RHEUMATOID ARTHRITIS

Description

(RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks the joints producing an inflammatory synovitis, serositis (inflammation of the lining surfaces of the joints, pericardium, and pleura), rheumatoid nodules, and vasculitis that often progresses to destruction of the articular cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, pericardium, pleura, and sclera, and also nodular lesions, most common in subcutaneous tissue under the skin. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in its chronicity and progression.

The hallmark feature of the disease is persistent symmetric polyarthritis (synovitis) that affects the hands and feet, although any joint lined by a synovial membrane may be involved. In addition to articular deterioration, systemic involvement may lead to weight loss, low-grade fever, and malaise. The severity of RA may fluctuate over time, but chronic RA most commonly results in the progressive development of various degrees of joint destruction, deformity, and a significant decline in functional status.

AKA

RA ( Rheumatic Arthritis )

INCIDENCES

About 1% of the world's population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but no age is immune.The prevalence rate of rheumatoid arthritis is approximately 1% of the population (range 0.3-2.1%)

A study from Denmark investigated whether the higher rate of RA among women could be linked to certain reproductive risk factors. Reviewing the cases of men and women who had been hospitalized with RA between 1977 and 2004, the authors found that the rate of RA was higher in women who had given birth to just 1 child than it was in women who had delivered 2 or 3 offspring. (However, no increased rate was found in women who were nulliparous or who had a history of lost pregnancies.)

The study also found a higher RA risk among women with a history of preeclampsia, hyperemesis during pregnancy, or gestational hypertension. The authors suggested that this portion of the data indicated that a reduced immune adaptability to pregnancy may exist in women who have a predisposition to the development of RA or that there may be a link between fetal microchimerism (in which fetal cells are present in the maternal circulation) and RA.

Although rheumatoid arthritis (RA) can occur at any age, the incidence increases with advancing age. The peak incidence of RA occurs in individuals aged 40-60 years.

RISK / PREDISPOSING FACTORS

Blood Transfusions

You may have an increased risk of developing rheumatoid arthritis if you have received blood transfusions.

Age

Although rheumatoid arthritis can develop at any age, you’re most likely to develop the condition between the ages of 25 and 45.

Gender

Women are 2.5 to 3 times more likely to develop rheumatoid arthritis than men.

Genetic Factors

You are more likely to develop rheumatoid arthritis if there are other people in your family with this condition or with other autoimmune disorders.

Ethnic Background

You have a greater risk of developing rheumatoid arthritis if you are:

White Native American (particularly belonging to the Yakima, Chippewa, or

Inuit tribes)

Weight

People who are obese may have an increased risk of developing rheumatoid arthritis.

Coffee and Cigarettes

Some studies have suggested that there is a connection between drinking coffee and developing rheumatoid arthritis. More work needs to done to confirm this association.

Long-term smoking may be a risk factor for the development of rheumatoid arthritis.

MANIFESTATION

Early phase of the disease is characterized by the following features:

Joint swelling that may affect joint margins Joint tenderness upon palpation

Systemic malaise

Loss of energy

Severe morning stiffness that limits function and generally lasts more than an hour.

TYPE OF RHEUMATOID ARTHRITIS

Juvenile rheumatoid arthritis (JRA) is the most common form of childhood arthritis. The cause remains unknown. For most patients, the immunogenic associations, clinical pattern, and functional outcome are different from adult onset RA.

Ankylosis in the cervical spine at several levels due to long-standing juvenile rheumatoid arthritis (also known as juvenile idiopathic arthritis).

Widespread osteopenia, carpal crowding (due to cartilage loss), and several erosions affecting the carpal bones and metacarpal heads in particular in a child with advanced juvenile rheumatoid arthritis (also known as juvenile idiopathic arthritis)

The diagnostic criteria for JRA are onset occurring when younger than 16 years, persistent arthritis in 1 or more joints for at least 6 weeks, and exclusion of other types of childhood arthritis. The key points that characterize the diagnosis of JRA are as follows:

Arthritis must be present. Arthritis is defined as the presence of swelling, the presence of effusion, or the presence of 2 or more of the following signs: limited range of motion (ROM), tenderness, pain on motion, or joint warmth.

Arthritis must persist for at least 6 weeks.

Other causes of chronic arthritis in children must be ruled out.

No specific laboratory or other test can establish the diagnosis of JRA.

PATHOPHYSIOLOGY

RA is commonly used as the prototype for inflammatory arthritis. The autoimmune reaction primarily occurs in the synovial tissue. Phagocytosis produces enzymes within the joint. The enzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroys cartilage and erodes the bone. The consequence is loss of articular surfaces and joint motion. Muscle fibers undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost. Presentation of antigen to T cells

T- and B-cell proliferation.

Angiogenesis in synovial lining.

Neutrophil accumulation in synovial fluid. Cell proliferation. No cartilage invasion.

Synovitis. Early pannus invasion. Chondrocyte activation. Degradation of cartilage by proteinase.

Subchondral bone erosion.

Pannus invasion of cartilage.

Chindrocyte proliferation. Laxity

of ligaments.

Swelling in small joints,

associated with pain,

stiffness, and fatigue.

Warm,swollen,effusions,pain,

and decreased motion with

possible rheumatoid nodules.

Increase in severity of

physical signs and

symptoms.

Joint instability,

contractures,decreased ROM,

systemic complications.

Initiation of rheumatoid arthritis

Production of rheumatoid factorsImmunoglobulin G

Prostaglandin release

Deposition of immune complex

Inflammation of synovium

Edema Release of lysosomal enzymes

Release of oxygen free radicals

Release of arachidonic acid and prostaglandin

Release of antibodies

Release of complement

Synovial hypoxia

Destruction of Synovium

Pain

Leukocyte attracted

Macrophages attracted

Rheumatoid nodules

Loss of joint space

Joint fusion

Muscle spasm

Joint swelling

Legend:

- pathophysiology

- manifestation

- manifestation

DIAGNOSTIC STUDIES

Serum protein abnormalities are often present. Rheumatoid factor (RF), an immunoglobulin M (IgM) antibody directed against the Fc fragment of immunoglobulin G (IgG), is present in the sera of more than 75% of patients. High titers of RF are commonly associated with severe rheumatoid disease. Antinuclear antibodies are demonstrable in 20% of patients, though their titers are lower in rheumatoid arthritis than in SLE. During the acute and chronic phases, the erythrocyte sedimentation rate and gamma globulins (commonly IgM and IgG) are usually elevated; however, leukopenia may occur in the presence of splenomegaly (Felty syndrome). The platelet count often is elevated, roughly in proportion to the severity of overall joint inflammation. Joint fluid examination is valuable, reflecting abnormalities that are correlated with varying degrees of inflammation.

Imaging Studies

Plain radiographs o Radiography is the most specific workup study for rheumatoid arthritis.

o Radiographs taken during the first 6 months typically are read as negative because of decreased sensitivity during that period.

o The earliest changes occur in the wrists or feet and consist of soft-tissue swelling and juxta-articular demineralization. Later, diagnostic changes of uniform joint-space narrowing are evident, and erosions develop. The erosions are often first evident at the ulnar styloid and at the juxta-articular margins, where the bony surface is not protected by cartilage.

Prominent juxta-articular osteopenia in all interphalangeal joints in a patient with rheumatoid arthritis of the hands.

Prominent juxta-articular osteopenia in all interphalangeal joints in a patient with rheumatoid arthritis of the hands.

o Diagnostic changes also occur in the cervical spine with C1-2 subluxation, but these changes usually take several years to develop.

Nuclear imaging studies

o Nuclear imaging studies are quite sensitive for detecting many disease processes, and the entire body can be imaged at once. However, this technique is not specific because of the number of disease processes that may cause radionuclide accumulation.

o When areas of increased uptake are observed, additional studies such as radiography are usually necessary to specify the type of abnormality.

o Joints affected by inflammatory or degenerative arthritis demonstrate increased uptake and can map the extent of disease in a single examination.

o In a patient with inflammatory arthritis and widespread changes on radiographs, scintigraphy may help to locate areas of early active inflammation.

MANAGEMENT

There is no known cure for rheumatoid arthritis, but many different types of treatment can alleviate symptoms and / or modify the disease process.

Rehabilitation Program

Physical Therapy

The goals of rehabilitation for patients with rheumatoid arthritis (RA) include pain relief, increased range of motion (ROM), increased strength and endurance, prevention and correction of deformities, and provision of various counseling and educational services. Numerous nonpharmacologic methods are available to the physiatrist to assist patients in achieving these goals. These methods include therapeutic modalities, splints and orthotics, assistive device equipment, joint protection and energy conservation techniques, and education and therapeutic exercise programs.

Therapeutic modalities

Heat, either superficial or deep, is an effective modality for the relief of joint pain and stiffness caused by RA. In addition, it is also used to treat joints in preparation for ROM, stretching, and muscle strengthening exercises. Heat may be administered via moist hot packs, electric mittens, a hot shower, spas, ultrasonography, diathermy, or paraffin. Superficial and deep heating methods have been shown to raise the intra-articular temperature in patients with RA.

Cold is preferable for treatment of an acutely inflamed joint. Application of cold results in decreased pain and decreased muscle spasm. Cold may be delivered via ice packs, ice sticks, topical sprays, or ice water.

Splints and orthotics

Orthotic devices play an important role in the rehabilitation management of patients with RA. These devices are used to decrease pain and inflammation, improve function, reduce deformity, and correct biomechanical malalignment.

Lower extremity orthoses are prescribed to provide stability and proper alignment or to shift weight bearing off the affected limb. The most common orthoses used for the lower extremity involve the foot and ankle joints. Approximately 80% of patients affected with RA illustrate significant foot involvement. These problems are easily accommodated by providing a deep, wide, soft leather shoe. A metatarsal pad or bar is typically used to remove weight from painful MTP joints, and a rocker-bottom sole can be used to facilitate roll-off. Hindfoot pronation should be addressed with custom inserts. Finally, knee orthoses may be used to control edema, pain, patellar alignment, hyperextension, or collateral or cruciate ligament instability.

Therapeutic exercise

Fatigue and decreased endurance are frequent symptoms in patients with RA. When comparing these patients to age-matched subjects without RA, a reduction in aerobic capacity and muscle strength is noted. This reduction is due to the disease itself and to the lack of physical activity in these patients. Exercise is an important part of the rehabilitation management of RA.

Aerobic conditioning in patients with RA (if tolerated) improves maximum oxygen uptake and decreases perceived exertion at submaximal workloads. At the same time, no adverse effects have been noted in the joints of these patients. In addition, patients undergoing long-term endurance training have been known to feel less isolated, to take less sick leave, and to develop improved function in activities of daily living (ADL). Thirty minutes of daily aerobic exercise, several times each week, should be encouraged in patients with well-controlled RA.

Muscle atrophy often accompanies RA and is exacerbated by inactivity, bed rest, splints, and medications. Isometric exercises restore and maintain strength in patients with RA without producing pain. Resistance exercises may be initiated when the isometric program has been well established and when the patient is free of pain.

Occupational Therapy

Occupational therapy also can be very useful for patients with rheumatoid arthritis (RA). An occupational therapist may work in conjunction with the physical therapist to ensure that the patient is able to meet his or her goals. An occupational therapist may also assist in the recommendation and use of splints and orthotics, especially when the upper extremity is affected. Upper extremity orthoses may be classified as either static or dynamic. Static splints are used to support a weak or unstable joint, to rest a joint for pain relief, or to maintain functional alignment. Dynamic splints traditionally have been used to manage the postoperative hand, but they also may be used to increase manual dexterity. The most commonly used splints for the hand are the finger-ring splints and the thumb-post splint. The functional wrist splint and the resting hand splint are commonly used for wrist splinting.

Adaptive equipment

Many assistive devices are available to patients with RA and are used to provide maximal function, maintain independence, reduce joint stress, conserve energy, and provide pain relief. Equipment is available to assist patients with transfers, dressing, feeding, toileting, cooking, and ambulation.

Joint protection education

Joint protection education provides the patient with techniques and recommendations for the prevention of joint overuse and the avoidance of biomechanical torques that excessively bend the joint. The use of adaptive equipment is important. Other components of a good joint protection program include maintenance of good posture, avoidance of overuse during inflammation, modification of tasks to decrease joint stress, and use of appropriate splints.

Energy conservation education

Fatigue is a major component of RA and is due to the systemic nature of the disease, as well as to the decreased cardiovascular endurance observed in patients with this inflammatory disorder.

The goal of energy conservation techniques is to save energy while maximizing function. Adaptive equipment is an essential part of this program. Other elements include maintaining joint ROM and strength, improving cardiovascular fitness, and taking short rest periods during the day. Every individual with RA should implement joint protection and energy conservation programs into their lifestyle.

Surgical

Surgical intervention in patients with rheumatoid arthritis (RA) includes pain relief, deformity correction, and functional improvement.5 A number of surgical procedures are available to obtain these goals. These options include myofascial techniques, excisions, reconstructions, joint fusions, and joint replacements. The timing of surgery is a complex decision; the patient's age, stage of disease, and level of disability, as well as the location of the involved joints, must be considered. Early surgical intervention may be helpful in maintaining a patient's functional level of independence.

Medications

Nonsteroidal anti-inflammatory agents

First-line agents in the treatment of rheumatoid arthritis. Have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions. Choice of NSAIDs is individualized and usually is based on factors

such as adverse effects profiles (eg, GI, renal, hepatic, CNS toxicities), polypharmacy (drug-drug interactions), and comorbidities.

Aspirin is inexpensive, but it can cause GI complications. Aspirin can be administered in an enteric coated preparation or in nonacetylated compounds. Concomitant gastroprotective agents may be used such as misoprostol, Carafate, H2 blockers, or omeprazole. Monitoring electrolytes, creatinine, Hgb, and LFTs every 4-6 months is important.

Gold compounds

Second-line therapy for rheumatoid arthritis. Up to two thirds of patients get some benefit initially, but the long-term effect is unsatisfactory given a high profile of adverse effects (eg, dermatitis, stomatitis, proteinuria, cytopenia).

For patients who fail to improve on or who cannot tolerate methotrexate, treatment with gold salts may be effective. About 60% of patients may be expected to benefit from gold therapy, though complete remissions are uncommon. The mode of action of gold compounds is not known.

Immunosuppressant agents

Second-line agents for rheumatoid arthritis (RA). Inhibit key steps in the development of immune reactions.5 Methotrexate is commonly used. Other cytotoxic agents, such as cyclophosphamide, also have been used in combination with other agents in the treatment of RA, especially in severe cases. However, due to the severity of toxic effects of cyclophosphamide (eg, hemorrhagic cystitis, infections, malignancy), investigators have not recommended combination chemotherapies that include cyclophosphamide.

NURSING DIAGNOSIS Pain related to inflammation, increased disease activity, tissue damage, fatigue,

and lowered tolerance. Fatigue related to increased disease activity, pain, inadequate rest,

deconditioning, inadequate nutrition, emotional stress, depression. Impaired physical mobility related to muscle weakness, pain on movement, lack

of or improper use of ambulatory devices. Self-care deficits (feeding, bathing, dressing, toileting) related to contractures,

fatigue, or loss of motion. Disturbed sleep pattern related to pain and fatigue. 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 RESPONSIBILITIES1. Administer prescribed medications, which may include nonsteroidal anti-

inflammatory drugs, aspirin, slow acting antirheumatic medication and corticosteroid.

2. Provide pain relief. Provide comfort measures, including massage and position changes. Apply hot or cold therapy to affected joints according to the client’s needs.

3. Promote self care.4. Promote adequate rest and sleep to prevent fatigue; provide comfort

measures, including a foam mattress and supportive pillows; and discuss energy conservation techniques.

5. Promote client and family coping.6. Encourage proper body alignment to prevent contractures.7. Collaborate with the physical therapist to design and provide the client

with a physical therapy program, which begins after the acute phase resolves. Encourage a muscle activity program for self- care. Water exercises are excellent because water promotes buoyancy, which eases joint movements.

8. Recommend a weight reduction program, if appropriate.9. Collaborate with the occupational therapist and promote the use of braces,

splints, and assistive mobility devices, if appropriate.10.Discuss relaxation techniques, such as imagery, self- hypnosis,

biofeedback, diversionary activities, and distraction for pain management.11.Discuss maintaining optimal nutritional status.12.Provide a referral to the Arthritis Foundation.

ILLUSTRATION

Effects of rheumatoid arthritis on particular joints

Boutonniere deformity.

Subluxation in the metacarpophalangeal joints, with ulnar deviation, in a patient with rheumatoid arthritis of the hands.

Coronal, T1-weighted magnetic resonance imaging (MRI) scan shows characteristic pannus and erosive changes in the wrist in a patient with active rheumatoid arthritis.

Rheumatoid nodules at the elbow.

Lateral view of the cervical spine in a patient with rheumatoid arthritis shows erosion of the odontoid process.

Rheumatoid changes in the hand.

X-ray of the hand in rheumatoid arthritis.

REFERENCES:www.medscape.comwww.google.comwww.wikipedia.comMedical Surgical Nursing, fourth Edition.Hargrove-Huttel, RN.PhD-pg294-295.Medical Surgical Nursing, 10’Th Edition, Johnson-pg.76.Medical Surgical Nursing, 10’Th Edition,Smeltzer-Bare-pg.1621.Medical Surgical Nursing, 8th ed., by Black and Hawks