uric acid synthesis?
8
Slide 46
Gout (cont.)
• Assessment
• Pain, joint swelling, tophi, uric acid stones, fever, and a history of trauma, injury, or
surgery
• Interventions
• Acute pain
• Impaired physical mobility
6
Slide 47
Progressive Systemic Sclerosis (PSS)
• Pathophysiology
• Primary vessel injury/dysfunction of immune system
• Manifestations: from inflammation to degeneration of tissues, that results in
decreased elasticity, stenosis, and occlusion of vessels
• Signs and symptoms
TALKING POINTS:
• Progressive systemic sclerosis (PSS) is commonly called scleroderma.
• What organs are commonly affected by PSS?
Slide 48
Progressive Systemic Sclerosis (cont.)
• Medical diagnosis
• History and physical examination may lead the provider to suspect fibrotic changes
typical of PSS in the skin, lungs, heart, or esophagus
• Positive ANA assay result, elevated ESR, and increased serum muscle enzyme levels
_______________________________________________________ Chapter 43Connective Tissue Disorders 23
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
Slide 49
Progressive Systemic Sclerosis (cont.)
• Medical treatment
• No cure
• High doses of steroids or other immunosuppressants may bring about remission
• Physical therapy
• d-Penicillamine; antihypertensives
• Management of Raynaud phenomenon
TALKING POINTS:
• Esophageal reflux may be treated with drugs to decrease the acidity of gastric secretions
• Antihypertensives are used to control hypertensive crisis.
8
Slide 50
Progressive Systemic Sclerosis (cont.)
• Assessment
• Pain and stiffness in the fingers; intolerance for cold
• Signs and symptoms suggestive of cardiovascular, respiratory, renal, and
• Palpate the fingers to determine warmth
Slide 51
Progressive Systemic Sclerosis (cont.)
• Interventions
• Impaired skin integrity
• Self-care deficit
• Chronic pain
6
Slide 52
Dermatomyositis/Polymyositis
• Pathophysiology
• Polymyositis: infiltration of inflammatory cells, causing destruction of muscle fibers
• Inflammation of tissues surrounding blood vessels is an outstanding pathologic
feature of the disease
• Condition is sometimes associated with malignancy
• Signs and symptoms
• Polymyositis: muscle weakness, Raynaud phenomenon, and joint pain and
inflammation
• Dermatomyositis: periorbital edema as well
TALKING POINTS:
• Dermatomyositis and polymyositis are relatively rare acute or chronic inflammatory
diseases that primarily affect the skeletal muscle.
24 Chapter 43Connective Tissue Disorders _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
Slide 53
Dermatomyositis/Polymyositis (cont.)
• Medical diagnosis
• Proximal muscle weakness, a muscle biopsy positive for muscle degeneration,
elevated muscle enzymes, and myopathic electromyographic changes
• Medical treatment
• Drug therapy
• High-dose glucocorticoids, such as prednisone, and chemotherapeutic agents,
such as methotrexate
• Supportive treatment: balancing rest and exercise to prevent contractures
Slide 54
Other Connective Tissue Disorders
• Bursitis
• Carpal tunnel syndrome
• Ankylosing spondylitis
Activities
Classroom Choose from below to make 30 minutes
Online
5
DISCUSS
• Discuss the side effects and
contraindications for treatment with each of
the drugs listed in your text.
PRACTICE
• Divide the class into small groups. Using a
drug reference and the information listed on
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Discuss
important elements to include in patient
_______________________________________________________ Chapter 43Connective Tissue Disorders 25
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
6
DISCUSS
• Discuss the pathophysiology and risk factors
for osteoporosis and the preventive
measures that may be taken to minimize risk
PRACTICE
• In a class discussion, call out the following
disorders and have the class discuss and
identify the pathophysiology. Provide
feedback and guidance to the students as
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Ask students
to conduct an image search for selected
8
DISCUSS
• Discuss the appropriate nursing care of
patients with connective tissue disorders.
PRACTICE
• Divide the class into small groups and
present the following scenario to the class:
• A 68-year-old female with rheumatoid
arthritis underwent a total hip
replacement 24 hours ago. She has
limited neck mobility and severe joint
deformities from her RA. She is
complaining of neck pain and groans
POST AND COMMENT
• Post the following discussion topic online
and have students comment. From the
viewpoint of a patient with severe
rheumatoid arthritis, what do you, as a
patient, wish you could say to the nurse who
is providing care for you? Ask students to
provide constructive comments on each
other’s postings.
26 Chapter 43Connective Tissue Disorders _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 43.2
Critical Thinking Question
A 60-year-old patient has had increasing pain and decreased mobility in her right knee and
has decided to have a total knee replacement. How would you describe the nursing care
following a total joint replacement?
Discussion Guidelines: In the immediate postoperative period, the nurse should frequently
assess the patient’s vital signs, level of consciousness, urinary function, bowel elimination, wound
condition, and level of comfort. After total joint replacement, the nurse should monitor circulation
Instructor Notes/Student Feedback
_______________________________________________________ Chapter 43Connective Tissue Disorders 27
Introduction to Medical-Surgical Nursing, 6th ed.
43
Assessments for
Connective Tissue Disorders
CHAPTER OBJECTIVES
Lesson 43.1:
2. Describe the function of connective tissue.
4. Describe the diagnostic tests and procedures used for assessing connective tissue diseases.
7. Describe the characteristics and prevalence of connective tissue diseases.
Lesson 43.2:
5. Discuss the drugs used to treat connective tissue diseases.
6. Describe the pathologic basis for osteoarthritis (degenerative joint disease), rheumatoid arthritis,
8. Assist in developing a nursing care plan for a patient whose life has been affected by a connective
tissue disease.
Assessments by Lesson & Objective
Lesson 43.1
1
Study Guide
• Part IA: 2 (p. 277)
• Part IG: A-H (p. 280)
Evolve Instructor Resources
Evolve Student Resources
• NCLEX Review: 5
2
Study Guide
• Part IIH: 1, 2, 13
Evolve Instructor Resources
• Test Bank: 10
Evolve Student Resources
• NCLEX Review: 6
Study Guide
Evolve Instructor Resources
• Test Bank: 11
Evolve Student Resources
• NCLEX Review: 7, 8
28 Chapter 43Connective Tissue Disorders _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
4
Study Guide
• Part IB: 1-7 (p. 278)
• Part IC: 1-7 (p. 278)
Evolve Instructor Resources
• Test Bank: 22
• Open Book Quiz: 1
7
Evolve Instructor Resources
• Test Bank: 9, 28
5
Study Guide
• Part ID: 1-15 (pp. 278-279)
• Part IIH: 5, 7, 12, 17, 18 (pp. 281-282)
• Part III I: 3, 4 (p. 283)
Evolve Student Resources
• Prioritization: 1
6
Study Guide
• Part IA: 3-7, 9, 10 (p. 277)
• Part IE: 1-14 (p. 279)
• Part IF: 1-16 (p. 280)
• Part IIH: 4, 6, 10, 19 (pp. 281-282)
• Part III I: 1, 8, 9, 14-16 (pp. 283-284)
• Part IIIJ: 2, 3 (p. 284)
Evolve Instructor Resources
• Test Bank: 1, 12, 20, 26, 29-31, 33
• Open Book Quiz: 3-7, 10
Evolve Student Resources
• NCLEX Review: 1-3, 9, 10
8
Study Guide
• Part IIH: 8-11, 14–16 (p. 281)
Evolve Instructor Resources
• Test Bank: 3, 4, 6, 7, 15-19, 21, 24, 25, 34
• Open Book Quiz: 9
_______________________________________________________ Chapter 43Connective Tissue Disorders 29
Introduction to Medical-Surgical Nursing, 6th ed.
Assessments by Lesson & Objective
Instructor’s Notes/Student Feedback