Rheumatoid-Arthritis

Definition

  • Rheumatoid arthritis (RA) is an inflammatory disorder of unknown origin that primarily involves the synovial membrane of the joints. Phagocytosis produces 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 power are lost.

Pathophysiology

  1. Systemic inflammatory process originating in the synovium or synovial fluid involving connective tissue and characterized by destruction and proliferation of synovial membrane.
  2. Phagocytosis produces enzymes within the joint, causing inflammation.
  3. Collagen is destroyed over time and pannus formations occur, narrowing the joint space.
  4. May result in joint destruction, ankylosis and deformity with loss of articulation and joint motion.
  5. Inflammatory process can also affect the spine, blood vessels, the pleural membrane of the lungs or the pericardial sac.
  6. Condition may be short lived and limited or progressive and severe.
  7. Spontaneous remissions and unpredictable exacerbations can occur.

Statistics

  • Morbidity: prevalence in United States is approximately 1% or 2.1 million adults.
  • Mortality: Dependent on overall deterioration in health and secondary organ dysfunction.
  • RA affects 1% of the population worldwide, affecting women two to four times more often than men.

Signs and Symptoms

Clinical features are determined by the stage and severity of the disease.

  • Joint pain, swelling, warmth, erythema, and lack of function are classic symptoms.
  • Palpation of joints reveals spongy or boggy tissue.
  • fluid can usually be aspirated from the inflamed joint.

Characteristic Pattern of Joint Involvement

  • Begins with small joints in hands, wrists, and feet.
  • Progressively involves knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints.
  • Symptoms are usually acute in onset, bilateral, and symmetric.
  • Joints may be hot, swollen, and painful; joint stiffness often occurs in the morning.
  • Deformities of the hands and feet can result from misalignment and immobilization.

Extraarticular Features

  • Fever, weight loss, fatigue, anemia, sensory changes, and lymph node enlargement
  • Raynaud’s phenomenon (cold and stress-induced vasospasm)
  • Rheumatoid nodules, nontender and movable; found in subcutaneous tissue over bony prominences
  • Arteritis, neuropathy, scleritis, pericarditis, splenomegaly, and Sjögren syndrome (dry eyes and mucous membranes)

Complications

  1. Pericarditis
  2. Iridocyclitis

Assessment and Diagnostic Methods

  • Several factors contribute to an RA diagnosis: rheumatoid nodules, joint inflammation detected on palpation, laboratory findings, extraarticular changes.
  • Rheumatoid factor is present in about three fourths of patients.
  • RBC count and C4 complement component are decreased; erythrocyte sedimentation rate is elevated.
  • C Reactive protein and antinuclear antibody test results may be positive.
  • Arthrocentesis and x-rays may be performed.

Assessment

ACTIVITY/REST

  • May report: Joint pain and tenderness worsened by movement and stress placed on joint; morning stiffness (duration often l hr or more), usually occurs symmetrically
  • Functional limitations affecting ADLs, desired lifestyle, leisure time, and occupation
  • Fatigue; sleep disturbances
  • May exhibit: Malaise
  • Impaired ROM of joints; particularly hand (fingers and wrist), hips, knees, ankles, elbows, and shoulders
  • Muscle atrophy; joint and muscle contractures/deformities
  • Decreased muscle strength, altered gait/posture

CARDIOVASCULAR

  • May report: Intermittent pallor, cyanosis, then redness of fingers/toes before color returns to normal (Raynaud’s phenomenon)

EGO INTEGRITY

  • May report: Acute/chronic stress factors (e.g., financial, employment, disability, relationship factors)
  • Hopelessness and powerlessness (incapacitating situation)
  • Threat to self-concept, body image, personal identity (e.g., dependence on others)

FOOD/FLUID

  • May report: Inability to obtain/consume adequate food/fluids (temporomandibular joint [TMJ] involvement)
  • Anorexia, nausea
  • May exhibit: Weight loss
  • Dryness of oral mucous membranes, decreased oral secretions; dental caries (Sjögren’s syndrome)

HYGIENE

  • May report: Varying difficulty performing self-care activities; dependence on others

NEUROSENSORY

  • May report: Numbness/tingling of hands and feet, loss of sensation in fingers
  • May exhibit: Symmetrical joint swelling

PAIN/DISCOMFORT

  • May report: Acute episodes of pain (may/may not be accompanied by soft-tissue swelling in joints)
  • Chronic aching pain and stiffness (mornings are most difficult)
  • May exhibit: Red, swollen, hot joints (during acute exacerbations)

SAFETY

  • May report: Difficulty managing homemaker/maintenance tasks
  • Persistent low-grade fever
  • Dryness of eyes and mucous membranes
  • May exhibit: Pale, shiny, taut skin; subcutaneous rounded, nontender nodules; lesions, leg ulcers
  • Skin/periarticular local warmth, erythema
  • Decreased muscle strength, altered gait, reduced ROM
  • Sexuality
  • May report: Deficulty engaging in sexual activity as desired/abstinence

SOCIAL INTERACTION

  • May report: Impaired interactions with family/others; change in roles; isolation

TEACHING/LEARNING

  • May report: Familial history of RA (in juvenile onset)
  • Usual onset between ages 25 and 50, ratio of women to men 3:1
  • Use of health foods, vitamins, untested arthritis “cures”
  • History of pericarditis, valvular lesions; pulmonary fibrosis, pleuritis

Diagnostic Studies

  • Antinuclear antibody (ANAtiter: Screening test for rheumatic disorders, elevated in 25%–30% of RA patients. Follow-up tests are needed for the specific rheumatic disorders, e.g., anti-RNP is used for differential diagnosis of systemic rheumatic disease.
  • Rheumatoid factor (RF): Positive in more than 80% of cases (Rose-Waaler test).
  • Latex fixation: Positive in 75% of typical cases.
  • Agglutination reactions: Positive in more than 50% of typical cases.
  • Serum complement: C3 and C4 increased in acute onset (inflammatory response). Immune disorder/exhaustion results in depressed total complement levels.
  • Erythrocyte sedimentation rate (ESR): Usually greatly increased (80–100 mm/hr). May return to normal as symptoms improve.
  • CBC: Usually reveals moderate anemia. WBC is elevated when inflammatory processes are present.
  • Immunoglobulin (Ig) (IgM and IgG): Elevation strongly suggests autoimmune process as cause for RA.
  • X-rays of involved joints: Reveals soft-tissue swelling, erosion of joints, and osteoporosis of adjacent bone (early changes) progressing to bone-cyst formation, narrowing of joint space, and subluxation. Concurrent osteoarthritic changes may be noted.
  • Radionuclide scans: Identify inflamed synovium.
  • Direct arthroscopy: Visualization of area reveals bone irregularities/degeneration of joint.
  • Synovial/fluid aspirate: May reveal volume greater than normal; opaque, cloudy, yellow appearance (inflammatory response, bleeding, degenerative waste products); elevated levels of WBCs and leukocytes; decreased viscosity and complement (C3 and C4).
  • Synovial membrane biopsy: Reveals inflammatory changes and development of pannus (inflamed synovial granulation tissue).

Nursing Priorities

  1. Alleviate pain.
  2. Increase mobility.
  3. Promote positive self-concept.
  4. Support independence.
  5. Provide information about disease process/prognosis and treatment needs.

Discharge Goals

  1. Pain relieved/controlled.
  2. Patient is dealing realistically with current situation.
  3. Patient is managing ADLs by self/with assistance as appropriate.
  4. Disease process/prognosis and therapeutic regimen understood.
  5. Plan in place to meet needs after discharge.

Nursing Diagnosis

The following NANDA nursing diagnosis are applicable for patients with rheumatoid arthritis:

  1. Impaired Physical Mobility related to pain and restricted joint movement.
  2. Acute pain related to swollen, inflamed joints and restricted movement.
  3. Fatigue related to chronic inflammatory process.
  4. Risk for Ineffective Therapeutic Regimen Management related to insufficient knowledge of condition, pharmacologic therapy, exercise program, myths and community resources.

Nursing Care Plans

Main Article: 6 Rheumatoid Arthritis Nursing Care Plans

Care Setting

  • Community level unless surgical procedure is required.

Related Concerns

  • Psychosocial aspects of care
  • Total joint replacement

Medical Management

Treatment begins with education, a balance of rest and exercise, and referral to community agencies for support.

  • Early RA: medication management involves therapeutic doses of salicylates or NSAIDs; includes new COX2 enzyme blockers, antimalarials, gold, penicillamine, or sulfasalazine; methotrexate; biologic response modifiers and tumor necrosis factor alpha (TNF) inhibitors are helpful; analgesic agents for periods of extreme pain.
  • Moderate, erosive RA: formal program of occupational and physical therapy; an immunosuppressant such as cyclosporine may be added.
  • Persistent, erosive RA: reconstructive surgery and corticosteroids.
  • Advanced unremitting RA: immunosuppressive agents such as methotrexate, cyclophosphamide, azathioprine, and leflunomide (highly toxic, can cause bone marrow suppression, anemia, GI tract disturbances, and rashes). Also promising for refractory RA is a Food and Drug Administration (FDA)–approved apheresis device: a protein A immunoadsorption column (Prosorba) that binds circulating immune system complex (IgG).
  • RA patients frequently experience anorexia, weight loss, and anemia, requiring careful dietary history to identify usual eating habits and food preferences. Corticosteroids may stimulate appetite and cause weight gain.
  • Lowdose antidepressant medications (amitriptyline) are used to reestablish adequate sleep pattern and manage pain.

Nursing Management

The most common issues for the patient with RA include pain, sleep disturbance, fatigue, altered mood, and limited mobility. The patient with newly diagnosed RA needs information about the disease to make daily self management decisions and to cope with having a chronic disease.

Relieving Pain and Discomfort

  • Provide a variety of comfort measures (eg, application of heat or cold; massage, position changes, rest; foam mattress, supportive pillow, splints; relaxation techniques, diversional activities).
  • Administer anti-inflammatory, analgesic, and slow-acting antirheumatic medications as prescribed.
  • Individualize medication schedule to meet patient’s need for pain management.
  • Encourage verbalization of feelings about pain and chronicity of disease.
  • Teach pathophysiology of pain and rheumatic disease, and assist patient to recognize that pain often leads to unproven treatment methods.
  • Assist in identification of pain that leads to use of unproven methods of treatment.
  • Assess for subjective changes in pain.

Reducing Fatigue

  • Provide instruction about fatigue: Describe relationship of disease activity to fatigue; describe comfort measures while providing them; develop and encourage a sleep routine (warm bath and relaxation techniques that promote sleep); explain importance of rest for relieving systematic, articular,
  • and emotional stress.
  • Explain how to use energy conservation techniques (pacing, delegating, setting priorities).
  • Identify physical and emotional factors that can cause fatigue.
  • Facilitate development of appropriate activity/rest schedule.
  • Encourage adherence to the treatment program.
  • Refer to and encourage a conditioning program.
  • Encourage adequate nutrition, including source of iron from food and supplements.

Increasing Mobility

  • Encourage verbalization regarding limitations in mobility.
  • Assess need for occupational or physical therapy consultation: Emphasize range of motion of affected joints; promote use of assistive ambulatory devices; explain use of safe footwear; use individual appropriate positioning/posture.
  • Assist to identify environmental barriers.
  • Encourage independence in mobility and assist as needed: Allow ample time for activity; provide rest period after activity; reinforce principles of joint protection and work simplification.
  • Initiate referral to community health agency.

Facilitating Self Care

  • Assist patient to identify self care deficits and factors that
  • interfere with ability to perform self-care activities.
  • Develop a plan based on the patient’s perceptions and priorities on how to establish and achieve goals to meet self care needs, incorporating joint protection, energy conservation, and work simplification concepts: Provide appropriate assistive devices; reinforce correct and safe use of assistive devices; allow patient to control timing of self-care activities; explore with the patient different ways to perform difficult tasks or ways to enlist the help of someone else.
  • Consult with community health care agencies when individuals have attained a maximum level of self care yet still have some deficits, especially regarding safety.

Improving Body Image and Coping Skills

  • Help patient identify elements of control over disease symptoms and treatment.
  • Encourage patient’s verbalization of feelings, perceptions, and fears.
  • Identify areas of life affected by disease. Answer questions and dispel possible myths.
  • Develop plan for managing symptoms and enlisting support of family and friends to promote daily function.

Monitoring and Managing Potential Complications

  • Help patient recognize and deal with side effects from medications.
  • Monitor for medication side effects, including GI tract bleeding or irritation, bone marrow suppression, kidney or liver toxicity, increased incidence of infection, mouth sores, rashes, and changes in vision. Other signs and symptoms include bruising, breathing problems, dizziness, jaundice, dark urine, black or bloody stools, diarrhea, nausea and vomiting, and headaches.
  • Monitor closely for systemic and local infections, which often can be masked by high doses of corticosteroids.

Teaching Points

  • Focus patient teaching on the disease, possible changes related to it, the prescribed therapeutic regimen, side effects of medications, strategies to maintain independence and function, and safety in the home.
  • Encourage patient and family to verbalize their concerns and ask questions.
  • Address pain, fatigue, and depression before initiating a teaching program, because they can interfere with patient’s ability to learn.
  • Instruct patient about basic disease management and necessary adaptations in lifestyle.

Continuing Care

  • Refer for home care as warranted (eg, frail patient with significantly limited function).
  • Assess the home environment and its adequacy for patient safety and management of the disorder.
  • Identify any barriers to compliance, and make appropriate referrals.
  • For patients at risk for impaired skin integrity, monitor skin status and also instruct, provide, or supervise the patient and family in preventive skin care measures.
  • Assess patient’s need for assistance in the home, and supervise home health aides.
  • Make referrals to physical and occupational therapists as problems are identified and limitations increase.
  • Alert patient and family to support services such as Meals on Wheels and local Arthritis Foundation chapters.
  • Assess the patient’s physical and psychological status, adequacy of symptom management, and adherence to the management plan.
  • Emphasize the importance of follow up appointments to the patient and family.

SIMILAR ARTICLES

NO COMMENTS

Leave a Reply