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Nursing IV Exam 3 > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

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0
Q

Rheumatoid Factors

A
  1. Normal antibodies (immunoglobulins) that become autoantibodies and attack host tissues.
  2. They combine with their target antigens in the blood and synovial membranes, forming immune complexes.
  3. Activation of B and T lymphocytes increase production of RA factors.
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1
Q

Rheumatoid Arthritis (RA)

A
  1. Chronic systemic autoimmune disorder
  2. Inflammation of connective tissue, primarily in the joints
  3. RA contributes to disability and tends to shorten life expectancy.
  4. Most ppl. have symmetric involvement of multiple peripheral joints and periods of remission and exacerbation.
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2
Q

Pathophysiology of RA

A
  1. RA Factors from immune complexes & settle on tissue
  2. Leukocytes attracted from circulation to synovial membrane
  3. Neutrophils & Macrophages ingest immune complexes & release enzymes that degrade synovial tissue & articular cartilage
  4. Activation of B & T Lymphocytes increase RA factors
  5. Synovial membrane swells from infiltration of leukocytes
  6. Inflammation spreads to synovial blood vessels, causing vessel occlusion-> vascular flow to tissues decrease-> hypoxia-> metabolic acidosis-> erosion of articular cartilage.
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3
Q

Inflammation of joint also causes:

A
  1. Hemorrhage
  2. Coagulation
  3. Deposits of fibrin-> develops into granulation tissue (Pannus) over denuded areas of synovial membrane. Pannus-> scar tissue-> immobilization of joint
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4
Q

Etiology of RA

A
  1. Affects 3x more women than men
  2. Men tend to have more severe symptoms
  3. Onset occurs most frequently between 40-60 yrs.
  4. Cause is Unknown- combo of genes, environment, hormones, & reproductive factors
  5. RA is less common than osteoarthritis
  6. Incidence of RA increases with age
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5
Q

Risk Factors for RA

A
  1. Most commonly found in women :(
  2. Ages (40-60 yrs)
  3. Family history
  4. heavy smokers
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6
Q

Clinical manifestations of RA

A
  1. Symmetric inflammation of peripheral joints
  2. Pain (especially in upper extremities)
  3. Swelling, Redness, warmth
  4. Significant & often disabling morning stiffness- lasts >1 hr.
  5. Fatigue- disturbed sleep pattern
    6 Malaise
  6. Disease progression is fastest during 1st 6 yrs
  7. Tenderness & limitation of movement
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7
Q

Onset of RA

A
  1. usually insidious, may be abrupt
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8
Q

Course of RA

A
  1. Generally progressive, characterized by remissions and exacerbations
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9
Q

Pain & Stiffness of RA

A
  1. Predominant on rising, lasting > 1hr, also occurs after prolonged inactivity
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10
Q

Affected joints of RA

A
  1. Appear red, hot, and swollen; (boggy) and tender to palpation, decreased range of motion, weakness
  2. Multiple joints affected in symmetric pattern, proximal interphalangeal, metacarpophalangeal , wrists, knees, ankles, and toes often involved.
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11
Q

Systemic Manifestations of RA

A
  1. Fatigue
  2. Weakness
  3. anorexia
  4. weight loss
  5. fever
  6. Rheumatoid nodules
  7. Anemia
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12
Q

Remissions:

A
  1. most likely to occur in 1st year of disease

2. Many women experience remission during pregnancy & relapse after delivery

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13
Q

Salicylate Therapy

A
  1. May result in blood loss causing anemia

2. May prolong labor and induce teratogenic effects

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14
Q

Bed Rest & Inactivity

A
  1. Prolonged bed rest & inactivity is not perscribed for acute episodes, because it may lead to irreversible immobility in the older adult.
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15
Q

Joint Manifestations:

A
  1. Joint manifestations are often preceded by systemic s/s
  2. Typically poly articular and symmetric
  3. Proximal interphalangeal (PIP) & metacarpophalangeal (MCP) joints are most frequently involved
  4. Stiffness in pronounced in the morning lasting > 1hr & may occur with prolonged rest during the day
  5. Boggy (spongelike on palpation because of synovial edema)
  6. persistent inflammation -> deformities of joint & supporting structures- ligaments, tendons, & muscles-> weakening of structures-> lack of opposition to muscle pull-> deformities
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16
Q

Swan-neck deformity

A
  1. Characteristic change in the hands & fingers
  2. Ulnar deviation of the fingers & subluxation at the MCP joints
  3. Hyperextension of PIP joints & compensatory flexion of the Distal interphalangeal joints (DIP)
17
Q

Boutonniere deformity

A
  1. flexion of the PIP joints and extension of the DIP joints
18
Q

Rheumatoid nodules

A
  1. generally in subcutaneous tissue of areas subject to pressure: on forearm, olcranon bursa, over MCP joints, and on the toes
  2. Granulomatous lesions that are firm and either movable or fixed.
  3. May also be found on viscera: heart, lungs, GI, and dura.
19
Q

Extra-articular manifestation of RA:

A
  1. Subcut. nodules
  2. pleural effusion
  3. vasculitis
  4. pericarditis
  5. Splenomegaly
20
Q

Increased risk of Coronary Heart Disease

A
  1. Direct effects on blood vessels, with measures of C-reactive proteins (inflammatory markers) being more predictive of future cardiovascular disease than levels of LDLs
  2. Increased risk of having low LDL level, high cholesterol and triglyceride levels, high BP, & high homocysteine levels
  3. Damaging side effects of medications have on coronary vessles
21
Q

Juvenile Rheumatoid Arthritis (JRA)

A
  1. more often in girls than boys, onset before 17 yrs, and persisting for at least 6 weeks, w/no other cause.
  2. Treatment is similar to that provided for adults
  3. RA affects joints, organs, heart, lungs, liver, & eyes
  4. May interfere with normal growth & development
  5. Children with an early onset of JRA hae a better prognosis for complete recovery
22
Q

3 Types of JRA

A
  1. Pauciarticular arthritis
  2. Systemic arthritis
  3. Polyarticular arthritis
23
Q

Pacuiarticular arthritis

A
  1. primarily affects the knees, ankles, and elbows, occurs more frequently in females
  2. Uveitis is common- children with systemic or polyarticular should be examined by an opthalmologist every 6 months & children with pacuiarticular should be examined every 3 months
24
Q

Systemic arthritis

A
  1. affects male and female clients equally and characteristically manifests by high fever, polyarthritis, and rheumatoid rash
  2. also affects internal organs and joints
25
Q

Polyarticular arthritis

A
  1. involves many joints (5 or more) particularly the small joints of the hands, and fingers. It also may affect the hips, knees, feet, ankles, and neck.
26
Q

Goals of therapy for RA

A
  1. No cure currently exists
  2. Goal is to relieve manifestations:
    a. Relieve pain
    b. reduce inflammation
    c. slow or stop joint damage
    d. improve well-being & ability to funciton
27
Q

Diagnostic Tests:

A
  1. Rheumatoid factors
  2. Erythrocyte sedimentation rate- typically elevated
  3. CBC- anemia
  4. Cyclic citrullinated peptide- highly effective in accurately identifying RA
  5. Examination of synovial fluid- cloudiness,
  6. X-rays of joints- most specific test
28
Q

Pharmacologic Therapies

A
  1. Aspirin & other NSAIDs & mild analgesics- reduce inflammatory process & manage manifestation of the disease. Have little effect on disease progression
  2. Low-dose oral corticosteroids- reduce pain & inflammation. slow the development & progression of bone erosions
  3. Disease modifying/ slow-acting antirheumatic drugs: d-penicillamine, antimalarial agents, infliximab (remicade), and sulfasalazine. Alter the course of disease, reducing destrucion of joints. Immunosuppressives & cytotoxic drugs included.
  4. Intra-articular corticosteroids- provide temp. relief
29
Q

Aspirin

A
  1. often the 1st drug prescribed for treatment of RA
  2. Inexpensive, effective anti-inflammatory
  3. analgesic agent
  4. 15-30 mg/dL, increase dose gradually
    GI side effects, interferes w/ platelet function
    Toxicity: tinnitus & hearing loss
    Drink a full glass of water*
30
Q

Corticosteroids

A
  1. Systemic corticosteroids can dramatically relieve symptoms of RA and appear to slow the progression of joint destruction.
  2. Long term use-> poor wound healing, increased risk of infection, osteoporosis, GI bleeding
  3. should wean off medication over a period of several days to weeks
31
Q

Disease modifying drugs:

A
  1. modify the immune and inflammatory responses, gold salts, antimalarial agents, sulfasalazine, and d-penicillamine.
  2. Beneficial effects not apparent for several weeks or months
  3. clinical improvement and decreased disease activity
  4. Anti-inflammatory effect is minimal, also use NSAIDs
  5. all are fairly toxic, close monitoring
32
Q

Immune and inflammatory agents

A
  1. Methotrexate
  2. reduce body’s autoimmune response, controlling the effects of the disease process
  3. may be used along with NSAIDs
  4. Weekly dose produces effects within 2-4 weeks
  5. Gastric irritation & stomatitis controlled by folic acid
  6. Alcoholism, diabetes, obesity, advanced age, and renal disease increase risk of toxicity.
33
Q

Adalimuab (Humira)

A
  1. A biologic response modifier that is given to people with RA to reduce the inflammatory events of polyarthritis and to slow the progression of joint damage.
  2. Given Subcut.
  3. Cannot be given to a person who has an acute or chronic infection in any part of the body. Pt. should be tested for TB.
34
Q

Gold Salts

A

God Sodium, Thimalate (Myochrysine), Aurothioglucose (Solganal)

  1. May be administered PO, IM is more effective.
  2. mode of action unknown
  3. may produce clinical remission & decrease new bony erosions
  4. Weekly therapy is continued until significant improvement
  5. Toxic effects: dermatitis, stomatitis, bone marrow depression, & proteinuria. CBC & Urinalysis monitored
    * EXTREME FATIGUE*
35
Q

Antimalarial Agents

A
  1. Hydroxchloroquine (Plaquenil)
  2. 3-6 months of therapy required to achieve desired response
  3. pigmentary retinitis and vision loss!
  4. Require a thorough vision exam every 6 months!
36
Q

Surgery and other procedures:

A
  1. Synovectomy- excision of synovial membrane
  2. Arthrodesis- joint fusion (stabilize joints, cervical vertebra, wrists, and ankles)
  3. Arthroplasty- total joint replacement
  4. Plasmapheresis- remove circulating antibodies
  5. Total lymphoid irradiation- expect skin color changes, leathery skin
37
Q

Rest & Exercise

A
  1. Rest must be balanced with a program of physical therapy and exercise to maintain muscle strength and joint mobility.
  2. Swimming and walking benefit clients w/o adversely affecting joint inflammation of prompting acute episodes
38
Q

Heath & cold

A

Heat and cold are used for analgesic and muscle-relaxing effects. Moist heat generally is most effective and can be provided by a tub bath. Joint pain is relieved in some clients through the application of cold.

39
Q

Nursing Diagnosis for RA

A
  1. Chronic Pain RT Joint inflammation
  2. Fatigue RT chronic pain & complaints of disease process
  3. Disturbed body image RT joint deformities
  4. Impaired physical mobility RT joint stiffness
  5. Anxiety RT stress of chronic illness
  6. Activity intolerance RT chronic pain
40
Q

Corticosteroids Pt. edu.

A
  1. May cause weight gain
  2. may increase blood sugar
  3. decreases immune system
  4. Take at the same time every day!
  5. Take with food!

Nursing IV Exam 3 (4 decks)

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