Rheumatoid Arthritis

DIFFUSE CONNECTIVE TISSUE DISEASES CONNECTIVE TISSUE DISEASES • • • • •

A group of diseases that are chronic in nature and characterized by diffuse inflammation and degeneration in the connective tissues. (you have connective tissue about everywhere) These disorders share similar clinical features and may affect some of the same organs. The characteristic clinical course is one of exacerbations and remissions. Some CTD can become systemic and affect organs May be a result of an autoimmune abnormality o The body is attacking itself; thus beginning the autoimmune action Include: RA, Systemic Lupus Erythamatosus, Scleraderma, Polymyositis, Polymyalgia

RHEUMATOID ARTHRITIS RHEUMATOID ARTHRITIS • • • •

• •

Chronic, systemic disease with periods of exacerbations and remission Progressively deteriorating connective tissue disease that is characterized by inflammation of the synovial membrane of the Diarthrodial Joint (freely moveable) A systemic disease that can affect all connective tissue including nonarticular connective tissue. It attacks the collagen; which is the protein in the connective tissue that is found in the lungs, heart, muscles, blood vessels, and tendon. o May also cause lesions of vasculature, nervous system, and other major organs of the body. Progressive in nature OA has interactions in the joint capsule that lead to inflammation and RA the inflammation occurs first**

ETIOLOGY AND INCIDENCE • • • •

Could be an autoimmune disorder Could be a metabolic factor that causes an abnormal function in the production of the collagen. Usually diagnosed at 35-45 (family and careers) May be a genetic predisposition

PATHOPHYSIOLOGY •

• •

Synovium becomes inflamed o Edema with vascular congestion increases production of synovial fluid o Continued inflammation with thickening of the synovium and granulation tissue (pannus) begins to form over cartilage which results in necrosis of the cartilage o If areas of cartilage are lost this will result in formation of adhesions, ankylosis, and weakening of tendons and ligaments o Destruction leads to dislocation of joints and deformities Joint involvement is usually bilateral and symmetrical. Process often starts in fingers and toes, however all joints can become involved (hips, knees, wrists, elbows, shoulders, jaws)

o o

Cartilage – Absorbs the load (cushion) of weight bearing Nourished by the synovial fluid; if there is a problem with the synovial membrane it cannot nourish the joint capsule.

CLINICAL MANIFESTATIONS •

Local o Inflammation o o

•

Swelling Pain

Heat Erythema - Redness Decreased ROM

Systemic Fever Weight loss Fatigue Generalized aching Edema Lymph node enlargement  You have a problem o Joint tissue becomes spongy o Presents bilaterally and symmetrically o Onset may be acute (OA slowly) o Hands, hips, and feet are involved and can progress to shoulders, knees, elbows, spine, and also temporal mandibular joint o Joint stiffness in the a.m. lasting longer than 30 minutes (OA Feel stiff at first but can work the pain out) o o o o

•

Complications – Structural Deformities o o

o

o

Z-thumb deformity  Overflex or hyperextention of the thumb Ulnar deviations  Fingers deviate toward the ulnar side of hand (pinky)  Metacarpal phalengeal joints are swollen – Spongy moveable nodules (OA are hard) Genu Valgun  Knock knees  May tend to sublux (dislocate) Hallux melleus  Hammertoes with lower arch  Some cannot walk – wide toed shoes

These people are on prednisone and things that mask infection and lot of times they can get infection from attempting surgery.

o o

Swan-neck deformity  Hyperextension of the PIP joint and flexion of the distal joint Boutonniere’s deformity  Hyperflexion of the PIP joint and extension of the distal joint

DIAGNOSTIC EVALUATION • • • • •

Full History and Physical Increase in Sed rate – ESR o Only looking for inflammation C-Reactive Protein – Shows abnormal glycoprotein due to inflammatory process and active inflammation. Coming in periodically to see if this is beginning to rise the MD may increase medication to combat the inflammation ANA – Anti nuclear antibodies – Measuring antibodies that react to nuclear antigens Rheumatoid Factor Test (RF) or Latex Fixation o Specifically for RA; Positive indicates RA; keep in mind you may get a false positive so assess all the other manifestations

• • • • •

Decreased in RBC’s - RA can cause anemia C3 and C4 Complement Components Athrocentesis o Fluid should be clear, viscous, straw colored, that would be normal o RA the fluid would be cloudy, milky, or dark yellow X-Ray - Will show narrowing of joint space; could help diagnose what stage of disease Physical assessment

MEDICAL MANAGEMENT Relief of Inflammation with Medications • • •

If you decrease inflammation you will decrease pain; then you would have possible functioning of the joint for that individual. Every thing you do revolves around joint protection There are 3 stages of RA: Early, Moderate, Persistent or Erosive RA o Now they begin with large doses of medications while they still have the opportunity to combat the autoimmune process and prevent deformities

DRUG THERAPY • DMARD’s – Disease Modifying Anti Rheumatic Drug o Plaquenil – Anti-malarial -Have a lot of side effects;Have pretty bad side  Reduces the inflammation effects, so need to be monitored o Gold Salts -Can be toxic and need to be followed -Will not be prescribed if appointments are  Myochrysine, Solganal, Radura kept up with.  Decrease breakdown -DMARD’s given with an NSAID or Corticosteriods o Penicillamine – Cuprimine, Depen  Inhibits T-Cell function  Decreases inflammation • NSAID’s – Non Steroidal Anti Inflammatory Drug • Corticosteroids o Prednisone o Reduce inflammation and slow joint damage; given short term o Carry side effects: Weight gain, retaining fluid, cushings, Increase BP, Increase blood glucose, causes sodium retention, can lead to Osteoporosis by reducing bone mass, Masks S/S of infection, slows down healing. • Immunosuppressive o Because it is an autoimmune process; they tame the immune system o Methotrexate, Imuran, Sandimmune, Neoral, Cytoxan, Arava • Antidepressant - Depressed, change in alteration of lifestyle

Relief of Pain • •

Pain, decreased ROM, Fatigue, and sleep disturbances are the most common problems associated with RA. Traditional Methods of Pain Management o Medications o Splinting  To decrease inflammation. Support optimal position of function o Exercise, keep mobile o Positioning

o Heat / Ice o Emotional Support o Rest body – “systemic disease”

Fatigue o Make sure they rest o Don’t over do it

Sleep Disturbance o Medication – sleep aids

Maintenance of Optimal Function o Good posture o Exercise o Splinting  Some will have splints made specifically for them.  To rest and support the joint in its most optimal position o Joint protection o Energy conservation o Assistive devices  Cane o Surgeries

Education of Patient Sitting in firm chair with arm rest and help with getting up Good posture Isometric / Isotonic exercise Therapy for daily routine Balance activity with rest Plan ahead, Set priorities, Pace activity, Learn activity Assistive devices  Increase independence  Simplify task  Utilize available function in pain free and atraumatic manner o Shoe low heel with wide toe (may have shoes fitted) o Develop realistic acceptance of disease o Help client strive for independence o o o o o o o

NURSING DIAGNOSIS • • • • • •

Altered Comfort: pain R2 inflamed joints Impaired Physical Mobility R2 pain and deformity Self care Deficit R2 fatigue, pain or deformity Body image disturbance R2 deformities Powerlessness R2 loss of independence and change in life-style Knowledge deficit