Autoimmune disorders.RA, OA, Gout
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About This Presentation
Autoimmune disorders, rheumatoid arthritis, osteoarthritis, gout, gouty arthritis
Slide Content
Autoimmune Disorders:
Rheumatoid Arthritis, Osteoarthritis, &
Gouty Arthritis Gouty Arthritis
Maria Carmela L. Domocmat, RN, MSN
Instructor, Curative and Rehabilitative Nursing Care II
School of Nursing
Northern Luzon Adventist College
Rheumatoid Arthritis, Osteoarthritis, &
Gouty Arthritis Gouty Arthritis
Maria Carmela L. Domocmat, RN, MSN
Instructor, Curative and Rehabilitative Nursing Care II
School of Nursing
Northern Luzon Adventist College
Rheumatic Disorders
Comprise autoimmune and inflammatory
disorders
the primary crippling disease Inflammation of joint Inflammation of joint Primary reason for work-related disability Leading cause of disability among 65 yrs old
and above
Maria Carmela L. Domocmat, RN, MSN
Comprise autoimmune and inflammatory
disorders
the primary crippling disease Inflammation of joint Inflammation of joint Primary reason for work-related disability Leading cause of disability among 65 yrs old
and above
Maria Carmela L. Domocmat, RN, MSN
What causes autoimmune disease?
http://www.medscape.com/content/2000/00/40/87/408750/art-mrc4856.lymp.fig2.gif
Certain variants or mutations in the MHC genes may
result in abnormal MHC proteins
Maria Carmela L. Domocmat, RN, MSN
http://www.medscape.com/content/2000/00/40/87/408750/art-mrc4856.lymp.fig2.gif
Certain variants or mutations in the MHC genes may
result in abnormal MHC proteins
Maria Carmela L. Domocmat, RN, MSN
Reaction to Self
Occurs when the immune system sees self
antigens as nonself
may be due to genetic factors, infectious agents, may be due to genetic factors, infectious agents, gender, and age the autoimmune response results in tissue
damage
Some damage occurs in only one or a few organs, in
other cases it may be body-wide (systemic)
Maria Carmela L. Domocmat, RN, MSN
Occurs when the immune system sees self
antigens as nonself
may be due to genetic factors, infectious agents, may be due to genetic factors, infectious agents, gender, and age the autoimmune response results in tissue
damage
Some damage occurs in only one or a few organs, in
other cases it may be body-wide (systemic)
Maria Carmela L. Domocmat, RN, MSN
Reaction to Self
~ 3.5 % of people have autoimmune diseases
On average, women are 2.7 times more likely to
develop these diseases than men
most have no known cause or cure treatment is aimed at controlling symptoms
Maria Carmela L. Domocmat, RN, MSN
~ 3.5 % of people have autoimmune diseases
On average, women are 2.7 times more likely to
develop these diseases than men
most have no known cause or cure treatment is aimed at controlling symptoms
Maria Carmela L. Domocmat, RN, MSN
Why does the immune system attack the body that
its supposed to protect?
failure to recognize some cells as self
in rheumatic fever, the streptococcus antigen is ve ry similar to a
protein in heart tissue, so the body mistakenly ide ntifies heart
tissues as foreign
cells seen as foreign are attacked and destroyed cells seen as foreign are attacked and destroyed
may be only a few select cells or organs (organ-spe cific) e.g.,
multiple sclerosis, juvenile diabetes, rheumatic fe ver
may be systemic - e.g., systemic lupus erythematosu s, rheumatoid
arthritis
Maria Carmela L. Domocmat, RN, MSN
its supposed to protect?
failure to recognize some cells as self
in rheumatic fever, the streptococcus antigen is ve ry similar to a
protein in heart tissue, so the body mistakenly ide ntifies heart
tissues as foreign
cells seen as foreign are attacked and destroyed cells seen as foreign are attacked and destroyed
may be only a few select cells or organs (organ-spe cific) e.g.,
multiple sclerosis, juvenile diabetes, rheumatic fe ver
may be systemic - e.g., systemic lupus erythematosu s, rheumatoid
arthritis
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid Arthritis (RA)
chronic systemic autoimmune disease
-anti-self antibodies that react with the constant r egions of other
antibodies (
rheumatoid factor
)
onset of disease occurs most often between the ages of
25-55
women are 3 times more likely to develop this than men women are 3 times more likely to develop this than men
symptoms include weakness, fatigue, and joint pain infections, hormones and genetic factors may be involved
X-ray shows severe arthritis
affecting the joints and
limiting mobility
Maria Carmela L. Domocmat, RN, MSN
chronic systemic autoimmune disease
-anti-self antibodies that react with the constant r egions of other
antibodies (
rheumatoid factor
)
onset of disease occurs most often between the ages of
25-55
women are 3 times more likely to develop this than men women are 3 times more likely to develop this than men
symptoms include weakness, fatigue, and joint pain infections, hormones and genetic factors may be involved
X-ray shows severe arthritis
affecting the joints and
limiting mobility
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid arthritis (RA)affects peripheral
joints and may cause destruction of both cartilage
and bone. The disease affects mainly individuals
carrying the
DR4 variant of MHC
genes.
Maria Carmela L. Domocmat, RN, MSN
joints and may cause destruction of both cartilage
and bone. The disease affects mainly individuals
carrying the
DR4 variant of MHC
genes.
Maria Carmela L. Domocmat, RN, MSN
Treatment
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
ACR Clinical Classification
Criteria for Rheumatoid Arthritis using history, physical examination, laboratory
and radiographic findings:
Maria Carmela L. Domocmat, RN, MSN
Criteria for Rheumatoid Arthritis using history, physical examination, laboratory
and radiographic findings:
Maria Carmela L. Domocmat, RN, MSN
ACR Clinical Classification
Criteria for Rheumatoid Arthritis
Maria Carmela L. Domocmat, RN, MSN
Criteria for Rheumatoid Arthritis
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
ACR Clinical Classification Criteria
for Juvenile Rheumatoid Arthritis
GENERAL CLASS
a. Persistent arthritis of at least six weeks durat ion
in one or more joints
b. Exclusion of other causes of arthritis (see list of
exclusions+) exclusions+) onset subtypes-determined by manifestations
during the first six months of disease although
manifestations more closely resembling another
subtype may appear later
Maria Carmela L. Domocmat, RN, MSN
for Juvenile Rheumatoid Arthritis
GENERAL CLASS
a. Persistent arthritis of at least six weeks durat ion
in one or more joints
b. Exclusion of other causes of arthritis (see list of
exclusions+) exclusions+) onset subtypes-determined by manifestations
during the first six months of disease although
manifestations more closely resembling another
subtype may appear later
Maria Carmela L. Domocmat, RN, MSN
ACR Classification Criteria for
Determining Progression of
Rheumatoid Arthritis
*These criteria describe either spontaneous remissi on
or a state of drug-induced disease suppression.
Rheumatoid Arthritis
Determining Progression of
Rheumatoid Arthritis
*These criteria describe either spontaneous remissi on
or a state of drug-induced disease suppression.
Rheumatoid Arthritis
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
http://img.medscape.com/slide/migrated/editorial/c
mecircle/2004/3415/images/moreland/slide07.gif
Maria Carmela L. Domocmat, RN, MSN
mecircle/2004/3415/images/moreland/slide07.gif
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Initial Laboratory work-up
Complete blood count Comprehensive metabolic panel Urinalysis Sedimentation Rate Sedimentation Rate Rheumatoid Factor Anti-nuclear Antibody
Maria Carmela L. Domocmat, RN, MSN
Complete blood count Comprehensive metabolic panel Urinalysis Sedimentation Rate Sedimentation Rate Rheumatoid Factor Anti-nuclear Antibody
Maria Carmela L. Domocmat, RN, MSN
Chemistries
normal with the exception of a slight decrease in albumin
and increase in total protein reflecting the chroni c
inflammatory process.
Renal and liver function should be checked prior
to instituting therapy.
Maria Carmela L. Domocmat, RN, MSN
normal with the exception of a slight decrease in albumin
and increase in total protein reflecting the chroni c
inflammatory process.
Renal and liver function should be checked prior
to instituting therapy.
Maria Carmela L. Domocmat, RN, MSN
Hematology
mild anemia with hematocrit values in the range of 30 - 34%
occurs in approximately 25 to 35% of patients In most cases, the reduced red cell mass is caused by the anemia of chronic
disease, a normocytic-normochromic process characterized by a low concentration
of serum iron, a low serum iron-binding capacity, a nd a normal or increased serum
ferritin concentration.
occasionally true iron deficiency anemia can develo p secondary to
intercurrent
occasionally true iron deficiency anemia can develo p secondary to
intercurrent
blood loss often from gastrointestinal (GI) bleedin g due to NSAIDS.
Patients should be monitored closely for symptoms o f GI bleeding and
consideration must also be given to other causes of GI blood loss such
as colonic lesions.
Maria Carmela L. Domocmat, RN, MSN
mild anemia with hematocrit values in the range of 30 - 34%
occurs in approximately 25 to 35% of patients In most cases, the reduced red cell mass is caused by the anemia of chronic
disease, a normocytic-normochromic process characterized by a low concentration
of serum iron, a low serum iron-binding capacity, a nd a normal or increased serum
ferritin concentration.
occasionally true iron deficiency anemia can develo p secondary to
intercurrent
occasionally true iron deficiency anemia can develo p secondary to
intercurrent
blood loss often from gastrointestinal (GI) bleedin g due to NSAIDS.
Patients should be monitored closely for symptoms o f GI bleeding and
consideration must also be given to other causes of GI blood loss such
as colonic lesions.
Maria Carmela L. Domocmat, RN, MSN
white cell count platelet count
usually normal can be mildly elevated secondary to
usually normal but thrombocytosis occurs in response to
Hematology
secondary to inflammation.
occurs in response to inflammation. Drug reactions and
Felty'ssyndrome are rare
causes of leukopeniaor
thrombocytopenia
Maria Carmela L. Domocmat, RN, MSN
usually normal can be mildly elevated secondary to
usually normal but thrombocytosis occurs in response to
Hematology
secondary to inflammation.
occurs in response to inflammation. Drug reactions and
Felty'ssyndrome are rare
causes of leukopeniaor
thrombocytopenia
Maria Carmela L. Domocmat, RN, MSN
Hematology
Increased erythrocyte sedimentation rate (ESR)
Maria Carmela L. Domocmat, RN, MSN
Increased erythrocyte sedimentation rate (ESR)
Maria Carmela L. Domocmat, RN, MSN
Serology
(+) RF Rheumatoid factors
are autoantibodies directed against IgG
A positive test for rheumatoid factor (RF) A positive test for rheumatoid factor (RF)
pathognomonicof rheumatoid arthritis
Maria Carmela L. Domocmat, RN, MSN
(+) RF Rheumatoid factors
are autoantibodies directed against IgG
A positive test for rheumatoid factor (RF) A positive test for rheumatoid factor (RF)
pathognomonicof rheumatoid arthritis
Maria Carmela L. Domocmat, RN, MSN
Radiology
early in the disease
show nothing other than soft tissue swelling.
periarticularosteopeniamay develop. With progression of disease With progression of disease
narrowing of the joint space is caused by loss of
cartilage, and juxta-articular erosions appear, general ly
at the point of attachment of the synovium.
end-stage disease
large cystic erosions of bone may be seen. Bony
proliferation may occur because of degenerative
changes that follow inflammation
.
Maria Carmela L. Domocmat, RN, MSN
early in the disease
show nothing other than soft tissue swelling.
periarticularosteopeniamay develop. With progression of disease With progression of disease
narrowing of the joint space is caused by loss of
cartilage, and juxta-articular erosions appear, general ly
at the point of attachment of the synovium.
end-stage disease
large cystic erosions of bone may be seen. Bony
proliferation may occur because of degenerative
changes that follow inflammation
.
Maria Carmela L. Domocmat, RN, MSN
Clinical manifestations
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
http://nobelprize.org/medicine/laureates/1996/illpre s/implications.html
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Typical visible changes
include ulnar deviation of
the fingers at the MCP
joints, hyperextension or
hyperflexion of the MCP
and PIP joints, flexion and PIP joints, flexion contractures of the
elbows, and subluxation
of the carpal bones and
toes (cocked -up).
Maria Carmela L. Domocmat, RN, MSN
include ulnar deviation of
the fingers at the MCP
joints, hyperextension or
hyperflexion of the MCP
and PIP joints, flexion and PIP joints, flexion contractures of the
elbows, and subluxation
of the carpal bones and
toes (cocked -up).
Maria Carmela L. Domocmat, RN, MSN
Extra-Articular Disease
Rheumatoid Nodules Cardiopulmonary Disease Ocular Disease Neurologic Disease Neurologic Disease Felty's Syndrome Rheumatoid Vasculitis Sjogren's Syndrome
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid Nodules Cardiopulmonary Disease Ocular Disease Neurologic Disease Neurologic Disease Felty's Syndrome Rheumatoid Vasculitis Sjogren's Syndrome
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid Nodules
subcutaneous nodule
the most characteristic extra-articular lesion of the
disease.
occur in 20 to 30% of cases, almost exclusively in seropositive
patients.
seropositive
patients.
located most commonly on the extensor surfaces of the
arms and elbows but are also prone to develop at
pressure points on the feet and knees.
Maria Carmela L. Domocmat, RN, MSN
subcutaneous nodule
the most characteristic extra-articular lesion of the
disease.
occur in 20 to 30% of cases, almost exclusively in seropositive
patients.
seropositive
patients.
located most commonly on the extensor surfaces of the
arms and elbows but are also prone to develop at
pressure points on the feet and knees.
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid Nodules
http://images.rheumatology.org/vi ewphoto.php?imageId=3011201 &albumId=75692
Maria Carmela L. Domocmat, RN, MSN
http://images.rheumatology.org/vi ewphoto.php?imageId=3011201 &albumId=75692
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid Nodules
Rheumatoid nodules
commonly form near the
extensor surface of the
elbow. They can be fixed
to the underlying to the underlying periosteum or can be
freely mobile.
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid nodules
commonly form near the
extensor surface of the
elbow. They can be fixed
to the underlying to the underlying periosteum or can be
freely mobile.
Maria Carmela L. Domocmat, RN, MSN
CaplansSyndrome
Presence of rheumatoid nodules in lungs
pneumococcus(noted in among coal miners and
asbestos workers)
http://images.rheumatology.
org/image_dir/album75692/
md_99-05-0096_1.tif.jpg
Maria Carmela L. Domocmat, RN, MSN
Presence of rheumatoid nodules in lungs
pneumococcus(noted in among coal miners and
asbestos workers)
http://images.rheumatology.
org/image_dir/album75692/
md_99-05-0096_1.tif.jpg
Maria Carmela L. Domocmat, RN, MSN
Cardiopulmonary Disease
There are several pulmonary manifestations of
rheumatoid arthritis,
including pleurisy with or without effusion, intrapulmonary nodules, intrapulmonary nodules, rheumatoid pneumoconiosis (Caplan's syndrome), diffuse interstitial fibrosis, and rarely, bronchiolitis obliterans pneumothorax.
Maria Carmela L. Domocmat, RN, MSN
There are several pulmonary manifestations of
rheumatoid arthritis,
including pleurisy with or without effusion, intrapulmonary nodules, intrapulmonary nodules, rheumatoid pneumoconiosis (Caplan's syndrome), diffuse interstitial fibrosis, and rarely, bronchiolitis obliterans pneumothorax.
Maria Carmela L. Domocmat, RN, MSN
Cardiopulmonary Disease
On pulmonary function testing,
there commonly is a restrictive ventilatory defect with
reduced lung volumes and a decreased diffusing
capacity for carbon monoxide.
Although mostly asymptomatic, of greatest Although mostly asymptomatic, of greatest concern is distinguishing these manifestations
from infection and tumor.
Pericarditis is the most common cardiac
manifestation.
Maria Carmela L. Domocmat, RN, MSN
On pulmonary function testing,
there commonly is a restrictive ventilatory defect with
reduced lung volumes and a decreased diffusing
capacity for carbon monoxide.
Although mostly asymptomatic, of greatest Although mostly asymptomatic, of greatest concern is distinguishing these manifestations
from infection and tumor.
Pericarditis is the most common cardiac
manifestation.
Maria Carmela L. Domocmat, RN, MSN
Neurologic Disease
most common -is a mild, primarily sensory
peripheral neuropathy, usually more marked in the
lower extremities.
Entrapment neuropathies (e.g., carpal tunnel syndrome and tarsal tunnel syndrome) sometimes syndrome and tarsal tunnel syndrome) sometimes occur because of compression of a peripheral
nerve by inflamed edematous tissue.
Maria Carmela L. Domocmat, RN, MSN
most common -is a mild, primarily sensory
peripheral neuropathy, usually more marked in the
lower extremities.
Entrapment neuropathies (e.g., carpal tunnel syndrome and tarsal tunnel syndrome) sometimes syndrome and tarsal tunnel syndrome) sometimes occur because of compression of a peripheral
nerve by inflamed edematous tissue.
Maria Carmela L. Domocmat, RN, MSN
Neurologic Disease
Cervical myelopathy secondary to atlantoaxial
subluxation is an uncommon but particularly
worrisome complication potentially causing
permanent, even fatal neurologic damage.
Maria Carmela L. Domocmat, RN, MSN
Cervical myelopathy secondary to atlantoaxial
subluxation is an uncommon but particularly
worrisome complication potentially causing
permanent, even fatal neurologic damage.
Maria Carmela L. Domocmat, RN, MSN
Felty'sSyndrome
is characterized by
splenomegaly leukopenia-predominantly granulocytopenia.
rare complication Recurrent bacterial infections and chronic
refractory leg ulcers are the major complications.
Maria Carmela L. Domocmat, RN, MSN
is characterized by
splenomegaly leukopenia-predominantly granulocytopenia.
rare complication Recurrent bacterial infections and chronic
refractory leg ulcers are the major complications.
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid Vasculitis
most common clinical manifestations are small
digital infarcts along the nailbeds.
Maria Carmela L. Domocmat, RN, MSN
most common clinical manifestations are small
digital infarcts along the nailbeds.
Maria Carmela L. Domocmat, RN, MSN
Sjogren'sSyndrome
a chronic inflammatory disorder characterized by
lymphocytic infiltration of lacrimal and salivary
glands.
leads to impaired secretion of saliva and tears and results in the
sicca
complex:
results in the
sicca
complex:
dry mouth (xerostomia) dry eyes (keratoconjunctivitissicca) dry vagina (rare)
Maria Carmela L. Domocmat, RN, MSN
a chronic inflammatory disorder characterized by
lymphocytic infiltration of lacrimal and salivary
glands.
leads to impaired secretion of saliva and tears and results in the
sicca
complex:
results in the
sicca
complex:
dry mouth (xerostomia) dry eyes (keratoconjunctivitissicca) dry vagina (rare)
Maria Carmela L. Domocmat, RN, MSN
Criteria for Diagnosis of
Sjögren'sSyndrome
Four or
more of
the
following following criteria
must be
present
Maria Carmela L. Domocmat, RN, MSN
Sjögren'sSyndrome
Four or
more of
the
following following criteria
must be
present
Maria Carmela L. Domocmat, RN, MSN
Ocular Disease
Keratoconjunctivitisof Sjogren'ssyndrome is the
most common ocular manifestation of rheumatoid
arthritis.
Sicca(dry eyes) is a common complaint.
Episcleritisoccurs occasionally and is manifested
by mild pain and intense redness of the affected
eye.
Scleritisand corneal ulcerations are rare but more
serious problems.
Maria Carmela L. Domocmat, RN, MSN
Keratoconjunctivitisof Sjogren'ssyndrome is the
most common ocular manifestation of rheumatoid
arthritis.
Sicca(dry eyes) is a common complaint.
Episcleritisoccurs occasionally and is manifested
by mild pain and intense redness of the affected
eye.
Scleritisand corneal ulcerations are rare but more
serious problems.
Maria Carmela L. Domocmat, RN, MSN
Keratoconjunctivitis, Sicca
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
PROGNOSIS
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Disability is higher among patients with
rheumatoid arthritis with 60% being unable to
work 10 years after the onset of their disease.
Recent studies have demonstrated an increased mortality in rheumatoid patients. mortality in rheumatoid patients. Median life expectancy was shortened an average
of 7 years for men and 3 years for women
compared to control populations.
Maria Carmela L. Domocmat, RN, MSN
rheumatoid arthritis with 60% being unable to
work 10 years after the onset of their disease.
Recent studies have demonstrated an increased mortality in rheumatoid patients. mortality in rheumatoid patients. Median life expectancy was shortened an average
of 7 years for men and 3 years for women
compared to control populations.
Maria Carmela L. Domocmat, RN, MSN
Patients at higher risk for shortened survival are
those with
systemic extra-articular involvement, low functional capacity, low socioeconomic status, low socioeconomic status, low education, and prednisone use.
Maria Carmela L. Domocmat, RN, MSN
those with
systemic extra-articular involvement, low functional capacity, low socioeconomic status, low socioeconomic status, low education, and prednisone use.
Maria Carmela L. Domocmat, RN, MSN
ACR Guidelines for Medical
Management of Rheumatoid
Arthritis
(updated April, 2002)
Arthritis
Management of Rheumatoid
Arthritis
(updated April, 2002)
Arthritis
Maria Carmela L. Domocmat, RN, MSN
http://rezidentiat.3x.ro/eng/pareng.files/image015. gif
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Management Maria Carmela L. Domocmat, RN, MSN
The goal of treatmentnow aims toward
achieving the
lowest possible level of arthritis disease activity
and remission if possible,
the minimization of joint damage, and enhancing physical function and quality of life.
Maria Carmela L. Domocmat, RN, MSN
achieving the
lowest possible level of arthritis disease activity
and remission if possible,
the minimization of joint damage, and enhancing physical function and quality of life.
Maria Carmela L. Domocmat, RN, MSN
R
Reduce pain and inflammation
R
Protect Articular surface
›
Reduction of joint stress
R
Maintain function
R
Maintain function
›
ROM exercises
›
Physical and occupational therapy
R
Surgical intervention
Maria Carmela L. Domocmat, RN, MSN
Reduce pain and inflammation
R
Protect Articular surface
›
Reduction of joint stress
R
Maintain function
R
Maintain function
›
ROM exercises
›
Physical and occupational therapy
R
Surgical intervention
Maria Carmela L. Domocmat, RN, MSN
REDUCE PAIN AND
INFLAMMATION
Maria Carmela L. Domocmat, RN, MSN
INFLAMMATION
Maria Carmela L. Domocmat, RN, MSN
Pharmacologic treatment
1. Non-steroidal Anti-inflammatory Agents
(NSAIDs)
2. Corticosteroids
3.
Disease Modifying Anti
-
rheumatic Drugs
3.
Disease Modifying Anti
-
rheumatic Drugs
(DMARDs)
Maria Carmela L. Domocmat, RN, MSN
1. Non-steroidal Anti-inflammatory Agents
(NSAIDs)
2. Corticosteroids
3.
Disease Modifying Anti
-
rheumatic Drugs
3.
Disease Modifying Anti
-
rheumatic Drugs
(DMARDs)
Maria Carmela L. Domocmat, RN, MSN
http://www.medscape.com/content/2004/00/48/77/487710/art-487710.fig9.jpg
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
NSAIDs and corticosteroids
have a short onset of action while DMARDs can
take several weeks or months to demonstrate a
clinical effect
Maria Carmela L. Domocmat, RN, MSN
have a short onset of action while DMARDs can
take several weeks or months to demonstrate a
clinical effect
Maria Carmela L. Domocmat, RN, MSN
NON-STEROIDAL ANTI-
INFLAMMATORY AGENTS
(NSAIDS)
Maria Carmela L. Domocmat, RN, MSN
INFLAMMATORY AGENTS
(NSAIDS)
Maria Carmela L. Domocmat, RN, MSN
NSAIDs
major effect -reduce acute inflammationthereby
decreasing pain and improving function.
have mild to moderate analgesicproperties
independent of their anti-inflammatory effect.
Note: these drugs alone do not change the course
of the disease of rheumatoid arthritis or prevent
joint destruction.
Maria Carmela L. Domocmat, RN, MSN
major effect -reduce acute inflammationthereby
decreasing pain and improving function.
have mild to moderate analgesicproperties
independent of their anti-inflammatory effect.
Note: these drugs alone do not change the course
of the disease of rheumatoid arthritis or prevent
joint destruction.
Maria Carmela L. Domocmat, RN, MSN
OTC NSAIDs
Aspirin ibuprofen
(
Advil
®, Motrin®, Nuprin®)
naproxen
(Alleve®,
Flanax
)
ketoprofen
(
Actron
,
Orudis
KT)
ketoprofen
(
Actron
,
Orudis
KT)
Maria Carmela L. Domocmat, RN, MSN
Aspirin ibuprofen
(
Advil
®, Motrin®, Nuprin®)
naproxen
(Alleve®,
Flanax
)
ketoprofen
(
Actron
,
Orudis
KT)
ketoprofen
(
Actron
,
Orudis
KT)
Maria Carmela L. Domocmat, RN, MSN
Aspirin -oldest drug of the non-steroidal class
but because of its high rate of GI toxicity, a narrow
window between toxic and anti-inflammatory serum
levels, and the inconvenience of multiple daily doses,
aspirin's use as the initial choice of drug therapy aspirin's use as the initial choice of drug therapy has largely been replaced by other NSAIDs.
Maria Carmela L. Domocmat, RN, MSN
but because of its high rate of GI toxicity, a narrow
window between toxic and anti-inflammatory serum
levels, and the inconvenience of multiple daily doses,
aspirin's use as the initial choice of drug therapy aspirin's use as the initial choice of drug therapy has largely been replaced by other NSAIDs.
Maria Carmela L. Domocmat, RN, MSN
Prescription NSAIDs include
meloxicam(Mobic®), etodolac(Lodine®), nabumetone(Relafen®), sulindac(Clinoril®), tolementin
(
Tolectin
®),
diclofenac(Cataflam®,
Voltaren®, Arthrotec®),
diflusinal(Dolobid®), indomethicin(Indocin®), ketoprofen
(
Orudis
®,
tolementin
(
Tolectin
®),
cholinemagnesium
salicylate (Trilasate®),
flurbiprofen(Ansaid), dexibuprofen(Seractil)
ketoprofen
(
Orudis
®,
Oruvail®), oxaprozin(Daypro®), piroxicam (Feldene®).
Maria Carmela L. Domocmat, RN, MSN
meloxicam(Mobic®), etodolac(Lodine®), nabumetone(Relafen®), sulindac(Clinoril®), tolementin
(
Tolectin
®),
diclofenac(Cataflam®,
Voltaren®, Arthrotec®),
diflusinal(Dolobid®), indomethicin(Indocin®), ketoprofen
(
Orudis
®,
tolementin
(
Tolectin
®),
cholinemagnesium
salicylate (Trilasate®),
flurbiprofen(Ansaid), dexibuprofen(Seractil)
ketoprofen
(
Orudis
®,
Oruvail®), oxaprozin(Daypro®), piroxicam (Feldene®).
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Drugs for Prevention NSAID-
Induced Ulcers
If NSAID-induced ulcers are identified, the
following steps have been suggested:
Switch to alternative pain relievers.
proton-pump inhibitors (PPIs). misoprostolor Arthrotec. L-arginine
If cannot change drugs, then should use lowest
NSAID dose possible
Maria Carmela L. Domocmat, RN, MSN
Induced Ulcers
If NSAID-induced ulcers are identified, the
following steps have been suggested:
Switch to alternative pain relievers.
proton-pump inhibitors (PPIs). misoprostolor Arthrotec. L-arginine
If cannot change drugs, then should use lowest
NSAID dose possible
Maria Carmela L. Domocmat, RN, MSN
Drugs for Prevention NSAID-
Induced Ulcers
proton-pump inhibitors (PPIs).
Can reduce NSAID-ulcer rates by as much as 80%
compared with no treatment.
omeprazole(Prilosec) esomeprazole
(
Nexium
)
esomeprazole
(
Nexium
)
lansoprazole(Prevacid), rabeprazole(Aciphex), pantoprozole(Protonix).
Maria Carmela L. Domocmat, RN, MSN
Induced Ulcers
proton-pump inhibitors (PPIs).
Can reduce NSAID-ulcer rates by as much as 80%
compared with no treatment.
omeprazole(Prilosec) esomeprazole
(
Nexium
)
esomeprazole
(
Nexium
)
lansoprazole(Prevacid), rabeprazole(Aciphex), pantoprozole(Protonix).
Maria Carmela L. Domocmat, RN, MSN
Drugs for Prevention NSAID-
Induced Ulcers
Try misoprostolor Arthrotec.
If other agents are inappropriate, misoprostol prote cts against
the major intestinal toxicity of NSAIDs.
the first drug approved for preventing NSAID-induce d ulcers. It is equally or even more effective than some of t he PPIs, but it does not heal existing ulcers and has more side eff ects than does not heal existing ulcers and has more side eff ects than PPIs. Patients tend to stop using it.
Arthrotec -a combination of an ulcer protective
agent called misoprostoland the NSAID
diclofenac.
Maria Carmela L. Domocmat, RN, MSN
Induced Ulcers
Try misoprostolor Arthrotec.
If other agents are inappropriate, misoprostol prote cts against
the major intestinal toxicity of NSAIDs.
the first drug approved for preventing NSAID-induce d ulcers. It is equally or even more effective than some of t he PPIs, but it does not heal existing ulcers and has more side eff ects than does not heal existing ulcers and has more side eff ects than PPIs. Patients tend to stop using it.
Arthrotec -a combination of an ulcer protective
agent called misoprostoland the NSAID
diclofenac.
Maria Carmela L. Domocmat, RN, MSN
L-arginine supplement
an amino acid found in health stores may help protect against damage from NSAIDs. an alternative agent not government regulated and more research is
needed to confirm its benefits.
Maria Carmela L. Domocmat, RN, MSN
an amino acid found in health stores may help protect against damage from NSAIDs. an alternative agent not government regulated and more research is
needed to confirm its benefits.
Maria Carmela L. Domocmat, RN, MSN
Topical NSAIDs
delivered in gels, creams, or patches are proving
to reduce arthritic pain and pose less of a risk fo r
gastrointestinal complications associated with
oral NSAIDs.
diclofenac(Pennsaid, OxaSat) eltenac, ibuprofen, or ketoprofen.
Maria Carmela L. Domocmat, RN, MSN
delivered in gels, creams, or patches are proving
to reduce arthritic pain and pose less of a risk fo r
gastrointestinal complications associated with
oral NSAIDs.
diclofenac(Pennsaid, OxaSat) eltenac, ibuprofen, or ketoprofen.
Maria Carmela L. Domocmat, RN, MSN
$63.07
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
NSAIDS: COX-2 inhibitor
includes COX-2 inhibitors also effective in controlling inflammation. Only one of these agents is currently available in the United States (
celecoxib
, Celebrex
®) while
the United States (
celecoxib
, Celebrex
®) while
additional compounds are available in other
countries (etoricoxib, Arcoxia®; lumiracoxib,
Prexige®).
Maria Carmela L. Domocmat, RN, MSN
includes COX-2 inhibitors also effective in controlling inflammation. Only one of these agents is currently available in the United States (
celecoxib
, Celebrex
®) while
the United States (
celecoxib
, Celebrex
®) while
additional compounds are available in other
countries (etoricoxib, Arcoxia®; lumiracoxib,
Prexige®).
Maria Carmela L. Domocmat, RN, MSN
or COX-2 medications
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
COX-2 inhibitors
designed to decrease the gastrointestinal risk of
NSAIDS,
but concerns of possible increases in but concerns of possible increases in cardiovascular risk with these agents has led to
the withdrawal of two of these drugs from the
market (rofecoxib, Vioxx®; valdecoxib, Bextra®).
Maria Carmela L. Domocmat, RN, MSN
designed to decrease the gastrointestinal risk of
NSAIDS,
but concerns of possible increases in but concerns of possible increases in cardiovascular risk with these agents has led to
the withdrawal of two of these drugs from the
market (rofecoxib, Vioxx®; valdecoxib, Bextra®).
Maria Carmela L. Domocmat, RN, MSN
CORTICOSTEROIDS
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Corticosteroids
anti-inflammatory & immunoregulatoryactivity. PO, IV, IM or can be injected directly into the joi nt. useful in early disease as temporary adjunctive therapy while waiting for DMARDs to exert their therapy while waiting for DMARDs to exert their antiinflammatoryeffects.
Maria Carmela L. Domocmat, RN, MSN
anti-inflammatory & immunoregulatoryactivity. PO, IV, IM or can be injected directly into the joi nt. useful in early disease as temporary adjunctive therapy while waiting for DMARDs to exert their therapy while waiting for DMARDs to exert their antiinflammatoryeffects.
Maria Carmela L. Domocmat, RN, MSN
Corticosteroids
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Corticosteroids
also useful as chronic adjunctive therapy in
patients with severe disease that is not well
controlled on NSAIDs and DMARDs.
Weight gain and a cushingoid appearance (increased fat deposition around the face, redness
of the cheeks, development of a buffalo hump
over the neck) is a frequent problem and source of
patient complaints
Maria Carmela L. Domocmat, RN, MSN
also useful as chronic adjunctive therapy in
patients with severe disease that is not well
controlled on NSAIDs and DMARDs.
Weight gain and a cushingoid appearance (increased fat deposition around the face, redness
of the cheeks, development of a buffalo hump
over the neck) is a frequent problem and source of
patient complaints
Maria Carmela L. Domocmat, RN, MSN
cushingoid appearance
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Prevent osteoporosis due to steroid
use
adequate calcium and vitamin D supplementation Bisphosphonates
alendronate(Fosamax®) risedronate(Actonel®) ibandronate(Boniva®)
Patients with and without osteoporosis risk factors
on low dose prednisone should undergo bone
densitometry (DEXA Scan) to assess fracture risk.
Maria Carmela L. Domocmat, RN, MSN
use
adequate calcium and vitamin D supplementation Bisphosphonates
alendronate(Fosamax®) risedronate(Actonel®) ibandronate(Boniva®)
Patients with and without osteoporosis risk factors
on low dose prednisone should undergo bone
densitometry (DEXA Scan) to assess fracture risk.
Maria Carmela L. Domocmat, RN, MSN
Intra-articular corticosteroids
(e.g., triamcinoloneor
methylprednisoloneand others) are effective for controlling a local
flare in a joint without changing the flare in a joint without changing the overall drug regimen.
Maria Carmela L. Domocmat, RN, MSN
(e.g., triamcinoloneor
methylprednisoloneand others) are effective for controlling a local
flare in a joint without changing the flare in a joint without changing the overall drug regimen.
Maria Carmela L. Domocmat, RN, MSN
http://www.mayoclinicproceedings.com/con tent/84/9/831.full
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
DISEASE MODIFYING ANTI-
RHEUMATIC DRUGS
(DMARDS)
Maria Carmela L. Domocmat, RN, MSN
RHEUMATIC DRUGS
(DMARDS)
Maria Carmela L. Domocmat, RN, MSN
Disease Modifying Anti-rheumatic
Drugs (DMARDs)
Can alter the disease course and improve
radiographic outcomes.
DMARDs have an effect upon rheumatoid arthritis
that is different and may be more delayed in onset
than either NSAIDs or corticosteroids. than either NSAIDs or corticosteroids. when the diagnosis of rheumatoid arthritis is
confirmed, DMARD agents should be started.
Maria Carmela L. Domocmat, RN, MSN
Drugs (DMARDs)
Can alter the disease course and improve
radiographic outcomes.
DMARDs have an effect upon rheumatoid arthritis
that is different and may be more delayed in onset
than either NSAIDs or corticosteroids. than either NSAIDs or corticosteroids. when the diagnosis of rheumatoid arthritis is
confirmed, DMARD agents should be started.
Maria Carmela L. Domocmat, RN, MSN
DMARDs
Methotrexate(Rheumatrex®, Trexall®) Hydroxychloroquine(Plaquenil®) Sulfasalazine(Azulfidine®) Leflunomide
(
Arava
®)
Leflunomide
(
Arava
®)
Tumor Necrosis Factor Inhibitors
etanercept(Enbrel®, adalimumab(Humira®), and infliximab(Remicade®)
T-cell CostimulatoryBlocking Agents
abatacept(Orencia®)
Maria Carmela L. Domocmat, RN, MSN
Methotrexate(Rheumatrex®, Trexall®) Hydroxychloroquine(Plaquenil®) Sulfasalazine(Azulfidine®) Leflunomide
(
Arava
®)
Leflunomide
(
Arava
®)
Tumor Necrosis Factor Inhibitors
etanercept(Enbrel®, adalimumab(Humira®), and infliximab(Remicade®)
T-cell CostimulatoryBlocking Agents
abatacept(Orencia®)
Maria Carmela L. Domocmat, RN, MSN
DMARDs
B cell Depleting Agents
rituximab (Rituxan®)
Interleukin-1 (IL-1) Receptor Antagonist Therapy
anakinra (Kineret®)
Intramuscular Gold Other Immunomodulatory and Cytotoxic agents
azathioprine (Imuran®), cyclophosphamide, and cyclosporine A(Neoral®, Sandimmune®)
Maria Carmela L. Domocmat, RN, MSN
B cell Depleting Agents
rituximab (Rituxan®)
Interleukin-1 (IL-1) Receptor Antagonist Therapy
anakinra (Kineret®)
Intramuscular Gold Other Immunomodulatory and Cytotoxic agents
azathioprine (Imuran®), cyclophosphamide, and cyclosporine A(Neoral®, Sandimmune®)
Maria Carmela L. Domocmat, RN, MSN
Methotrexate
the first-line DMARD agent Has rapid onset of action at therapeutic doses (6-
8 weeks)
good efficacy good efficacy favorable toxicity profile ease of administration and relatively low cost.
Maria Carmela L. Domocmat, RN, MSN
the first-line DMARD agent Has rapid onset of action at therapeutic doses (6-
8 weeks)
good efficacy good efficacy favorable toxicity profile ease of administration and relatively low cost.
Maria Carmela L. Domocmat, RN, MSN
http://www.muabannhadat123.com/forum/showthread.php?p=3477
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Hydroxychloroquine
an antimalarialdrug relatively safe and well-tolerated agent for the
treatment of rheumatoid arthritis.
have limited ability to prevent joint damage on have limited ability to prevent joint damage on their own, their use should probably be limited to
patients with very mild and nonerosivedisease.
Maria Carmela L. Domocmat, RN, MSN
an antimalarialdrug relatively safe and well-tolerated agent for the
treatment of rheumatoid arthritis.
have limited ability to prevent joint damage on have limited ability to prevent joint damage on their own, their use should probably be limited to
patients with very mild and nonerosivedisease.
Maria Carmela L. Domocmat, RN, MSN
Hydroxychloroquine
is sometimes combined with methotrexate for
additive benefits for signs and symptoms or as
part of a regimen of
triple therapy
with
methotrexate and sulfasalazine.
Maria Carmela L. Domocmat, RN, MSN
is sometimes combined with methotrexate for
additive benefits for signs and symptoms or as
part of a regimen of
triple therapy
with
methotrexate and sulfasalazine.
Maria Carmela L. Domocmat, RN, MSN
Sulfasalazine
Azulfidine®
effectiveness -somewhat less than
that methotrexate,
reduce signs and symptoms and reduce signs and symptoms and slow radiographic damage. given in conjunction with
methotrexate and
hydroxychloroquineas part of a
regimen of triple therapy
Maria Carmela L. Domocmat, RN, MSN
Azulfidine®
effectiveness -somewhat less than
that methotrexate,
reduce signs and symptoms and reduce signs and symptoms and slow radiographic damage. given in conjunction with
methotrexate and
hydroxychloroquineas part of a
regimen of triple therapy
Maria Carmela L. Domocmat, RN, MSN
Leflunomide(Arava®)
efficacy is similar to methotrexate in terms of sig ns
and symptoms
viable alternative -failed or are intolerant to
methotrexate.
Maria Carmela L. Domocmat, RN, MSN
efficacy is similar to methotrexate in terms of sig ns
and symptoms
viable alternative -failed or are intolerant to
methotrexate.
Maria Carmela L. Domocmat, RN, MSN
Tumor necrosis factor (TNF)
inhibitors Tumor necrosis factor alpha (TNF)
is a pro-inflammatory cytokine produced by
macrophages and lymphocytes.
found in large quantities in the rheumatoid joint an d is produced locally in the joint by synovial macrophages produced locally in the joint by synovial macrophages and lymphocytes infiltrating the joint synovium. TNF is one of the critical cytokines that mediate joint
damage and destruction due to its activities on many
cells in the joint as well as effects on other organs and
body systems.
Maria Carmela L. Domocmat, RN, MSN
inhibitors Tumor necrosis factor alpha (TNF)
is a pro-inflammatory cytokine produced by
macrophages and lymphocytes.
found in large quantities in the rheumatoid joint an d is produced locally in the joint by synovial macrophages produced locally in the joint by synovial macrophages and lymphocytes infiltrating the joint synovium. TNF is one of the critical cytokines that mediate joint
damage and destruction due to its activities on many
cells in the joint as well as effects on other organs and
body systems.
Maria Carmela L. Domocmat, RN, MSN
TNF antagonists
first of the biological DMARDS to be approved for
the treatment of RA and
have also been referred to as
biological
response modifiers or biologics
to
differentiate them from other DMARDS such as differentiate them from other DMARDS such as methotrexate, leflunomide, or sulfasalazine.
Maria Carmela L. Domocmat, RN, MSN
first of the biological DMARDS to be approved for
the treatment of RA and
have also been referred to as
biological
response modifiers or biologics
to
differentiate them from other DMARDS such as differentiate them from other DMARDS such as methotrexate, leflunomide, or sulfasalazine.
Maria Carmela L. Domocmat, RN, MSN
TNFs or Biological Response
Modifiers (BRMs) Etanercept(Enbrel®) Infliximab(Remicade®) Adalimumab(Humira®)
Maria Carmela L. Domocmat, RN, MSN
Modifiers (BRMs) Etanercept(Enbrel®) Infliximab(Remicade®) Adalimumab(Humira®)
Maria Carmela L. Domocmat, RN, MSN
Etanercept(Enbrel®)
Etanercept is effective in reducing the signs and
symptoms of RA, as well as in slowing or halting
radiographic damage, when used either as
monotherapy or in combination with methotrexate.
Maria Carmela L. Domocmat, RN, MSN
Etanercept is effective in reducing the signs and
symptoms of RA, as well as in slowing or halting
radiographic damage, when used either as
monotherapy or in combination with methotrexate.
Maria Carmela L. Domocmat, RN, MSN
Infliximab(Remicade®)
Infliximab, in combination with methotrexate, is
approved for the treatment of RA, and for the
treatment of psoriatic arthritis, and ankylosing
spondylitis, as well as psoriasis and Crohns
disease. disease.
Maria Carmela L. Domocmat, RN, MSN
Infliximab, in combination with methotrexate, is
approved for the treatment of RA, and for the
treatment of psoriatic arthritis, and ankylosing
spondylitis, as well as psoriasis and Crohns
disease. disease.
Maria Carmela L. Domocmat, RN, MSN
Adalimumab(Humira®)
Adalimumab is a fully human anti-TNF monoclonal
antibody with high specificity for TNF.
Maria Carmela L. Domocmat, RN, MSN
Adalimumab is a fully human anti-TNF monoclonal
antibody with high specificity for TNF.
Maria Carmela L. Domocmat, RN, MSN
Anakinra(Kineret)
a human recombinant IL-1 receptor antagonist (hu
rIL-1ra)
can be used alone or in combination with
DMARDs other than TNF blocking agents
(
Etanercept
,
Infliximab
,
Adalimumab
).
(
Etanercept
,
Infliximab
,
Adalimumab
).
Maria Carmela L. Domocmat, RN, MSN
a human recombinant IL-1 receptor antagonist (hu
rIL-1ra)
can be used alone or in combination with
DMARDs other than TNF blocking agents
(
Etanercept
,
Infliximab
,
Adalimumab
).
(
Etanercept
,
Infliximab
,
Adalimumab
).
Maria Carmela L. Domocmat, RN, MSN
T-cell Costimulatoryblockade
Abatacept(Orencia®) first of a class of agents known as T -cell
costimulatoryblockers.
interfere with the interactions between antigen
-
interfere with the interactions between antigen
-
presenting cells and T lymphocytes and affect
early stages in the pathogenic cascade of events
in rheumatoid arthritis.
Maria Carmela L. Domocmat, RN, MSN
Abatacept(Orencia®) first of a class of agents known as T -cell
costimulatoryblockers.
interfere with the interactions between antigen
-
interfere with the interactions between antigen
-
presenting cells and T lymphocytes and affect
early stages in the pathogenic cascade of events
in rheumatoid arthritis.
Maria Carmela L. Domocmat, RN, MSN
Intramuscular Gold
Myochrysine® and Solganal® IM have been replaced by Methotrexate and other DMARDS Methotrexate and other DMARDS as the preferred agents to treat RA. rarely used now due to their
numerous side effects and
monitoring requirements, their
limited efficacy, and very slow
onset of action.
Maria Carmela L. Domocmat, RN, MSN
Myochrysine® and Solganal® IM have been replaced by Methotrexate and other DMARDS Methotrexate and other DMARDS as the preferred agents to treat RA. rarely used now due to their
numerous side effects and
monitoring requirements, their
limited efficacy, and very slow
onset of action.
Maria Carmela L. Domocmat, RN, MSN
Plasmapheresis
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Alternative treatments
glucosamine sulfate chondroitinsulfateare
are dietary supplements usually taken in pill form that
are thought to protect and possibly help repair are thought to protect and possibly help repair cartilage cells.
Maria Carmela L. Domocmat, RN, MSN
glucosamine sulfate chondroitinsulfateare
are dietary supplements usually taken in pill form that
are thought to protect and possibly help repair are thought to protect and possibly help repair cartilage cells.
Maria Carmela L. Domocmat, RN, MSN
NURSING MANAGEMENT
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Chronic pain r/t inflammation and swelling from
pressure on surrounding tissues, joint deformity
and joint destruction
Teach about meds Promote comfort with nonpharmacologicmeasures Manage stiffness Promote sleep and rest
Maria Carmela L. Domocmat, RN, MSN
pressure on surrounding tissues, joint deformity
and joint destruction
Teach about meds Promote comfort with nonpharmacologicmeasures Manage stiffness Promote sleep and rest
Maria Carmela L. Domocmat, RN, MSN
Promote comfort with
nonpharmacologicmeasures
Maria Carmela L. Domocmat, RN, MSN
nonpharmacologicmeasures
Maria Carmela L. Domocmat, RN, MSN
Manage stiffness
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Promote sleep and rest
Encourage to sleep at least 8 hrs at night, take
daily naps
Promote a quiet envt Provide warm beverages before retiring to sleep Provide warm beverages before retiring to sleep Administer hypnotics or relaxants as prescribed
Maria Carmela L. Domocmat, RN, MSN
Encourage to sleep at least 8 hrs at night, take
daily naps
Promote a quiet envt Provide warm beverages before retiring to sleep Provide warm beverages before retiring to sleep Administer hypnotics or relaxants as prescribed
Maria Carmela L. Domocmat, RN, MSN
REDUCTION OF JOINT
STRESS
Maria Carmela L. Domocmat, RN, MSN
STRESS
Maria Carmela L. Domocmat, RN, MSN
Reduction of joint stress
Because obesity stresses the musculoskeletal
system,
ideal body weight
should be achieved and
maintained.
Rest
, in general, is an important feature of
management. management. When the joints are actively
inflamed
,
vigorous
activity should be avoided
because of the danger
of intensifying joint inflammation or causing
traumatic injury to structures weakened by
inflammation.
Maria Carmela L. Domocmat, RN, MSN
Because obesity stresses the musculoskeletal
system,
ideal body weight
should be achieved and
maintained.
Rest
, in general, is an important feature of
management. management. When the joints are actively
inflamed
,
vigorous
activity should be avoided
because of the danger
of intensifying joint inflammation or causing
traumatic injury to structures weakened by
inflammation.
Maria Carmela L. Domocmat, RN, MSN
Readiness for enhanced self-care r/t complex
medication schedules, high risk of S/E of meds,
health maintenance, and self-care
Promote balanced diet Promote decision-making Promote hope Promote coping
Maria Carmela L. Domocmat, RN, MSN
medication schedules, high risk of S/E of meds,
health maintenance, and self-care
Promote balanced diet Promote decision-making Promote hope Promote coping
Maria Carmela L. Domocmat, RN, MSN
Self-care
Use china or heavy plastic cup with handle
which is easier to manipulate rather than
styrofoamor paper cup which may bend or
collapse
When fine motor activities become impossible
use larger joints or body surfaces
Ex: use palm of hand to press the toothpaste to
toothbrush rather than the fingers
Use devices long-handed brushes to brush hair or
dressing sticks for facilititewearing of pants
Maria Carmela L. Domocmat, RN, MSN
Use china or heavy plastic cup with handle
which is easier to manipulate rather than
styrofoamor paper cup which may bend or
collapse
When fine motor activities become impossible
use larger joints or body surfaces
Ex: use palm of hand to press the toothpaste to
toothbrush rather than the fingers
Use devices long-handed brushes to brush hair or
dressing sticks for facilititewearing of pants
Maria Carmela L. Domocmat, RN, MSN
Reduction of joint stress
urge to maintain a modest level of activity to
prevent joint laxity and muscular atrophy.
Splinting of acutely inflamed joints, particularly at
night and the use of walking aids (canes, walkers)
are all effective means of reducing stress on are all effective means of reducing stress on specific joints.
Maria Carmela L. Domocmat, RN, MSN
urge to maintain a modest level of activity to
prevent joint laxity and muscular atrophy.
Splinting of acutely inflamed joints, particularly at
night and the use of walking aids (canes, walkers)
are all effective means of reducing stress on are all effective means of reducing stress on specific joints.
Maria Carmela L. Domocmat, RN, MSN
Assistive devices
Computer Keyboard Aid
Arthritic's Pen
Computer Keyboard Aid
Maria Carmela L. Domocmat, RN, MSN
Computer Keyboard Aid
Arthritic's Pen
Computer Keyboard Aid
Maria Carmela L. Domocmat, RN, MSN
Phone & Cup Holder with
Hook and Loop Strap
Maria Carmela L. Domocmat, RN, MSN
Hook and Loop Strap
Maria Carmela L. Domocmat, RN, MSN
Arthritis in your hands
causes your finger joints
and knuckles to become
stiff and sometimes
painful and swollen.
Protect your hands by Protect your hands by avoiding pushing, pulling
and twisting motions.
Avoid making a tight fist
or pinching objects tightly.
Maria Carmela L. Domocmat, RN, MSN
causes your finger joints
and knuckles to become
stiff and sometimes
painful and swollen.
Protect your hands by Protect your hands by avoiding pushing, pulling
and twisting motions.
Avoid making a tight fist
or pinching objects tightly.
Maria Carmela L. Domocmat, RN, MSN
Instead, use a grasp that
aligns your knuckles
evenly along the handle
of the tool or utensil.
This makes grasping the tool more comfortable tool more comfortable and requires less effort to
use the tool.
For instance, a built-up
handle made of foam can
make it easier for you to
grasp your toothbrush.
Maria Carmela L. Domocmat, RN, MSN
aligns your knuckles
evenly along the handle
of the tool or utensil.
This makes grasping the tool more comfortable tool more comfortable and requires less effort to
use the tool.
For instance, a built-up
handle made of foam can
make it easier for you to
grasp your toothbrush.
Maria Carmela L. Domocmat, RN, MSN
For tasks that require you to
pinch objects tightly, look for
assistive devices that can help
you hold the object with less
force.
For instance, using a special key holder may help you turn key holder may help you turn keys more comfortably without
putting strain on your hand.
This type of holder aligns your
knuckles evenly along the
handle of the tool or utensil,
allowing you to use a larger
grip to turn the key.
Maria Carmela L. Domocmat, RN, MSN
pinch objects tightly, look for
assistive devices that can help
you hold the object with less
force.
For instance, using a special key holder may help you turn key holder may help you turn keys more comfortably without
putting strain on your hand.
This type of holder aligns your
knuckles evenly along the
handle of the tool or utensil,
allowing you to use a larger
grip to turn the key.
Maria Carmela L. Domocmat, RN, MSN
Use assistive devices to
help you open jars. This
spares your fingers from
the twisting motion
required to open a jar.
Maria Carmela L. Domocmat, RN, MSN
help you open jars. This
spares your fingers from
the twisting motion
required to open a jar.
Maria Carmela L. Domocmat, RN, MSN
To protect your finger joints,
avoid tightly pinching with
your fingers.
For example, use a button aid to help you grasp and aid to help you grasp and fasten buttons on your
clothes. Choose clothes with
easy-to-close fasteners,
such as zippers, large
buttons or hooks.
Maria Carmela L. Domocmat, RN, MSN
avoid tightly pinching with
your fingers.
For example, use a button aid to help you grasp and aid to help you grasp and fasten buttons on your
clothes. Choose clothes with
easy-to-close fasteners,
such as zippers, large
buttons or hooks.
Maria Carmela L. Domocmat, RN, MSN
Promote balanced diet
Good oral hygiene b4 and after meals Small, frequent feedings High-caloric snacks If with xerostamiamoisten foods, extra fluids with meals meals Eliminate spicy or acidic foods Sit upright to eat Take all meds with food and full glass of water to
ameliorate GI distress
Use assistive device if with stiffness
Maria Carmela L. Domocmat, RN, MSN
Good oral hygiene b4 and after meals Small, frequent feedings High-caloric snacks If with xerostamiamoisten foods, extra fluids with meals meals Eliminate spicy or acidic foods Sit upright to eat Take all meds with food and full glass of water to
ameliorate GI distress
Use assistive device if with stiffness
Maria Carmela L. Domocmat, RN, MSN
Promote decision-making
Exercise healthy control over the disease
Client should be able to verbalize cause of illness Educate the client
Increase participation in decision
-
making
Increase participation in decision
-
making
allow as many choices as possible
Decide on own ADL
Maria Carmela L. Domocmat, RN, MSN
Exercise healthy control over the disease
Client should be able to verbalize cause of illness Educate the client
Increase participation in decision
-
making
Increase participation in decision
-
making
allow as many choices as possible
Decide on own ADL
Maria Carmela L. Domocmat, RN, MSN
Promote hope
Avoid false reassurance Help set realistic goals Praise for accomplishments (no matter how small) small) Active listening Be sensitive to changes in mind and affect
Maria Carmela L. Domocmat, RN, MSN
Avoid false reassurance Help set realistic goals Praise for accomplishments (no matter how small) small) Active listening Be sensitive to changes in mind and affect
Maria Carmela L. Domocmat, RN, MSN
Promote coping
The client would be able to integrate disease
into the demands of daily living
Sign that the client has healthy approach strategies strategies
Seek out info and assistance Find strength through spiritual support Verbalize feelings and concerns Set goals Express positive thoughts Maintain realistic independence
Maria Carmela L. Domocmat, RN, MSN
The client would be able to integrate disease
into the demands of daily living
Sign that the client has healthy approach strategies strategies
Seek out info and assistance Find strength through spiritual support Verbalize feelings and concerns Set goals Express positive thoughts Maintain realistic independence
Maria Carmela L. Domocmat, RN, MSN
Signs of less adaptive strategies
Avoidance strategies ex: denial Excessive sleeping Other passive behaviors Depression
Maria Carmela L. Domocmat, RN, MSN
Avoidance strategies ex: denial Excessive sleeping Other passive behaviors Depression
Maria Carmela L. Domocmat, RN, MSN
FATIGUE
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Management of Fatigue:
For muscle atrophy aggressive PT to
strengthen muscle and prevent further atrophy
Maria Carmela L. Domocmat, RN, MSN
For muscle atrophy aggressive PT to
strengthen muscle and prevent further atrophy
Maria Carmela L. Domocmat, RN, MSN
Management of Fatigue
Principles of energy conservation
Pacing activities-do not plan too much activity for one
day
Allow rest periods Set priorities
determine which activities are most
Set priorities
determine which activities are most
important and do them first Obtain assistance when needed delegate
responsibilities
balance activity and rest
Plan ahead to prevent last minute rushing and stress Learn own activity tolerance and do not exceed it
Maria Carmela L. Domocmat, RN, MSN
Principles of energy conservation
Pacing activities-do not plan too much activity for one
day
Allow rest periods Set priorities
determine which activities are most
Set priorities
determine which activities are most
important and do them first Obtain assistance when needed delegate
responsibilities
balance activity and rest
Plan ahead to prevent last minute rushing and stress Learn own activity tolerance and do not exceed it
Maria Carmela L. Domocmat, RN, MSN
BODY IMAGE DISTURBANCE
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Enhance body image
Body image may be affected by both the disease
process and drug therapy
Ulnar deviation, swan-neck deformity, boutonnière
deformity, rheumatoid nodules
Steroid side effect
cushingoid syndrome
Steroid side effect
cushingoid syndrome
Determine clients perception of the changes
and impact of reaction of the SO
Most imptIx communicate acceptance of the
client ; establish and maintain trusting
relationship to encourage the client to express
feelings
Maria Carmela L. Domocmat, RN, MSN
Body image may be affected by both the disease
process and drug therapy
Ulnar deviation, swan-neck deformity, boutonnière
deformity, rheumatoid nodules
Steroid side effect
cushingoid syndrome
Steroid side effect
cushingoid syndrome
Determine clients perception of the changes
and impact of reaction of the SO
Most imptIx communicate acceptance of the
client ; establish and maintain trusting
relationship to encourage the client to express
feelings
Maria Carmela L. Domocmat, RN, MSN
Let the client wear own clothes rather than the
hosp gown, brush own hair, use make-up if
desired
Use colored hair accessories , nail polish, Use colored hair accessories , nail polish, perfume
Maria Carmela L. Domocmat, RN, MSN
hosp gown, brush own hair, use make-up if
desired
Use colored hair accessories , nail polish, Use colored hair accessories , nail polish, perfume
Maria Carmela L. Domocmat, RN, MSN
SURGICAL INTERVENTIONS
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Surgical interventions
Tendon transfer and osteotomy Synovectomy Arthrodesis Joint
arthroplasty
or replacement
Joint
arthroplasty
or replacement
Maria Carmela L. Domocmat, RN, MSN
Tendon transfer and osteotomy Synovectomy Arthrodesis Joint
arthroplasty
or replacement
Joint
arthroplasty
or replacement
Maria Carmela L. Domocmat, RN, MSN
Tendon transfer and osteotomy
Nodules or benign bony tumors (exostoses)
surgically removed and flexion contractures
surgically relieved
Osteotomies Osteotomies
Excision or cutting through bones
Maria Carmela L. Domocmat, RN, MSN
Nodules or benign bony tumors (exostoses)
surgically removed and flexion contractures
surgically relieved
Osteotomies Osteotomies
Excision or cutting through bones
Maria Carmela L. Domocmat, RN, MSN
Synovectomy
Surgical removal of synoviaelbow, wrist, fingers,
knees
Maria Carmela L. Domocmat, RN, MSN
Surgical removal of synoviaelbow, wrist, fingers,
knees
Maria Carmela L. Domocmat, RN, MSN
Synovectomy
ordinarily not recommended for patients with
rheumatoid arthritis, primarily because relief is
only transient.
synovectomyof the wrist -an exception
recommended if intense synovitisis persistent despite
medical treatment over 6 to 12 months.
Persistent synovitisinvolving the dorsal compartments
of the wrist can lead to extensor tendon sheath rupture
resulting in severe disability of hand function.
Maria Carmela L. Domocmat, RN, MSN
ordinarily not recommended for patients with
rheumatoid arthritis, primarily because relief is
only transient.
synovectomyof the wrist -an exception
recommended if intense synovitisis persistent despite
medical treatment over 6 to 12 months.
Persistent synovitisinvolving the dorsal compartments
of the wrist can lead to extensor tendon sheath rupture
resulting in severe disability of hand function.
Maria Carmela L. Domocmat, RN, MSN
Synovectomy Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Arthrodesis
Operation that produce bony fusion of joint used for clients with bone loss after joint
infection , tumors, musculoskeletal trauma,
paralysis paralysis Immobilize the joint but eliminate some
discomfort or arthritic process
Ankle -most common
Maria Carmela L. Domocmat, RN, MSN
Operation that produce bony fusion of joint used for clients with bone loss after joint
infection , tumors, musculoskeletal trauma,
paralysis paralysis Immobilize the joint but eliminate some
discomfort or arthritic process
Ankle -most common
Maria Carmela L. Domocmat, RN, MSN
Joint arthroplastyor replacement
particularly of the knee, hip, wrist, and elbow, are hi ghly
successful.
Arthroplasty of the metacarpophalangeal (knuckle)
joints also can reduce pain and improve function.
Maria Carmela L. Domocmat, RN, MSN
particularly of the knee, hip, wrist, and elbow, are hi ghly
successful.
Arthroplasty of the metacarpophalangeal (knuckle)
joints also can reduce pain and improve function.
Maria Carmela L. Domocmat, RN, MSN
Hip Replacement
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Surgical intervention
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Surgical intervention
Other operations include
release of nerve entrapments (e.g., carpal tunnel
syndrome)
arthroscopic procedures removal of a symptomatic rheumatoid nodule.
-
removal of a symptomatic rheumatoid nodule.
-
occasionally
Maria Carmela L. Domocmat, RN, MSN
Other operations include
release of nerve entrapments (e.g., carpal tunnel
syndrome)
arthroscopic procedures removal of a symptomatic rheumatoid nodule.
-
removal of a symptomatic rheumatoid nodule.
-
occasionally
Maria Carmela L. Domocmat, RN, MSN
Complementary/ Alternative
therapies Pain relief hypnosis, acupuncture, magnet Good nutrition
Omega-3 fatty acids
Found in coldwater fish (salmon, sea bass, tuna) May help reduce inflam But amount needed is impractical to human consumption
Fish oil capsules
Maria Carmela L. Domocmat, RN, MSN
therapies Pain relief hypnosis, acupuncture, magnet Good nutrition
Omega-3 fatty acids
Found in coldwater fish (salmon, sea bass, tuna) May help reduce inflam But amount needed is impractical to human consumption
Fish oil capsules
Maria Carmela L. Domocmat, RN, MSN
Complementary/ Alternative
therapies
Antioxidant vitamins (A,C, E) to help maintain normal
function of the immune system
Trace elements for joint health
Zinc, Selenium, Copper, Iron
Maria Carmela L. Domocmat, RN, MSN
therapies
Antioxidant vitamins (A,C, E) to help maintain normal
function of the immune system
Trace elements for joint health
Zinc, Selenium, Copper, Iron
Maria Carmela L. Domocmat, RN, MSN
Osteoarthritis
associated with the
aging process and
can affect any joint.
The cartilage of the
affected joint is affected joint is gradually worn
down, eventually
causing bone to rub
against bone. Bony
spurs develop on
the unprotected
bones, causing pain
and inflammation.
Maria Carmela L. Domocmat, RN, MSN
associated with the
aging process and
can affect any joint.
The cartilage of the
affected joint is affected joint is gradually worn
down, eventually
causing bone to rub
against bone. Bony
spurs develop on
the unprotected
bones, causing pain
and inflammation.
Maria Carmela L. Domocmat, RN, MSN
WHATS THE DIFFERENCE
BETWEEN RA AND OA?
Maria Carmela L. Domocmat, RN, MSN
BETWEEN RA AND OA?
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Osteoarthritis is a deterioration of cartilage and
overgrowth of bone often due to "wear and tear."
Rheumatoid arthritis is the inflammation of a Rheumatoid arthritis is the inflammation of a joint's connective tissues, such as the synovial
membranes, which leads to the destruction of
the joint's cartilage.
Maria Carmela L. Domocmat, RN, MSN
overgrowth of bone often due to "wear and tear."
Rheumatoid arthritis is the inflammation of a Rheumatoid arthritis is the inflammation of a joint's connective tissues, such as the synovial
membranes, which leads to the destruction of
the joint's cartilage.
Maria Carmela L. Domocmat, RN, MSN
Known as the wear-and-tear kind of arthritis a chronic condition characterized by the
breakdown of the joints cartilage. Cartilage is th e
part of the joint that cushions the ends of the
bones and allows easy movement of joints. The bones and allows easy movement of joints. The breakdown of cartilage causes the bones to rub
against each other, causing stiffness, pain and
loss of movement in the joint.
Maria Carmela L. Domocmat, RN, MSN
breakdown of the joints cartilage. Cartilage is th e
part of the joint that cushions the ends of the
bones and allows easy movement of joints. The bones and allows easy movement of joints. The breakdown of cartilage causes the bones to rub
against each other, causing stiffness, pain and
loss of movement in the joint.
Maria Carmela L. Domocmat, RN, MSN
AKA
degenerative joint disease,
ostoarthrosis,
hypertrophic arthritis degenerative arthritis. degenerative arthritis.
Maria Carmela L. Domocmat, RN, MSN
degenerative joint disease,
ostoarthrosis,
hypertrophic arthritis degenerative arthritis. degenerative arthritis.
Maria Carmela L. Domocmat, RN, MSN
stages of osteoarthritis
Cartilage loses elasticity and is more easily
damaged by injury or use.
Wear of cartilage causes changes to underlying
bone. The bone thickens and cysts may occur
under the cartilage. Bony growths, called spurs or under the cartilage. Bony growths, called spurs or osteophytes, develop near the end of the bone at
the affected joint.
Maria Carmela L. Domocmat, RN, MSN
Cartilage loses elasticity and is more easily
damaged by injury or use.
Wear of cartilage causes changes to underlying
bone. The bone thickens and cysts may occur
under the cartilage. Bony growths, called spurs or under the cartilage. Bony growths, called spurs or osteophytes, develop near the end of the bone at
the affected joint.
Maria Carmela L. Domocmat, RN, MSN
stages of osteoarthritis
Bits of bone or cartilage float loosely in the join t
space.
The joint lining, or the synovium, becomes
inflamed due to cartilage breakdown causing
cytokines (inflammation proteins) and enzymes cytokines (inflammation proteins) and enzymes that damage cartilage further.
Maria Carmela L. Domocmat, RN, MSN
Bits of bone or cartilage float loosely in the join t
space.
The joint lining, or the synovium, becomes
inflamed due to cartilage breakdown causing
cytokines (inflammation proteins) and enzymes cytokines (inflammation proteins) and enzymes that damage cartilage further.
Maria Carmela L. Domocmat, RN, MSN
The main problem in
knee OA is degeneration
of thearticular cartilage.
Articular cartilage is the smooth lining that covers smooth lining that covers the ends of bones where
they meet to form the
joint. The cartilage gives
the knee joint freedom of
movement by decreasing
friction.
Maria Carmela L. Domocmat, RN, MSN
knee OA is degeneration
of thearticular cartilage.
Articular cartilage is the smooth lining that covers smooth lining that covers the ends of bones where
they meet to form the
joint. The cartilage gives
the knee joint freedom of
movement by decreasing
friction.
Maria Carmela L. Domocmat, RN, MSN
The articular cartilage is
kept slippery by joint fluid
made by the joint lining
(thesynovial membrane).
The fluid, called
synovial
The fluid, called
synovial
fluid, is contained in a soft
tissue enclosure around
synovial joints called
thejoint capsule.
Maria Carmela L. Domocmat, RN, MSN
kept slippery by joint fluid
made by the joint lining
(thesynovial membrane).
The fluid, called
synovial
The fluid, called
synovial
fluid, is contained in a soft
tissue enclosure around
synovial joints called
thejoint capsule.
Maria Carmela L. Domocmat, RN, MSN
An important substance
present in articular
cartilage and synovial
fluid is calledhyaluronic
acid
.
Hyaluronic
acid
acid
.
Hyaluronic
acid
helps joints collect and
hold water, improving
lubrication and reducing
friction. It also acts by
allowing cells to move
and work within the joint.
Maria Carmela L. Domocmat, RN, MSN
present in articular
cartilage and synovial
fluid is calledhyaluronic
acid
.
Hyaluronic
acid
acid
.
Hyaluronic
acid
helps joints collect and
hold water, improving
lubrication and reducing
friction. It also acts by
allowing cells to move
and work within the joint.
Maria Carmela L. Domocmat, RN, MSN
When the articular
cartilagedegenerates, or
wears away, the bone
underneath is uncovered
and rubs against bone. and rubs against bone. Small outgrowths called
bone spurs,
orosteophytes, may form
in the joint.
Maria Carmela L. Domocmat, RN, MSN
cartilagedegenerates, or
wears away, the bone
underneath is uncovered
and rubs against bone. and rubs against bone. Small outgrowths called
bone spurs,
orosteophytes, may form
in the joint.
Maria Carmela L. Domocmat, RN, MSN
Changes in the cartilage and bones of the joint
can lead to pain, stiffness and use limitations.
Deterioration of cartilage can:
Affect the shape and makeup of the joint so it doesnt function smoothly.
-
limp when walk or have trouble
function smoothly.
-
limp when walk or have trouble
going up and down stairs. Cause fragments of bone and cartilage to float in join t fluid
causing irritation and pain.
Cause bony spurs, called osteophytes, to develop near
the ends of bones
Mean the joint fluid doesnt have enough hyaluronan,
which affects the joints ability to absorb shock.
Maria Carmela L. Domocmat, RN, MSN
can lead to pain, stiffness and use limitations.
Deterioration of cartilage can:
Affect the shape and makeup of the joint so it doesnt function smoothly.
-
limp when walk or have trouble
function smoothly.
-
limp when walk or have trouble
going up and down stairs. Cause fragments of bone and cartilage to float in join t fluid
causing irritation and pain.
Cause bony spurs, called osteophytes, to develop near
the ends of bones
Mean the joint fluid doesnt have enough hyaluronan,
which affects the joints ability to absorb shock.
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Causes and Risk factors
there is no single known cause of osteoarthritis
(OA),
there are several risk factors that should be
considered
Age Obesity Injury or Overuse Genetics or Heredity Muscle Weakness Other Diseases and Types of Arthritis
Maria Carmela L. Domocmat, RN, MSN
there is no single known cause of osteoarthritis
(OA),
there are several risk factors that should be
considered
Age Obesity Injury or Overuse Genetics or Heredity Muscle Weakness Other Diseases and Types of Arthritis
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Treatment
Acetaminophen Nonsteroidal anti-inflammatory drugs (NSAIDs) or
COX-2 medications
Capsaicin Tramadol Narcotic pain relievers glucosamine sulfate and chondroitinsulfate
Maria Carmela L. Domocmat, RN, MSN
Acetaminophen Nonsteroidal anti-inflammatory drugs (NSAIDs) or
COX-2 medications
Capsaicin Tramadol Narcotic pain relievers glucosamine sulfate and chondroitinsulfate
Maria Carmela L. Domocmat, RN, MSN
Acetaminophen
Tylenol, Anacin-3, Panadal, Phenaphen,
Valadol, and others)
for mild to moderate osteoarthritis. usually the first choice usually the first choice
Maria Carmela L. Domocmat, RN, MSN
Tylenol, Anacin-3, Panadal, Phenaphen,
Valadol, and others)
for mild to moderate osteoarthritis. usually the first choice usually the first choice
Maria Carmela L. Domocmat, RN, MSN
Nonsteroidal anti-inflammatory
drugs (NSAIDs)
for moderate to severe arthritic pain. OTC NSAIDs Prescription NSAIDs include
Maria Carmela L. Domocmat, RN, MSN
drugs (NSAIDs)
for moderate to severe arthritic pain. OTC NSAIDs Prescription NSAIDs include
Maria Carmela L. Domocmat, RN, MSN
Drugs for Prevention NSAID-
Induced Ulcers
If NSAID-induced ulcers are identified switch to
alternative pain relievers.
Maria Carmela L. Domocmat, RN, MSN
Induced Ulcers
If NSAID-induced ulcers are identified switch to
alternative pain relievers.
Maria Carmela L. Domocmat, RN, MSN
Topical NSAIDs
$63.07
Maria Carmela L. Domocmat, RN, MSN
$63.07
Maria Carmela L. Domocmat, RN, MSN
Capsaicin (Zostrix)
is an ointment prepared from the active
ingredient in hot chili peppers that has been
helpful for relieving painful areas in other
disorders.
Maria Carmela L. Domocmat, RN, MSN
is an ointment prepared from the active
ingredient in hot chili peppers that has been
helpful for relieving painful areas in other
disorders.
Maria Carmela L. Domocmat, RN, MSN
SALONPAS PAIN PATCH WITH CAPSAICIN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Tramadol(Ultram)
is a pain reliever that has some properties that
are similar to narcotics.
not as addictive, however, and may be an
alternative for patients who do not respond to
NSAIDs or less potent agents.
Maria Carmela L. Domocmat, RN, MSN
is a pain reliever that has some properties that
are similar to narcotics.
not as addictive, however, and may be an
alternative for patients who do not respond to
NSAIDs or less potent agents.
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Narcotic pain relievers
oxycodone, oxymorphone, or morphine may be necessary for severe pain that does not
respond to less potent pain relievers.
Maria Carmela L. Domocmat, RN, MSN
oxycodone, oxymorphone, or morphine may be necessary for severe pain that does not
respond to less potent pain relievers.
Maria Carmela L. Domocmat, RN, MSN
http://differncebetween.infoloommedia.netdna-cdn.com/wp-
content/uploads/2009/11/oxycodone.png
Maria Carmela L. Domocmat, RN, MSN
content/uploads/2009/11/oxycodone.png
Maria Carmela L. Domocmat, RN, MSN
Management
Same with RA
Maria Carmela L. Domocmat, RN, MSN
Same with RA
Maria Carmela L. Domocmat, RN, MSN
Lets Exercise
http://www.medicinenet.com/rheumatoid_arthritis _exercises_slideshow/article.htm
Maria Carmela L. Domocmat, RN, MSN
http://www.medicinenet.com/rheumatoid_arthritis _exercises_slideshow/article.htm
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Gouty arthritis
is a disease characterized by an abnormal
metabolism ofuric acid, resulting in an excess of
uric acid in the tissues and bloodcausing
inflammation
People with gout either produce too much uric
acid, or more commonly, their bodies have a
problem in removing it.
AKA
gout the disease of kings
the king of diseases
Maria Carmela L. Domocmat, RN, MSN
is a disease characterized by an abnormal
metabolism ofuric acid, resulting in an excess of
uric acid in the tissues and bloodcausing
inflammation
People with gout either produce too much uric
acid, or more commonly, their bodies have a
problem in removing it.
AKA
gout the disease of kings
the king of diseases
Maria Carmela L. Domocmat, RN, MSN
Gouty arthritis
2 major types
Primary Secondary
Maria Carmela L. Domocmat, RN, MSN
2 major types
Primary Secondary
Maria Carmela L. Domocmat, RN, MSN
Gouty arthritis
Primary
Inherited X-lined trait Caused by several inborn errors of purine metabolism
Uric acid- is the end-product of purine metabolism; excreted in urine in urine
Production of uric acid exceeds the excretion
capability of kidneys
Sodium urate is deposited in the synovium and other
tissues which results in inflammation
Males, 30s and 40s
Maria Carmela L. Domocmat, RN, MSN
Primary
Inherited X-lined trait Caused by several inborn errors of purine metabolism
Uric acid- is the end-product of purine metabolism; excreted in urine in urine
Production of uric acid exceeds the excretion
capability of kidneys
Sodium urate is deposited in the synovium and other
tissues which results in inflammation
Males, 30s and 40s
Maria Carmela L. Domocmat, RN, MSN
Gouty arthritis
Secondary
Hyperuricemia
Excessive uric acid in blood casued by anoterh diseas e
Affects all ages
Renal insufficiency Renal insufficiency Diuretic therapy Multiple myeloma Carcinomas
Causes:
decreased normal excretion of uric acid and other w aste
products
Increased production of uric acid
Maria Carmela L. Domocmat, RN, MSN
Secondary
Hyperuricemia
Excessive uric acid in blood casued by anoterh diseas e
Affects all ages
Renal insufficiency Renal insufficiency Diuretic therapy Multiple myeloma Carcinomas
Causes:
decreased normal excretion of uric acid and other w aste
products
Increased production of uric acid
Maria Carmela L. Domocmat, RN, MSN
Four Stages Of Gouty Arthritis Asymptomatic Hyperuricemia Acute Gout / Acute Gouty Arthritis Interval / Intercritical Chronic TophaceousGout
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Four Stages Of Gouty Arthritis Asymptomatic Hyperuricemia:
Asypmptomatic but with elevated blood uric acid
levels
Serum uric acid level (mg/dl)
Incidence of gout
Maria Carmela L. Domocmat, RN, MSN
Serum uric acid level (mg/dl)
Incidence of gout
>9.0 7.0-8.9
7.0-8.9 0.5-0.37
<7.0 0.1%
Asypmptomatic but with elevated blood uric acid
levels
Serum uric acid level (mg/dl)
Incidence of gout
Maria Carmela L. Domocmat, RN, MSN
Serum uric acid level (mg/dl)
Incidence of gout
>9.0 7.0-8.9
7.0-8.9 0.5-0.37
<7.0 0.1%
Four Stages Of Gouty Arthritis Acute Gout / Acute Gouty Arthritis
hyperuricemia has caused deposits of uric acid
crystals in joint spaces, leading to gouty attacks.
Excruciating pain and inflammation of one or more joints
esp
metatarsophalangeal joints of the great
joints
esp
metatarsophalangeal joints of the great
toe (podagra) Increased ESR, WBC
Maria Carmela L. Domocmat, RN, MSN
hyperuricemia has caused deposits of uric acid
crystals in joint spaces, leading to gouty attacks.
Excruciating pain and inflammation of one or more joints
esp
metatarsophalangeal joints of the great
joints
esp
metatarsophalangeal joints of the great
toe (podagra) Increased ESR, WBC
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
http://cdn.nursingcrib.com/wp-content/uploads/gouty-arthr itis.jpg
http://cdn.nursingcrib.com/wp-content/uploads/gouty-arthr itis.jpg
http://img.medscape.com/slide/migrated/e
ditorial/cmecircle/2004/3689/images/cohen
/slide019.gif
Maria Carmela L. Domocmat, RN, MSN
ditorial/cmecircle/2004/3689/images/cohen
/slide019.gif
Maria Carmela L. Domocmat, RN, MSN
Four Stages Of Gouty Arthritis Interval / Intercritical
the periods between acute gouty attacks may be
months or years after the 1
st
attack
Asymptomatic period No abnormality in joints No abnormality in joints
Chronic TophaceousGout:
the disease has caused permanent damage Deposits or urate crytalsunder skin and within major
organs (i.e., urate kidney stone formation)
Maria Carmela L. Domocmat, RN, MSN
the periods between acute gouty attacks may be
months or years after the 1
st
attack
Asymptomatic period No abnormality in joints No abnormality in joints
Chronic TophaceousGout:
the disease has caused permanent damage Deposits or urate crytalsunder skin and within major
organs (i.e., urate kidney stone formation)
Maria Carmela L. Domocmat, RN, MSN
Tophi
Tophideposits of sodium urate crystals
May occur anywhere; common in outer ear
Maria Carmela L. Domocmat, RN, MSN
http://www.hopkins-arthritis.org/images/gout_fig7.gif
Tophideposits of sodium urate crystals
May occur anywhere; common in outer ear
Maria Carmela L. Domocmat, RN, MSN
http://www.hopkins-arthritis.org/images/gout_fig7.gif
Maria Carmela L. Domocmat, RN, MSN
http://www.cdaarthritis.com/images_slides/40_gout_b_toe1_360.jpg
http://www.cdaarthritis.com/images_slides/40_gout_b_toe1_360.jpg
http://img.medsca
pe.com/slide/migr
ated/editorial/cme
Maria Carmela L. Domocmat, RN, MSN
ated/editorial/cme circle/2004/3689/i
mages/cohen/slid
e019.gif
pe.com/slide/migr
ated/editorial/cme
Maria Carmela L. Domocmat, RN, MSN
ated/editorial/cme circle/2004/3689/i
mages/cohen/slid
e019.gif
Maria Carmela L. Domocmat, RN, MSN
http://img.medscape.com/slide/migr
ated/editorial/cmecircle/2004/3689/i
mages/cohen/slide019.gif
http://img.medscape.com/slide/migr
ated/editorial/cmecircle/2004/3689/i
mages/cohen/slide019.gif
Maria Carmela L. Domocmat, RN, MSN
http://msnbcmedia1.msn.com/i/ms
nbc/Components/Interactives/Healt
h/MiscHealth/GOUT.gif
http://msnbcmedia1.msn.com/i/ms
nbc/Components/Interactives/Healt
h/MiscHealth/GOUT.gif
Maria Carmela L. Domocmat, RN, MSN
http://img.medscape.com/slide/migrated/editorial/cmecircle /2004/3689/images/cohen/slide019.gif
http://img.medscape.com/slide/migrated/editorial/cmecircle /2004/3689/images/cohen/slide019.gif
Dxtests
Synovial fluid analysis (shows uric acid crystals) Uric acid -blood Joint x-rays(may be normal) Synovial biopsy Synovial biopsy Uric acid -urine
Maria Carmela L. Domocmat, RN, MSN
Synovial fluid analysis (shows uric acid crystals) Uric acid -blood Joint x-rays(may be normal) Synovial biopsy Synovial biopsy Uric acid -urine
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Management
Drug therapy Diet therapy
Maria Carmela L. Domocmat, RN, MSN
Drug therapy Diet therapy
Maria Carmela L. Domocmat, RN, MSN
Management
Drug therapy
acute gouty arthritis inflammation subsides
spontaneously within 3 to 5 days
But if cannot tolerate pain
Colchicine
(
Colsalide
,
Novocolchicine
) and NSAIDs
Colchicine
(
Colsalide
,
Novocolchicine
) and NSAIDs
Taken for 4-7 days
(NSAIDs) -Indomethacin(Indocin),ibuprofen(Advil),
and naproxen(Aleve), celecoxib(Celebrex)
painkillers such ascodeine,hydrocodone,
andoxycodone
Corticosteroids
Maria Carmela L. Domocmat, RN, MSN
Drug therapy
acute gouty arthritis inflammation subsides
spontaneously within 3 to 5 days
But if cannot tolerate pain
Colchicine
(
Colsalide
,
Novocolchicine
) and NSAIDs
Colchicine
(
Colsalide
,
Novocolchicine
) and NSAIDs
Taken for 4-7 days
(NSAIDs) -Indomethacin(Indocin),ibuprofen(Advil),
and naproxen(Aleve), celecoxib(Celebrex)
painkillers such ascodeine,hydrocodone,
andoxycodone
Corticosteroids
Maria Carmela L. Domocmat, RN, MSN
Management
Drug therapy
Chronic or repeated acute episodes
Allopurinol (Zyloprim)
A xanthine oxidase inhibitor prevents conversion of xanthi ne to uric acid to uric acid
Probenecid (Benemid, Benuryl)
Uricosuric drug promotes excretion of excess uric acid drink at least 2 liters of fluid a day while taking thi s medication
(to help prevent uric acid kidney stones from forming).
Combination drug
Probenecid and Colchicine (ColBenemid)
Note: avoid aspirin it inactivates the drug
Maria Carmela L. Domocmat, RN, MSN
Drug therapy
Chronic or repeated acute episodes
Allopurinol (Zyloprim)
A xanthine oxidase inhibitor prevents conversion of xanthi ne to uric acid to uric acid
Probenecid (Benemid, Benuryl)
Uricosuric drug promotes excretion of excess uric acid drink at least 2 liters of fluid a day while taking thi s medication
(to help prevent uric acid kidney stones from forming).
Combination drug
Probenecid and Colchicine (ColBenemid)
Note: avoid aspirin it inactivates the drug
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Febuxostat(Uloric)
first new medication developed specifically for the
control of gout in over 40 years.
Decreases formation of uric acid by the body and is a very reliable way to lower the blood uric acid level. very reliable way to lower the blood uric acid level. can be used in patients with mild to moderate kidney
impairment.
should not be taken with 6-mercaptopurine (6-MP), or
azathioprine.
Maria Carmela L. Domocmat, RN, MSN
http://www.emedicinehealth.com/gout/page7_em.htm#Medications
first new medication developed specifically for the
control of gout in over 40 years.
Decreases formation of uric acid by the body and is a very reliable way to lower the blood uric acid level. very reliable way to lower the blood uric acid level. can be used in patients with mild to moderate kidney
impairment.
should not be taken with 6-mercaptopurine (6-MP), or
azathioprine.
Maria Carmela L. Domocmat, RN, MSN
http://www.emedicinehealth.com/gout/page7_em.htm#Medications
Maria Carmela L. Domocmat, RN, MSN
Management
Diet therapy
Avoid alcohol, anchovies, sardines, oils, herring,
organ meat (liver, kidney, and sweetbreads), legumes
(dried beans and peas), gravies, mushrooms,
spinach, asparagus, cauliflower, consommé, and spinach, asparagus, cauliflower, consommé, and baking or brewer's yeast.
Maria Carmela L. Domocmat, RN, MSN
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/
Diet therapy
Avoid alcohol, anchovies, sardines, oils, herring,
organ meat (liver, kidney, and sweetbreads), legumes
(dried beans and peas), gravies, mushrooms,
spinach, asparagus, cauliflower, consommé, and spinach, asparagus, cauliflower, consommé, and baking or brewer's yeast.
Maria Carmela L. Domocmat, RN, MSN
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/
Limit meat Avoid fatty foods such as salad dressings, ice
cream, and fried foods.
Eat enough carbohydrates. Eat enough carbohydrates. If losing weight, lose it slowly. Quick weight loss
may cause uric acid kidney stones to form.
Maria Carmela L. Domocmat, RN, MSN
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/
cream, and fried foods.
Eat enough carbohydrates. Eat enough carbohydrates. If losing weight, lose it slowly. Quick weight loss
may cause uric acid kidney stones to form.
Maria Carmela L. Domocmat, RN, MSN
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/
Maria Carmela L. Domocmat, RN, MSN
http://s1.hubimg.com/u/1184832_f496.jpg
http://s1.hubimg.com/u/1184832_f496.jpg
Avoid all forms of aspirin and diuretics may
precipitate attack
Excessive physical or emotional stress-can exacerbate disease exacerbate disease
Maria Carmela L. Domocmat, RN, MSN
precipitate attack
Excessive physical or emotional stress-can exacerbate disease exacerbate disease
Maria Carmela L. Domocmat, RN, MSN
Prevention of kidney stone
formation Increase fluid intake prevent stone formation
Dilute urine and prevent sediment formation
Alkaline ash diet
Citrus fruits, juices, milk and certain dairy products Citrus fruits, juices, milk and certain dairy products Uric acid is more soluble in high pH urine less likely
to form urinary stones
Maria Carmela L. Domocmat, RN, MSN
formation Increase fluid intake prevent stone formation
Dilute urine and prevent sediment formation
Alkaline ash diet
Citrus fruits, juices, milk and certain dairy products Citrus fruits, juices, milk and certain dairy products Uric acid is more soluble in high pH urine less likely
to form urinary stones
Maria Carmela L. Domocmat, RN, MSN
Complications
Chronic gouty arthritis Kidney stones Deposits in the kidneys, leading tochronic kidney failure kidney failure
Maria Carmela L. Domocmat, RN, MSN
Chronic gouty arthritis Kidney stones Deposits in the kidneys, leading tochronic kidney failure kidney failure
Maria Carmela L. Domocmat, RN, MSN
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