Gina had been a sales manager for 31 years. Now that she has retired, she is starting to feel the pangs of long term standing when she was once working. Oftentimes, she feels pain on her knees and she could see redness and swelling on the same area. The same sensation started spreading towards her hips, her elbows, and shoulders. She went for a consultation, and after a series of laboratory tests, she was diagnosed with rheumatoid arthritis.
What is Rheumatoid Arthritis?
Rheumatoid arthritis is classified as a diffuse connective tissue disease.
- Rheumatoid arthritis (RA) is an autoimmune disease of unknown origin.
- It is classified as a diffuse connective tissue disease and is chronic in nature.
- It is characterized by diffuse inflammation and degeneration in the connective tissues.
The pathophysiology of rheumatoid arthritis is brief and concise.
- Autoimmune reaction. In RA, the autoimmune reaction primarily occurs in the synovial tissue.
- Phagocytosis. Phagocytosis produces enzymes within the joint.
- Collagen breakdown. The enzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation.
- Damage. Pannus destroys cartilage and erodes the bone.
- Consequences. The consequences are loss of articular surfaces and joint motion.
- Degenerative changes. Muscle fibers undergo degenerative changes, and tendon and ligament elasticity and contractile power are lost.
Statistics and Incidences
Rheumatoid arthritis is common worldwide.
- Rheumatoid arthritis affects 1% of the population worldwide.
- The ratio of female to male with RA is between 2:1 and 4:1.
Diffuse connective tissue diseases have unknown causes, but they are also thought to be the result of immunologic abnormalities.
- Genetics. Researchers have shown that people with a specific gene marker called the HLA shared epitope have a fivefold greater chance of developing rheumatoid arthritis than do people without the marker.
- Infectious agents. Infectious agents such as bacteria and viruses may trigger the development of the disease in a person whose genes make them more likely to get it.
- Female hormones. 70% of people with RA are women, and this occur because of the fluctuations of the female hormones.
- Environmental factors. Environmental factors such as exposure to cigarette smoke, air pollution, and insecticides.
- Occupational exposures. Substances such as silica and mineral oil may harm the worker and result in contact dermatitis.
Clinical manifestations of RA vary, usually reflecting the stage and severity of tge disease.
- Joint pain. One of the classic signs, joints that are painful are not easily moved.
- Swelling. Limitation in function occurs as a result of swollen joints.
- Warmth. There is warmth in the affected joint and upon palpation, the joints are spongy or boggy.
- Erythema. Redness of the affected area is a sign of inflammation.
- Lack of function. Because of the pain, mobilizing the affected area has limitations.
- Deformities. Deformities of the hands and feet may be caused by misalignment resulting in swelling.
- Rheumatoid nodules. Rheumatoid nodules may be noted in patients with more advanced RA, and they are nontender and movable in the subcutaneous tissue.
Medications used for treating rheumatoid arthritis may cause serious and adverse side effects.
- Bone marrow suppression. Improper use of immunosuppressants could lead to bone marrow suppression.
- Anemia. Immunosuppressive agents such as methotrexate and cyclophosphamide are highly toxic and can produce anemia.
- Gastrointestinal disturbances. Some NSAIDs are likely to cause gastric irritation and ulceration.
Assessment and Diagnostic Findings
Several factors contribute to the diagnosis of RA.
- Antinuclear antibody (ANA) titer: 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).
Medical management is aligned with each phase of rheumatoid arthritis.
- Rest and exercise. There should be a balance of rest and exercise planned for a patient with RA.
- Referral to community agencies such as the Arthritis Foundation could help the patient gain more support.
- Biologic response modifiers. An alternative treatment approach for RA, biologic response modifiers, has emerged, wherein a group of agents that consist of molecules produced by cells of the immune system participate in the inflammatory reactions.
- Therapy. A formal program with occupational and physical therapy is prescribed to educate the patient about the principles of joint protection, pacing activities, work simplification, range of motion, and muscle-strengthening exercises.
- Nutrition. 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.
The drugs used in each phase of rheumatoid arthritis include:
Early Rheumatoid Arthritis
- NSAIDs. COX-2 medications block the enzyme involved in inflammation while leaving intact the enzyme involved in protecting the stomach lining.
- Methotrexate. Methotrexate is currently the standard treatment of RA because of its success in preventing both joint destruction and long-term disability.
- Analgesics. Additional analgesia may be prescribed for periods of extreme pain.
Moderate, Erosive Rheumatoid Arthritis
- Cyclosporine. Neoral, an immunosuppressant is added to enhance the disease modifying effect of methotrexate.
Persistent, Erosive Rheumatoid Arthritis
- Corticosteroids. Systemic corticosteroids are used when the patient has unremitting inflammation and pain or needs a “bridging” medication while waiting for slower DMARDs to begin taking effect.
Advanced, Unremitting Rheumatoid Arthritis
- Immunosuppressants. Immunosuppressive agents are prescribed because of their ability to affect the production of antibodies at the cellular level.
- Antidepressants. For most patients with RA, depression and sleep deprivation may require the short-term use of low-dose antidepressants such as amitriptyline, paroxetine, or sertraline, to reestablish an adequate sleep pattern and to manage chronic pain.
For persistent, erosive RA, reconstructive surgery is often used.
- Reconstructive surgery. Reconstructive surgery is indicated when pain cannot be relieved by conservative measures and the threat of loss of independence is eminent.
- Synovectomy. Synovectomy is the excision of the synovial membrane.
- Tenorrhaphy. Tenorrhaphy is the suturing of a tendon.
- Arthrodesis. Arthrodesis is the surgical fusion of the joint.
- Arthroplasty. Arthroplasty is the surgical repair and replacement of the joint.
Nursing care of the patient with RA should follow a basic plan of care.
The assessment of a patient with RA can contribute to its diagnosis.
- History and physical exam. The history and physical examination address manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints.
- Extra-articular changes. The patient is also assessed for extra-articular changes and these include weight loss, sensory changes, lymph node enlargement, and fatigue.
Bases on the assessment data, the major nursing diagnoses appropriate for the patient are:
- 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, and emotional stress/depression
- Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack or improper use of ambulatory devices.
- Self-care deficit related to contractures, fatigue, or loss of motion.
- 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 Care Planning & Goals
Main Article: 6 Rheumatoid Arthritis Nursing Care Plans
The major goals for a patient with RA are:
- Improvement in comfort level.
- Incorporation of pain management techniques into daily life.
- Incorporation of strategies necessary to modify fatigue as part of the daily activities.
- Attain and maintain optimal functional mobility.
- Adapt to physical and psychological changes imposed by the rheumatic disease.
- Use of effective coping behaviors for dealing with actual or perceived limitations and role changes.
The patient with RA needs information about the disease to make 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.
- 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.
- 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 ofself-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.
- 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.
- 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.
Expected outcomes include:
- Improved comfort level.
- Incorporated pain management techniques into daily life.
- Incorporated strategies necessary to modify fatigue as part of the daily activities.
- Attained and maintained optimal functional mobility.
- Adapted to physical and psychological changes imposed by the rheumatic disease.
- Used effective coping behaviors for dealing with actual or perceived limitations and role changes.
Discharge and Home Care Guidelines
Patient teaching is an essential aspect of discharge and home care.
- Disorder education. The patient and family must be able to explain the nature of the disease and principles of disease management.
- Medications. The patient or caregiver must be able to describe the medication regimen (name of medications, dosage, schedule pf administration, precautions, potential side effects, and desired effects.
- Pain management. The patient must be able to describe and demonstrate use of pain management techniques.
- Independence. The patient must be able to demonstrate ability to perform self-care activities independently or with assistive devices.
The focus of documentation include:
- Client’s description of response to pain.
- Specifics of pain inventory.
- Expectations of pain management.
- Acceptable level of pain.
- Manifestations of fatigue and other assessment findings.
- Degree of impairment and effect on lifestyle.
- Level of function, ability to participate in specific or desired activities.
- Functional level and specifics of limitations.
- Needed resources and adaptive devices.
- Available and use of community resources.
- Observations, presence of maladaptive behavior, emotional changes, level of independence.
- Prior medication use.
- Plan of care.
- Teaching plan.
- Response to interventions, teachings, and actions performed.
- Attainment or progress towards desired outcomes.
- Modifications to plan of care.
- Long term needs.
Practice Quiz: Rheumatoid Arthritis
C. Joint pain.
D. Metallic taste.
1. Answer: D. Metallic taste.
- D: Gold sodium thiomalate toxicity signs are pruritus, diarrhea, dermatitis, stomatitis, and metallic taste.
- A&B: Flushing and dizziness are the side effects that may occur soon after the injection.
- C: Increased joint pain may occur 1-2 days after the injection.
2. Adalimumab (Humira) is given to a client for the treatment of rheumatoid arthritis. Which of the following side effect is associated with the medication?
2. Answer: A. Numbness.
- A: Adalimumab (Humira) has been associated with neurological side effects such as numbness, tingling, dizziness, visual disturbances, and weakness in the legs).
- B, C, D: Options B, C, and D are not associated with the use of medication.
3. A client has just been prescribed with Methotrexate (Trexall) for the treatment of rheumatoid arthritis who did not respond to any other treatment. An important reminder for the client is to?
A. Clay-colored stool is a normal response of the treatment.
B. Pregnancy is not contraindicated with the use of the medication.
C. Strict hand washing.
D. Get a daily source of sunlight during the day.
3. Answer: C. Strict hand washing.
- C: Clients taking Methotrexate are more likely to get infections or may worsen any current infections. Therefore, hand washing will help to prevent the spread of infection.
- A: Option A is a sign of a liver toxicity and the physician should be notified of it.
- B: Pregnancy is not allowed during the treatment.
- D: Photosensitivity may happen during the treatment so the client is advised to wear sunscreen or any protective gear against the sunlight.
4. Mr. Mc Princeton who is diagnosed with rheumatoid arthritis (RA) complains about joints that always hurt, saying, “I just feel like staying in bed all day.” Which discharge instruction would be aimed at maintaining as such function as possible?
A. “Refrain from exercise because it only aggravates the disease process.”
B. “Apply elastic bandages to all joints to increase the pain threshold.”
C. “Maintain a supine position most of the day to prevent the stress of weight bearing.”
D. “Promote aquatic (water) exercises to enhance joint mobility.”
4. Answer: D. “Promote aquatic (water) exercises to enhance joint mobility.”
- D: Water exercises are excellent because water promotes buoyancy, which eases joint movement.
- A: Persons with RA should maintain an active exercise program to strengthen and preserve muscle movement.
- B: Elastic bandage wraps would not be helpful.
- C: Being active instead of just lying supine all day could help strengthen the muscles and joints.
5. The classic signs and symptoms of rheumatoid arthritis include which of the following?
A. Pain on weight-bearing, rash and low-grade fever.
B. Joint swelling, joint stiffness in the morning and bilateral joint movement.
C. Crepitus, development of Heberden’s nodes and anemia.
D. Fatigue, leucopenia and joint pain.
5. Answer: B. Joint swelling, joint stiffness in the morning and bilateral joint movement.
- B: Joint swelling, joint stiffness in the morning and bilateral joint movement are the classic signs of rheumatoid arthritis.
- A, C, D: The other symptoms are not found on a patient with rheumatoid arthritis.
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