1. Rheumatoid Arthritis

2. Rheumatoid Arthritis (RA)
Chronic, systemic autoimmune disease
Inflammation of connective tissue in diarthrodial (synovial) joints
Periods of remission and exacerbation
Frequently accompanied by extra-articular manifestations

3. Incidence Occurs globally, affecting all ethnic groups
Occurs at any time of life
Incidence increases with age
Peaks between 30s and 50s
Nearly 2.1 million Americans affected
Women have incidences three times higher than men

4. Etiology Cause of RA is unknown No infectious agent found
Two etiologies
Autoimmune etiology
Most widely accepted
Genetic factor etiology

5. Pathophysiology Chronic inflammation of the joints leads to:
Scar tissue (pannus) & joint cartilage destruction
Joint laxity, subluxation ( dislocation), & contracture

6. Pathophysiology
Fig. 65-3

7. Pathophysiology

8. Pathophysiology
Pathogenesis of RA is more clearly understood than its etiology
If unarrested, RA progresses in four stages
Stage 1: Early
No destructive changes on x-ray, possible x-ray evidence of osteoporosis

9. Etiology and Pathophysiology
RA progresses in four stages (cont'd)
Stage 2: Moderate
X-ray evidence of osteoporosis, with or without slight bone or cartilage destruction
No joint deformities, adjacent muscle atrophy, possibly presence of extra-articular soft tissue lesions

10. Etiology and Pathophysiology
RA progresses in four stages (cont'd)
Stage 3: Severe
X-ray evidence of cartilage and bone destruction in addition to osteoporosis; joint deformity; extensive muscle atrophy; possible presence of extra-articular soft tissue lesions
Stage 4: Terminal
Fibrous or bony ankylosis, stage III criteria

11. Clinical Manifestations Onset
Onset is typically insidious
Nonspecific manifestations may precede onset of arthritic complaints
Fatigue, anorexia, weight loss, generalized stiffness
Some report a history of precipitating events

12. Clinical Manifestations Joints
Specific articular involvement
Pain, stiffness, limitation of motion, and signs of inflammation
Symptoms occur symmetrically
Frequently affect small joints of hands and feet
Larger peripheral joints may also be involved

13. Typical Deformities of Rheumatoid Arthritis
Fig. 65-4

14. Clinical Manifestations Joints
Patient experiences joint stiffness after periods of inactivity
Morning stiffness may last from 60 minutes to several hours or more
MCP and PIP joints typically swollen
Fingers may become spindle shaped from synovial hypertrophy and thickening of joint capsule

15. Clinical Manifestations Joints
Joints become tender, painful, and warm
Joint pain
Increases with motion
Varies in intensity
May not be proportional to degree of inflammation
Tenosynovitis frequently affects extensor and flexor tendons near wrists

16. Clinical Manifestations Joints
Tenosynovitis
Produces manifestations of carpal tunnel syndrome
Makes grasping objects difficult
As RA progresses, inflammation and fibrosis of joint capsule and supporting structures may lead to deformity and disability

17. Clinical Manifestations Joints
Atrophy of muscles and destruction of tendons around joint cause one articular surface to slip past other
Typical distortion of hand
Ulnar drift, swan neck, and boutonnière deformities
Metatarsal head subluxation and hallux valgus (bunion) in feet may cause pain

18. Extraarticular Manifestations of Rheumatoid Arthritis
Fig. 65-5

19. Clinical Manifestations Extraarticular Manifestations
Three most common
Rheumatoid nodules
Sjögren’s syndrome
Felty syndrome
Rheumatoid nodules develop in up to 25% of all patients with RA
Those affected usually have high titers of RF

20. Clinical Manifestations Extraarticular Manifestations
Sjögren’s syndrome
Seen in 10% to 15% of patients with RA
Can occur as a disease by itself or in conjunction with other arthritic disorders
RA and systemic lupus erythematosus (SLE)

21. Clinical Manifestations Extraarticular Manifestations
Sjögren’s syndrome (cont'd)
Patients have diminished lacrimal and salivary gland secretion
Complaints of burning, gritty, itchy eyes
Decreased tearing, photosensitivity

22. Clinical Manifestations Extraarticular Manifestations
Felty’s syndrome
Most commonly in patients with severe, nodule-forming RA
Characterized by
Inflammatory eye disorder
Splenomegaly
Lymphadenopathy
Pulmonary disease
Blood dyscrasias

23. Complications
Joint destruction begins as early as first year of disease without treatment
Flexion contractures and hand deformities
Cause diminished grasp strength
Affect patient’s ability to perform self-care tasks

24. Complications Cardiopulmonary effects may occur later in RA
Pleurisy, pleural effusion, pericarditis, pericardial effusion, cardiomyopathy
Carpal tunnel syndrome can result from swelling of synovial membrane

25. Diagnostic Studies
RA is defined as having at least 4 of the following seven criteria
Following must be present for at least 6 weeks
Morning stiffness that lasts ≥1 hour
Swelling in three or more joints

26. Diagnostic Studies Criteria for RA (cont'd)
Must be present for at least 6 weeks
Swelling in hand joints
Symmetrical joint swelling
Erosions or decalcification seen on hand x-rays
Rheumatoid nodules
Presence of serum RF

27. Diagnostic Studies
Accurate diagnosis is essential to initiation of appropriate treatment and prevention of unnecessary disability
Diagnosis is often made
Based on history and physical findings
Some laboratory tests are useful for confirmation and to monitor disease progression

28. Diagnostic Studies Positive RF occurs in ~80% of patients
Titers rise during active disease
Antinuclear antibody (ANA) titers
Indicators of active inflammation
ESR
C-reactive protein (CRP)

29. Collaborative Care
Care begins with a comprehensive program of education and drug therapy
Education of drug therapy
Correct administration, reporting side effects
Frequent medical and laboratory follow-up visits
A caring, long-term relationship with an arthritis health care team can increase patient’s self-esteem and positive coping

30. Collaborative Care
Physical therapy helps maintain joint motion and muscle strength
Occupational therapy develops extremity function and encourages joint protection

31. Collaborative Care
Since irreversible joint changes can begin within the first year of RA, aggressive treatment with disease-modifying antirheumatic drugs (DMARDs) is initiated early

32. Drug Therapy Drugs remain cornerstone of treatment
DMARDs can lessen permanent effects of RA
Choice of drug is based on
Disease activity
Patient’s level of function
Lifestyle considerations

33. Drug Therapy Many of the drugs used to treat RA are expensive
Methotrexate (Rheumatrex) is drug of choice
Rapid antiinflammatory effect decreases clinical symptoms in days to weeks
Inexpensive
Lower toxicity compared to other drugs

34. Drug Therapy Effective DMARDs for mild to moderate disease
Sulfasalazine (Azulfidine)
Antimalarial drug hydroxychloroquine
Leflunomide (Arava) is a newer synthetic DMARD that blocks immune cell overproduction

35. Drug Therapy
Use of combination therapy can slow symptoms and joint damage while improving function
Drug combinations are individualized and often include
A DMARD
An NSAID
A corticosteroid

36. Drug Therapy
Biologic/targeted drug therapies can also slow disease progression in RA
Can be used in patients with moderate to severe disease who have not responded to DMARDs or in combination therapy with an established DMARD

37. Drug Therapy Corticosteroid therapy can aid in symptom control
Intraarticular injections may relieve pain and inflammation associated with flare-ups
Long-term use should not be a mainstay
Risk osteoporosis, avascular necrosis
Low-dose prednisone for a limited time to decrease disease activity until DMARD effect is seen

38. Drug Therapy
Various NSAIDs and salicylates to treat arthritis pain and inflammation
Aspirin is often used in high dosages of 4 to 6 g/day (10 to 18 tablets)
NSAIDs have antiinflammatory, analgesic, and antipyretic properties

39. Drug Therapy NSAIDs Do not alter natural history of RA
Full effectiveness may take 2 to 3 weeks
Some relief may be noted within days
May be used when patient cannot tolerate high doses of aspirin

40. Nursing Implementation Acute Intervention
Usually treated on an outpatient basis
Hospitalization may be necessary for patients with extraarticular complications or advancing disease
Reconstructive surgery for disabling deformities
Nursing intervention begins with a careful physical assessment

41. Nursing Management Assessment
Nurse must also
Evaluate psychosocial needs and environmental concerns
After problem identification, coordinate a carefully planned program for rehabilitation and education for interdisciplinary health care team

42. Nursing Management Problems
Chronic pain
Impaired physical mobility
Activity intolerance
Self-care deficit
Ineffective therapeutic regimen management
Disturbed body image

43. Nursing Management Planning
Overall goals
Satisfactory pain relief
Minimal loss of functional ability of affected joints
Perform self-care
Participate in planning and carrying out therapeutic regimen
Maintain a positive self-image

44. Nursing Management Planning
Primary goals in managing RA
Decrease inflammation
Manage pain
Maintain joint function
Prevent or correct joint deformity

45. Nursing Management Interventions
Goals may be met through a comprehensive program
Drug therapy – pain control, antiinflammatory
Rest
Joint protection
Heat and cold applications – pain control
Exercise
Patient and family teaching

46. Nursing Management Interventions
Suppression of inflammation
NSAIDs
DMARDs
Biologic therapies
Careful attention to timing is critical to
Sustain a therapeutic drug level
Decrease early morning stiffness

47. Nursing Management Interventions
Discuss with patient
Action and side effects of each prescribed drug
Importance of laboratory monitoring
Many RA patients take several different drugs so the nurse must make the drug regimen as understandable as possible

48. Nursing Management Interventions
Nonpharmacologic relief of pain
Therapeutic heat and cold
Rest
Relaxation techniques
Joint protection
Biofeedback
Transcutaneous electrical stimulation
Hypnosis

49. Nursing Management Interventions
Lightweight splints may be prescribed to rest an inflamed joint and prevent deformity
Should be removed regularly to perform skin care and ROM exercises
Should be reapplied as prescribed
Occupational therapist may help identify additional self-help devices to assist in activities of daily living

50. Nursing Management Interventions
Morning care and procedures should be planned around morning stiffness
To relieve joint stiffness and increase comfort
Sitting or standing in a warm shower
Sitting a tub with warm towels around shoulders
Simply soaking hands in a basin of warm water

51. Ambulatory and Home Care Rest
Alternate scheduled rest periods with activity throughout day
Helps relieve pain and fatigue
Amount of rest varies
Total bed rest
Rarely necessary
Should be avoided to prevent stiffness and immobility

52. Ambulatory and Home Care Rest
Even a patient with mild disease may require daytime rest in addition to 8 to 10 hours of sleep at night
Nurse should help patient
Identify ways to modify daily activities to avoid overexertion
Pace activities and set priorities on basis of realistic goals

53. Ambulatory and Home Care Rest
Good body alignment while resting can be maintained through use of a firm mattress or bed board
Encourage positions of extension
Avoid flexion positions
Splints and casts can help maintain proper alignment and promote rest

54. Ambulatory and Home Care Rest
Lying prone for half an hour twice daily is recommended
Pillows should never be placed under knees
Increases risk of joint contracture
A small, flat pillow may be used under head and shoulders

55. Ambulatory and Home Care Joint Protection
Important to protect joints from stress
Nurse can help identify ways to modify tasks to put less stress on joints during routine activities
Energy conservation requires careful planning
Pacing: Work should be done in short periods with scheduled breaks

56. Ambulatory and Home Care Joint Protection
Time-saving joint protective devices should be used whenever possible
Tasks can also be delegated to other family members
Assistive devices that help with simple tasks can increase patient independence

57. Ambulatory and Home Care Heat and Cold Therapy
Help relieve pain, stiffness, and muscle spasm
Ice
Especially beneficial during periods of disease exacerbation
Application should not exceed 10 to 15 minutes at one time

58. Ambulatory and Home Care Heat and Cold Therapy
Superficial heat sources
Can relieve stiffness to allow participation in therapeutic exercises
Moist heat
Relief of chronic stiffness
Application should not exceed 20 minutes
Alert patient to not use a heat-producing cream with another external heat device

59. Ambulatory and Home Care Exercise
Individualized exercise is an integral part of the treatment plan
Usually developed by a physical therapist
Nurse should reinforce program participation and ensure that exercises are being done correctly

60. Ambulatory and Home Care Exercise
Inadequate joint movement can result in progressive joint immobility and muscle weakness
Overaggressive exercise can result in increased pain, inflammation, and joint damage
Gentle ROM exercises are usually done daily to keep joints functional

61. Ambulatory and Home Care Psychologic Support
Self-management and adherence to an individualized home treatment program can only be done if patient has a thorough understanding of RA
Nature and course of disease
Goals of therapy

62. Ambulatory and Home Care Psychologic Support
Patient’s value system and perception of disease must be considered
Patient is constantly challenged by problems of
Limited function and fatigue
Loss of self-esteem
Altered body image
Fear of disability or deformity

63. Ambulatory and Home Care Psychologic Support
Alterations in sexuality should be discussed
Chronic pain or loss of function may make patient vulnerable to unproven or even dangerous remedies
Nurse can help patient recognize fear and concerns

64. Ambulatory and Home Care Psychologic Support
Evaluation of family support system is important
Financial planning may be necessary
Community resources may be considered
Self-help groups are beneficial for some patients