1. Adult Medical-Surgical Nursing Musculo-skeletal Module: Rheumatoid Arthritis

2. Rheumatoid Arthritis: Description  Rheumatoid arthritis is classified as a diffuse connective tissue disease  Auto-immune condition with potential widespread joint destruction  Chronic condition with remission and exacerbation and systemic features (general ill health) also  Progressively debilitating

3. Rheumatoid Arthritis: Aetiology  Unknown aetiology  Thought to relate to immunologic abnormalities  2-3 times greater incidence in women

4. Rheumatoid Arthritis: Pathophysiology  Auto-immune reaction in the synovial tissue of the joints

5. Rheumatoid Arthritis: Pathophysiology  Phagocytosis: proteolytic enzymes break down joint collagen →  Oedema and joint effusion  Proliferation of synovial membrane: “ pannus ” formation  Pannus destroys cartilage and erodes bone → loss of articular surfaces  Muscle, tendon, ligament degeneration

6. Rheumatoid Arthritis: Pathophysiology (cont)  Immune complexes initially destroy/ deform small joints in hands/ wrists  Later knees, shoulders, hips, elbows, ankles, cervical spine, tempero- mandibular joints  Symmetric distribution of inflamed and deformed joints  Systemic inflammation:arteritis,lungs pericarditis, scleritis, splenomegaly

7. Rheumatoid Arthritis: Clinical Manifestations (Joints)  Acute onset: joint pain, swelling, warmth, erythema, loss of function  Spongy joint tissue on palpation, fluid may be aspirated  Bilateral symmetric distribution beginning with hands  Persistent joint stiffness early morning  Joint deformity  Rheumatoid nodules

8. Rheumatoid Arthritis: Systemic Clinical Manifestations  Fever  Anorexia  Weight loss  Fatigue  Anaemia/ pallor  Lymph node enlargement  Raynauds phenomenon (vasospasm)  Depression and sleep deprivation

9. Rheumatoid Arthritis: Diagnosis  Patient history and clinical picture  Positive rheumatic factor (not all)  ESR ( ↑ ); CRP positive; RBC ( ↓ )  C4 complement component ( ↓ )  Anti-nuclear antibody (ANA) often positive  Xrays monitor disease progression: bony spurs/ reduced joint space as it advances

10.  Rheumatoid Arthritis: Medical Management

11. Rheumatoid Arthritis: Medical Management  Management differs with the disease progression  Four stages of the disease:  Early stage  Moderate erosive stage  Persistent erosive stage  Advanced stage

12. Rheumatoid Arthritis: Medical Management: Early Stage  Aim: control symptoms/ slow degeneration  Balance of rest and exercise  NSAIDs or salicylates  More aggressive therapy initially:  Anti-malarials, gold, penicillamine, sulfasalazine, methotrexate (gold standard treatment)  Biological response modifiers

13. Rheumatoid Arthritis: Management (Moderate Erosive Stage)  Programme to educate patient on joint protection:  Physiotherapy  Occupational therapy  Cyclosporine (immune modulator)  Methotrexate

14. Rheumatoid Arthritis: Management (Persistent Erosive Stage)  Reconstructive surgery (elective, not performed during exacerbation):  Synovectomy  Tenorrhaphy  Arthrodesis (joint fusion)  Arthroplasty (joint replacement)  Systemic or local corticosteroids (lowest dose/ shortest time)

15. Rheumatoid Arthritis: Management (Advanced Stage)  Immunosuppressive agents:  High-dose methotrexate, cyclophosphamide, azathioprine (Imuran) (all depress marrow)  12-weekly apheresis to bind circulating IgG immune complex  Anti-depressants often required  Nutrition (anorexia): vitamins, iron, protein

16. Rheumatoid Arthritis: Nursing Considerations  Patient education on how to protect and strengthen joints  Ensure adequate pain relief  Address sleep disturbance, fatigue and altered mood  Small nutritious meals, vitamins, iron  Encourage informed decisions on self-management  Counselling/ emotional support for patient and family