Rheumatoid Arthritis Flashcards
Rheumatoid Arthritis (RA)
Chronic, systemic autoimmune disease
Inflammation of connective tissue in synovial joints
Periods of remission and exacerbation
Extraarticular manifestations- Rheumatoid nodules, Sjogren’s syndrome, felty syndrome , depression
Etiology and Pathophysiology of RA
Autoimmune etiology
Combination of genetics and environmental triggers
Antigen triggers formation of abnormal immunoglobulin G (IgG)
Autoantibodies develop against the abnormal IgG
Rheumatoid factor (RF)
Rheumatoid factor combines with IgG immune complexes → deposit on synovial membranes or cartilage in joints → activates complement → inflammatory response
Neutrophils → proteolytic enzymes → damage cartilage and thicken synovial lining
Pathologic Changes in Rheumatoid Arthritis Picture
Clinical Manifestations Joints
Onset typically insidious
Fatigue, anorexia, weight loss, generalized stiffness
May report history of precipitating event
Infection, stress, exertion, childbirth, surgery
Specific articular involvement
Pain, stiffness, limitation of motion, and signs of inflammation
Symptoms occur symmetrically
Most often affects small joints
Larger joints and cervical spine may be involved
Other Clinical Manifestations Joints
Joint stiffness after inactivity
Morning stiffness 60 minutes to several hours or longer
MCP and PIP joints typically swollen-metacarpal and peripheral
Fingers spindle shaped
Joints tender, painful, warm to touch
Pain ↑ with motion, intensity varies
Tenosynovitis
Deformity and disability
Subluxation
Walking disability
What is Tenosynovitis
inflammation of the tendon sheath, flexor and extender and cartlidge. Similar to carpal tunnel
What is Subluxation
Dislocation and they over lap
Typical Deformities of Rheumatoid Arthritis
A. Ulnar drift
B. Boutonnière deformity
C. Hallux valgus
D. Swan neck deformity
Clinical Manifestations Extraarticular-outside joints Manifestations
Rheumatoid nodules can be in both eyes
Sjögren’s syndrome
Felty syndrome
Flexion contractures
Nodular myositis
Cataracts- Can cause blindeness with these patients
Depression
What is Sjögren’s syndrome
decrease secretion of the salivary glands and eye gland- give over the counter eye drops
Diagnostic Studies in RA
Laboratory studies
Rheumatoid factor (RF)
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)
Antinuclear antibody (ANA)
Anti-citrullinated protein antibody (ACPA)-
Synovial fluid analysis
X-rays of involved joints
Bone scan
Why is Anti-citrullinated protein antibody (ACPA) important
Very important in Dx of RA most definitive
What does Synovial fluid analysis show
It would be cloudy and increased WBC’s
Collaborative Care
Patient teaching
Drug therapy
Disease process
Home management strategies
NSAIDs
Physical therapy
Occupational therapy
Individualized treatment plan
What is DMARDS
Disease Mofifying Antirheumatic Drugs
Drug Therapy: DMARDs
↓ Permanent effects of RA- Why we give these meds
Methotrexate (Rheumatrex)
Sulfasalazine (Azulfidine)
Hydroxychloroquine (Plaquenil)- Can cause retinopathy-teach regular eye exams- also a antimalarial drug
Leflunomide (Arava)
Monitor for bone marrow suppression and hepatotoxicity
Teratogenic-Can be harmful to babies, careful in women of childbearing age
Drug Therapy: Biologic/Targeted Therapies
Tumor necrosis factor (TNF) inhibitors-Prevent inflammation, at high risk for infection due topreventing S/S of inflammation-Do not give live vaccinations
Etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab (Cimzia), and golimumab (Simponi)
Bind with TNF, inhibiting inflammation
Tumor necrosis factor (TNF) inhibitors
TB test and chest x-ray before start of therapy
Monitor for infection
Avoid live vaccinations
Drug Therapy
Antibiotics (minocycline [Minocin])
Immunosuppressants (azathioprine [Imuran])
Penicillamine (Cuprimine)
Gold preparations (auranofin [Ridaura])-injections used
Drug Therapy CorticosteroidsHow would you know therapy was affective?
Look at CRP and ESR. Must be tapered off
Intraarticular injections
Low-dose oral for limited time
Drug Therapy NSAIDS
Anti-inflammatory, analgesic, and antipyretic
May take 2 to 3 weeks for full effectiveness
Nutritional Therapy
Balanced nutrition important
Loss of appetite or inability to shop for and prepare food → weight loss
Corticosteroid therapy → weight gain
Surgical Therapy
Relieve severe pain
Improve function
Synovectomy-Removal of joint lining to improve movement
Total joint replacement (arthroplasty)-Common in elderly. How to prevent infection. Aseptic technique
Nursing Assessment Subjective Data
Recent infections, presence of precipitating factors, pattern of remissions and exacerbations
Use of aspirin, NSAIDs, corticosteroids, DMARDs
Any joint surgery
Family history
Malaise
Ability to participate in therapeutic regimen
Impact on functional ability
Anorexia, weight loss
Dry mucous membranes of mouth and pharynx
Stiffness and joint swelling, muscle weakness, difficulty walking, fatigue
Paresthesia of hands and feet
Loss of sensation
Symmetric joint pain and aching that ↑ with motion or stress on joint
Nursing Assessment Objective Data
Lymphadenopathy, fever
Keratoconjunctivitis- Cornea inflamed due to dryness
Rheumatoid nodules
Skin ulcers
Shiny, taut skin over joints
Peripheral edeRaynaud’s phenomenon- fingers and feet numb and cold
Distant heart sounds, murmurs
Dysrhythmias
Chronic bronchitis, tuberculosis
Histoplasmosis-fungal infection of lung, fibrosing alveolitis
Splenomegaly (Felty syndromemaSymmetric joint involvement
Swelling, erythema
Heat, tenderness
Deformities
Joint enlargement
Limitation of movement
Muscle contractures; atrophy
Nursing Assessment Objective Data Diagnostic Findings
+ Rheumatoid factor
↑ESR
↑ WBCs in synovial fluid
X-ray findings
Joint space narrowing
Bony erosion
Deformity
Osteoporosis
Nursing Diagnoses
Impaired physical mobility
Chronic pain
Disturbed body image
Overall goals
Satisfactory pain management
Minimal loss of functional ability
Participate in therapeutic regimen
Maintain positive self-image
Perform self-care
Nursing Implementation Health Promotion
Prevention not possible at this time
Early treatment to prevent further joint damage
Community education programs
Symptom recognition to promote early diagnosis and treatment
Arthrititis.org
Nursing Implementation Acute Intervention
Primary goals in managing RA???? Decrease inflammation to improve pain management, maintain function tha tis left, prevent any other complications or deformities
Comprehensive program
Drug therapy
Balance of rest and activity- Sitting is better to protect joints
Joint protection
Heat and cold applications-cold is better for acute inflammation, heat is used for stiffness
Exercise- range of motion
Patient and caregiver teaching
Multidisciplinary team- PT, OT,& SS
Usually treated on an outpatient basis
Start with assessment
Physical
Psychosocial
Identify problems
Coordinate program for rehabilitation and education
Multidisciplinary team
Nursing Implementation Acute Intervention Medications
Suppression of inflammation
NSAIDs
DMARDs
Biologic/targeted therapies
Patient teaching about medications
Timing of administration
Action and side effects
Compliance
Nursing Implementation Acute Intervention Non drug relief for pain
Therapeutic heat and cold
Rest
Relaxation techniques
*Joint protection- soft splints to preserve joint function
Biofeedback- electrodes to the body to see how the body is responding*
Transcutaneous electrical stimulation
Hypnosis
Nursing Implementation Acute Intervention Light weight splints
preserve joint function
Removed at regular intervals
Perform ROM exercises
Reapply as prescribed
Occupational therapist → additional self-help devices
Nursing Implementation Acute Intervention Planning routine
Plan care around morning stiffness- go slowly to allow stiffness to decrease
To relieve joint stiffness and ↑ ability to perform ADLs
Sit or stand in warm shower
Sit in tub with warm towels around shoulders
Soak hands in warm water
Etanercept (Enbrel) is prescribed for a patient with stage II rheumatoid arthritis. The nurse determines that the medication is effective if what is observed?
Decreased lymphocyte count
Absence of Rh factor in the blood
Decreased C-reactive protein (CRP)
Increased serum immunoglobulin G
