Transcript Rheumatoid Arthritis (relates to Chapter 63, “Nursing Management

Rheumatoid Arthritis
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Rheumatoid Arthritis (RA)
• Chronic, systemic autoimmune disease
• Inflammation of connective tissue in
diarthrodial (synovial) joints
• Periods of remission and exacerbation
• Frequently accompanied by extraarticular manifestations
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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
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Etiology
• Cause of RA is unknown
• No infectious agent found
• Two etiologies
 Autoimmune etiology
• Most widely accepted
 Genetic factor etiology
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Pathophysiology
• Chronic inflammation of the joints
leads to:
 Scar tissue (pannus) & joint cartilage
destruction
 Joint laxity, subluxation ( dislocation), &
contracture
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Pathophysiology
Fig. 65-3
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Pathophysiology
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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 xray evidence of osteoporosis
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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
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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
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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
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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
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Typical Deformities of
Rheumatoid Arthritis
Fig. 65-4
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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
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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
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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
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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
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Extraarticular Manifestations of
Rheumatoid Arthritis
Fig. 65-5
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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
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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)
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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
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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
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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
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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
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Diagnostic Studies
•
RA is defined as having at least 4 of
the following seven criteria

Following must be present for at least 6
weeks
1. Morning stiffness that lasts ≥1 hour
2. Swelling in three or more joints
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Diagnostic Studies
•
•
Criteria for RA (cont'd)
Must be present for at least 6 weeks
3. Swelling in hand joints
4. Symmetrical joint swelling
5. Erosions or decalcification seen on hand
x-rays
6. Rheumatoid nodules
7. Presence of serum RF
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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
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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)
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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
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Collaborative Care
• Physical therapy helps maintain joint
motion and muscle strength
• Occupational therapy develops
extremity function and encourages
joint protection
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Collaborative Care
• Since irreversible joint changes can
begin within the first year of RA,
aggressive treatment with diseasemodifying antirheumatic drugs
(DMARDs) is initiated early
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Nursing Management
Problems
•
•
•
•
•
Chronic pain
Impaired physical mobility
Activity intolerance
Self-care deficit
Ineffective therapeutic regimen
management
• Disturbed body image
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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
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Nursing Management
Planning
• Primary goals in managing RA
 Decrease inflammation
 Manage pain
 Maintain joint function
 Prevent or correct joint deformity
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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
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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
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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
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Nursing Management
Interventions
• Nonpharmacologic relief of pain
 Therapeutic heat and cold
 Rest
 Relaxation techniques
 Joint protection
 Biofeedback
 Transcutaneous electrical stimulation
 Hypnosis
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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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