Rheumatoid Arthritis

ARTHIRITIS RHEUMATOID ARTHRITIS •Chronic systemic inflammatory disease •Destruction of connective tissues and synovial membrane •Permanent deformity •RA affects persons of all races. Sex: Common in women. Age: The onset is mid 20s to 30 years GENERAL DISTRIBUTION OF RA 1. Symmetric arthritis of the small joints of hands ( MCP, PIP) 2. Feet 3. Wrists (all compartments) 4. Knees 5. Ankles 6. Elbows 7. Glenohumeral and acromioclavicular joints 8. Hips 9. Articulations of the cervical spine DIAGNOSTIC CRITERIA 1. Morning stiffness 2. Symmetrical soft tissue swelling 3. Rheumatoid nodules 4. The presence of rheumatoid factor 5. Radiographic erosions RADIOGRAPHIC CHANGES •Soft tissue swelling and early erosions in the proximal interphalangeal joints. •Symmetrical narrowing of the joints. •Prominent juxta-articular osteopenia in all interphalangeal joints in a patient with rheumatoid arthritis of the hands. •Well-defined bony erosions in the carpal bones and metacarpal bases in a patient with rheumatoid arthritis of the hands. •Subluxation in the metacarpophalangeal joints, with ulnar deviation, in a patient with rheumatoid arthritis of the hands. •Subluxation at the third metacarpophalangeal joint and marginal erosions at the heads of the second to fourth metacarpals •Marked ankylosis of most of the carpal bones in a patient with rheumatoid arthritis of the hands. •Partial collapse of fused carpal bones with subluxation at the radiocarpal joint in a patient with rheumatoid arthritis of the hands •Boutonniere Deformity •Swan neck deformity •Lateral view of the cervical spine in a patient with rheumatoid arthritis shows erosion of the odontoid process Diagnostic: • RA Factor • ↑ ESR • Synovial Biopsy (+) inflammation Management Goals: • Relief of pain • Reduction of inflammation • Protection from systemic involvement

• Maintenance of function • Control of systemic involvement Medical Management: • NSAIDS • DMARDS – Disease –Modifying Antirheumatic Drugs(methotrexate, gold compounds) • Glucocorticoids (low dose prednisone) Nursing Care: • Immobilize affected joints • Apply heat or cold therapy as prescribed • Avoid weight bearing on inflamed joints • Encourage ROM exercises • Prevent contractures

GOUTY ARTHRITIS • Urate crystal deposits in joints leading to destruction of cartilage. • Pathophysiology Primarily caused by overproduction or underexcretion of uric acid or combination of both • Primary gout • Secondary gout ASSESSMENT Typical manifestations include: – Pain, usually monarticular – Joint swelling and inflammation – Pruritus or skin ulceration over the affected joint – Severe disease may produce signs of renal involvement – Podagra, an acute attack of gout in the great toe, > 50% of all acute attacks – Recurrent attacks have longer duration; more likely polyarthritic – ascending, asymmetric pattern – other areas affected include the heels, ankles, knees, fingers, wrists, elbows, shoulders, hip, sacroiliac and the spine STAGES • Asymptomatic hyperuricemia • Acute gouty arthritis • Interval gout • Chronic tophaceous gout DIAGNOSTIC EVALUATION • BASELINE LABORATORY TESTS: – complete blood cell count – Urinalysis – serum creatinine – blood urea nitrogen – serum uric acid measurements • SYNOVIAL FLUID ANALYSIS • Confirms the diagnosis of gout by the presence of: – polymorphonuclear leukocytes • intracellular monosodium urate crystals : needle-shaped and negatively birefringent • RADIOGRAPHY • Periarticular soft tissue swelling – first radiographic sign of an acute gouty attack

MANAGEMENT • Treatment goals: – Termination of the acute attack – Prevention of recurrent attacks – Prevention of complications associated with the deposition of urate crystals in tissues Pharmacologic Management • Termination of acute attacks – NSAIDs – Colchicine – Intra-articular injections of corticosteroids • Prevention of recurrent attacks – Probenecid – Allopurinol NURSING CARE • Apply ice to affected joints and elevate affected limbs • Maintain strict bedrest • Teach client about: – The prescribed meds regimen – The need to increase fluid to 3L/day – Dietary modifications to limit foods high in purine

OSTEOARTHRITIS Degenerative Joint Disease Wear and tear Affects weight bearing joints knees, toes, lower spine PATHOPHYSIOLOGY

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SIGNS/SYMPTOMS Pain worsens as day progresses Minimal am stiffness Decreased ROM Crepitus Bony enlargement Restricted movement Joint instability Severe medial compartment arthritis

• Bone angulation deformity • Patient demonstrating varus deformity of right knee and a valgus deformity of left knee GOALS OF TREATMENT • Relieve pain and inflammation • Retard disease progression • Control comorbidity • Minimize risk of therapy TREATMENT • Non-pharmacologic • Pharmacologic • Intra-articular • Surgery Non-pharmacologic Treatment • Social support • Education • Assisted devices • Weight reduction • Heat/Ice • Muscle strengthening/ROM exercises Pharmacologic Treatment • OTC – APAP – NSAIDs – Capsaicin – Glucosamine • NSAIDs • Opiod analgesics, tramadol Intra-articular Therapy • Corticosteroids – Do not use if joint infected or unstable – Not recommended > 4 times/year • Viscosupplementation – Hyaluronic acid • Efficacious in reducing pain; do not slow OA progression • High placebo response • Expensive SURGERY • Reserved as last line • Average life span 10-12 years