UNIT 3- RHEUMATOID ARTHRITIS Flashcards
OA vs. RA what are the ages of onset?
OA: usually begins after age 40
RA: May begin at any age usually before age 50
OA vs. RA Where is the joint pain located?
OA: Usually effects eight-bearing joints, such as the knees and hips, but also effects the ginger joints, pain is often on 1 side of the body only
RA: Usually effects small joins, such as the hand, foot, wrist, elbow, shoulders or ankle usually on both sides of the body
OA vs. RA What is the appearance of the joints?
OA: Usually cool, not red or swollen
RA: Inflammatory causes joints to be warm, red, swollen.
OA vs RA: Length of morning joint stiffness?
OA: Lasts only a few mins
RA: Lasts for at least 60 mins and can persist for hours
OA vs. RA: What are the symptoms besides joint pain stiffness?
OA: Usually does not affect overall health
RA: May be accompanied by fatigue, weight loss and fever.
OA vs. RA: What is the disease progression like?
OA: Symptoms gradually worsen over periods of year
RA: Symptoms worsen over a period of weeks to months
OA vs. RA: What eases pain or stiffness?
OA: Pain subsides with rest and worsens w/activity
RA: Stiffness decreases w/activity
What is rheumatoid arthritis?
Chronic, systemic autoimmune disease that causes inflammation of connective tissue in joints.
Usually exhibits extraarticular manifestations (outside of the joints)
There are periods of remission and exacerbation
True or False: There is a genetic link with RA?
True
What is the etiology of RA?
Autoimmune- combination of genetics and environmental triggers
- Antigen triggers formation of abnormal immunoglobulin (IgG)
- Autoantibodies develop against the abnormal IgG
-RF factor
What are the 5 stages of RA?
1.Healthy joints
2. Synovitis
3. Pannus
4. Fibrous ankylosis
5. Bony Ankylosis
What should we know about stage 2 of RA- Synovitis?
- Synovial membrane inflamed and thickened
- Bones and cartilage gradually erode
What should we know about stage 3 of RA- Pannus?
- Excessive cartilage loss; exposed and pitted bones
What should we know about stage 4 Fibrous ankylosis of RA?
- Joint invaded by fibrous connective tissue
What should we know about stage 5 RA bony ankylosis?
- Bones fused
What is the onset of RA?
Typically insidious- slow and sneaky
What are some clinical manifestations of RA?
- Fatigue
- Anorexia
- Weight loss,
- generalized stiffness
True or False: some patients may report a history of precepting event that triggers there RA?
True- Some examples are infections, stress, exertion, childbirth, surgery, emotional upset
Symptoms of RA typically occur asymmetric or symmetric?
Symmetrical
How long can morning RA stiffness last
60mins.
How will the joints present in RA?
Tender, painful and warm to touch
True or false: Skin might get tight around a joint with RA?
True
What is Tenosynovitis?
Inflammation of the tendon sheath where muscle connects to bone
True or false: Deformity and disability are not common in RA?
False
What are the typical deformitites of RA?
- Ulnar deviation
- Boutonniere
- Bunions
- Swan neck
What is ulnar deviation?
Also known as ulnar drift. This hand condition occurs when your knuckle bones or metacarpophalangeal (MCP) joints, become swollen and cause your fingers to bend abnormally toward your little finger.
What is Boutonniere?
Flexion of the proximal interphalangeal and the distal interphalangeal joint
What is swan neck deformity?
Characterized by proximal interphalangeal (PIP) joint hyperextension and flexion of the distal interphalangeal (DIP) joint
What are the extraarticular manifestations of RA?
- Rheumatoid nodule
- Sjogren’s syndrome
- Felty syndrome
- Flexion contractures
- Depression
What are we concerned about when a person with RA presents with Rheumatoid nodules?
Our concern is skin breakdown. These nodules are not usually painful– as they are just inflamed tissue that hardens over time. But overall this increases the risk of skin breakdown.
What is important to know about Sjogren’s syndrome?
- Can happen on its own or as a part of RA
What does Sjogren’s syndrome effect?
- Targets salivary and tear glands which leads to dry mouth and eyes.
- Patients may have difficulty swallowing and may be more prone to injections due to dry eyes and dental carriers.
Review: These are the systems in the body that RA effects.
- Pleura: Effusions
- Lymph nodes: Reactive lymphadenopathies
- Kidney: amyloidosis
- Gut: Amyloidosis
- Bone marrow: anemia, thrombocytopenia
- Nervous system: peripheral neuropathy (mononeuritis multiplex)
- Eye: scleritis keratoconjunctivitis
- Pericardium: Effusions
- Lung: Fibrosis nodules effusion (these pts can be diff. to get off vents) TCDB important because lungs harden
- Spleen: Splenomegaly
- Muscle: wasting
- Skin: Thinning–> ulceration
True or false: RA can effect any body system… usually the higher the inflammation in the body the more likely you are to have a systemic impact?
True
What is some subjective data you may collect on your RA patient?
- Presence of precipitating factor
- Patter of remission and exacerbation of
- Use of medications (current and past)
- Family hx
- Impact on functional ability
- Anorexia, weight loss, malaise hx.
- Stiffness and joint swelling, muscle weakness, difficulty walking hx.
- Paresthesia of hands and feet.
- Systemetric joint pain and aching
How often might an RA patient see the doctor?
every 3m to assess function w/extensive questionare
What objective data might you collect from your patients RA history?
- Lymphadenopathy, fever?
2.Rheumatoid nodules - Skin ulcers- more prone
- Shiny, taught skin over joints
What cardiovascular objective data might you collect from your RA pt history?
- Do they have Raynaud’s phenomenon
- Do they have dysrhythmias
What is Raynaud’s phenomenon?
Extreme vasodilation when patient is exposed to cold temp– usually in hands and feet but can occur on ears and nose.
Typically treated with BB or CCB
What respiratory objective data might you collect from your RA pt?
- history of chronic bronchitis or TB
Why is important to ask your RA patient about TB?
- Because you are immunosuppressed with RA you have an increased risk of catching.
What GI objective data might you collect from your RA pt?
- Splenomeglary (felty syndrome)
What is felty syndrome using the acronym S-A-N-T-A?
S- Splenomegaly
A- Anemia
N- Neutropenia (decreased WBC)
T- Thrombocytopenia
A- Arthritis (RA)
What Musculoskeletal objective data might you collect from your RA patient?
- What Systemic joints are involved (small joints typically but can affect larger joints)
- Is there swelling or erythema
- Hot? or Tender?
- Deformities (boney developement)
- Joint enlargement (hard to touc)
What lab valves might we expect to see for an RA patient?
- Positive + Rheumatoid factor
-(not all patients will have a + RF, those who do not tend to have a lesser case of RA) - Increased ESR and CRP
- Not specific for RA, just tells us that the body has inflammation somewhere/somehow
- Increased WBC in synovial fluid
-must rule out RA vs. Infection etc.
What might we expect to see on an xray of an RA patient?
- Joint space narrowing
- Bone erosion
- Deformity
- Osteoporosis
What will our patient teaching include for a patient with RA?
- Drug therapy
- Disease process
- Home management strategies
- PT/OT therapy
- Individualized treatment plan
What are the goals of drug therapy for RA?
- Relieve symptoms
- Maintain joint function & ROM
- Manage systemic involvement
- Delay disease progression: No cure, NO prevention
What are different classes of antiarthritic drugs?
- NSAIDS
- DMARDS: Disease modifying antirheumatic drugs
-non biologic
-biologic - Glucocorticoids
What is another name for Nonbiologic DMARDS?
- Traditional
What kind of effect does a non biologic dmard have?
Shot gun effect– broader
What kind of effect does a biologic dmard have?
Sniper effect
Methotrexate (MTX) is what class of medication?
- Immunosuppressant DMARD nonbiologic
What are the uses of Methotrexate (MTX)
RA and Psoriasis
What is the responsibility of Methotrexate (MTX)?
Hard on liver, monitor cbc, wbc, liver fxn studies, assess pain and ROM
What are the side effects of methotrexate (MTX)?
Gi upset, anemia, thrombocytopenia, may cause fetal harm.
What education should be given for the medication Methotrexate (MTX)
1.Risk of infection,
2. use of birth control,
3. photosensitivity
Biologic response modifiers (BRM’s) are also known as
Biologics or immunotherapy
What is the MOA of BRM’s aka biologic response modifiers (biologics)
Slows progression of disease. Used to treat moderate to severe RA in patients who have not responded to DMARDS. Can be used alone in combination with DMARDS
What is the class of Etanercept (ENBREL)
Biologic DMARD (TNF inhibitors)
What is the MOA of Etanercept (ENBREL)
Disrupts at the TNF inhibitor which inhibits the inflammatory response.
What are the uses of Etanercept (enbrel)
RA and Psoriatic arthritis
What responsibility does the RN have with of Etanercept (enbrel)
Assess
1.pain
2. Swelling,
3. ROM
4. Monitor CBC, esp. wbc
5. TB testing
What side effecs of Etanercept (Enbrel)
- URI
- Injection site rxn
- Risk for tb and malignancies
Why are patients who take etanercept (Enbrel) at risk for tb and malignancies?
They are immunosuppressed
It is recommended to tb test prior to start of medication and during current tb not good candidates.
What education needs to be taught to a patient taking etanercept (enbrel)?
- how to self admin – sub q injection
- risk of adverse rxn to live virus-vaccine– still recommend the flue
What other drug therapy is used for RA?
Corticosteroid
1. Intraarticular injections- directly in joint
2. low dose oral for limited time.
NSAIDS & Salicylates
1. Anti-inflammatory, analgesic and antipyretic
2. May take up to 2-3wks, for full effectiveness
3. Does NOT stop the progression of RA
What diet is recommended for a patient with RA?
No special diet– balanced
For every 5lbs of weight it adds how much pressure to the hips, knees and back?
20lbs
True or false: Corticosteroid therapy can cause weight gain?
True
What is the benefit of surgical therapy for RA patients?
- Relieves severe pain
- Improves function
What is a synovectomy?
Removal of synovial fluid
What should we know about total joint replacement with RA patient?
- By the time surgery is an option, the joints have already atrophied. So it is hard/close to impossible to get ROM back to normal
- Joint replacement in the wrist and fingers are not as effective as replacement in larger joints
What are the overall goals of RA management?
- Satisfactory pain management
- Minimal loss of functional ability
- Maintain positive self-image.
What health promotion do we do for RA patients?
- Encourage early treatment to prevent further damage
- Inform them of community education programs
- Symptom recognition to promote early dx and treatment
What are our primary goals RA treatment?
- Reduce inflammation
- Manage pain
- Maintain joint function
- Prevent or correct joint deformity
What interventions could you suggest to help with joint stiffness and increase ability to perform ADL’s?
- Sit or stand in warm water
- Sit in tub w/ warm towels around shoulders
- Soak hands in warm water
What should we educate our RA patient on as far as rest goes?
- Alternate rest periods w/activity
- Helps relieve pain and fatigue
- Amount of rest varies
- AVOID total bed rest
- 8-10 hours of sleep + daytime rest PRN
- modify activities to avoid overexertion
What are some body alignment teaching we could tell our patient with RA about?
- Firm mattress or bed board
- Encourage positions of extension
- AVOID position of flexion
- no pillows under knees
- small, flat pillow under head and shoulders
What are some joint protection tips we could teach our patients with RA about?
- Modify tasks for less stress on joints
- Energy conservation
-work simplification techniques
-Pacing and organization
-Delegation - Occupational therapy for assistive devices
True or false: it is best to avoid any unwanted stress on the joints?
True
What should we know about ICE therapy with RA patients?
- Beneficial during periods of exacerbation
- Application 10-15 mins at one time
What should we know about HEAT therapy with RA patinets?
- Moist hot packs, paraffin baths, warm baths, or showers are good choices
- Relieves stiffness
- 20 mins at a time.
- Be alert for burn potentials
What should we teach our RA patient about exercise?
- Need recreational and therapeutic exercise
- Gentle ROM exercise done daily (THIS IS A MUST)
- Weight limit to one or two reps during acute inflammation
What should we be looking at or teaching patients in terms of psychologic support in RA patients
- We need to evaluate if they have family or a support system– this dx can be upsetting
- finical planning
- Consider community resources
- Self- help groups
- Strategies to decrease depression. due to limited function and fatigue, loss of self-esteem, altered body image and fear of disability/deformity.
