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Rheumatoid Arthritis

Presented by

Taghreed hamza hawsawi

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5Describe the medical management of rheumatoid arthritis .

Illustrate the symptoms of rheumatoid arthritis.

Describe the assessment relevant diagnostic tests.

Mention the clinical manifestation.

Explain the pathophysiology of rheumatoid arthritis .

Learning Objectives

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7Discuss the nursing interventions based on nursing diagnosis that commonly occur in rheumatoid arthritis

Describe the role of nutritional support in rheumatoid arthritis management.

Learning Objectives

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints.in developed countries the prevalence from 0.7% to 3%, with an average of 1% in the adult population. In the Kingdom of Saudi Arabia, one study identified a prevalence of RA to be 2.2 per thousand people in Al Qassim (Al-Dalaan et al. 1998).

Introduction

Pathophysoilogy

Systemic inflammatory process originating in the synovium or synovial fluid involving connective tissue .

characterized by destruction and proliferation of synovial membrane.

Step 1 Step 2 Step 3 Step 4 Step 5

Phagocytosis produces enzymes within the joint, causing inflammation.

Collagen is destroyed over time and pannus formations occur, narrowing the joint space.

May result in joint destruction, ankylosis and deformity with loss of articulation and joint motion.

Inflammatory process can also affect the spine, blood vessels, the pleural membrane of the lungs or the pericardial sac.

Condition may be short lived and limited or progressive and severe.

As the disease

progresses, the

knees, shoulders,

hips, elbows,

ankles, cervical

spine, and temporomandibula

r joints are

involved.

1.Joint pain, swelling, warmth, erythema, and lack of function are classic.

2.Palpation of the joints reveals spongy tissue.

3.Initially, the small joints in the hands, wrists, and feet are involved.

4.The patient has limitation in function, and he tends to guard the joints through immobilization, which can lead to contractures, creating soft tissue deformity.

Clinical Manifestations

Clinical Manifestations

Symptoms are usually bilateral

and symmetric.

RA is a systemic disease with

multiple extra-articular

features (fever, weight loss,

fatigue, anemia, lymph node

enlargement, and Raynaud’s

phenomenon (cold- and stress-

induced vasospasm causing

episodes of digital blanching

or cyanosis).

Clinical Manifestations

Around the joints warmth redness swelling pain limitations in joint

motion General sickness tiredness fever

Other extra-articular features of RA include: arteritis, neuropathy, scleritis, pericarditis, splenomegaly, and Sjogrens’ syndrome (dry eyes and dry mucous membranes).Rheumatoid nodules may be noted in patients with advanced RA.

Assessment and Diagnostic Findings

Patient history - questions about the intensity of pain symptoms - frequency of symptoms - what makes the pain better or worse

laboratory findings (Presence of rheumatoid factor, high erythrocyte sedimentation rate (ESR), C-reactive protein and antinuclear antibody may be positive).

Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow. X-ray studies show characteristic bony erosions.

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

Medical management

Take 1 capsule

Every 6 hours

paracetamol

Take with water

Treatments can: Relieve pain Reduce swelling Slow down or help prevent joint damage Increase ability to function Improve sense of well-being

Medical management

Early-stage RA1- Patient education, a balance of rest and exercise.2-Salicylates or NSAIDs (Anti inflammatory drug). 3- Several COX-2 (cyclo-oxygenase) inhibitors, another class of NSAIDs, block the enzyme involved in inflammation.4-Antirheumatic agents (antimalarials, gold, penicillamine, or sulfasalazine) are initiated early in treatment. 5-Methotrexate is currently the gold standard in the treatment of RA.

Medical management

Persistent, erosive RA

Surgical procedures include synovectomy (excision of the synovial membrane) .

tenorrhaphy (suturing a tendon) . arthroplasty (surgical repair and

replacement of the joint).

Medical management

Persistent, erosive RASystemic low-dose corticosteroid is used for the shortest duration when the patient has unresolved inflammation and pain.

Joints that are severely inflamed and fail to respond promptly to the measures outlined previously may be treated by local injection of a corticosteroid.

Medical management

Advanced, unremitting RAHigh dose immunosuppressive agents such as methotrexate and azathioprine are prescribed Because of their ability to affect the production of antibodies at the cellular level.

Depression and sleep deprivation may require the short-term use of low-dose antidepressant medications, such as amitriptyline (Elavil).

Nonpharmacologic relief of pain

Therapeutic heat and coldRestRelaxation techniquesJoint protectionBiofeedbackTranscutaneous electrical stimulation Hypnosis

Nutrition Therapy

Patients with RA frequently experience anorexia, weight loss, and anemia.

Food selection should include the daily requirements from the basic food groups.

For the extremely anorexic patient, small, frequent feedings with increased protein supplements may be prescribed.

Patients may need diet counselling.

Nursing management

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

Nurse must alsoEvaluate psychosocial needs and environmental concernsAfter problem identification, coordinate a carefully planned program for rehabilitation and education for interdisciplinary health care team

Nursing management

Chronic painImpaired physical mobility Activity intoleranceSelf-care deficit Ineffective therapeutic regimen managementDisturbed body image

Discuss with patient Action and side effects of each prescribed drug

Importance of laboratory monitoringMany Rheumatoid Arthritis patients take several different drugs so the nurse must make the drug regimen as understandable as possible.

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Nursing Care Plan

Nursing Diagnosis: Acute Pain related to distension of tissues by accumulation of fluid/inflammatory process, destruction of jointExpected Outcome (Objectives): Patient reports pain is relieved/controlled.

Nursing Intervention Rational Evaluation

1. Consider reports of pain, noting location and intensity (scale of 0–10). Note precipitating factors and nonverbal pain cues.

2. Recommend or provide firm mattress or bed board, small pillow. Elevate linens with bed cradle as needed.

3. Suggest patient assume position of comfort while in bed or sitting in chair. Promote bed rest as indicated.

4. Encourage frequent changes of position. Assist patient to move in bed, supporting affected joints above and below, avoiding jerky movements.

5. Monitor the duration, not the intensity, of morning stiffness. 

1. Favorable in determining pain management needs and effectiveness of program.

2. Soft and sagging mattress, large pillows prevent maintenance of proper body alignment, placing stress on affected joints. Elevation of bed linens reduces pressure on inflamed or painful joints.

3. In severe disease or acute exacerbation, total bed rest may be necessary (until objective and subjective improvements are noted) to limit pain or injury to joint.

4. Prevents general fatigue and joint stiffness. Stabilizes joint, decreasing joint movement and associated pain.

5. Duration more accurately reflects the disease’s severity.

 Patient verbalized reduce pain.

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Nursing Care Plan

Nursing Diagnosis: Impaired Physical Mobility related to Pain, discomfort and intolerance to activity.Expected Outcome (Objectives): Reluctance to attempt movement/inability to purposefully move within the physical environmentNursing Intervention Rational Evaluation

1. Assess and continuously monitor degree of joint inflammation and pain.

2. Maintain bed rest or chair rest when indicated. Schedule activities providing frequent rest periods and uninterrupted nighttime sleep.

3. Assist with active and passive ROM and resistive exercises and isometrics when able.

4. Encourage patient to maintain upright and erect posture when sitting, standing, walking.

5. Position with pillows, sandbags, trochanter roll. Provide joint support with splints, braces.

   

1. Level of activity and exercise depends on progression and resolution of inflammatory process.

2. Systemic rest is mandatory during acute exacerbations and important throughout all phases of disease to reduce fatigue, improve strength.

3. Maintains and improves joint function, muscle strength, and general stamina. Note: Inadequate exercise leads to joint stiffening, whereas excessive activity can damage joints.

4. Maximizes joint function, maintains mobility. 5. Promotes joint stability (reducing risk of injury)

and maintains proper joint position and body alignment, minimizing contractures.

 The patient can move within the physical environment

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Nursing Care Plan

Nursing Diagnosis: Disturbed Body Image related to changes in ability to perform usual tasks.Expected Outcome (Objectives): Verbalize increased confidence in ability to deal with illness, changes in lifestyle, and possible limitations.

Nursing Intervention Rational Evaluation

1. Encourage verbalization about concerns of disease process, future expectations.

2. Encouraged a balanced diet, but make sure the patient understands that special diets won’t cure RA. Stress the need for weight control.

3. Ascertain how patient views self in usual lifestyle functioning, including sexual aspects.

4. Discuss patient’s perception of how SO perceives limitations.

5. Involve patient in planning care and scheduling activities.

6. Assist with grooming needs as necessary.

7. Give positive reinforcement for accomplishments.

1. Provides opportunity to identify fears and misconceptions and deal with them directly.

2. Obesity adds further stress to joints. 3. Identifying how illness affects perception of self

and interactions with others will determine need for further intervention and counseling.

4. Verbal and nonverbal cues from SO may have a major impact on how patient views self.

5. Enhances feelings of competency and self-worth, encourages independence and participation in therapy.

6. Maintaining appearance enhances self-image. 7. Allows patient to feel good about self. Reinforces

positive behavior. Enhances self-confidence.

  Patient showed more confidence and able to deal with illness, changes in lifestyle, and possible limitations.

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Nursing Care Plan

Nursing Diagnosis: Self Care Deficit related to Musculoskeletal impairment and pain on movementExpected Outcome (Objectives): Perform self-care activities at a level consistent with individual capabilities.

Nursing Intervention Rational Evaluation

1. Ascertain usual level of functioning (0–4) before onset or exacerbation of illness and potential changes now anticipated.

2. Maintain mobility, pain control, and exercise program.

3. Urge the patient to perform activities of daily living (ADLs), such as practicing good hygiene, dressing and feeding himself.

4. Prepares for increased independence, which enhances self-esteem.

5. Allow patient sufficient time to complete tasks to fullest extent of ability. Capitalize on individual strengths.

6. Consult with rehabilitation specialists (occupational therapist).

1. May be able to continue usual activities with necessary adaptations to current limitations.

2. Support physical and emotional independence.

3. ADLs that can be done should be encouraged to maximize function.

4. Assess barriers to participation in self-care. Identify and plan for environmental modifications.

5. May need more time to complete tasks by self but provides an opportunity for greater sense of self-confidence and self-worth.

6. Helpful in determining assistive devices to meet individual needs (buttonhook, long-handled shoehorn, reacher, hand-held shower head).

 Patient can perform some self-care activities at a level consistent according to his capabilities.

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Nursing Care Plan

Nursing Diagnosis: Deficient Knowledge related to information misinterpretationExpected Outcome (Objectives): Verbalize understanding of condition/prognosis, and potential complications.

Nursing Intervention Rational Evaluation

1. Review disease process, prognosis, and future expectations.

2. Discuss patient’s role in management of disease process through nutrition, medication, and balanced program of exercise and rest.

3. Identify individually appropriate exercise program components (swimming, stationary bike, nonimpact aerobics)

4. Stress importance of continued pharmaco therapeutic management.

5. Suggest taking medications, such as NSAIDs, with meals, milk products, or antacids and at bedtime.

1. Provides knowledge base from which patient can make informed choices.

2. Goal of disease control is to suppress inflammation in joints and other tissues to maintain joint function and prevent deformities.

3. Can increase patient’s energy level and mental alertness, minimize functional limitations. Program needs to be customized based on joints involved and patient’s general condition to maximize effect and reduce risk of injury.

4. Benefits of drug therapy depend on correct dosage (aspirin must be taken regularly to sustain therapeutic blood levels of 18–25 mg per dL).

5. Limits gastric irritation. Reduction of pain at hs enhances sleep, and increased blood level decreases early-morning stiffness.

 Patient verbalized understanding of condition/prognosis, and potential complications.

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Rheumatoid arthritis is:a. Temporaryb. Chronicc. Both

Rheumatoid arthritis is a disease caused by abnormalities in which system of the body?a. Nervous systemb. Immune systemc. Digestive systemd. Respiratory system

Manifestations of rheumatoid arthritis: A) inflammatory synovitisB) cartilage destructionC) bone erosionD) changes in joint integrityE) progressive, relentless polyarthritis with functional impairment

Which of these is not a feature of rheumatoid arthritis?a. Swollen jointsb. Painful jointsc. limitations in joint motion d. Headache

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Al-Dalaan A, Al Ballaa S, Bahabri S, Biyari T, Al Sukait M, Mousa M. The prevalence of rheumatoid arthritis in the Qassim region of Saudi Arabia. Annals of Saudi Medicine 1998;18(5):396-397.American Academy of Orthopaedic Surgeons. (2012) . Arthritis. Retrieved from http://orthoinfo.aaos.org/menus/arthritis.cfmArthritis Foundation. (2012). Common Myths. Retrieved from http://www.arthritis.org/aam-common-myths.phpArthritis Society. (2010). Lupus. Retrieved from http://http://www.arthritis.ca/document.doc?id=327Arthritis Society. (2011). Osteoarthritis: Know Your Options. Retrieved from

http://www.arthritis.ca/document.doc?id=328Arthritis Society. (2012). About Arthritis. Retrieved from http://www.arthritis.ca/aboutarthritis

References

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