RHEUMATOID

ARTHRITISBaljinder singh

M. Sc (MSN)Assistant Professor

PIMS , Panipat

RHEUMATOID ARTHRITIS Rheumatoid arthritis

isautoimmune disorder in which Immune system identifies the synovial membrane as "foreign" and begins attacking it.

Synovial membrane shown in picture

DEFINITION Rheumatoid Arthritis (RA) is a chronic

inflammatory disorder that may affect many tissues and organs, but mainly attacks the joints producing an inflammatory synovitis.

RISK FACTORS Idiopathic Positive family history  Inherited tissue type major

histocompatibility complex (MHC) antigen 

Smoking Bacterial and Fungal Infection  Herpes simplex virus infections  Epstein-Barr virus (EBV) Vitamin D deficiency

INCIDENCE RA affects 0.5-1.0% of population in USA Females > males 3:1 but people of any age can be affected Peak age 45-65 but onset early from age

20-45 yrs About 75% of these are women.

The disease strikes women three times more often than men

PATHOPHYSIOLOGY Presentation of antigen to T cells T- and B-cell Proliferation Angiogenesis

in synovial lining Neutrophil accumulation in synovial

fluid. Synovitis. Early pannus Formation(The pannus is a

sheet of inflammatory granulation tissue that spreads from the synovial membrane and invades the joint)

CONT.. Subchondral bone erosion. Pannus invasion of cartilage

Chondrocyte proliferation. Laxity of ligaments Joint instability, contractures, decreased

ROM, systemic complications

Sign and Symptoms

SYMPTOMS AND SIGNS OF RHEUMATOID ARTHRITIS The joints of the

hands are often the very first joints affected by rheumatoid arthritis. These joints are swollen red and tender when squeezed.

Swelling due to synovitis

RA - HANDS

RA - HANDS

SWAN NECK DEFORMITY The deformity

arises from hyperextension of the proximal interphalangeal joint, while the distal interphalangeal joint is flexed.

MALLET FINGER Mallet finger is a

simple flexion deformity of the distal interphalangeal joint preventing extension.

Z- DEFORMITY OF THUMB Severe

hyperextension of the interphalangeal joint of the thumb

CONT.. Fatigue Joint pain Joint tenderness Joint swelling Joint redness Joint warmth

CONT.. Joint stiffness Loss of joint range of motion Many joints affected (polyarthritis) Limping Joint deformity Both sides of the body affected

(symmetric)

Diagnosis

X RaysX rays of hands and feet are generally performed

in people with RA. Magnetic Resonance Imaging (MRI) Ultrasounds

Blood TestsRheumatoid Factor (RF)

RF is a specific antibody in the blood. A negative RF does not rule out RA. The arthritis is then

called seronegative, most common during the first year of illness and converting to seropositive status over time.

Anti-citrullinated Protein Antibodies (ACPAs) Like RF, this testing is only positive in a proportion of all

RA cases. Unlike RF, this test is rarely found positive if RA is NOT

present, giving it a specificity of about 95%.

Other blood tests performed when RA is suspected: Erythrocyte Sedimentation Rate (ESR)

The rate at which red blood cells precipitate in a 1 hour period.

C-Reactive ProteinA protein found in the blood in response to

inflammation. Full Blood Count

Gives information about all blood cells. Renal Function

Kidney Function Liver Enzymes

Gives information on the state of a patient’s liver

MEDICAL MANAGEMENT Salicylates Acetylated

aspirin Nonacetylated

choline magnesium trisalicylate (Trilisate)choline salicylate (Arthropan)

CONT.. Nonsteroidal Anti-inflammatory

Drugs (NSAIDs)diclofenac (Voveran)etodolac (Lodine)flurbiprofen (Ansaid) ibuprofen meclofenamate (Meclomen)meloxicam nabumatone (Relafen)

Disease-Modifying Antirheumatic Drugs (DMARDs)

Antimalarials Action: Anti-inflammatory, inhibits lysosomal enzymes

hydroxychloroquine chloroquine

CONT.. Gold-containing compounds

Action: Inhibits T- and B-cell activity, suppresses synovitis during active stage of rheumatoid

aurothioglucose (Solganol)gold sodium thiomalateauranofin (Ridaura)sulfasalazine (Azulfidine)penicillamine (Cuprimine)

CONT.. Immunosuppressives

Action: Immune suppression, effects DNA synthesis and other cellular effects

methotrexate (Rheumatrex) azathioprine (Imuran) cyclophosphamide (Cytoxan)

CONT.. Corticosteroids Action: Anti-inflammatory, analgesic

Used for shortest duration and at lowest dose possible to minimize adverse effectsprednisoneprednisolonehydrocortisone intra-articular injections

CONT.. Topical Analgesics

capsaicin (Zostrix)

SURGICAL MANAGEMENTSurgeries considered for people who have severe rheumatoid arthritis include:

Arthroplasty, to replace part or all of a joint, such as the hip or knee.

Arthroscopy, which uses a small lighted instrument to remove debris or inflamed tissue from a joint.

Carpal tunnel release, to relieve pressure on the median nerve in the wrist.

CONT.. Cervical spinal fusion, to treat

severe neck pain and nerve problems. Finger and hand surgeries, to correct

joint problems in the hand. Foot surgery such as phalangeal head

resection. Synovectomy, to remove inflamed joint

tissue.

NURSING MANAGEMENT NURSING DIAGNOSES• Acute and chronic pain related to inflammation

and increased disease activity, tissue damage, fatigue, or lowered tolerance level

• Fatigue related to increased disease activity, pain, inadequate sleep/rest, deconditioning, inadequate nutrition, emotional stress/depression

• Disturbed sleep pattern related to pain, depression, and medications

•• Self-care deficits related to contractures,

fatigue, or loss of motion

Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack of or improper use of ambulatory devices

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