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Rheumatoid arthritis

RA is a chronic, systematic autoimmune disease characterized by inflammation of connective tissue in the synovial joints, typically with periods of remission and exacerbation. RA is frequently accompanied by extra articular manifestation. Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body

Incidence

Women are affecting 2-3 times more often than a men. RA is most common in people between the ages of 20-30. The incidence of RA is about 1-3 per100.

Etiology of RA

The cause of RA is unknown. Usually insidious associated with physical and or emotional stress. An autoimmune etiology is currently the most widely accepted.

  1. Autoimmunity the autoimmune theory suggests that changes associated with RA begins when a susceptible host experiences an initial immune response to an antigen. The antigen which is probably not the same in all patients triggers the formation of an abnormal immunoglobulin G (IgG). The autoantibodies are known as rheumatoid factor (RF) and they combine with IgG to form immune complexes that initially deposit on synovial membranes or superficial articular cartilage in the joints.
  2. Genetic factors genetic predisposition appears to be important in the development of RA. e.g a higher occurrence of the disease has been noted in identical than in fraternal twins. The strongest evidence for a familial influences is the increased occurrence with HLA( human leukocyte antigen).

Disease Severity

Mild disease

  • 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 limitatio
  • Elevated ESR/CRP
  • Radiographic evidence of inflammation
  • No extraarticular disease

Severe disease

  • >20 persistently inflamed joints
  • Rapid decline in functional capacity
  • Radiographic evidence of rapid progession of bony erosions & loss of cartilage
  • Extra articular disease: Hypoalbuminemia

ACR Criteria for Diagnosis

Four or more of the following criteria must be present:

–       Morning stiffness > 1 hour

–       Arthritis of > 3 joint areas

–       Arthritis of hand joints

–       Symmetric swelling (arthritis)

–       Serum rheumatoid factor

–       Rheumatoid nodules

–       Radiographic changes

First four criteria must be present for 6 weeks or more.

Pathophysiology of RA                                         

  • Presentation of antigen to T cells leading to T- and B-cell proliferation and Angiogenesis in synovial lining resulting in Swelling in small joints, associated with pain, stiffness, and fatigue.
  • Neutrophil accumulation in synovial fluid causes Cell proliferation. Cartilage invasion may be there resulting in Warm, swollen, effusions, pain, and decreased motion with possible rheumatoid nodules.

Sign and symptoms of RA

Sign and symptoms
Eyes Episcleritis , keratoconjuctivitis
Synovial joints Warm tender red painful guarded movements, limited ROM, limited strength. Stiffness and pain worst in morning
Hands Red palms, enlarged dorsal veins, pain and stiffness weak grip , inability to make tight fist
Feet Stiff painful broadened forefoot, depressed metatarsal heads “ cockup” toe deformity
Systemic effects Fever, malaise, weakness, wt loss, numbness, enlarged lymph nodes , enlarged spleen, depression anorexia

 

Diagnosis of Rheumatoid Arthritis

  • Patient’s subjective evaluation

–          Degree of joint pain

–          Duration of morning stiffness

–          Presence/absence of fatigue

–          Functional limitation(s)

  • Physical examination

–          Actively inflamed joints

–          Mechanical joint problems including:

  • Loss of motion
  • Crepitus
  • Instability
  • Misalignment and/or deformity

Arthrocentesis

  • Confirm diagnoses
  • Differentiate between inflammatory & noninflammatory

Lab tests

  • cell count
  • crystal analysis
  • Gram stain & Culture
  • WBC >2000/µL indicates inflammatory arthritis

Arthroscopy

  • Evaluate ligamentous & cartilaginous integrity
  • Biopsy

Radiological Studies

X-Ray show bone erosion and bone displacement.

Management goals

  •  Early and aggressive disease control
  •  Early/Undiagnosed: NSAIDs, short course Corticosteroids
  •  Late/Uncontrolled: DMARD (Disease modifying anti rheumatic drug) therapy.
Non pharmacology Pharmacology
  • Referral to PT/OT
  • Evaluate ADLs
  • Assistive devices/splints
  • Weight loss
  • Smoking cessation
  • Anti-inflammatory
  • Analgesics
  • NSAIDs
  • Glucocorticoids
  • DMARD
  • Anticytokine therapy

Analgesics

  • Tylenol
  • Opiods
  • Diclofenac

NSAIDs: Mechanism of Action

                 Cyclo-oxygenase inhibition

COX-1                                     COX-2

COX cyclo-oxygenase is an enzyme involved in inflammatory process. COX 2 inhibitors blocks the enzyme involved in inflammation while leaving intact the enzyme involved in protecting the stomach lining. As a result COX 2 inhibitors are less likely to cause gastric irritation and ulcer than NSAID.

NSAIDs: COX-2 Inhibitors

  • Improved GI tolerability
  • Reduced effects on renal blood flow
  • No effect on platelet function

Pros and Cons of NSAID Therapy

Pros Cons
  • Effective control of inflammation and pain
  • Effective reduction in swelling
  • Improves mobility, flexibility, range of motion
  • Improve quality of life
  • Relatively low-cost
  • GI toxicity common
  • Renal complications (eg, irreversible renal insufficiency, papillary necrosis)
  • Hepatic dysfunction
  • CNS toxicity
  • Does not affect disease progression

 

Pros and Cons of Corticosteroid Therapy

Pros cons
  • Anti-inflammatory and immunosuppressive effects
  • Can be used to bridge gap between initiation of DMARD therapy and onset of action
  • Intra-articluar injections can be used for individual joint flares
  • Does not conclusively affect disease progression
  • Tapering and discontinuation of use often unsuccessful
  • Long term use results in skin thinning, ecchymoses, and Cushingoid appearance
  • Significant cause of steroid-induced osteopenia

Disease modification

  • SAARD – slow acting antirheumatic drugs
  • DMARD – disease modifying antirheumatic drugs

Antimalarials, gold, penicillamine, or sulfasalazine are initiated. If symptoms appear to be aggressive methotrexate may be considered.

Methotrexate: considered as the drug of choice for RA. It produces a beneficial effect in 2-6 weeks and is given once weekly. The usual dose is 7.5-15 mg once a week. The most common side effect is gastric irritation and stomatitis. Other side effects are hepatotoxicity, pancytopenia and interstitial pneumonitis.

Advantages of DMARDs

  • Slow disease progression
  • Improve functional disability
  • Decrease pain
  • Interfere with inflammatory processes
  • Retard development of joint erosions

Surgery

For persistent erosive RA, reconstructive surgery used. Surgery is indicated when pain cannot be relieved by conservative measures. Surgical procedures include synovectomy (excision of the synovial membrane) tenorrhaphy (suturing tendon) and arthroplasty (surgical repair and replacement of the joint)

Nutrition Therapy

Patients with RA frequently experience anorexia, weight loss, and anemia. A dietary history identifies usual eating habits and food preferences. Food selection should include the daily requirements from the basic food groups, with emphasis on foods high in vitamins, protein, and iron for tissue building and repair. For the extremely anorexic patient, small, frequent feedings with increased protein supplements may be prescribed. Some medications (ie, oral corticosteroids) used in RA treatment stimulate the appetite and, when combined with decreased activity, may lead to weight gain. Therefore, patients may need to be counselled about eating a healthy, calorie-restricted diet.

Difference between Osteo and Rheumatoid arthritis

  Osteoarthritis Rheumatoid Arthritis
Pathology Progressive process of central cartilage (spurs) destruction
Peripheral bone growth in joint
Progressive process marked by exacerbations and remissions
Inflammation of synovial membrane with cartilage damage and bone destruction
Ligament, tendon, and joint capsule damage
Affected Joints Weight-bearing joints (hips, knees, ankles), spine, DIP and PIP joints*
Asymmetric
Small joints (PIP, MCP), wrists, knees
Symmetric
Joint Effusions Mild swelling possible from localized inflammatory response Common
Clinical Manifestations Localized pain an stiffness, mild swelling possible
Pain with activity, improves with rest Heberden’s and Bouchard’s nodules
Pain, swelling, tenderness, redness, and warmth Nodules over extensor surfaces
Anemia, fatigue, and muscle aches
Pain at rest, especially at night
Elevated ESR, often positive rheumatoid factor
Other affected systems None Lung, heart, skin
Body size Possible overweight Usually average to below average weight for size
Age at onset Fourth to fifth decade of life Young to middle age
Gender 2:1 female-to-male ratio 3:1 female-to-male ratio
Heredity Genetic factors contribute Familial tendency
Diagnostic tests X-rays Rheumatoid factor (80% positive); x-rays; joint fluid analysis; negative Lyme disease titer
X-ray evidence Osteophytes, subchondral cysts Erosions, osteoporosis
Treatment Exercise and weight control, maintenance of activity level with joint protection
Heat or cold applications
Relaxation strategies
Medication and/or surgery
Inflammation reduction
Balanced diet and exercise program with joint protection
Relaxation strategies; heat or cold applications
Medication and/or surgery

 

Nursing management

Nursing diagnosis: Acute and Chronic pain related to joint inflammation, overuse of joints

Nursing goal: To relieve pain .

Intervention

  • Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain and precipitating factors to establish a pattern and baseline assessment
  • Evaluate with patient and health care team, effectiveness of past pain control measures that have been used to determine what has helped and not helped in the past
  • Reduce or eliminate factors that precipitate or increase the pain experiences (fear, fatigue and lack of knowledge) to minimize negative stimuli that may increase pain.
  • Teach use of non pharmacologic techniques (relaxation, distraction, hot/cold application, massage) before pain occurs or increase and along with other pain relief measures, to promote muscle relaxation and decrease tension.
  • Provide the person with optimal pain relief with prescribed analgesics to help to decrease pain and inflammation.

Nursing Diagnosis: Impaired physical mobility related to joint pain, stiffness and deformity

Goal: Improved physical mobility.

Intervention

  • Determine limitation of joint movement and effect on function to establish baseline for plan of care.
  • Collaborate with physical therapy in developing and executing an exercise programe to maintain and improve joint function
  • Explain to patient/ family the purpose and plan for joint exercises to provide information and support for the patient.
  • Initiate pain control measures before beginning joint exercises (hot packs, warm shower) to relieve stiffness and increase mobility.
  • Assist patient to optimal body position for passive/active joint movements (with correct application of resting splints, selection of properly fitting footwear and selection and use of assistive devices) to prevent or limit joint deformity.

Nursing Diagnosis: Disturbed body image related to chronic disease activity, long term treatment, stiffness, and inability to perform usual activities

Goal: Improved self image.

Interventions

  • Identify effects of patients culture ,religion, race, sex and age in terms of body image to determine extent of problems
  • Assist patient to discuss changes caused by illness or surgery to identify problems and plan treatment.
  • Facilitate contact with individual with similar changes in body image to promote sharing and socialization.

 

Nursing Diagnosis: Fatigue related to increased disease activity, pain, inadequate sleep/rest.

Goal: Relief from fatigue.

Interventions:

  • Provide instructions about fatigue

-Describe relationship of disease activity to fatigue.

-Describe comfort measures.

-Develop and encourage sleep routine.

-Explain how to conserve energy.

  • Facilitate development of appropriate activity / rest schedule.
  • Encourage adherence to the treatment regime.

 

Nursing Diagnosis: Ineffective therapeutic regime management related to chronic health problems

Goal: Adherence to therapeutic regime and follow-up care.

Interventions:

  • Determine patient usual methods of problem solving to identify where interventions needs to focus.
  • Provide information on realistic expectation related to patient behaviour to ensure correct understanding of disease management.
  • Refer patient to the community agencies to allow the patient to meet desired outcomes.
  • Include family to increase their sense of control and to increase patient sense of support.