9.3 Immune, Rheumatologic, and Connective Tissue Disorders
Key Takeaways
- Rheumatoid arthritis produces symmetrical small-joint involvement with morning stiffness lasting more than an hour, whereas osteoarthritis produces asymmetrical large weight-bearing joint pain with stiffness that eases within about 30 minutes.
- Apply heat before activity to loosen stiff rheumatoid joints and cold after activity or during an acute flare to reduce inflammation.
- Systemic lupus erythematosus requires strict photoprotection because ultraviolet exposure triggers both cutaneous and systemic flares; lupus nephritis is the leading determinant of long-term outcome, so proteinuria and creatinine are monitored closely.
- Long-term corticosteroid therapy must never be stopped abruptly because adrenal suppression can precipitate an adrenal crisis; taper according to prescription and increase the dose during physiological stress as directed.
- Patients on biological or other disease-modifying antirheumatic drugs must be screened for latent tuberculosis and hepatitis before starting and must not receive live vaccines during therapy.
9.3 Immune, Rheumatologic, and Connective Tissue Disorders
These conditions share a therapeutic theme that dominates the exam questions: the drugs used to suppress an overactive immune system also suppress the defence against infection, and the nursing plan is built around managing that trade-off safely.
Hypersensitivity Reactions
| Type | Mechanism | Timing | Clinical example |
|---|---|---|---|
| I — Immediate (IgE) | Mast cell degranulation | Minutes | Anaphylaxis, allergic asthma, urticaria |
| II — Cytotoxic (IgG/IgM) | Antibody against cell surface antigen | Hours | Acute haemolytic transfusion reaction, Goodpasture syndrome |
| III — Immune complex | Complex deposition in tissue | Hours to days | Systemic lupus erythematosus, serum sickness, post-streptococcal glomerulonephritis |
| IV — Delayed cell-mediated | T lymphocytes | 48–72 hours | Contact dermatitis, tuberculin skin test, transplant rejection |
Anaphylaxis is managed with intramuscular adrenaline (epinephrine) 1:1000 into the anterolateral thigh as the immediate action — covered in detail in the shock section. What belongs here is the follow-up: every patient must be observed for biphasic reaction, which can recur 4 to 12 hours after apparent recovery; must be prescribed and taught to use an adrenaline auto-injector, including a return demonstration; must receive a documented allergy alert on the record and an alert bracelet; and must be referred for allergy evaluation to identify the trigger. Teach the patient to carry two auto-injectors, to use it into the outer thigh through clothing if necessary, and to call emergency services immediately after use even if they feel better.
Rheumatoid Arthritis vs. Osteoarthritis
| Feature | Rheumatoid arthritis | Osteoarthritis |
|---|---|---|
| Nature | Systemic autoimmune inflammation | Mechanical cartilage degeneration |
| Joint pattern | Symmetrical, small joints first (MCP, PIP, wrists) | Asymmetrical, large weight-bearing joints, DIP |
| Morning stiffness | > 1 hour, improves with movement | < 30 minutes, worsens with use |
| Systemic features | Fatigue, low-grade fever, weight loss, anaemia | None |
| Deformity | Ulnar deviation, swan-neck, boutonnière, rheumatoid nodules | Heberden and Bouchard nodes |
| Laboratory | Raised ESR and CRP, rheumatoid factor, anti-CCP | Usually normal inflammatory markers |
Nursing management of rheumatoid arthritis centres on preserving function. Balance rest with activity; use heat before activity to reduce stiffness and cold after activity or during a flare to reduce inflammation; teach joint-protection principles (use the largest and strongest joint for a task, slide rather than lift, use built-up handles and assistive devices, avoid sustained grip); maintain range-of-motion exercise even during flares to prevent contracture; and involve occupational therapy early. Morning stiffness is best managed by a warm shower before attempting fine tasks.
Systemic Lupus Erythematosus
A multisystem immune-complex disease that most commonly affects women of childbearing age. Features include the photosensitive malar (butterfly) rash sparing the nasolabial folds, discoid lesions, oral ulcers that are typically painless, non-erosive arthritis, serositis, haematological cytopenias, neuropsychiatric involvement, and lupus nephritis, which is the principal determinant of long-term prognosis.
Nursing priorities:
- Photoprotection is non-negotiable: ultraviolet exposure triggers both skin and systemic flares. Teach broad-spectrum high-SPF sunscreen, protective clothing, wide-brimmed hats, and avoidance of peak midday sun — a message with particular weight in Qatar's climate, where ambient UV is high year-round.
- Monitor renal involvement: urinalysis for proteinuria and haematuria, serum creatinine, blood pressure, and weight. Report new oedema or a rising blood pressure.
- Infection vigilance: both the disease and its treatment are immunosuppressive, and infection is a leading cause of death.
- Fatigue and pacing, energy conservation, and psychological support for an unpredictable relapsing illness.
- Pregnancy planning should be discussed with the rheumatology team, because several drugs are teratogenic and disease activity influences outcomes.
Hydroxychloroquine, a mainstay, requires baseline and annual ophthalmological examination because of the risk of retinal toxicity.
Gout
An inflammatory arthritis caused by monosodium urate crystal deposition, classically presenting as an exquisitely painful, red, swollen first metatarsophalangeal joint, often at night.
Distinguish clearly between the two treatment phases, which examiners like to blur:
- Acute attack: non-steroidal anti-inflammatory drugs, colchicine, or corticosteroids. Rest and elevate the joint, use a bed cradle to keep bedding off it, and apply cold.
- Long-term prevention: allopurinol or febuxostat. Do not start a urate-lowering agent during an acute attack unless the patient is already established on it, because shifting urate levels can prolong the flare. Allopurinol requires generous fluid intake to prevent urate stone formation.
Dietary teaching: limit organ meats, red meat, anchovies, sardines, shellfish, and yeast extracts; avoid alcohol, particularly beer; limit fructose-sweetened drinks; and maintain a high fluid intake of 2 to 3 litres daily unless contraindicated.
Immunosuppressive and Anti-inflammatory Therapy
| Drug class | Example | Principal nursing concern |
|---|---|---|
| Corticosteroids | Prednisolone | Never stop abruptly; infection masking; hyperglycaemia; osteoporosis; take with food in the morning |
| Conventional DMARDs | Methotrexate | Weekly, not daily; folic acid supplementation; hepatotoxicity and myelosuppression; teratogenic |
| Antimalarial | Hydroxychloroquine | Annual retinal screening |
| Biologics (TNF inhibitors) | Etanercept, infliximab | Screen for latent TB and hepatitis before starting; no live vaccines; report any infection |
| Calcineurin inhibitors | Ciclosporin, tacrolimus | Nephrotoxicity; trough level monitoring; avoid grapefruit juice |
Two safety points carry disproportionate exam weight. Methotrexate is dosed weekly, and daily administration is a recognised fatal medication error; verify the prescribed frequency against the patient's understanding at every encounter. And corticosteroids must be tapered, never stopped abruptly, because suppression of the hypothalamic-pituitary-adrenal axis leaves the patient unable to mount a cortisol response; abrupt cessation or an untreated physiological stressor can precipitate an adrenal crisis. Patients on long-term steroids should carry a steroid alert card and understand that illness, injury, or surgery may require a temporary dose increase as prescribed.
A nurse is reviewing the medication list of a patient newly diagnosed with rheumatoid arthritis. The discharge prescription reads: methotrexate 15 mg orally once weekly, folic acid 5 mg orally once weekly on a different day, and prednisolone 7.5 mg daily. The patient says, "I take the methotrexate every morning with my prednisolone." What is the nurse's priority action?
A 27-year-old woman with systemic lupus erythematosus is being discharged from a Doha hospital after a flare. Which instruction is most important for the nurse to emphasise?
A patient with an acutely painful, red, swollen first metatarsophalangeal joint is diagnosed with a first attack of gout. Which prescription should the nurse question?