RHEUMATOID ARTHRITIS

Description

(RA) is a chronic, systemic inflammatory disorder that may affect many tissues
and organs, but principally attacks the joints producing an inflammatory synovitis,
serositis (inflammation of the lining surfaces of the joints, pericardium, and pleura),
rheumatoid nodules, and vasculitis that often progresses to destruction of the articular
cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse
inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions,
most common in subcutaneous tissue under the skin. Although the cause of rheumatoid
arthritis is unknown, autoimmunity plays a pivotal role in its chronicity and progression.

The hallmark feature of the disease is persistent symmetric polyarthritis

(synovitis) that affects the hands and feet, although any joint lined by a synovial
membrane may be involved. In addition to articular deterioration, systemic involvement
may lead to weight loss, low-grade fever, and malaise. The severity of RA may fluctuate
over time, but chronic RA most commonly results in the progressive development of
various degrees of joint destruction, deformity, and a significant decline in functional
status.

AKA
RA ( Rheumatic Arthritis )
INCIDENCES
About 1% of the world's population is afflicted by rheumatoid arthritis, women
three times more often than men. Onset is most frequent between the ages of 40 and
50, but no age is immune.The prevalence rate of rheumatoid arthritis is approximately
1% of the population (range 0.3-2.1%)

A study from Denmark investigated whether the higher rate of RA among

women could be linked to certain reproductive risk factors. Reviewing the cases of men
and women who had been hospitalized with RA between 1977 and 2004, the authors
found that the rate of RA was higher in women who had given birth to just 1 child than it
was in women who had delivered 2 or 3 offspring. (However, no increased rate was
found in women who were nulliparous or who had a history of lost pregnancies.)

The study also found a higher RA risk among women with a history of preeclampsia,
hyperemesis during pregnancy, or gestational hypertension. The authors suggested
that this portion of the data indicated that a reduced immune adaptability to pregnancy
may exist in women who have a predisposition to the development of RA or that there
may be a link between fetal microchimerism (in which fetal cells are present in the
maternal circulation) and RA.

Although rheumatoid arthritis (RA) can occur at any age, the incidence increases
with advancing age. The peak incidence of RA occurs in individuals aged 40-60 years.
RISK / PREDISPOSING FACTORS

 Blood Transfusions

You may have an increased risk of developing rheumatoid arthritis if you have
received blood transfusions.

 Age

Although rheumatoid arthritis can develop at any age, you’re most likely to
develop the condition between the ages of 25 and 45.

 Gender

Women are 2.5 to 3 times more likely to develop rheumatoid arthritis than
men.

 Genetic Factors

You are more likely to develop rheumatoid arthritis if there are other people in
your family with this condition or with other autoimmune disorders.

 Ethnic Background

You have a greater risk of developing rheumatoid arthritis if you are:

 White
 Native American (particularly belonging to the Yakima, Chippewa, or
Inuit tribes)

 Weight

People who are obese may have an increased risk of developing rheumatoid
arthritis.

 Coffee and Cigarettes

Some studies have suggested that there is a connection between drinking

coffee and developing rheumatoid arthritis. More work needs to done to confirm this
association.

Long-term smoking may be a risk factor for the development of rheumatoid

arthritis.
MANIFESTATION

Early phase of the disease is characterized by the following features:

 Joint swelling that may affect joint margins

 Joint tenderness upon palpation
 Systemic malaise
 Loss of energy
 Severe morning stiffness that limits function and generally lasts more than an
hour.

TYPE OF RHEUMATOID ARTHRITIS

 Juvenile rheumatoid arthritis (JRA) is the most common form of childhood

arthritis. The cause remains unknown. For most patients, the immunogenic
associations, clinical pattern, and functional outcome are different from adult
onset RA.

Ankylosis in
the cervical spine at
several levels due
to long-standing
juvenile rheumatoid
arthritis (also known
as juvenile
idiopathic arthritis).

Widespread osteopenia, carpal crowding (due to

cartilage loss), and several erosions affecting the carpal
bones and metacarpal heads in particular in a child with
advanced juvenile rheumatoid arthritis (also known as
juvenile idiopathic arthritis)
The diagnostic criteria for JRA are onset occurring when younger than 16 years,
persistent arthritis in 1 or more joints for at least 6 weeks, and exclusion of other types
of childhood arthritis. The key points that characterize the diagnosis of JRA are as
follows:
  Arthritis must be present. Arthritis is defined as the presence of swelling, the
presence of effusion, or the presence of 2 or more of the following signs: limited
range of motion (ROM), tenderness, pain on motion, or joint warmth.
 Arthritis must persist for at least 6 weeks.
 Other causes of chronic arthritis in children must be ruled out.
 No specific laboratory or other test can establish the diagnosis of JRA.

PATHOPHYSIOLOGY

RA is commonly used as the prototype for inflammatory arthritis. The

autoimmune
Presentation reaction
of antigen toprimarily
occurs in the synovial tissue. Phagocytosis produces
T cells
enzymes within the joint. The enzymes break down collagen, causing edema,
proliferation of the synovial membrane, and ultimately pannus formation. Pannus
destroys cartilage and erodes the bone. The consequence is loss of articular surfaces
and joint motion. Muscle fibers undergo degenerative
changes. Tendon and ligament elasticity and contractile Swelling in small joints,
T- and B-cell proliferation.
power are lost. associated with pain,
Angiogenesis in synovial lining.
stiffness, and fatigue.

Warm,swollen,effusions,pain,
Neutrophil accumulation in
synovial fluid. Cell proliferation. No and decreased motion with
cartilage invasion. possible rheumatoid nodules.

Synovitis. Early pannus

Increase in severity of
invasion. Chondrocyte
activation. Degradation of physical signs and
cartilage by proteinase. symptoms.

Subchondral bone erosion.

Joint instability,
Pannus invasion of cartilage.
contractures,decreased ROM,
Chindrocyte proliferation. Laxity
systemic complications.
of ligaments.
 Initiation of rheumatoid arthritis

Immunoglobulin G Production of rheumatoid factors

Prostaglandin release

Deposition of immune complex Legend:

- pathophysiology

Inflammation of synovium - manifestation

- manifestation

Edema Release of Release of oxygen Release of Release of

lysosomal free radicals arachidonic acid antibodies
enzymes and prostaglandin

Synovial
hypoxia
Release of
complement
Pai
n
Destruction of Synovium

Macrophage Leukocyte
Joint s attracted attracted
fusion
Joint swelling Loss of
joint space Rheumatoid
nodules

Muscle
spasm
DIAGNOSTIC STUDIES

 Serum protein abnormalities are often present. Rheumatoid factor (RF), an

immunoglobulin M (IgM) antibody directed against the Fc fragment of
immunoglobulin G (IgG), is present in the sera of more than 75% of patients.
High titers of RF are commonly associated with severe rheumatoid disease.
Antinuclear antibodies are demonstrable in 20% of patients, though their titers
are lower in rheumatoid arthritis than in SLE. During the acute and chronic
phases, the erythrocyte sedimentation rate and gamma globulins (commonly IgM
and IgG) are usually elevated; however, leukopenia may occur in the presence of
splenomegaly (Felty syndrome). The platelet count often is elevated, roughly in
proportion to the severity of overall joint inflammation. Joint fluid examination is
valuable, reflecting abnormalities that are correlated with varying degrees of
inflammation.

Imaging Studies
 Plain radiographs
o Radiography is the most specific workup study for rheumatoid arthritis.

o Radiographs taken during the first 6 months typically are read as negative
because of decreased sensitivity during that period.
o The earliest changes occur in the wrists or feet and consist of soft-tissue
swelling and juxta-articular demineralization. Later, diagnostic changes of
uniform joint-space narrowing are evident, and erosions develop. The
erosions are often first evident at the ulnar styloid and at the juxta-articular
margins, where the bony surface is not protected by cartilage.

Prominent juxta-articular osteopenia in all interphalangeal joints in a

patient with rheumatoid arthritis of the hands.

Prominent juxta-articular osteopenia in all interphalangeal joints in a patient with

rheumatoid arthritis of the hands.
o Diagnostic changes also occur in the cervical spine with C1-2 subluxation,
but these changes usually take several years to develop.
 Nuclear imaging studies
o Nuclear imaging studies are quite sensitive for detecting many disease
processes, and the entire body can be imaged at once. However, this
technique is not specific because of the number of disease processes that
may cause radionuclide accumulation.
 o When areas of increased uptake are observed, additional studies such as
radiography are usually necessary to specify the type of abnormality.
o Joints affected by inflammatory or degenerative arthritis demonstrate
increased uptake and can map the extent of disease in a single
examination.
o In a patient with inflammatory arthritis and widespread changes on
radiographs, scintigraphy may help to locate areas of early active
inflammation.

MANAGEMENT

There is no known cure for rheumatoid arthritis, but many different types of treatment
can alleviate symptoms and / or modify the disease process.

Rehabilitation Program

Physical Therapy
The goals of rehabilitation for patients with rheumatoid arthritis (RA) include pain relief,
increased range of motion (ROM), increased strength and endurance, prevention and
correction of deformities, and provision of various counseling and educational services.
Numerous nonpharmacologic methods are available to the physiatrist to assist patients
in achieving these goals. These methods include therapeutic modalities, splints and
orthotics, assistive device equipment, joint protection and energy conservation
techniques, and education and therapeutic exercise programs.

Therapeutic modalities

Heat, either superficial or deep, is an effective modality for the relief of joint pain and
stiffness caused by RA. In addition, it is also used to treat joints in preparation for ROM,
stretching, and muscle strengthening exercises. Heat may be administered via moist hot
packs, electric mittens, a hot shower, spas, ultrasonography, diathermy, or paraffin.
Superficial and deep heating methods have been shown to raise the intra-articular
temperature in patients with RA.

Cold is preferable for treatment of an acutely inflamed joint. Application of cold results in
decreased pain and decreased muscle spasm. Cold may be delivered via ice packs, ice
sticks, topical sprays, or ice water.

Splints and orthotics

Orthotic devices play an important role in the rehabilitation management of patients with
RA. These devices are used to decrease pain and inflammation, improve function,
reduce deformity, and correct biomechanical malalignment.
Lower extremity orthoses are prescribed to provide stability and proper alignment or to
shift weight bearing off the affected limb. The most common orthoses used for the lower
extremity involve the foot and ankle joints. Approximately 80% of patients affected with
RA illustrate significant foot involvement. These problems are easily accommodated by
providing a deep, wide, soft leather shoe. A metatarsal pad or bar is typically used to
remove weight from painful MTP joints, and a rocker-bottom sole can be used to
facilitate roll-off. Hindfoot pronation should be addressed with custom inserts. Finally,
knee orthoses may be used to control edema, pain, patellar alignment, hyperextension,
or collateral or cruciate ligament instability.

Therapeutic exercise

Fatigue and decreased endurance are frequent symptoms in patients with RA. When
comparing these patients to age-matched subjects without RA, a reduction in aerobic
capacity and muscle strength is noted. This reduction is due to the disease itself and to
the lack of physical activity in these patients. Exercise is an important part of the
rehabilitation management of RA.

Aerobic conditioning in patients with RA (if tolerated) improves maximum oxygen uptake
and decreases perceived exertion at submaximal workloads. At the same time, no
adverse effects have been noted in the joints of these patients. In addition, patients
undergoing long-term endurance training have been known to feel less isolated, to
take less sick leave, and to develop improved function in activities of daily living (ADL).
Thirty minutes of daily aerobic exercise, several times each week, should be
encouraged in patients with well-controlled RA.

Muscle atrophy often accompanies RA and is exacerbated by inactivity, bed rest,

splints, and medications. Isometric exercises restore and maintain strength in patients
with RA without producing pain. Resistance exercises may be initiated when the
isometric program has been well established and when the patient is free of pain.

Occupational Therapy
Occupational therapy also can be very useful for patients with rheumatoid arthritis (RA).
An occupational therapist may work in conjunction with the physical therapist to ensure
that the patient is able to meet his or her goals. An occupational therapist may also
assist in the recommendation and use of splints and orthotics, especially when the
upper extremity is affected. Upper extremity orthoses may be classified as either static
or dynamic. Static splints are used to support a weak or unstable joint, to rest a joint for
pain relief, or to maintain functional alignment. Dynamic splints traditionally have been
used to manage the postoperative hand, but they also may be used to increase manual
dexterity. The most commonly used splints for the hand are the finger-ring splints and
the thumb-post splint. The functional wrist splint and the resting hand splint are
commonly used for wrist splinting.
Adaptive equipment

Many assistive devices are available to patients with RA and are used to provide
maximal function, maintain independence, reduce joint stress, conserve energy, and
provide pain relief. Equipment is available to assist patients with transfers, dressing,
feeding, toileting, cooking, and ambulation.

Joint protection education

Joint protection education provides the patient with techniques and recommendations
for the prevention of joint overuse and the avoidance of biomechanical torques that
excessively bend the joint. The use of adaptive equipment is important. Other
components of a good joint protection program include maintenance of good
posture, avoidance of overuse during inflammation, modification of tasks to decrease
joint stress, and use of appropriate splints.

Energy conservation education

Fatigue is a major component of RA and is due to the systemic nature of the disease, as
well as to the decreased cardiovascular endurance observed in patients with this
inflammatory disorder.

The goal of energy conservation techniques is to save energy while maximizing

function. Adaptive equipment is an essential part of this program. Other elements
include maintaining joint ROM and strength, improving cardiovascular fitness, and
taking short rest periods during the day. Every individual with RA should implement joint
protection and energy conservation programs into their lifestyle.

Surgical

Surgical intervention in patients with rheumatoid arthritis (RA) includes pain relief,
deformity correction, and functional improvement. 5 A number of surgical procedures are
available to obtain these goals. These options include myofascial techniques, excisions,
reconstructions, joint fusions, and joint replacements. The timing of surgery is a
complex decision; the patient's age, stage of disease, and level of disability, as well
as the location of the involved joints, must be considered. Early surgical intervention
may be helpful in maintaining a patient's functional level of independence.

Medications

 Nonsteroidal anti-inflammatory agents

First-line agents in the treatment of rheumatoid arthritis. Have analgesic, anti-
inflammatory, and antipyretic activities. Their mechanism of action is not known, but
they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other
mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal
enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell
membrane functions. Choice of NSAIDs is individualized and usually is based on factors
such as adverse effects profiles (eg, GI, renal, hepatic, CNS toxicities), polypharmacy
(drug-drug interactions), and comorbidities.

Aspirin is inexpensive, but it can cause GI complications. Aspirin can be administered in

an enteric coated preparation or in nonacetylated compounds. Concomitant
gastroprotective agents may be used such as misoprostol, Carafate, H2 blockers, or
omeprazole. Monitoring electrolytes, creatinine, Hgb, and LFTs every 4-6 months is
important.

 Gold compounds
Second-line therapy for rheumatoid arthritis. Up to two thirds of patients get some
benefit initially, but the long-term effect is unsatisfactory given a high profile of adverse
effects (eg, dermatitis, stomatitis, proteinuria, cytopenia). eee

For patients who fail to improve on or who cannot tolerate methotrexate, treatment with
gold salts may be effective. About 60% of patients may be expected to benefit from gold
therapy, though complete remissions are uncommon. The mode of action of gold
compounds is not known.

 Immunosuppressant agents
Second-line agents for rheumatoid arthritis (RA). Inhibit key steps in the development of
immune reactions.5 Methotrexate is commonly used. Other cytotoxic agents, such as
cyclophosphamide, also have been used in combination with other agents in the
treatment of RA, especially in severe cases. However, due to the severity of toxic
effects of cyclophosphamide (eg, hemorrhagic cystitis, infections, malignancy),
investigators have not recommended combination chemotherapies that include
cyclophosphamide.
NURSING DIAGNOSIS
 Pain related to inflammation, increased disease activity, tissue damage, fatigue,
and lowered tolerance.
 Fatigue related to increased disease activity, pain, inadequate rest,
deconditioning, inadequate nutrition, emotional stress, depression.
 Impaired physical mobility related to muscle weakness, pain on movement, lack
of or improper use of ambulatory devices.
 Self-care deficits (feeding, bathing, dressing, toileting) related to contractures,
fatigue, or loss of motion.
 Disturbed sleep pattern related to pain and fatigue.
 Disturbed body image related to physical and psychological changes and
dependency imposed by chronic illness.
 Ineffective coping related to actual or perceived lifestyle or role changes.

NURSING RESPONSIBILITIES
1. Administer prescribed medications, which may include nonsteroidal anti-
inflammatory drugs, aspirin, slow acting antirheumatic medication and
corticosteroid.
2. Provide pain relief. Provide comfort measures, including massage and
position changes. Apply hot or cold therapy to affected joints according to
the client’s needs.
3. Promote self care.
4. Promote adequate rest and sleep to prevent fatigue; provide comfort
measures, including a foam mattress and supportive pillows; and discuss
energy conservation techniques.
5. Promote client and family coping.
6. Encourage proper body alignment to prevent contractures.
7. Collaborate with the physical therapist to design and provide the client
with a physical therapy program, which begins after the acute phase
resolves. Encourage a muscle activity program for self- care. Water
exercises are excellent because water promotes buoyancy, which eases
joint movements.
8. Recommend a weight reduction program, if appropriate.
9. Collaborate with the occupational therapist and promote the use of braces,
splints, and assistive mobility devices, if appropriate.
10. Discuss relaxation techniques, such as imagery, self- hypnosis,
biofeedback, diversionary activities, and distraction for pain management.
11. Discuss maintaining optimal nutritional status.
12. Provide a referral to the Arthritis Foundation.
ILLUSTRATION

Effects of rheumatoid arthritis on particular joints

Boutonniere deformity.

Subluxation in the metacarpophalangeal joints, with ulnar

deviation, in a patient with rheumatoid arthritis of the hands.

Coronal, T1-weighted magnetic resonance imaging (MRI)

scan shows characteristic pannus and erosive changes in
the wrist in a patient with active rheumatoid arthritis.

Rheumatoid nodules at the elbow.

Lateral view of the cervical spine in a patient with rheumatoid

arthritis shows erosion of the odontoid process.
Rheumatoid changes in the hand.

X-ray of the hand in rheumatoid arthritis.

REFERENCES:
www.medscape.com
www.google.com
www.wikipedia.com
Medical Surgical Nursing, fourth Edition.Hargrove-Huttel, RN.PhD-pg294-295.
Medical Surgical Nursing, 10’Th Edition, Johnson-pg.76.
Medical Surgical Nursing, 10’Th Edition,Smeltzer-Bare-pg.1621.
Medical Surgical Nursing, 8th ed., by Black and Hawks