Title:
URL Source: blob://pdf/f1deee5c-a9f8-473c-afc8-1104d95be50c
Markdown Content:
Rheumatoid
# Arthritis
> (Ch. 89)
# Etiology, Pathophysiology, History
RA is an autoimmune disease that is precipitated by
WBCs attacking synovial tissue.
The WBCs cause the synovial tissue to become inflamed
and thickened
The inflammation can extend to the cartilage, bones,
ligaments and tendons that surround the joint.
Joint deformity and bone erosion can result from these
changes, decreasing the joints range of motion and function.
RA is also a systemic disease that can affect the
connective tissue in the body affecting blood vessels,
pleura surrounding the lungs, and pericardium
# Rheumatoid Arthritis (RA) A chronic, progressive inflammatory disease that can affect the tissues and
organs but principally attacks the joints. Joint swelling and deformity
(late manifestation)
Joint swelling, warmth, &
erythema are common .
Finger, hands, wrists,
knees, & foot joints are
generally affected.
Finger joints affected are the
proximal interphalangeal &
metacarpophalangeal joints
Joints become deformed
simply from performing ADLs
Ulnar deviation, swan
neck, & boutonniere
deformities are common in the
fingers
## EXPECTED
## FINDINGS
Early manifestation of RA is fatigue and joint
discomfort
Pain at rest and with movement
Morning stiffness
Pleuritic pain (upon inspiration)
Xerostomia
Anorexia/weight loss
Fatigue
Paresthesias
Recent illness/stressor
Joint pain
Lack of function
Subcutaneous nodules
Fever (usually low grade)
Muscle weakness/ atrophy
Reddened Sclera &/or abnormal shape of
pupils
Lymph nodes enlarged
Findings depend
on the area
affected by the
disease process
How the joints are
affected a) Boutonniere
deformity
b) Swan neck
deformity
c) Ulnar deviation
> A
> B
> C
# Activity! Diagnostic Findings
- No definitive test for diagnosis due to
many conditions cause joint stiffness
and inflammation.
- Ask about symptoms during physical
exam; Check joints for swelling and
assess how easily they move
- If RA is suspected, a referral will be
made to the rheumatologist
- Several tests can show INDICATIONS of
the condition Diagnostic Findings
Blood Tests used:
A. Erythrocyte Sedimentation Rate (ESR) - associated w/ inflammation or infection in the
body (20 -40mm/hr is mild inflammation, 40 -70mm/hr is moderate inflammation, 70 -
150mm/hr is severe inflammation, other autoimmune diseases also can increase ESR
antibody.
B. C-Reactive Protein -elevated levels indicate inflammation (ERR is <1.0mg/dL) - may be
done in place of ESR -useful for diagnosing disease or monitoring disease activity. -
monitor for the response to anti -Inflammatory therapy
C. CBC - rule out other symptoms
- Anemia is common in people with RA but does not prove RA
A. Antinuclear Antibody (ANA) titer - Antibody produced against ones own DNA - +ANA titer
is associated with RA, normally negative at 1:20 dilution. - other autoimmune diseases
can also increase ANA. Diagnostic Findings
Other Blood Tests used:
Rheumatoid Factors : looks for proteins that are produced when the immune system attacks healthy
tissue
- Diagnostic level for rheumatoid arthritis is 1:40 to 1:60 (ERR is 1:20 or less) -high tigers correlate
with severe disease. -other autoimmune diseases can also increase RF
antibody
Anti -CCP (Anti -cyclic citrullinated peptide) - test detects antibodies to CCP. not everyone w/ RA has this
antibody
- Testing positive in most people who have RA, even years before manifestations develop. Test is
more sensitive for RA than rheumatoid factor antibodies. Diagnostic Findings
Joint Scans
To check for joint inflammation and damage
Helps tell the difference b/t type of arthritis and how the condition is progressing over time
X-rays and MRI
Other Diagnostic Findings:
Specialist will ask the patient to fill out a questionnaire with questions asking how well you can do
things such as getting dressed, walk, eat, and how good is your grip strength
- May be repeated to track progress Health Assessment Diagnostic Procedures
Arthrocentesis
Arthrocentesis is synovial fluid aspiration by needle
With RA, increased WBCs and RF are present in fluid
Nursing action: Monitor for bleeding or synovial fluid leak
X-ray
Determine degree of joint destruction and monitor
progression.
Provides adequate visualization, reveal bony erosions
and narrowed joint spaces
*Cheaper than CT or MRI*
Nursing Action: Assist client to position and tell them to
not move do you want? The Notebook Medical Treatment
Plasmapheresis
Removes circulating
antibodies from plasma,
decreasing attacks on the
clients tissues
May be done for severe, life -
threatening exacerbation Medical Treatment
Total Joint Arthroplasty
Surgical repair and
replacement of joint
It can be used with metal,
plastic or ceramic Medical Treatment
Synovectomy
Surgical removal of the
synovial membrane
surrounding the
affected joints
Performed on knee,
ankle, hip, elbow,
shoulder, wrist, and
finger Nursing Interventions
Physical activity > joint mobility
Monitor for fatigue
Teach the client measures to do the following:
1) Maximize functional activity
2) Minimize pain
3) Monitor skin closely
Provide a safe environment (referral to PT/OT, give info on support
organizations, assistive devices, remove unnecessary equipment and
supplies, monitor for medication effectiveness (inc. mobility, reduced
pain) ) Patient Education
- Apply heat or cold compresses to
affected area based on client
response ( morning stiffness=hot
shower, pain in hands/fingers=heated
paraffin *photo*, edema=cold
therapy)
- Follow routine health screenings
- Conserve energy and ask for help
with tasks (space out activities, take
rest periods)
- Use progressive muscle relaxation
- Report manifestations of early or late
exacerbations of RA (fever, pain upon
inspiration, pain in chest)
- Express feelings about body image
and self -esteem issues regarding the
effects of the disease POTENTIAL COMPLICATIONS RELATED TO RA
Sjogrens
Syndrome
Secondary
Osteoporosis
Triad of manifestations: dry eyes, dry
mouth, and vagina
Caused by obstruction of secretory ducts
and glands
NCProvide eye drops and artificial saliva,
and recommended vaginal lubricants as
needed
NCProvide fluids with meals
Immobilization caused by arthritis can
contribute to the development of osteoporosis
NCEncourage weight bearing exercises as
tolerated POTENTIAL COMPLICATIONS RELATED TO RA
Vasculitis (organ
ischemia)
Respiratory
Inflammation of arteries can disrupt
blood flow, causing Ischemia. Smaller
arteries in the skin, eyes, and brain are
most commonly affected in RA.
NC monitor for skin lesions, decrease
in vision, and manifestations of cognitive
dysfunction.
The inflammatory process can lead to lung
tissue complications (pleurisy, pneumonitis,
diffuse interstitial fibrosis, pulmonary
hypertension).
NC Monitor for dyspnea & administer
oxygen therapy
Cardiac
The inflammatory process can affect
cardiac tissue, leading to issues such as
pericarditis and myocarditis.
NCAdminister anti inflammatory agents Pharmacology
Non -pharmacological therapies: Hypnosis, acupuncture, imagery, music
therapy and spiritual practice
Pharmacological:
1) NSAIDs (1st in line): analgesic, antipyretic, and anti -inflammatory effect
- Can cause GI distress
- Monitor for fluid retention, HTN, & renal dysfunction
- Take with food or full glass of water/milk. If taking routinely, an H2 -receptor
antagonist can also be prescribed.
- Observe for GI bleeding and avoid alcohol Pharmacology
2) COX -2 enzyme blockers
- Cause less GI distress
- Risk of cardiac disease
- COX -2 Inhibitor medications (like celecoxib) are not recommended if client has a history
of myocardial infarction
3) Corticosteroids (prednisone)
- Strong anti -inflammatory medication that can be given for acute exacerbations or
advanced forms of the disease
- Not given for long -term therapy due to significant adverse side effects: osteoporosis,
hyperglycemia, cataracts, immunosuppression
- Observe for Cushingoid changes and monitor weight & BP
- Educate client on following prescription (ex alternate -day dosing, tapering, discont.
medication.
- Avoid crowds
- Observe changes in vision, blood glucose, impaired healing, black stools or weight gain Pharmacology
4) Disease modifying anti -rheumatic drugs (DMARDs)
-works in variety of ways to slow progression and suppress the immune systems reaction to RA that causes pain and
inflammation. Relief of manifestations might not occur for several weeks!
Types:
a. Antimalarial agent: Hydroxychloroquine
b. Antibiotic: Minocycline
c. Sulfonamide: Sulfasalazine
d. Biologic response modifiers: Etanercept, infliximab, adalimumab and chelator penicillamine
e. Cytotoxic medications: Methotrexate, leflunomide , cyclophosphamide, and azathioprine = severe adverse
effects
- Leflunomide Rx monitoring : allergic reaction, low WBC count, low platelets, and increased liver enzymes,
avoid crowds to reduce risk of infection, monitor for allergic reaction, report hair loss or diarrhea, avoid alcohol
as Mandy DMARDs affect liver causing additional harm and this Rx is contraindicated for pregnancy, increases
risk for fetal birth defects. Exercise
Health promotion is important for clients who have RA to maintain joint
mobility and ROM. It is a KEY treatment to help reduce disability often
associated with RA.
Think LOW IMPACT
30 mins a day, 5 times a week
Physical activity benefits:
Reduce fatigue
Strengthen muscles around joints
Reduce risk of chronic diseases: heart disease, diabetes, and
depression.
Client Ed:
Increase the amount of exercise you do gradually
Avoid high intensity and resistance exercises
Avoid daily inactivity
Stop smoking Nutritional Instructions
Maintaining a healthy weight is important
for patients with RA.
Diet plans should avoid foods that cause
inflammation.
Encourage foods high in vitamins, protein,
and iron.
Educate patient to eat small, frequent meals Pediatric Considerations
Kids get Arthritis too!
JRA is rarely life threatening and can subside over
time.
Risk Factors:
1. Female
2. Immunogenic susceptibility:
HLA helps the immune system identify
which cells belong in the body and which
are foreign.
PTPN22 encodes a protein that acts as a
negative regulator of immune cell
signaling. Variations in the PTPN22 gene
have been linked to an increased risk of
several autoimmune diseases.
1. Environmental triggers Quiz
Question 1
A nurse is caring for a client who has rheumatoid arthritis. Which of the
following tests are used to diagnose this disease? (Select all that apply)
A. Erythrocyte Sedimentation Rate
B. Red Blood Cell Count
C. White Blood Cell Count
D. Antinuclear Antibody Titer
E. Potassium Level Quiz
Question 1
A nurse is caring for a client who has rheumatoid arthritis. Which of the
following tests are used to diagnose this disease? (Select all that apply)
A. Erythrocyte Sedimentation Rate
B. Red Blood Cell Count
C. White Blood Cell Count
D. Antinuclear Antibody Titer
E. Potassium Level Quiz
Question 2
A nurse is assessing pain in a client who has rheumatoid arthritis. Which
question should the nurse ask first?
A. Where is your pain?
B. What does it feel like?
C. How does it change with time?
D. How severe is your pain? Quiz
Question 2
A nurse is assessing pain in a client who has rheumatoid arthritis. Which
question should the nurse ask first?
A. Where is your pain?
B. What does it feel like?
C. How does it change with time?
D. How severe is your pain? Quiz
Question 3
A nurse is educating a client who has an acute exacerbation of rheumatoid arthritis
about a new prescription of prednisone. Which of the following should the nurse
include in the education?
A. You may have confusion while taking the medication.
B. This medication will be prescribed for long -term treatment.
C. Avoid crowds while taking this medication.
D. Your blood glucose may increase while taking this medication.
E. Drink plenty of fluids while taking this medication.
F. Visual changes should be reported if they occur. Quiz
Question 3
A nurse is educating a client who has an acute exacerbation of rheumatoid arthritis
about a new prescription of prednisone. Which of the following should the nurse
include in the education?
A. You may have confusion while taking the medication.
B. This medication will be prescribed for long -term treatment.
C. Avoid crowds while taking this medication.
D. Your blood glucose may increase while taking this medication.
E. Drink plenty of fluids while taking this medication.
F. Visual changes should be reported if they occur. Quiz
Question 4
True or False
There is a definitive test to diagnose rheumatoid arthritis. Quiz
Question 4
True or False
There is a definitive test to diagnose rheumatoid arthritis. Quiz
Question 5
A client with rheumatoid arthritis states, I cant do my household chores
without becoming tired. My knees hurt whenever I walk. Which nursing
diagnosis would be most appropriate?
1. Activity tolerance related to fatigue and pain.
2. Self care deficit related to increasing joint pain.
3. Ineffective coping related to chronic pain.
4. Disturbed body image related to fatigue and joint pain. Quiz
Question 5
A client with rheumatoid arthritis states, I cant do my household chores without
becoming tired. My knees hurt whenever I walk. Which nursing diagnosis would
be most appropriate?
1. Activity tolerance related to fatigue and pain.
2. Self care deficit related to increasing joint pain.
3. Ineffective coping related to chronic pain.
4. Disturbed body image related to fatigue and joint pain.
Nursing interventions would be based on conserving energy and decreasing
episodes of fatigue. Citations
Althoff, A., Ball, B.S., Cawley, M. E., Davis, S., Falk, S.M., Fontenot, L., Grace, L., Henry, N.J., Holman,
H.C., Johnson, J., Lemon, T., Phillips, B.C., Roland, P. Wheless, L., Williams, D. (2023). RN Adult
medical surgical nursing: Review module (12th ed.). Assessment Technologies Institute.
Althoff, A., Cawley, M. E., Davis, S., Gearhart, M., Grace, L., Henry, N.J., Holman, H.C., Johnson, J.,
Phillips, B.C., Roland, P. Wheless, L. (2023). RN Pediatric nursing: Review Module (12th ed.).
Assessment Technologies Institute.