N325 Rheumatoid Arthritis · 2019. 8. 23. · 2/25/16 6 ClinicalManifestations! Joints!!...

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Rheumatoid Arthritis Chapter 65

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Rheumatoid Arthritis (RA) §  Chronic, systemic autoimmune

disease §  Inflammation of connective tissue in

diarthrodial (synovial) joints §  Periods of remission and exacerbation §  Extraarticular manifestations


Rheumatoid Arthritis (RA) §  Affects all ethnic groups §  Incidence ↑ with age, peaks 30–50

years old §  1.3 million Americans §  Women > men


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Case Study

• T.S. is a 40-‐year-‐old woman who presents to the clinic with fatigue, morning stiffness, and painful swelling of her fingers.

• The health care provider suspects rheumatoid arthritis (RA).


iStockphoto/Thinkstock

Case Study

•  In preparation for teaching T.S. about this disease process, you decide to quickly review its etiology and pathophysiology.



Case Study

• What causes RA?

• Describe the pathophysiology of RA.



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Etiology and Pathophysiology §  Autoimmune etiology

§  Combination of genetics and environmental triggers

§  Antigen triggers formation of abnormal immunoglobulin G (IgG)

§  Autoantibodies develop against the abnormal IgG §  Rheumatoid factor (RF)


Etiology and Pathophysiology §  Rheumatoid factor combines with IgG

immune complexes → deposit on synovial membranes or cartilage in joints → activates complement → inflammatory response

§  Neutrophils → proteolytic enzymes → damage cartilage and thicken synovial lining


Etiology and Pathophysiology §  T helper cells (CD4) activated →

stimulate monocytes, macrophages, and synovial fibroblasts → secrete proinflammatory cytokines §  Interleukin-‐1 (IL-‐1) §  Interleukin-‐6 (IL-‐6) §  Tumor necrosis factor (TNF)


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Pathologic Changes in Rheumatoid Arthritis


Etiology and Pathophysiology §  Genetic link

§  Higher incidence in identical twins §  HLA-‐DR4 and HLA-‐DR1 antigens §  Smoking increases risk in patients

genetically predisposed


Case Study •  The results of T.S.’s hand x-‐rays demonstrate no significant abnormality.

•  In what stage would T.S.’s RA be classified?



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Etiology and Pathophysiology §  Stage I: Early

§  No destructive changes on x-‐ray, possible x-‐ray evidence of osteoporosis

§  Stage II: Moderate §  X-‐ray evidence of osteoporosis §  No joint deformities, adjacent muscle

atrophy, possible presence of extraarticular soft tissue lesions


Etiology and Pathophysiology §  Stage III: Severe

§  X-‐ray evidence of cartilage and bone destruction in addition to osteoporosis; joint deformity; extensive muscle atrophy; possible presence of extraarticular soft tissue lesions

§  Stage IV: Terminal §  Fibrous or bony ankylosis, stage III

criteria Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study • For what additional clinical manifestations of RA will you assess T.S.?



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Clinical Manifestations Joints §  Onset typically insidious §  Fatigue, anorexia, weight loss,

generalized stiffness §  May report history of precipitating

event §  Infection, stress, exertion, childbirth,

surgery


Clinical Manifestations Joints §  Specific articular involvement

§  Pain, stiffness, limitation of motion, and signs of inflammation

§  Symptoms occur symmetrically §  Most often affects small joints §  Larger joints and cervical spine may

be involved


Clinical Manifestations Joints §  Joint stiffness after inactivity §  Morning stiffness 60 minutes to

several hours or longer §  MCP and PIP joints typically swollen §  Fingers spindle shaped §  Joints tender, painful, warm to touch §  Pain ↑ with motion, intensity varies


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Clinical Manifestations Joints §  Tenosynovitis §  Deformity and disability §  Subluxation §  Walking disability


Typical Deformities of Rheumatoid Arthritis


Clinical Manifestations Extraarticular Manifestations §  Rheumatoid nodules §  Sjögren’s syndrome §  Felty syndrome §  Flexion contractures §  Nodular myositis §  Cataracts §  Depression


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Extraarticular Manifestations of Rheumatoid Arthritis


Case Study • What diagnostic testing would you expect the health care provider to order for T.S.?



Diagnostic Studies

§  Laboratory studies §  Rheumatoid factor (RF) §  Erythrocyte sedimentation rate (ESR) §  C-‐reactive protein (CRP) §  Antinuclear antibody (ANA) §  Anti-‐citrullinated protein antibody (ACPA)

§  Synovial fluid analysis §  X-‐rays of involved joints §  Bone scan


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Case Study

•  T.S.’s lab results indicate positive RF and ANA.

•  Her CRP and ESR are also elevated. •  The health care provider tells T.S. she has rheumatoid arthritis.

• What medication(s) would you expect the health care provider to prescribe for T.S.?



Collaborative Care §  Patient teaching

§  Drug therapy §  Disease process §  Home management strategies

§  NSAIDs §  Physical therapy §  Occupational therapy §  Individualized treatment plan


Drug Therapy: DMARDs §  ↓ Permanent effects of RA

§  Methotrexate (Rheumatrex) §  Sulfasalazine (Azulfidine) §  Hydroxychloroquine (Plaquenil) §  Leflunomide (Arava)

§  Monitor for bone marrow suppression and hepatotoxicity

§  Teratogenic Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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Drug Therapy: Biologic/Targeted Therapies §  Tumor necrosis factor (TNF) inhibitors

§  Etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab (Cimzia), and golimumab (Simponi)

§  Bind with TNF, inhibiting inflammation


Drug Therapy: Biologic/Targeted Therapies §  Tumor necrosis factor (TNF) inhibitors

§  TB test and chest x-‐ray before start of therapy

§  Monitor for infection §  Avoid live vaccinations


Drug Therapy: Biologic/Targeted Therapies §  IL-‐1 receptor antagonist (IL-‐1Ra)

§  Anakinra (Kineret) §  Given SQ; reduces pain and swelling

§  Tocilizumab (Actemra) §  Blocks IL-‐6, a proinflammatory cytokine

§  Abatacept (Orencia) §  Blocks T-‐cell activation

§  Rituximab (Rituxan) §  Targets B cells


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Drug Therapy

§  Antibiotics (minocycline [Minocin]) §  Immunosuppressants (azathioprine

[Imuran]) §  Penicillamine (Cuprimine) §  Gold preparations (auranofin [Ridaura])


Drug Therapy §  Corticosteroid therapy

§  Intraarticular injections §  Low-‐dose oral for limited time

§  NSAID and salicylates §  Antiinflammatory, analgesic, and

antipyretic §  May take 2 to 3 weeks for full

effectiveness


Nutritional Therapy §  Balanced nutrition important §  Loss of appetite or inability to shop for

and prepare food → weight loss §  Corticosteroid therapy → weight gain


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Surgical Therapy §  Relieve severe pain §  Improve function §  Synovectomy §  Total joint replacement (arthroplasty)


Nursing Assessment §  Subjective data

§  Recent infections, presence of precipitating factors, pattern of remissions and exacerbations

§  Use of aspirin, NSAIDs, corticosteroids, DMARDs

§  Any joint surgery



§  Family history §  Malaise §  Ability to participate in therapeutic

regimen §  Impact on functional ability §  Anorexia, weight loss §  Dry mucous membranes of mouth and

pharynx Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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§  Stiffness and joint swelling, muscle weakness, difficulty walking, fatigue

§  Paresthesia of hands and feet §  Loss of sensation §  Symmetric joint pain and aching that ↑

with motion or stress on joint


Nursing Assessment

§  Objective data §  Lymphadenopathy, fever §  Keratoconjunctivitis §  Rheumatoid nodules §  Skin ulcers §  Shiny, taut skin over joints §  Peripheral edema


Nursing Assessment

§  Objective data §  Raynaud’s phenomenon §  Distant heart sounds, murmurs §  Dysrhythmias §  Chronic bronchitis, tuberculosis §  Histoplasmosis, fibrosing alveolitis §  Splenomegaly (Felty syndrome)


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Nursing Assessment

§  Objective data §  Symmetric joint involvement §  Swelling, erythema §  Heat, tenderness §  Deformities §  Joint enlargement §  Limitation of movement §  Muscle contractures; atrophy


Nursing Assessment

§  Objective data §  + Rheumatoid factor §  ↑ESR §  ↑ WBCs in synovial fluid §  X-‐ray findings

§  Joint space narrowing §  Bony erosion §  Deformity §  Osteoporosis


Nursing Diagnoses §  Impaired physical mobility §  Chronic pain §  Disturbed body image


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Planning §  Overall goals

§  Satisfactory pain management §  Minimal loss of functional ability §  Participate in therapeutic regimen §  Maintain positive self-‐image §  Perform self-‐care


Nursing Implementation Health Promotion §  Prevention not possible at this time §  Early treatment to prevent further

joint damage §  Community education programs

§  Symptom recognition to promote early diagnosis and treatment


Nursing Implementation Acute Intervention §  Primary goals in managing RA

§  Decrease inflammation §  Manage pain §  Maintain joint function §  Prevent or correct joint deformity


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Nursing Implementation Acute Intervention §  Comprehensive program

§  Drug therapy §  Balance of rest and activity §  Joint protection §  Heat and cold applications §  Exercise §  Patient and caregiver teaching

§  Multidisciplinary team


Nursing Implementation Acute Intervention §  Usually treated on an outpatient basis §  Start with assessment

§  Physical §  Psychosocial

§  Identify problems §  Coordinate program for rehabilitation

and education §  Multidisciplinary team


Nursing Implementation Acute Intervention §  Suppression of inflammation

§  NSAIDs §  DMARDs §  Biologic/targeted therapies

§  Patient teaching about medications §  Timing of administration §  Action and side effects §  Compliance


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Case Study

• What type of nondrug interventions can you teach T.S. about to help with her joint pain?



Nursing Implementation Acute Intervention §  Nondrug relief of pain

§  Therapeutic heat and cold §  Rest §  Relaxation techniques §  Joint protection §  Biofeedback §  Transcutaneous electrical stimulation §  Hypnosis


Nursing Implementation Acute Intervention §  Lightweight splints

§  Removed at regular intervals §  Perform ROM exercises §  Reapply as prescribed

§  Occupational therapist → additional self-‐help devices


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Nursing Implementation Acute Intervention §  Plan care around morning stiffness §  To relieve joint stiffness and ↑ ability

to perform ADLs §  Sit or stand in warm shower §  Sit in tub with warm towels around

shoulders §  Soak hands in warm water


Case Study

• What interventions can you teach T.S. related to her fatigue issues?



Ambulatory and Home Care Rest §  Alternate rest periods with activity §  Helps relieve pain and fatigue §  Amount of rest varies §  Avoid total bed rest §  8–10 hours of sleep + daytime rest §  Modify activities to avoid overexertion


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Ambulatory and Home Care Body Alignment §  Firm mattress or bed board §  Encourage positions of extension §  Avoid flexion positions §  No pillows under knees §  Small, flat pillow under head and

shoulders


Case Study

• What will you teach T.S. to help her protect her joints from further stress?



Ambulatory and Home Care Joint Protection §  Modify tasks for less stress on joints §  Energy conservation

§  Work simplification techniques §  Pacing and organizing §  Use of carts §  Joint protective devices §  Delegation

§  Occupational therapy §  Assistive devices


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Case Study

• T.S. asks you whether she should use ice or heat on her painful joints.

• How will you respond?



Ambulatory and Home Care Heat and Cold Therapy §  Relieve pain, stiffness, and muscle

spasm §  Ice

§  Especially beneficial during periods of disease exacerbation

§  Application should not exceed 10–15 minutes at one time


Ambulatory and Home Care Heat and Cold Therapy §  Moist heat

§  Heating pads, moist hot packs, paraffin baths, warm baths or showers

§  Relieve stiffness §  Should not exceed 20 minutes at a time §  Be alert for burn potential


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Ambulatory and Home Care Exercise §  Individualized exercise plan to

§  Improve flexibility §  Increase strength §  Increase overall endurance

§  Reinforce program participation and ensure correct performance

§  Need both recreational and therapeutic exercise


Ambulatory and Home Care Exercise §  Gentle ROM exercises done daily to

keep joints functional §  Aquatic exercises in warm water

beneficial §  Limit to one or two reps during acute

inflammation


Ambulatory and Home Care Psychologic Support §  Patient teaching important

§  RA §  Nature and course of disease §  Goals of therapy

§  Consider value system and perception of disease


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Ambulatory and Home Care Psychologic Support §  Patient is constantly challenged by

problems of §  Limited function and fatigue §  Loss of self-‐esteem §  Altered body image §  Fear of disability or deformity


Ambulatory and Home Care Psychologic Support §  Discuss alterations in sexuality §  Patient vulnerable to unproven or

even dangerous remedies §  Help patient recognize fears and

concerns


Ambulatory and Home Care Psychologic Support §  Evaluation of family support system §  Financial planning §  Community resources may be

considered §  Self-‐help groups are beneficial for

some patients §  Strategies to decrease depression


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Etanercept (Enbrel) is prescribed for a patient with stage II rheumatoid arthritis. The nurse determines that the medication is effective if what is observed? a.   Decreased lymphocyte count b.   Absence of Rh factor in the blood c.   Decreased C-‐reactive protein (CRP) d.   Increased serum immunoglobulin G

Audience Response Question


N325 Rheumatoid Arthritis · 2019. 8. 23. · 2/25/16 6 ClinicalManifestations! Joints!!...

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