Rheumatoid Arthritis Flashcards
Immune system main functions
fight disease and foreign invaders
constant surveilance
distinguish between normal and foreign (self and non-self)
attach, destroy, and get rid of
Why elderly are more prone to immune diseases and CA?
The body can no longer distinguish between self and nonself (DM and CA)
Onset difference between RA and OA
RA: < 50 y/o
OA: > 40 y/o
Location of joint pain difference between RA and OA**
RA: small joints (hands) on both sides of the body
OA: weight-bearing joints (one-sided)
Joint Appearance difference between RA and OA**
RA: inflammation causing warmth, red and swollen
OA: cool not red or swollen
Morning stiffness difference between RA and OA**
RA: > 60 mins persist for hours
OA: few minutes
S/S besides the joint difference between RA and OA
RA: fatigue, weight loss, and fever
OA: none
Progression difference between RA and OA
RA: worsens over weeks or months
OA: Over years
Easing pain and stiffness difference between RA and OA**
RA: decrease with activity
OA: rest and worsens with activity
Rheumatoid Arthritis def
Chronic, systemic autoimmune disease
Inflammation of connective tissue in joints
RA has what type of manifestations
extraarticular
RA has periods of
remission and exacerbation
Is there a possible genetic link to RA
YES
Causes of RA needs to be a combination of
genetics and environmental triggers
Antigen triggers the formation of what in RA
abnormal IgG
What develops against the abnormal IgG?
autoantibodies
What percentage of people with RA test positive for the Rheumatoid factor in the blood?
85
What are the stages of RA?
Synovitis
Pannus
Fibrous Ankylosis
Bony Ankylosis
Order of RA onset Patho
combination of genetic and environmental triggers
IgG forms
RF forms (autoantibodies against abnormal IgG)
RF and IgG combine
- deposits on synovial joints
- activation of inflammatory response
Neutrophils release damaging cartilage
- Thickening of synovial lining
- Cytokines drive inflammatory response in RA
If untreated goes into the 4 stages
What drives the inflammatory response in RA?
Cytokines
Stage 1 RA - Early
Synovitis
synovial swelling with excess blood
lymphocyte infiltration
High WBCs
no destructive change; swelling and osteoporosis
Stage 2 RA - Moderate
Pannus
increase inflammation
no deformities
muscle atrophy
possible lesions
signs of gradual destruction in the joint, narrowing from a loss of cartilage
osteoporosis
Stage 3 RA: Severe
Fibrous Ankylosis
form of pannus
cartilage eroded and bone exposed
possible deformities
Stage 4 RA: End - stage
inflammation subsides
bony ankylosis
loss of joint function
subcut nodules
bone forms in between the joint
RA S/S: Joints
Fatigue, anorexia, weight loss, generalized stiffness (morning > 60+ mins)
symmetrically
tender, painful, swollen, pain with motion, and varies with the intensity
skin is stretched tightly
The onset of RA is usually
insidious and sneaky
don’t feel good but don’t know why
Common areas of RA
wrist
MCP (metacarpophalangeal joint) - knuckle of thumb
PIP (proximal interphalangeal joint) - knuckle of pinky
big tow
May Report precipitating triggers such as
infection
stress
exertion
childbirth
surgery
emotional upset
Tensynovitis
inflammation of the fluid-filled synovium within the tendon sheath.
Subluxation
inflammation of tendons/joints shifts the alignment of bones (spine)
Joint RA manifestations result in what complications
Tenosynovitis
Deformity and disability
Subluxation
Walking disability
Deformities in the hands
Typical deformities of RA
Ulnar deviation
Boudamire (button-hole)
Bunion
Swan-neck
Ulnar deviation
hand drifts out to the pinky side
Boudamire
button-hole
usually middle joint
can’t straighten out
Bunion (hallux valgus)
the base of big to
joint shifts and the toe goes inward
Swan-neck deformity
middle joint goes down and the top joint goes up
palmar side injury
RA S/S Extraarticular
Rheumatoid nodules
Sjogren’s syndrome
Felty syndrome
Flexion contractures (low mobility and ADLs)
Depression (chronic pain)
Extraarticular s/s will show on someone without
treatment, uninsured, or money
What happens to the salivary and tear glands with RA?
DRY UP
hard to swallow, infection in dry eyes, and dental hygiene decrease in dry mouth
Rheumatoid nodules
skin breakdown main concern
painless, inflamed tissue get hard over time
Sjogren’s syndrome
separate or combination with RA
salivary and tear glands become dry and hard to swallow
dry eyes = infection
dry mouth = dental
Felty syndrome
enlarged spleen
S/S of RA - Lungs
pleura effusions - stiffness
lung fibrous nodules effusions
S/S of RA - Eyes
scleritis
keratoconjunctivitis
S/S of RA - Lymph nodes
lymphadenopathies
S/S of RA - Pericardium
effusions
S/S of RA - Kidney/Gut
amyloidosis
S/S of RA - Spleen
splenomegaly
S/S of RA - Bone marrow
anemia
thrombocytosis
S/S of RA - Muscle
wasting/atrophy
S/S of RA - Nervous System
peripheral neuropathy
S/S of RA - Skin
thinning
ulcerations
HIgher the inflammation = higher
systemic impact
With pleural effusion, what nursing management needs to be done?
TCDB
IS
harder to get off the ventilator
Subjective Nursing Assessment of RA
The presence of precipitating factors,
Pattern of remissions and exacerbations
H&P (medications (current and past)) - ADLs 3-6 months through questionnaire of activity
Impact on functional ability
- Anorexia, weight loss, malaise
- Stiffness and joint swelling, muscle weakness, difficulty walking
- Paresthesia of hands and feet
Symmetric joint pain and aching, and temp
Extraarticular means
outside the joint
Objective Data of RA
Lymphadenopathy, fever
Rheumatoid nodules
Skin ulcers
Shiny, taut skin over joints
Raynaud’s phenomenon
Dysrrthrmias
chronic bronchitis
TB
Splenomegaly
RA pts are more prone to
swollen lymph nodes
skin ulcers
Raynaud’s phenomenon
exaggerated/severe vasoconstriction when pt is exposed to the cold
think of tip of finger is white while the others are red
Raynould’s phenomenon is commonly located in
hands
feet
ears
nose
What med is used to help prevent Raynould’s phenomenon?
mild beta-blocker, Ca channel blockers, ACE, Alpha-blockers
(gloves)
RA pts are more susceptible to TB because
immunosuppressants allow for dormant TB to become active
S/S of felty syndrome
S – Splenomegaly
A – Anemia
N – Neutropenia
T – Thrombocytopenia
A – Arthritis (Rheumatoid)
How does dysrhythmias occur in RA pts?
scaring of AV or SA node in a regular pt
S/S of felty syndrome
mnemonic
SANTA
Decrease WBC means increase in
infection
Objective Data RA
M/S
Symmetric joint involvement
Swelling, erythema
Heat, tenderness
Deformities
Joint enlargement
RA Labs
+ RF
increase ESR and CRP
increase of WBC in synovial fluid
SFA
RA Xray findings
Joint space narrowing
Bony erosion
Deformity
Osteoporosis type
ESR means
erythrocyte sedimentation rate
- the amount of inflammation
CRP means
C-reactive protein
made in the liver and increase with inflammation
If not + RF,
A lesser degree of RA can still be dx with it s/s not as severe
85% of people who do have RA will have + RA factor
Pt teaching of RA
drug therapy
- Individualized PT and OT
- NSAIDs, DMARDs, AND glucocorticoids
- delay progression and relieve symptoms
disease process
- build up over time
Mgmt
- Joint function and ROM
- manage systemic involvement
PT works on
mobility and larger muscle groups
OT works on
fine motor skills
ADLs - hands, adaptive devices
Is there a cure for RA?
NO
DMARDs types
non bio (traditional chem based)
bio (genetic base)
What drugs are used in RA pts?
NSAID
DMARD
Glucocorticoid
DMARDs do what
disrupt inflammatory process
Non-biologic DMARD has what type of effect
shotgun (overall)
1st to be used
chemical base
Biologic DMARD has what type of effect
genetic base
Sniper approach in one area
Methotrexate (MTX) class
DMARD immunosuppressant
Methotrexate (MTX) use
RA
psoriasis
leukemia
CA
Methotrexate (MTX) assess and monitor
CBC
WBC
Liver Function
pain and ROM
Methotrexate (MTX) side effects
GI upset
anemia
thrombocytopenia
fetal harm
Methotrexate (MTX) eduation
risk of infection
birth control needed
photosensitivity
All DMARDs are toxic to what organ and can cause infection-type
liver (hepatotoxic)
opportunistic
Methotrexate (MTX) is what DMARD type
NON-BIOLOGIC
common because cheap and form differences
BRMs (biologic and immunotherapy)
slow progression
mech of action
used to treat moderate to severe diseases
alone or combination
Biologic DMARDs adverse effects
Injection site irritation, pain, redness
Risk for serious infections
Heart failure
Liver failure
Hematologic disorders
Neurologic Disorders
Severe allergic reactions
Cancer
Etanercept (Enbrel) class
biologic DMARD (specific TNF inhibitor)
Etanercept (Enbrel) use
RA
psoriatic arthritis
Etanercept (Enbrel) assess and monitor
pain, swelling, and ROM
Monitor CBC, WBC and TB
Etanercept (Enbrel) side effects
URI
injection site reaction
risk of TB and malignancies
Etanercept (Enbrel) education
self admin SQ injection
risk of adverse reaction to live-virus vax
case manager on support for money (Expensive)
TB testing needs to be done when
before med and during
Corticosteroid Therapy
intraarticular injections
low dose oral for a limited time
NSAID and salicylates
anti-inflammatory, analgesic, and antipyretic
2-3 weeks for full effectiveness
**DO NOT STOP or progression of RA and flareups occur
Corticosteroids
TB testing in what conditions
dormant to active
crowded areas
Nutrition Therapy for RA
balanced
loss of appetite leads to wt loss
corticosteroids = wt gain
Surgical Therapy for RA
if nothing else works
relieve severe pain
improve function
synovectomy
total joint replacement
Arthroplasty
joint replacement
Health Promotion for RA
prevention
early id and treatment to prevent further damage
s/s recognition
What is the 1st to be stopped when the RA pt has an infection
immunosuppressant
Acute Care of RA
decrease inflammation
manage pain and function
prevent deformities
OT can provide what to RA pts
lightweight splints
-plan care around morning sytiffness
How to relieve joint stiffness and increase ability to perform ADLs?
sit/stand in warm shower
sit in tub with warm towels around the shoulders
soak hands in warm water
Ambulatory Care: RA rest
Alternate rest periods with activity
helps relieve pain and fatigue
8-10 hours of rest and daytime rest PRN
modify activities to avoid overexertion
plan out activites
For every 5 lbs of weight gain =
20 lbs of weight on the lower body
Body Alignment of RA for sleeping
firm mattress
encourage extension
avoid flexion positions
no pillows under knees, small,flat pillow under head and shoulders
Cold Therapy of RA
Beneficial during periods of exacerbation**
Application 10–15 minutes at one time
Helps with swelling to decrease blood flow
Moist Heat Therapy of RA
Moist hot packs, paraffin baths, warm baths, or showers
Relieve stiffness
20 minutes at a time
Be alert for burn potential
parastesia
Everyday stiffness
Exercise of RA
need
gentle ROM daily
wt limit to one or two reps during acute inflammation (same reps diff weights)
Psychologic of RA
SUPPORT
Patient is constantly challenged by problems
Limited function and fatigue
Loss of self-esteem*
Altered body image*
Fear of disability or deformity
Evaluate family support system**
Financial planning**
Consider community resources*
Self-help groups are helpful
Strategies to decrease depression*
Etanercept (Enbrel) is prescribed for a patient with stage II rheumatoid arthritis. The nurse determines that the medication is effective if which of the following is observed?
A) Decreased lymphocyte count
B) Absence of Rh factor in the blood
C) Decreased C-reactive protein (CRP)
D) Increased serum immunoglobulin G
C) Decreased C-reactive protein (CRP)
higher RH factor = more inflammation, severity, and increase of RA
never absent of antibodies
