Sjogren's syndrome—implications for perioperative practice - Home Study Program

AORN Journal,  March, 2003  by Lynn M. Petruzzi,  Frederick B. Vivino

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Table 1

EXTRAGLANDULAR MANIFESTATIONS OF SJOGREN'S SYNDROME

System              Common manifestations       Uncommon manifestations

Otorhino-           * Nasal dryness             * Hearing loss
laryngological      * Epistaxis
                    * Sinusitis

Gastrointestinal    * Esophageal dysmotility    * Esophageal webs
                    * Atrophic gastritis/       * Pancreatitis
                      reflux                    * Primary biliary
                                                  cirrhosis
                                                * Autoimmune hepatitis

Gynecological       * Vaginal dryness           * Vulvodynia
                    * Dyspareunia
                    * Vaginal candidiasis

Pulmonary           * Xerotrachea               * Interstitial
                    * Recurrent bronchitis        pneumonitis
                    * Recurrent pneumonia       * Pulmonary fibrosis

Neurological        * Carpal tunnel syndrome    * Central nervous
                    * Peripheral neuropathy       system involvement
                    * Cranial neuropathy
                      (eg, trigeminal
                      neuralgia)

Renal               * Interstitial nephritis    * Interstitial cystitis
                    * Renal tubular acidosis    * Glomerulonephritis
                                                  with cryoglobulinemia

Rheumatic           * Arthralgia                * Polyarthritis
                    * Myalgia
                    * Raynaud's phenomenon

Dermatological      * Xeroderma                 * Vasculitis
                    * Urticaria
                    * Purpura
                    * Dry hair/hair loss
                    * Brittle nails

Hematological       * Anemia                    * Pseudolymphoma
                    * Leukopenia                * Lymphoma (usually
                    * Lymphopenia                 B cell non-Hodgkin's)
                    * Cryoglobulinemia

Table 2

DIFFERENTIAL DIAGNOSES
OF SICCA SYNDROME

Aging                         Mouth breathing
Amyloidosis                   Multiple sclerosis
Anxiety                       Radiation injury
Chronic sialadenitis          Sarcoidosis
Diabetes mellitus             Salivary diffuse infiltrative
Eosinophilia-myalgia          lymphocytosis syndrome
syndrome                      (ie, HIV-related)
Graft-versus-host disease     Sclerosing sialadenitis
Hepatitis C infection         Silicone breast implant
Medication-related dryness    syndrome
                              Type 5 hyperlipidemia

Table 3

DIAGNOSTIC APPROACH TO SJOGREN'S SYNDROME (SS)

Criteria          Objective evidence               Significance

Xerophthalmia     * Schirmer's test finding        * Demonstrates tear
                    < 10 mm per 5 minutes            production
                  * Fluorescein tear breakup       * Demonstrates tear
                    time < 10 seconds                quality
                  * Abnormal finding on rose       * Demonstrates
                    bengal or fluorescein            corneal integrity
                    corneal staining
Xerostomia        * Abnormal salivary gland        * Demonstrates
                    scan                             gland function
                  * Decreased sublingual pool      * Demonstrates
                                                     salivary flow
                  * Unstimulated salivary flow     * Demonstrates
                    rate < 0.3 mL per minute         salivary flow
Serological       * Known connective tissue        * Associated with
autoimmunity        disease                          secondary SS
                  * Elevated antinuclear           * Present in 70% to
                    antibody                         80% of patients
                  * Positive anti-SS antigen A     * Specific for SS,
                    and anti-SS antigen B            present in 40% to
                                                     60% and 20% to
                                                     40%, respectively
Salivary gland    * Focal lymphocytic              * Typical histologi-
biopsy *            saliadenitis (focus score        cal finding in a
                    > 1/4 [mm.sup.2])                biopsy from a
                                                     patient with SS

* Should be performed when laboratory findings are negative.

Table 4

NURSING CARE PLAN FOR A PATIENT WITH SJOGREN'S SYNDROME (SS) UNDERGOING
SURGERY

Nursing
diagnosis           Interventions

Risk for injury     * Ensures that all perioperative team members are
related to            aware that the patient has SS and its affect on a
surgical              patient undergoing surgery.
procedure           * Implements protective measures to prevent ocular
and SS                tissue and mucous membrane injury.
                      * Ensures that preoperative and intraoperative
                        medications with anticholinergic effects, such
                        as atropine, diphenhydramine, glycopyrrolate,
                        and promethazine, are avoided.
                      * Ensures that patients on long-term steroid
                        medications receive stress doses before,
                        during, and after surgery as needed.
                    * Ensures that the anesthesia care provider has the
                      necessary equipment and supplies to prevent
                      ocular tissue and mucous membrane injury (eg,
                      humidifier for rebreathing system, endotracheal
                      tube lubrication, dental guard, ocular lubrica-
                      tion).
                    * Evaluates for signs and symptoms of physical
                      injury to ocular tissues and mucous membranes.

Risk for injury     * Confirms patient identity and verifies surgical
related to            procedure.
other associated    * Implements protective measures to prevent skin
diseases              and tissue injury due to electrical, thermal, and
                      physical sources.
                    * Turns temperature up in room to offset potential
                      problems with Raynaud's phenomenon.
                    * To minimize the potential for positioning inju-
                      ries associated with arthritis and fibromyalgia,
                      the nurse
                      * has the patient independently position himself
                        or herself,
                      * pads pressure points, and
                      * ensures that the patient is positioned neutral-
                        ly and anatomically correct.
                    * Performs skin preparation ensuring that prep
                      solution does not pool.
                    * Evaluates for signs and symptoms of physical
                      injury to skin and tissue.

Nursing             Interim               Outcome
diagnosis           outcome criteria      statement

Risk for injury     The patient's         The patient is
related to          ocular tissues and    free from signs
surgical            mucous mem-           and symptoms
procedure           branes are main-      of physical
and SS              tained or improved    injury.
                    from baseline lev-
                    els throughout the
                    perioperative
                    period.

Risk for injury     The patient's         The patient is
related to          function, sensa-      free from signs
other associated    tion, and motion      and symptoms
diseases            are maintained or     of injury related
                    improved from         to extraneous
                    baseline levels       objects and
                    throughout the        positioning.
                    perioperative
                    period.