RHEUMATOID ARTHRITIS

A. Description 1. Rheumatoid arthritis is a chronic systemic inflammatory disease (immune complex disorder); the cause may be related to a combination of environmental and genetic factors. 2. The name is derived from the Greek rheumatos meaning "flowing," the suffix oid meaning "in the shape of," arthr meaning "joint" and the suffix -itis, a "condition involving inflammation." 3. Rheumatoid arthritis leads to destruction of connective tissue and synovial membrane within the joints. 4. Rheumatoid arthritis weakens the joint, leading to dislocation and permanent deformity of the joint. 5. Pannus forms at the junction of synovial tissue and articular cartilage and projects into the joint cavity, causing necrosis. 6. Exacerbations of disease manifestations occur during periods of physical or emotional stress and fatigue. 7. Risk factors include exposure to infectious agents. 8. Vasculitis can impede blood flow, leading to organ or organ system malfunction and failure caused by tissue ischemia. 9. It is more common in women than in men, the women / men ratio is 3 / 1, and most often is diagnosed between 35 and 50 years.

B. Assessment 1. Inflammation, tenderness, and stiffness of the joints 2. Moderate to severe pain with morning stiffness lasting longer than 30 minutes 3. Joint deformities, muscle atrophy, and decreased range of motion in affected joints 4. Spongy, soft feeling in the joints 5. Low-grade temperature, fatigue, and weakness 6. Anorexia, weight loss, and anemia 7. Elevated ESR and positive rheumatoid factor 8. Radiographic study showing joint deterioration 9. Synovial tissue biopsy reveals inflammation

How is Rheumatoid Arthritis Diagnosed?

To diagnose rheumatoid arthritis, a doctor will perform a physical examination and discuss the symptoms. If arthritis of any kind is suspected, the patient is referred to a rheumatologist, a specialist who is trained to recognize and treat rheumatoid arthritis, as well as other kinds of arthritis. There are a number of forms of arthritis, and each must be considered and ruled out before a diagnosis can be made. * The American College of Rheumatology has defined (1987) the following criteria for the diagnosis of rheumatoid arthritis * Morning stiffness of >1 hour * Arthritis and soft-tissue swelling of >3 of 14 joints/joint groups * Arthritis of hand joints * Symmetric arthritis * Subcutaneous nodules in specific places * Rheumatoid factor at a level above the 95th percentile * Radiological changes suggestive of joint erosion At least four criteria have to be met to establish the diagnosis, although many patients are treated despite not meeting the criteria. The doctor may order the following tests: * Blood tests. These may show a higher than normal level of antibodies called rheumatoid factors. (Higher levels of these factors are also found in a number of other chronic conditions, and a positive test does not necessarily mean rheumatoid arthritis). * Samples of synovial fluid. * X-rays. During the first months of the disease, only the swelling of the soft tissues around the joint can be seen. As the disease condition progresses, there may be a narrowing of the space in which the joints move and damage to the ends of the bones. * MRI. This test may be used early in the course of the disease to help make a diagnosis and separate the condition (rheumatoid arthritis) from other possible problems that affect the bones and joints.

C. Rheumatoid factor 1. Blood test used to diagnose rheumatoid arthritis 2. Values a. Nonreactive: 0 to 39 international units/mL

b. Weakly reactive: 40 to 79 international units/mL c. Reactive: greater than 80 international units/mL D. Pathophysiology

E. Pain relief: Corticosteroids, anti inflammatories, analgesics, and immunosuppressive drugs; aspirin is the DOC, followed by the addition of NSAIDs, and then gold or penicillamine, an oral chelating agent; corticosteroids are reserved for acute inflammation, if possible. F. Plan/Implementation 1. Administer analgesics and other medications, as ordered 2. Teach the client to take the medications, as ordered and observe for aspirin toxicity (tinnitus, bleeding) and other adverse effects of the medications

3. Apply heat and cold, as ordered; heat paraffin to 52-52 degree Celsius 4. Promote rest and proper position to ease joint pains 5. Provide for ROM exercise up to the point of pain, recognizing that some discomfort is always present 6. Emphasize the need to remain active, but incorporate rest periods to prevent fatigue 7. Encourage the client to verbalize his/her feelings 8. Help set realistic goals, focusing on the clients strengths 9. Encourage the use of supportive devices to help the client conserve energy and maintain independence 10. Provide care for the client following joint replacement 11. Encourage a diet rich in nutrient-dense foods such as fruits, vegetables, whole grains, and legumes to improve and maintain the ideal nutritional status and to compensate for the nutrient interactions of corticosteroid and other treatment medications G. Client Education for Rheumatoid Arthritis and Degenerative Joint Disease Assist the client to identify and correct safety hazards in the home. Instruct the client in the correct use of assistive or adaptive devices. Instruct the client in energy conservation measures. Review the prescribed exercise program. Instruct the client to sit in a chair with a high, straight back. Instruct the client to use only a small pillow when lying down. Instruct the client in measures to protect the joints. Instruct the client regarding the prescribed medications. Stress the importance of follow-up visits with the health care provider. H. Positive Outcomes Experiences a reduction in pain Completes daily activities using supportive devices, as needed Accepts a lifestyle consistent with his/her abilities Maintains or improves the ROM of his/her involved joints I. Surgical interventions 1. Synovectomy: Surgical removal of the synovia to help maintain joint function ; removal of the synovial membrane from a joint using an arthroscope to reduce pain. 2. Arthrodesissurgical removal of cartillage from joint surfaces to fuse a joint into a functional position to regain some mobility

3. Joint replacement (arthroplasty): Surgical replacement of diseased joints with artificial joints; performed to restore motion to a joint and function to the muscles, ligaments, and other soft tissue structures that control a joint 4. Fusion of joints, so that the damaged parts are not moving against each other

J. Nursing dx: Activity intolerance related to pain and swelling of joints Chronic pain related to inflammation of joints Disturbed body image related to arthritic joints Ineffective health maintenance related to lack of mobility Altered family process Fear Risk for injury Self care deficit Sexual dysfunction Situational low self esteem Risk for impaired skin integrity