Rheumatoid Arthritis
systemic manifestations of rheumatoid arthritis
Fatigue, weakness, anorexia, weight loss, fever; rheumatoid nodules; anemia
Mr. Rappaport has been diagnosed with rheumatoid arthritis. He tells you that he is having trouble doing the prescribed physical therapy exercises because of stiffness. What intervention could you suggest to Mr. Rappaport to help him follow the prescribed physical therapy program?
"try doing your exercises in the shower" bc warm, moist heat promotes mobility and should relieve his feelings of stiffness.
Arthrodesis
(joint fusion) stabilizes joints such as ankles, wrist and cervical vertebrae
Lab tests for RA
-CBC: in most cases reveals mild anemia -WBC and Platelets: can be normal range, or the inflammation can increase both of these levels -Rheumatoid factor: 70% of clients with RA test positive -Antibodies to cyclic citrullinated peptide (CCP): a more specific marker for RA -Erythrocyte sedimentation rate: elevated -C-reactive protein (CRP) indicator of inflammation
NSAIDS
-to reduce inflammation and pain -Monitor for sings of GI bleed and gastric distress -Monitor for impaired kidney function -in long term use, monitor CBCs, electrolytes, KIDNEY and liver function
Prevalence of RA and who it affects?
1-2% of the population affects 3x as many women as men typical age at onset is btwn 40 and 60 yrs
What diagnostic tests are used for Rheumatoid arthritis?
1. Erythrocyte Sedimentation Rate (ESR) 2. C-reactive protein (CRP) (Antinuclear antibody (ANA) test, renal function test, and kidney biopsy are diagnostic tests for systemic lupus erythematous)
which characteristics are risk factors for the development of rheumatoid arthritis?
1. Genetic Predisposition 2. Family History 3. Psychological stressors (autoimmune disorders such as RA are more common in women than men)
A client diagnosed with rheumatoid arthritis (RA) is being seen in an outpatient clinic. Which diagnostic test results would indicate presence of RA?
1. Negative rheumatoid Factor (RF) 2. Positive anti-citrulline antibodies 3. Increased erythrocyte sedimentation rate (ESR) Increased ESR would indicate presence of inflammation in the joints, which occurs with rheumatoid arthritis. Rheumatoid arthritis may be present with a negative RF. A positive anti-citrulline antibody test indicates the presence of RA in the absence of RF. Positive, not negative, antinuclear antibodies indicate presence of RA. Decreased bone density is found in clients with psoriatic arthritis, not with RA.
4 general pharmacological to the treatment of rheumatoid arthritis
1. Nonsteroidal anti inflammatory drugs (NSAIDS) 2. Lose dose oral corticosteroids 3. Disease modifying anti rheumatic drugs (DMARDS) 4. Intra- articular steroid injections
Which independent nursing interventions are used to treat rheumatoid arthritis?
1. Promote a well balanced diet 2. Alternate periods of activity and rest 3. Educate about low impact aerobics
The nurse is volunteering in one of the local free autoimmune disease clinics. The next client was recently diagnosed with rheumatoid arthritis. What are the goals of care for clients with rheumatoid arthritis?
1. Reduce inflammation 2. Prevent deformity 3. Preserve Function 4. Reduce pain The treatment goals for clients with rheumatoid arthritis are to reduce pain, reduce inflammation, preserve function, and prevent deformity. There is no cure for rheumatoid arthritis.
The nurse, working in an internal medicine practice, prepares to see a client diagnosed with rheumatoid arthritis on the last visit. The client is complaining of pain and discomfort in the hands and knees. Which treatments can be used to reduce the pain and discomfort that the client is experiencing?
1. Taking corticosteroids 2. Exercising 3. Eating a balanced diet 4. Taking NSAIDs NSAIDs are used to treat inflammation and pain in clients with rheumatoid arthritis. Exercise increases muscle strength and preserves function. Low-dose corticosteroids are used to reduce pain and inflammation in clients with rheumatoid arthritis. These medications also slow the development and progression of bone erosion. Improving nutrition promotes a well-balanced diet improving overall health in clients. It is also recommended to substitute dietary fat with omega-3 fatty acids in fish oils. Some medications used to treat rheumatoid arthritis cause sun sensitivity. Clients are advised to decrease the amount of time in the sun and to use sunscreen with sun protection when outdoors.
What happens to individuals who do not enter remission within 10 years?
60 % of the individuals whose disease does not enter remission within 10 years will become permanently disabled.
joint manifestations in RA
Are often preceded by systemic manifestations: inflammation, fatigue, loss of appetite, weight loss. and aching and stiffness. Include joints swelling, stiffness, warmth tenderness, and pain: ROM is limited
The nurse on the inpatient orthopedic unit is preparing the client for surgery. The client was admitted for right knee joint replacement surgery. The nurse wants to use the right teaching handouts for this type of surgery. Which surgical teaching handout is the nurse going to use?
Arthroplasty Your answer is correct. Arthroplasty (total joint replacement) is used in severe joint destruction and bone deformities. Arthrodesis (joint fusion) stabilizes joints such as ankles, wrist and cervical vertebrae. Synovectomy is an excision of the synovial membrane and is used early in the disease to provide pain relief and decrease inflammation. Arthroscopy is a minimally invasive surgical procedure during which an endoscope is inserted into the joint trough a small incision for examination or treatment of the joint.
Clients with RA often have problems with:
Chronic pain Alternations in body image Activities of daily living (ADL)
The nursing student is preparing an educational handout for the parents of a client with juvenile idiopathic arthritis (JIA). Based on the etiology, risk factors, and clinical manifestations of the disease, which topic will be addressed in the handout? Teaching about the importance of monitoring growth rates in children.
Clients with JIA need to be educated about the etiology, risk factors, and clinical manifestations of the disease. Teaching the children's parents about the monitoring of growth rates is important for proper development. JIA is more frequent in girls than boys. Although JIA can affect multiple organs and joints, it does not result in acromegaly (a condition in which there is too much growth hormone and the body tissues get larger over time). 70% of children experience remission of the disease by adulthood.
The nurse is caring for Ms. Ruiz, a client recently diagnosed with rheumatoid arthritis. Ms. Ruiz is being seen by the primary care provider for a follow-up visit after a recent hospitalization. The nurse prepares to assess Ms. Ruiz. Which clinical manifestation found during the assessment process supports this client's diagnosis?
Clients with Rheumatoid arthritis will often have a low grade fever. (weight loss, morning stiffness that lasts more than 1 hour, and fatigue are other symptoms that support this diagnosis)
Your client, Alexandra Kowalski, is a 16-year-old cross-country runner diagnosed with juvenile idiopathic arthritis. Which diagnostic test does the nurse anticipate will be ordered for Alexandra?
Erythrocyte sedimentation rate: is a lab tests that will be used for the diagnosis of arthritis
The client was admitted to an inpatient unit for uncontrolled pain caused by rheumatoid arthritis (RA). Which ongoing problems will the client have in relation to the RA? 1. Poor self esteem 2. Ineffective role performance 3. Chronic pain 4. fatigue
Ongoing problems related to RA include chronic pain, fatigue, poor self-esteem related to body image issues, and ineffective role performance. Weight loss, not weight gain, is an issue for clients with RA.
A clinic nurse is assessing a client with a history of rheumatoid arthritis. The nurse would anticipate which assessment finding?
PROGRESSIVE joint stiffness and deformation The progressive joint stiffness and deformation is due to the fibrosis and calcification that occurs in the pathophysiology of rheumatoid arthritis. This client has rheumatic arthritis; therefore, the following choices are incorrect: Uric acid crystal formation in the joints causes the excruciating pain experienced by clients with gout. Osteoarthritis involves loss of joint elasticity, particularly of weight-bearing joints such as the knees, hips, and spine. Juvenile idiopathic arthritis (JIA) affects multiple joints and internal organs. Rheumatoid rash and fever can develop with JIA.
What is the clinical term for abnormal tissue that leads to joint damage and immobilization in the pathophysiology of rheumatoid arthritis?
Panes The abnormal granulation tissue that leads to joint damage in Rheumatoid arthritis is called panes (pleurodesis: is a medical procedure in which the pleural space is artificially scarred. It involved the adhesion of the 2 pleurae)
The nurse is caring for a pregnant client in the obstetrics clinic. The client has a history of rheumatoid arthritis. Which statement by the client would require a follow up by the nurse? "When my joints hurt I can take an aspirin.
The nurse needs to follow up with the client's statement of taking aspirin (salicylates); these drugs can prolong labor and may induce teratogenic effects; therefore they should be stopped during pregnancy. Pregnant clients need to be taught to schedule extra rest periods throughout the day; remission during pregnancy happens often; clients also may have prolonged gestation. "I might carry my baby longer than the normal 40 weeks for the pregnancy." "Now that I am in my second trimester, I actually feel good, and my joints are not hurting either." Review Only "I need to schedule extra rest periods throughout the day."
The nurse is working in a primary care office. A client diagnosed with rheumatoid arthritis has returned for a follow-up visit. The client states that his pain is controlled on NSAIDs. The nurse would supply what education related to the disease process and supportive care? 1. Take NSAIDS at regular intervals with food or milk 2. Exercise in the shower because warm, moist heat promotes mobility 3. Be aware of the adverse effects of prescribed medications 4. Application of heat or cold to relieve pain
The priorities of care for the client with rheumatoid arthritis are supportive care and education. Taking NSAIDs at regular intervals will provide continued control of pain and discomfort. Taking NSAIDs with food or milk will decrease the incidence of gastrointestinal upset. Clients should consume a well-balanced diet, use the application of heat and cold for pain, exercise in the shower because warm, moist heat promotes mobility; be aware of adverse effects of medications; lose weight if necessary; follow prescribed physical therapy; avoid smoking; and use muscle-strengthening exercises.
how do joints appear in RA?
The swollen joints are "boggy" to palpation because of the edema, joints become deformed,
why are non steroidal anti-inflammatory agents (NSAIDS) used to treat rheumatoid arthritis?
To reduce inflammation: (corticosteroids are used to slow the development and progression of bone erosion, and disease modifying anti rheumatic drugs (DMARS) are sued to alter the course of the disease and reduce joint destruction)
Nutrition and RA
a well balanced diet and omega 3 fatty acids are recommended
Osteoarthritis affected joints
affected joints may appear swollen; cool and bony hard on palpation; decreased range of motion
what happens to clients who are genetically susceptible?
an unknown antigen causes the immune system to start attacking itself
Rheumatoid arthritis affected joints symptoms
appears red, hot, and swollen;"boggy" and tender to palpation; decreased range of motion; weakness.
osteoarthritis
pain with activity; stiffness following periods of immobility, generally relived within minutes
synovectomy
excision of the synovial membrane. Used early in the disease; provides pain relief, decreases inflammation, slows the destructive process
Manifestations of RA outside of the joints
fatigue, weakness, loss of appetite, weight loss, and low grade fever are common when the disease is active, anemia resistant to iron therapy is common.
pain and stiffness with rheumatoid arthritis
predominant on arising, lasting >1 hr; also occurs after prolonged inactivity
Corticosteroids (low dose)
to reduce INFLAMMATION And PAIN -long term use associated with poor wound healing, risk of infection, gastrointestinal bleeding, osteoporosis, weight gain -no abrupt discontinuation; tapering is recommended with high doses
steroid injections
to reduce localize pain and inflammation -teach the client the purpose of this treatment -explain that pain should begin to decrease within a few days -instruct the client to notify HCP if pain increases or if there are any questions
DMARDS
to relive symptoms and slow disease progression -most of the drugs can be toxic, close monitoring is indicated (hepatotixcity, bone marrow suppression, interstitial pneumonitis -2/3 clients show improvement
arthroplasty
total joint replacement: is used for severe joint destruction and bone deformities
The nurse is performing an assessment on a client who complains of joint pain and stiffness. The client was admitted to the unit with a diagnosis of rheumatoid arthritis. Which reported signs and symptoms from the client interview would not be consistent with the clinical manifestations of rheumatoid arthritis?
"I have trouble with walking because of the pain, and when I am finally done with my morning chores and sit down; my knees get so stiff I can hardly get up after I rested." Osteoarthritis, not rheumatoid arthritis, is characterized by pain with activity and stiffness following the activity. Pain and stiffness on arising, lasting more than 1 hour; red, hot swollen joints; and fatigue and weakness are all signs and symptoms of rheumatoid arthritis. EX This is the correct answer. "I am in so much pain in the morning! It is very hard for me to get out of bed and start my day. I can hardly move my legs; my knees feel like they are frozen." "Whenever my disease gets worse, my joints get red, hot and swollen." Your answer is not correct. "I am just tired all the time, and feel very weak."
The nurse is caring for a client recently diagnosed with rheumatoid arthritis (RA). The client states, "I always take care of myself, how could this happen to me?" Which response by the nurse is most appropriate regarding the client's risk for developing RA?
"RA occurs when there is a family history of the disease." Risk factors for RA include a family history of the disease and heavy smoking. Use of herbal remedies, a family history of coronary artery disease, and being underweight do not increase the risk for developing RA.
A nurse is participating in a community health fair. Which statement made by a participant indicates the teaching about rheumatoid arthritis was understood?
"Rheumatoid arthritis is an autoimmune disorder and has associated genetic factors." Rationale The etiology of rheumatoid arthritis includes autoimmune disorders and genetic factors. The etiology of rheumatoid arthritis does not include joint trauma or increased uric acid. Osteoarthritis, not rheumatoid arthritis, is the most common arthritis in the United States and may affect only one joint.