Rheumatoid Arthri4s (RA)

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Darrell Rogers
5 years ago
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udy T.S. is a 40- year- old woman who presents to the clinic with fa4gue, morning s4ffness, and painful swelling of her fingers. The results of T.

1 Rheumatoid Arthri4s (RA) Chronic, systemic autoimmune disease Inflamma4on of connec4ve 4ssue in diarthrodial (synovial) joints Periods of remission and exacerba4on Extraar4cular manifesta4ons Extraar4cular Manifesta4ons of Rheumatoid Arthri4s Case Study T.S. is a 40- year- old woman who presents to the clinic with fa4gue, morning s4ffness, and painful swelling of her fingers. The results of T.S. s hand x- rays demonstrate no significant abnormality. The health care provider suspects rheumatoid arthri4s (RA). In what stage would T.S. s RA be classified? ( istockphoto/thinkstock) 1

2 E4ology and Pathophysiology Autoimmune e4ology Combina4on of gene4cs and environmental triggers An4gen triggers forma4on of abnormal immunoglobulin G (IgG) Autoan4bodies develop against the abnormal IgG Rheumatoid factor (RF) E4ology and Pathophysiology Rheumatoid factor combines with IgG immune complexes deposit on synovial membranes or car4lage in joints ac4vates complement inflammatory response Neutrophils proteoly4c enzymes damage car4lage and thicken synovial lining E4ology and Pathophysiology T helper cells (CD4) ac4vated s4mulate monocytes, macrophages, and synovial fibroblasts secrete proinflammatory cytokines Interleukin- 1 (IL- 1) Interleukin- 6 (IL- 6) Tumor necrosis factor (TNF) 2

Pathologic Changes in Rheumatoid Arthri4s E4ology and Pathophysiology Gene4c link Smoking increases risk in pa4ents gene4cally predisposed Without adequate treatment More than 60% may develop marked

3 Pathologic Changes in Rheumatoid Arthri4s E4ology and Pathophysiology Gene4c link Smoking increases risk in pa4ents gene4cally predisposed Without adequate treatment More than 60% may develop marked func4onal impairment within 20 years Need of mobility aids Loss of self- care ability Need for joint reconstruc4on By end- stage pa4ents experience loss of independence, require daily care E4ology and Pathophysiology Stage I Synovi4s X- ray: sob 4ssue swelling, possible osteoporosis, no joint destruc4on Stage II Increased joint inflamma4on Gradual destruc4on in joint car4lage Narrowing joint space from loss of car4lage 3

E4ology and Pathophysiology Stage III Forma4on of synovial pannus X- ray: extensive car4lage loss, erosion at joint margins, possible deformity Stage IV Inflammatory process subsides Loss of joint

4 E4ology and Pathophysiology Stage III Forma4on of synovial pannus X- ray: extensive car4lage loss, erosion at joint margins, possible deformity Stage IV Inflammatory process subsides Loss of joint func4on Forma4on of subcutaneous nodules Clinical Manifesta-ons - Joints Onset typically insidious May report history of precipita4ng event (i.e. infec4on, stress, exer4on, childbirth, surgery, emo4onal upset) Fa4gue, anorexia, weight loss, generalized s4ffness Specific joint involvement Pain, s4ffness, limited mo4on, and signs of inflamma4on Symptoms occur symmetrically Oben affects small joints Larger joints and cervical spine may be involved Clinical Manifesta-ons - Joints MCP and PIP joints typically swollen Fingers spindle shaped Deformity & disability Joint s4ffness aber inac4vity Morning s4ffness 60 minutes to several hours or longer Pain with mo4on, intensity varies Joints tender, painful, warm to touch 4

5 Clinical Manifesta4ons Extraar4cular Manifesta4ons Rheumatoid nodules Nodular myosi4s Sjögren s syndrome Felty syndrome Flexion contractures Cataracts Depression Diagnos-c Studies Laboratory studies Rheumatoid factor (RF) ESR and C- reac4ve protein (CRP) An4nuclear an4body (ANA) An4bodies to citrullinated pep4de (an4- CCP) Synovial fluid analysis X- rays of involved joints Bone scan Case Study ( istockphoto/thinkstock) T.S. s lab results indicate posi4ve RF and ANA. Her CRP and ESR are also elevated. The health care provider tells T.S. she has rheumatoid arthri4s. What medica4on(s) would you expect the health care provider to prescribe for T.S.? What type of nondrug interven4ons can you teach T.S. about to help with her joint pain? 5

6 Interprofessional Care Pa4ent teaching Drug therapy Disease process Home management strategies Nutri4onal therapy Surgical therapy Physical therapy Occupa4onal therapy Individualized treatment plan Nursing Diagnoses Impaired physical mobility Chronic pain Disturbed body image Planning & Overall Goals/ Evalua-on & Expected Outcomes Sa4sfactory pain management Minimal loss of func4onal ability Par4cipate in therapeu4c regimen Maintain posi4ve self- image Perform self- care Interprofessional Care Nursing Implementa-on in the Acute Care Primary goals in RA management: Decrease inflamma4on Manage pain Maintain joint func4on Prevent or correct joint deformity Comprehensive program usually treated on outpa4ent basis Drug therapy Balance of rest and ac4vity Joint protec4on Heat and cold applica4ons Exercise Pa4ent and caregiver teaching 6

7 Interprofessional Care Drug Therapy Suppression of inflamma4on NSAIDs DMARDs BRMs Pa4ent teaching about medica4ons Timing of administra4on Ac4on and side effects Compliance Drug Therapy: DMARDs Permanent effects of RA Methotrexate Monitor for bone marrow suppression and hepatotoxicity Hydroxychloroquine (Plaquenil) Baseline and then yearly eye exam Leflunomide (Arava) Teratogenic Tofaci4nib (Xeljanz) JAK (Janus kinase) inhibitor Drug Therapy: Biologic Response Modifiers (BRMs) Also called biologics or immunotherapy Slow progression Used to treat moderate to severe disease not responsive to DMARDs Used alone or in combina4on with DMARDs 7

8 Drug Therapy: Biologic Response Modifiers (BRMs) Tumor necrosis factor (TNF) inhibitors Infliximab (Remicade)- IV infusion Adalimumab (Humira)- subcutaneous Bind with TNF, inhibi4ng inflamma4on Tumor necrosis factor (TNF) inhibitors TB test and chest x- ray before start of therapy Monitor for infec4on Avoid live vaccina4ons Nondrug Therapy Nondrug relief of pain Therapeu4c heat and cold Rest Relaxa4on techniques Joint protec4on Biofeedback Transcutaneous electrical s4mula4on Hypnosis Therapeu4c Heat and Cold Plan care around morning s4ffness To relieve joint s4ffness and ability to perform ADLs Sit or stand in warm shower Sit in tub with warm towels around shoulders Soak hands in warm water Ice Especially beneficial during periods of disease exacerba4on Applica4on should not exceed minutes at one 4me Moist heat Hea4ng pads, moist hot packs, paraffin baths, warm baths, or showers Relieve s4ffness Should not exceed 20 minutes at a 4me Be alert for burn poten4al 8

9 Alignment and Exercise Lightweight splints Removed at regular intervals Perform ROM exercises Reapply as prescribed Occupa4onal therapist addi4onal self- help devices Alignment and Exercise Individualized exercise plan to Improve flexibility and strength Increase overall endurance Encourage program par4cipa4on and reinforce correct performance Need both recrea4onal and therapeu4c exercise Alignment and Exercise Gentle ROM exercises done daily to keep joints func4onal Aqua4c exercises in warm water beneficial Limit to one or two reps during acute inflamma4on 9

10 Alignment and Exercise Firm mapress or bed board Encourage posi4ons of extension Avoid flexion posi4ons No pillows under knees Small, flat pillow under head and shoulders Rest Alternate rest periods with ac4vity Helps relieve pain and fa4gue Amount of rest varies Avoid total bed rest 8 10 hours of sleep + day4me rest Modify ac4vi4es to avoid overexer4on Joint Protec4on Modify tasks for less stress on joints Energy conserva4on Work simplifica4on techniques Pacing and organizing Use of carts Joint protec4ve devices Delega4on Occupa4onal therapy Assis4ve devices 10

11 Nutri4onal Therapy Balanced nutri4on important Loss of appe4te or inability to shop for and prepare food weight loss Cor4costeroid therapy weight gain Surgical Therapy Relieve severe pain Improve func4on Synovectomy Total joint replacement (arthroplasty) Psychologic Support Pa4ent teaching important RA Nature and course of disease Goals of therapy Consider value system and percep4on of disease 11

12 Psychologic Support Pa4ent is constantly challenged by problems of Limited func4on and fa4gue Loss of self- esteem Altered body image Fear of disability or deformity Psychologic Support Discuss altera4ons in sexuality Pa4ent vulnerable to unproven or even dangerous remedies Help pa4ent recognize fears and concerns Evaluate family support system Financial planning Consider community resources Self- help groups are helpful for some pa4ents Strategies to decrease depression Health Promo4on Preven4on not possible at this 4me Early treatment to prevent further joint damage Community educa4on programs Symptom recogni4on to promote early diagnosis and treatment 12

13 Audience Response Ques-on Etanercept (TNF inhibitor) is prescribed for a pa4ent with stage II rheumatoid arthri4s. The nurse determines that the medica4on is effec4ve if what is observed? a. Decreased lymphocyte count b. Absence of Rh factor in the blood c. Decreased C- reac4ve protein (CRP) d. Increased serum immunoglobulin G 13

Patient #1. Rheumatoid Arthritis. Rheumatoid Arthritis. 45 y/o female Morning stiffness in her joints >1 hour

Patient #1. Rheumatoid Arthritis. Rheumatoid Arthritis. 45 y/o female Morning stiffness in her joints >1 hour Patient #1 Rheumatoid Arthritis Essentials For The Family Medicine Physician 45 y/o female Morning stiffness in her joints >1 hour Hands, Wrists, Knees, Ankles, Feet Polyarticular, symmetrical swelling