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Rheumatoid Arthritis.

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Presentation on theme: "Rheumatoid Arthritis."— Presentation transcript:

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


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