1. NRU 5200 Advanced Practice Presentation Rheumatoid Arthritis Erin Whitley, BSN, RN

2. Rheumatoid Arthritis (RA) Objective 1 Identify the classic presentation of RA. Objective 2 State the benefit of early diagnosis and treatment of RA. Objective 3 Discuss treatment options related to disease severity. Objectives

3. -A chronic, autoimmune disease which involves inflammation of the joints -Morning stiffness is a common finding -Deformities form with disease progression Rheumatoid Arthritis (RA) Introduction Description

4. Introduction Community Impact Why selected http://www.youtu be.com/watch?v=B aUkvTScQ6Y The Faces (and Hands) of Rheumatoid Arthritis - Occurs in approximately 1%- 2% of the population - More common in women than men - Onset is usually between ages 20-50. Rheumatoid Arthritis (RA)

5. Pathophysiology - Cause is unknown -Antibody formation in the joint area results in inflammation in the joint area” (Cash 2011, pp 508). -Not limited to joint issues Rheumatoid Arthritis (RA)

6. Subjective Findings: Typical first signs: -Symmetrical joint pain and swelling -Morning stiffness for longer that 30 min -Small joints of the hands and feet -Fatigue Rheumatoid Arthritis (RA) Patient Presentation (Papadakis 2013 pp 826)

7. Subjective Findings continued: Other findings -Rheumatoid Nodules -Dryness of the eyes, mouth and other mucous membranes -Interstitial lung disease -Pericarditis and pleural disease -Palmar erythema -Depression Rheumatoid Arthritis (RA) Patient Presentation (Papadakis 2013 pp 826)

8. Objective Findings: -Observe patient’s movements -Watch for signs of depression -”Inspect all joints, noting deformities, erythema, and temperature” (Cash, 2011, pp 509). -Assess skin for edema and lesions -Auscultate the lungs Rheumatoid Arthritis (RA) Patient Presentation

9. Objective Findings: -Patellar tap to evaluate effusion of the knee -Palpate all joints to look for tenderness with pressure -Assess grip Rheumatoid Arthritis (RA) Patient Presentation

10. American College of Rheumatology Criteria Five of the following seven symptoms must be present: A.Morning stiffness longer that 1 hour for more than 6 weeks B.Arthritis of at least 3 joint groups with soft tissue swelling or fluid longer than 6 weeks Rheumatoid Arthritis (RA) Criteria/ Diagnostic Guidelines (Cash 2011, pp 508)

11. American College of Rheumatology Criteria (continued) C. Swelling of at least one of the following joints longer than 6 weeks: -proximal interphalangeal -metacarpophalaneal -wrists D.Symmetrical joint swelling longer than 6 weeks Rheumatoid Arthritis (RA) (Cash 2011, pp 508) Criteria/ Diagnostic Guidelines

12. American College of Rheumatology Criteria (continued) E. Subcutaneous nodules F. Positive rheumatoid factor test G. Radiographic changes consistent with RA Rheumatoid Arthritis (RA) (Cash 2011, pp 508) Criteria/ Diagnostic Guidelines

13. Stage 1: No symptoms or signs, normal activity. Antigen Present Stage 2: Morning stiffness, warmth at joint, normal activities of daily living, minimal limitation in joint use. Increase T cells, B cells, antibody production, and synovial cells. Rheumatoid Arthritis (RA) Stages (Cash 2011, pp 508)

14. Stage 3: Morning stiffness, warmth at joint, and extra articular manifestations. Marked limitation in activities of daily living. Increase T cells, B cells, antibody production, and synovial cells. Stage 4: Same as 3 plus proliferating synovial membrane involved causing injury to the bone, tendons, and cartilage. Incapacitated or confined to wheelchair. Rheumatoid Arthritis (RA) Stages (Cash 2011, pp 508)

15. The primary goal is to decrease inflammation and prevent further damage. Pharmacologic Disease-modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis is made -Methotrexate -Plaquenil Rheumatoid Arthritis (RA) Interventions

16. DMARDs have a delayed onset of action and therefore should be accompanied by administration of a glycocorticosteroid (GC) such as Prednisone. -Shown to have an immediate impact to stop disease progression and aid in the goal of remission. -Due to side effects they should only be used short term. Rheumatoid Arthritis (RA) Interventions (Schneider 2013, pp 6)

17. Those patients that don’t respond to treatment with one or a combination of DMARDs may be trialed on biologic therapies. -Humira, Remicade, etc. -used in those with moderate to severe RA. Usually administered by the patient or a caregiver on a weekly or every other week schedule. Rheumatoid Arthritis (RA) Interventions

18. Non-Pharmacologic Treat Pain: -Hot -Cold Splints Exercise/Activity Rheumatoid Arthritis (RA) Interventions

19. Patient Education Focus on: Population involved Treatment Options Living with RA Seeking early treatment from a Rheumatologist www.rheumatology.org Rheumatoid Arthritis (RA)

20. Conclusion -Can be seen in any population -Treatment focuses on preventing further damage -New pharmacologic treatment options (biologics) make early treatment more effective in preventing disease progression “Clinical remission, defined as the absence of significant signs and symptoms of inflammation with or without additional treatment, occurs in 20% or less of patients. In contrast, remission or achievement of low disease activity (LDA), usually with continuing treatment, may be achieved in up to 75% of patients.” (Gibofsky 2012, pp 7) Rheumatoid Arthritis (RA)

21. References: Cash, J.C. & Glass, C.A. (2011). Chapter 19 Endocrine Guidelines. In M. Zuccarini & G. Lee(Eds.). Family Practice Guidelines (pp. 508-510). New York, NY: Springer Publishing Company. Gibofsky, A. (2012). Overview of Epidemiology, Pathophysiology, and Diagnosis of Rheumatoid Arthritis. The American journal of Managed Care, 18, 1-9. doi:S295-S302 Papadakis, M.A. & McPhee, S.J. (2013). Chapter 20 Musculoskeletal and Immunologic Disorders. In C. Diedrich, H. Lebowitz, B. Holton, & M.W. Rabow (Eds.). 2013 Current Medical Diagnosis & Treatment (pp. 826-830). New York, NY: McGraw-Hill Companies. Rheumatoid Arthritis (RA)

22. References: Rheumatoid Patient Foundation. The Faces of Rheumatoid Disease- Rheumatoid Arthritis. Available from http://www.youtube.com/watch?v=BaUkvTScQ6Y http://www.youtube.com/watch?v=BaUkvTScQ6Y Ruderman, E. & Tambar, S. (2012). In American College Of Rheumatology. Retrieved from http://www.rheumatology.org/Practice/Clinical/Patients/Disea ses_And_Conditions/Rheumatoid_Arthritis/ http://www.rheumatology.org/Practice/Clinical/Patients/Disea ses_And_Conditions/Rheumatoid_Arthritis/ Schneider, M. & Krüger, K. (2013). Rheumatoid Arthritis-Early Diagnosis and Disease Management. Deutsches Ärzteblatt International, 110, 1-10. doi:10.3238/arztebl.2013.0477 Rheumatoid Arthritis (RA)