Rheumatoid arthritis

Rheumatoid arthritis (RA) facts
Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body.
It can affect people of all ages.
The cause of rheumatoid arthritis is not known.
In rheumatoid arthritis, multiple joints are usually, affected in a symmetrical pattern.

1. Rheumatoid arthritis RN Arpana Bhusal BNS

2. Rheumatoid arthritis (RA) facts Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body. It can affect people of all ages. The cause of rheumatoid arthritis is not known. In rheumatoid arthritis, multiple joints are usually, affected in a symmetrical pattern.

3. Chronic inflammation of rheumatoid arthritis can cause permanent joint destruction and deformity. Damage to joints can occur early and does not correlate with the severity of symptoms. The "rheumatoid factor" is an antibody that can be found in the blood of 80% of people with rheumatoid arthritis. There is no known cure for rheumatoid arthritis. The treatment of rheumatoid arthritis optimally involves a combination of patient education, rest and exercise, joint protection, medications, and occasionally surgery. Early treatment of rheumatoid arthritis results in better outcomes .

4. Causes: 1.Unknown 2.Genetic factors 3.Other predisposing factors •Fatigue •Cold •Emotional stress •Infection

5. Pathophysiology Affected joints progress through four stages of deterioration; synovitis , pannus formation, fibrous ankylosis and bony ankylosis . Pathological changes begin with inflammatory changes in the synovial membrane. The synovial cells and subsynovial tissue undergo a reactive hyperplasia, vasodilation and increased blood flow- warmth, redness . Inflammatory process---Increased capillary permeability---swelling

6. The development of a destructive vascular granulation tissue— pannus , which extends from the synovium to involve the articular cartilage. The pannus development between the joint margins, leading to reduced joint motion and the possibility of eventual ankylosis . Pannus destroys cartilage and erodes the bone. The consequence is loss of articular surfaces and joint motion. Muscle fibers undergo degenerative changes. Muscle elasticity and contractile power are lost.

7. Clinical manifestations: Inflammation , tenderness and stiffness of the joint Moderate to severe pain and morning stiffness lasting longer then 30 minute Joint deformities, muscle atrophy and decrease ROM Rheumatoid nodules- elbow, occiput , sacrum Low grade fever, fatigue, weakness, anorexia, weight loss, anaemia , muscle weakness Some client have addition extra articular manifestations eg ; vasculitis , pleural effusion, pericarditis etc

8. Pathologic flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) join.t Swan neck deformity is a deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it (DIP flexion with PIP hyperextension).

9. Diagnosis: CBC- anaemia , ESR high RH factor positive 70-80% ANA (antinuclear antibody) may be positive C-reactive protein elevated X-ray shows various stages of joint disease Synovial fluid analysis Synovial biopsy MRI

10. The American College of Rheumatology has developed a system for classifying rheumatoid arthritis that is primarily based upon the X-ray appearance of the joints. Stage I no damage seen on X-rays, although there may be signs of bone thinning Stage II on X-ray, evidence of bone thinning around a joint with or without slight bone damage slight cartilage damage possible joint mobility may be limited; no joint deformities observed atrophy of adjacent muscle abnormalities of soft tissue around joint possible

11. Stage III on X-ray, evidence of cartilage and bone damage and bone thinning around the joint joint deformity without permanent stiffening or fixation of the joint extensive muscle atrophy abnormalities of soft tissue around joint possible Stage IV on X-ray, evidence of cartilage and bone damage and osteoporosis around joint joint deformity with permanent fixation of the joint (referred to as ankylosis ) extensive muscle atrophy abnormalities of soft tissue around joint possible

12. Rheumatologists also classify the functional status of people with rheumatoid arthritis as follows Class I: completely able to perform usual activities of daily living Class II: able to perform usual self-care and work activities but limited in activities outside of work (such as playing sports) Class III: able to perform usual self-care activities but limited in work and other activities Class IV: limited in ability to perform usual self-care, work, and other activities

13. Arthralgias >3 inflamed joints Mild functional limitation Minimally elevated ESR & CRP No erosions/cartilage loss No extraarticular disease i.e. anemia Moderate Disease 6-20 Inflamed joints Moderate functional limitation Elevated ESR/CRP Radiographic evidence of inflammation No extraarticular disease Mild Disease

14. Severe Disease >20 persistently inflamed joints Rapid decline in functional capacity Radiographic evidence of rapid progession of bony erosions & loss of cartilage Extraarticular disease

15. Management Early and aggressive disease control Rheumatologist Referral Early/Undiagnosed: NSAIDs, short course Corticosteroids Late/Uncontrolled: DMARD (disease modified anti-rheumatoid drugs) therapy Azathioprine Leflunomide Cyclophosphamide Sulfasalazine It helps to prevent from joint destruction.

16. Management: 1.Pharmacologic: •NSAIDs to relieve pain and inflammation •Aspirin- mainstay of treatment has both analgesic and anti-inflammatory effect •Gold compounds eg solganal , auranofin to induce remission and decrease pain and inflammation •Corticosteroids • Antineoplastic medication eg Methotraxate , Cytoxan to suppress immune response

17. 2.Local comfort measures: •Application of heat and cold •Use of spints •Use of TENS 3.Non-pharmacologic modalities: •Behavioral modification- relaxation technique 4.Surgery: • Synovectomy • Arthrodesis -joint fusion •Total joint replacement

18. Nursing interventions: Goals: •Controlling pain •Promoting self-care •Optimizing mobility •Strengthening coping •Providing education and maintaining health  

19. 1.Assess joints for pain, swelling, tenderness, limitation of motion. 2.Promote maintenance of joint mobility and muscle strength: •Perform ROM exercises several times a day; use of heat prior to exercise may decrease discomfort, stop exercise at the point of apin . •Use isometric or other exercise to strengthen muscles 3.Change position frequently; alternate sitting, standing and lying 4.Promote comfort and relieg /control pain: •Ensure balance between activity and rest •Provide 1 to 2 scheduled rest periods through out day •Rest and suppost inflamed joints, if splint used remove 1-2 tiems per day for gentle ROM exercise

20. 5.Ensure bed rest if ordered for acute exacerbation; •Provide firm mattress •Maintain proper body alignment •Have client lie prone for ½ hour twice a day •Avoid pillows under knees •Keep joints mainly in extension, not flexion •Prevent complications of immobility 6.Provide heat treatment (warm bath, shower, warm, moist compresses, paraffin dips) as ordered; y be more effective in chronic pain by educe stiffness, pain and muscle spasm 7.Provide cold treatment as ordered; most effective during acute episodes

21. 8.Provide psychological support and encourage client to express feelings 9.Assist client in setting realistic goals; focus on client’s strength 10.Provide teaching: Use of prescribed medications and side effects Importance of maintaining a balance between activity and rest Energy conversation methods Performance of ROM, isometric and prescribed exercise 

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