Rheumatoid Arthritis RA

wrists and elbows

wrist involvement is nearly universal, leading to limited movement, deformity, and carpal tunnel

the self-produced antibodies bind with their target antigens in the blood and synovial membranes forming:

immune complexes

Activation of B lymphocytes and T lymphocytes results in

increased production of rheumatoid factor and increase and continue the inflammatory process

people with RA have

increased risk of developing coronary heart disease increase risk of myocardial infarction

RA is the most prevalent

inflammatory arthritis of any group

A client diagnosed with rheumatoid arthritis (RA) is prescribed prednisone. Which client statement indicates to the nurse that medication teaching was successful? "I will take the specific dose ordered at the same time every day." "I do not need to limit my sodium intake." "I will take the medication on an empty stomach to maximize absorption." "I will not have to adjust my insulin regimen."

"I will take the specific dose ordered at the same time every day." Rationale: Steroid therapy is usually done as part of a taper-dose treatment plan. It is important to take the medication at the same time every day. Steroids are taken with food to minimize stomach upset. Steroids cause fluid retention, so sodium intake is limited. Steroids also cause an increase in blood glucose levels, so the client taking insulin may have to adjust doses while on steroid therapy.

Assessment

*Health History* pain stiffness fatigue joint problems effects on ADLs sleep patterns *physical assessment* height/weight gait joints symmetry, size, shape, color, appearance, temperature, ROM, and pain cough crackles

*Affected Joints*

*appear red hot swollen* boggy tender to palpation decreased range of motion weakness *multiple joints affected in symmetric pattern* proximal interphalangeal metacarpophalangeal wrists knees ankles toes

Antimalarial

*• Hydroxychloroquine (Plaquenil) * • 3-6 month therapy • Pigmentary retinitis and vision loss, therefore vision exam q6months

the client with RA has nontender, movable nodules in the subcutaneous tissue over the elbow and shoulders. which statement is the scientific rationale for the nodules? 1. the nodules indicate a rapidly progressive destruction of affected tissue 2. the nodules are small amounts of synovial fluid that have become crystallized 3. the nodules are lymph nodes which have proliferated to try to fight infection 4. the nodules present favorable prognosis and mean the client is better

1. the nodules may appear over bony prominences and resolve simultaneously. they appear in clients with Rheumatoid factor and are associated with rapidly progressive and destructive disease

Pharmacologic Therapies

1. Nsaids 2. low-dose corticosteriods 3. Dmards 4. intra-articular corticosteriods

Damage to cartilage that occurs in RA is the result of:

1. neutrophils, T cells, and other synovial fluids are activated and degrade the surface layer 2. cytokins, interleukin, necrosis factors, cause chondrocytes to attack cartilage 3. synovium digest nearby cartilage

the client diagnosed with RA who has been prescribed entanercept, a tumor necrosis factor alpha inhibitor, shows marked improvement. which instructions regarding the use of this medication should the nurse teach? 1. explain med loses it efficacy after a month 2. continue to have checkup and lab work while on med 3. have yearly magnetic resonance imaging 4. discuss the drug is taken 3 weeks and then stopped for a week

2. continue to have checkup and lab work while on med

Which nonpharmacologic interventions should a nurse include in the care plan for a client who has moderate rheumatoid arthritis? Select all that apply. massaging inflamed joints avoiding range-of-motion exercises applying splints to inflamed joints using assistive devices at all times selecting clothing that has hook-and-loop (Velcro) fasteners applying moist heat to joints

3,5,6 Rationale: Supportive, nonpharmacologic measures for the client with rheumatoid arthritis include applying splints to treat inflamed joints, using Velcro fasteners on clothes to aid in dressing, and applying moist heat to joints to relax muscles and relieve pain. Never massage inflamed joints because massage can aggravate inflammation. A physical therapy program including range-of-motion exercises and carefully individualized therapeutic exercises prevent loss of joint function. Use assistive devices only when marked loss of range of motion occurs.

the client diagnosed with RA is being seen in the outpatient clinic. which preventive care should the nurse include in the regularly scheduled clinic visits? 1. perform joint x-rays 2. send blood to the lab for ESR 3. recommend the flu and pneumonia 4. assess the client for increasing joint involvement

3: clients have increased susceptibility to infectious diseases

the nurse is assessing a client diagnosed with RA. which assessment findings warrant immediate intervention? 1. the client c/o joint stiffness and knees feel warm to touch 2. the client has experienced 1-kg weight loss and is very tired 3. the client requires heat pad applied to hips and back to sleep 4. the client is crying, has flat facial affect, and refuses to speak to nurse

4

Onset

insidious

onset of RA occurs most frequently between the ages

40-60

Boutonniere deformity

A flexion deformity of the PIP joints with extensions of the DIP joints

The nurse, caring for a 10-year-old client with symptoms of juvenile rheumatoid arthritis (JRA), should include which of the following when teaching the family about the child's illness? The child will grow normally. About 80% of children experience a spontaneous remission. Symptoms are different for children and adults. The child will need hospitalization.

About 80% of children experience a spontaneous remission. Rationale: About 80% of children with JRA experience a remission with no recurrence. The symptoms are the same for adults and children, as are the treatment regimens. The child does not need hospitalization. Depending on when the child has the disease, it may arrest the child's growth.

Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis? a. Avoid exercise because it fatigues the joints. b. Take prescribed anti-inflammatory medications with meals. c. Alternate hot and cold packs to affected joints. d. Avoid weight-bearing activity.

Answer B is correct. Anti-inflammatory drugs should be taken with meals to avoid stomach upset. Answers A, C, and D are incorrect. Clients with rheumatoid arthritis should exercise, but not to the point of pain. Alternating hot and cold is not necessary, especially because warm, moist soaks are more useful in decreasing pain. Weight-bearing activities such as walking are useful but is not the best answer for the stem.

When helping a patient with rheumatoid arthritis (RA) plan a daily routine, the nurse informs the patient that it is most helpful to start the day with a. a warm bath followed by a short rest. b. a 10-minute routine of isometric exercises. c. stretching exercises to relieve joint stiffness. d. active range-of-motion (ROM) exercises.

Answer: A Rationale: Taking a warm shower or bath is recommended to relieve joint stiffness, which is worse in the morning. Isometric exercises would place stress on joints and would not be recommended. Stretching and ROM should be done later in the day, when joint stiffness is decreased.

When teaching a patient who has rheumatoid arthritis (RA) about how to manage activities of daily living, the nurse instructs the patient to a. stand rather than sit when performing household chores. b. avoid activities that require continuous use of the same muscles. c. strengthen small hand muscles by wringing sponges or washcloths. d. protect the knee joints by sleeping with a small pillow under the knees.

Answer: B Rationale: Patients are advised to avoid repetitious movements. Sitting during household chores is recommended to decrease stress on joints. Wringing water out of sponges would increase the joint stress. Patients are encouraged to position joints in the extended position, and sleeping with a pillow behind the knees would decrease the ability of the knee to extend and also decrease knee ROM

Corticosteriods

Slow progression of joint destruction Long term use can cause poor wound healing, increased infection, osteoporosis, GI bleed Limited to small dosages daily Titer off medication

Prednisone (Deltasone) is prescribed for a patient with an acute exacerbation of rheumatoid arthritis. When the patient has a follow-up visit 1 month later, the nurse recognizes that the patient's response to the treatment may be best evaluated by a. blood glucose testing. b. liver function tests. c. serum electrolyte levels. d. C-reactive protein level.

Answer: D Rationale: C-reactive protein is a marker for inflammation, and a decrease would indicate that the corticosteroid therapy was effective. Blood glucose and serum electrolyte levels will also be monitored to check for side effects of prednisone. Liver function is not routinely monitored for patients receiving steroids. Cognitive Level: Application Text Reference: pp. 1698-1699 Nursing Process: Evaluation NCLEX: Physiological Integrity

. A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate?" a. "Your family may need some help to understand the impact of your rheumatoid arthritis." b. "You may need to see a family therapist for some help." c. "Perhaps it would be helpful for you and your family to get involved in a support group." d. "Tell me more about the situations that are causing stress."

Answer: D Rationale: The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.

Swan neck deformity

Characterized by hyperextension of the PIP joints with compensatory flexion of the distal interphalangeal (DIP) joints.

When the first class of drugs prescribed for rheumatoid arthritis fails, the nurse anticipates which category of drugs will be prescribed? A. Nonsteroidal anti-inflammatory B. Disease modifying antirheumatic C. Salicylates D. Biologic response modulators

D: Disease modifying antirheumatic drugs (DMARDs) are the first drugs used to try to reduce joint clinical manifestations in rheumatoid arthritis. Biologic response modulators have a 66% success rate after fail ure with DMARDs.

Ulnar deviation

Ulnar deviation of the fingers and subluxation at the MCP joints

Which of the following should the nurse provide when explaining therapeutic measures to a client prescribed methotrexate (Rheumatrix) for rheumatoid arthritis (RA)? Fluids are restricted to prevent formation of edema in the joints. Drug doses will be adjusted for optimum effect at the lowest dose once relief has been established. Six months of therapy will be adequate to stop disease progression. Relief of symptoms will be assessed within 1 week of starting medication.

Drug doses will be adjusted for optimum effect at the lowest dose once relief has been established. Rationale: Methotrexate takes several weeks to effect relief. Once relief is obtained, the dose is adjusted to achieve maximum response at the lowest dose. If the drug is discontinued, the symptoms will reappear. Fluids are not restricted.

NSAIDS

First drug prescribed in the treatment of RA therapeutic blood level 15-30mg/dL GI side effects and interference with platelet functions are the greatest hazards of aspirin therapy Clients are instructed to take with meals, milk, or antacids to minimize GI distress and decrease GI bleeding

Which of the following is a major factor in the susceptibility and severity of rheumatoid arthritis (RA)? Diabetes mellitus Infectious agents Frequent use of chemicals in pools Genetic predisposition

Genetic predisposition Rationale: The cause of RA is unknown, but it most likely is due to a variety of unknown environmental factors, including infectious agents and chemical exposures, all triggering an autoimmune response. However, a person's genetic predisposition is a major factor in both the susceptibility and the severity of RA.

Disease modifying Drugs

Immune and inflammatory agents mmunosuppression helps to reduce the body's autoimmune response *Methotrexate treatment of choice* o Maybe used with Nsaids o Gastric irritation and stomatitis are most frequent side effects but can be controlled if taken with folic acid Alcoholism, diabetes, obesity, advanced age, and renal disease increase the risk of toxic effects (hepatotoxicity, bone marrow suppression, interstitial pneumonitis) *Leflunomide (Arava): reversibly inhibits an enzyme involved in the autoimmune process* *etanercept (Enbrel): inhibits the binding of tumor necrosis factor to receptor sites. * *Humira is a biologic response modifier that is given to people with RA to reduce the inflammatory events of polyarthritis and to slow the progression of joint damage. Given by SubCu injection, can't be administered if person as an infection

The nurse, caring for a middle-age adult client who is employed in a stressful job and newly diagnosed with rheumatoid arthritis, would select which of the following nursing diagnoses for this client? (Select all that apply.) Caregiver Role Strain Anxiety Ineffective Coping Risk for Disuse Syndrome Risk for Confusion

Ineffective Coping Anxiety Rationale: The client with a stressful job will likely have a difficult time coping with the fatigue and will likely develop anxiety about job performance. At this age, family responsibilities may be an additional source of stress. The client is not the caregiver. This client is not at risk for confusion or disuse syndrome.

Medication instructions for a client with rheumatoid arthritis (RA) should include which of the following teaching points? Penicillamine may be safely used during pregnancy. NSAIDS, acetaminophen, and aspirin may be used interchangeably to decrease inflammation. Injection of gold salts requires monitoring for anaphylactic shock every half-hour. Treatment with sulfasalazine requires fluid restriction to avoid nausea and vomiting.

Injection of gold salts requires monitoring for anaphylactic shock every half-hour. Rationale: Gold salts can cause anaphylaxis, so monitoring is required. Sulfasalazine may cause nausea and vomiting, but fluids should be increased, not decreased. Acetaminophen does not provide anti-inflammatory effects. Penicillamine cannot be used during pregnancy.

Diagnostic Test

Lab Studies Rheumatoid Factor - 80% of patients ESR: elevated CBC: detect anemia C-Reactive Protein elevated Serum complement WBC up to 25,000/ul Synovial biopsy - inflammation Bone Scan

Joint Manifestations hands and fingers:

Metacarpophalangeal (MCP) joints Proximal interphalangeal (PIP) joints Distal interphalangeal (DIP) joints

The focus of treatment for rheumatoid arthritis is related directly to joint damage that is caused by: Vasculitis. Sjögren's syndrome. Felty's syndrome. Pannus.

Pannus. Rationale: Pannus is vascular granulation tissue composed of inflammatory cells that erodes articular cartilage and eventually destroys bones. A vasculitis usually indicates blood vessel involvement. Sjögren's syndrome is due to inflammatory cells and immune complexes obstructing secretory ducts and glands. Felty's syndrome is characterized by rheumatoid arthritis, hepatosplenomegaly, and leukopenia.

Rheumatoid arthritis (RA) overview:

RA is a chronic systemic autoimmune disorder

What is Rheumatoid Arthritis

RA is a chronic systemic autoimmune disorder. RA causes inflammation of connective tissues, primarily in the joints. It is believed that long-term exposure to an unidentified antigen causes an aberrant immune response in a genetically susceptible host. As a result, normal antibodies (immunoglobins) become autoantibodies and attach host tissues. These transformed antibodies, usually present in people with RA, are called rheumatoid factors. The self-produced antibodies bind with target antigens in blood and synovial membranes forming immune complexes. Leukocytes are attracted to the synovial membrane from the circulation, where neutrophils and macrophages ingest the immune complexes and release enzymes that degrade synovial tissue and articular cartilage. Activation of B lymphocytes and T lymphocytes results in increased production of rheumatoid factors and enzymes that increase the inflammatory process.

Transformed antibodies, usually present in people with RA are called

Rheumatoid Factors

The nurse, assessing a client with suspected rheumatoid arthritis (RA), would observe which of the following joint changes in the client? Charcot's joints Heberden's and Bouchard's nodes Swan-neck deformity and ulnar deviation Tophi

Swan-neck deformity and ulnar deviation Rationale: Swan-neck deformity occurs at the proximal interphalangeal joint. Ulnar deviation occurs as a result of joint destruction and disease progression. Heberden's and Bouchard's nodes are commonly found in clients with osteoarthritis. Tophi (firm moveable nodules) are associated with gout. Charcot's joints is considered a neuropathic disorder that falls under the broader category of rheumatism. It is not associated with RA and is more often seen in clients with diabetes.

Which of the following observations by the nurse warrants further investigation to determine if the client has rheumatoid arthritis (RA)? Complaints of pain with movement Negative family history Complaints of prolonged morning stiffness lasting for 1 hour Occasional use of NSAIDS for aches and pains

Your Answer: Complaints of prolonged morning stiffness lasting for 1 hour Rationale: Prolonged morning stiffness is associated with RA. Occasional use of NSAIDS is not by itself a direct link to RA. Pain with movement is more likely associated with degenerative joint disease. Negative family history indicates the client does not have an elevated risk for RA.

What is autoimmune disorders?

a disease caused by abnormal, overactive functioning of the immune system that produces a response against the body's own cells and tissues, normally resulting in damage to the tissue.

Rheumatoid arthritis causes tenderness and

limitation of movement

Ankles and feet

ambulation may be limited by pain and deformities when ankles and feet are involved deformities include: subluxation hallux valgus lateral deviation of the toes cock-up toes

Diagnostic Criteria

at least 4 of seven must be present to establish diagnosis: 1. morning stiffness lasting for at least an hour and persisting at least 6 weeks 2. arthritis with swelling or effusion of three or more joints 3. arthritis of wrist, MCP, PIP joints 4. symmetric arthritis with simultaneous involvement of corresponding joints on both sides 5. rheumatoid nodules 6. positive serum rheumatoid factor 7 characteristic radiologic changes of RA noted in hands and wrist

RA normal antibodies become

autoantibodies and attack host tissue

as the vascular flow to the synovial tissue decrease:

blood flow decreases and metabolic needs increase (from increased number and size of cells), hypoxia and metabolic acidosis occur

Cause of RA

unknown

Juvenile Rheumatoid Arthritis

chronic inflammatory autoimmune disorder diagnosed in children that is characterized by joint inflammation resulting in decreased mobility, swelling, and pain

Clients with RA must cope with

chronic pain experience alterations in body image

Diagnosis

chronic pain r/t joint inflammation fatigue r/t chronic pain and complications of disease process ineffective role performance r/t pain disturbed body image r/t joint deformities impaired physical mobility r/t joint stiffness anxiety r/t stress of chronic illness activity intolerance r/t chronic pain

Plan

client reports effectiveness of pain management client performs ADLs independently client expresses feelings about diagnosis of chronic disease and displays progression through grieving process

Diagnosis of RA is based on:

client's history physical assessment diagnostic test

RA causes inflammation to

connective tissue, primarily in joints

RA affects more

women

Risk factors:

women 40-60 family history heavy smokers

Second category of RA in older persons occurs in those who

have been diagnosed with the disease before 65 years old

the inflammation process also causes:

hemorrhage coagulation deposits of fibrin

Leukocytes are attracted to the synovial membrane from the circulation, where neutrophils and macrophages ingest the immune complexes & release enzymes that:

degrade synovial tissue and articular cartilage

RA contributes to

disability and tends to shorten life expectancy

Avoid taking nsaids on ____ stomach

empty

joint manifestations often are preceded by systemic manifestations of inflammation including

fatigue loss of appetitie weight loss nonspecific aching

Systemic manifestations

fatigue weakness anorexia weight loss fever rheumatoid nodules anemia

course

generally progressive, characterized by periods of remissions and exacerbation

Heat and cold

moist heat most effective

Does a cure exisit?

no cure, goal is to relieve manifestations

Small venules are what:

occluded and vascular flow to the synovial tissue decrease.

who do you refer the client to if they have swan-neck fingers?

occupational therapist

de novo development of RA

older person may experience the first symptoms of RA after the age of 65

orthotic and assistive devices

orthotic devise splints provide joint rest and prevent contractures

3 types of JRA

pauciarticular: affects knees, ankles, elbows systemic: affects males and females equally, high fever, polyarthritis, rheumatoid rash polyarticular: 5+ joints

the pattern of joint involvement is typically

polyarticular (involving multiple joints) and symmetric

pain and stiffness

predominant on arising, lasting > 1hour occurs after prolonged inactivity

Rest and excercise

regular rest periods during the day are beneficial to reduce manifestations of the disease rest must be balanced with a program of PT & exercise to maintain muscle strength and joint mobility

Goals of RA

relieve pain reduce inflammation slow or stop joint damage improve well-being and ability to function

complication of aspirin that requires immediate intervention

ringing in the ears

Fibrin develops into pannus which leads to

scar tissue formation that immobilizes the joint

Extraarticular Manifestations

seen in clients with high levels of circulatign Rheumatoid Factor fatigue weakness loss of appetite weight loss low-grade fever anemia skeletal muscle atrophy rheumatoid nodules may develop pericarditis splenomagly pleural effusion

in early stage of the disease, the older person may have symptoms that are:

severely disabling but deformities are not present

the onset of RA is typically insidious, although it may be acute precipitated by

stress infection surgery trauma

RA is a chronic condition that manifests clinically by:

symmetric inflammation of the peripheral joints, with marked pain, welling, significant and often disabling morning stiffness and general fatigue and malaise

Most clients exhibit a pattern of

symmetric involvement of multiple peripheral joints and periods of remission and exacerbation

Surgery

synovectomy: excision of synovial membrane arthrodesis: joint fusion arthroplasty: total joint replacement

Acidosis stimulates:

synovial cells to release hydrolytic enzymes into surrounding tissues, starting erosion of the articular cartilage and inflammation of the supporting ligaments and tendons

When planning the care for a client experiencing pain because of rheumatoid arthritis (RA), which of the following interventions would increase the client's mobility? Have the client use medication only when pain is present. Have the client work through pain by continuing exercise in order to establish endurance. Teach the client that both heat and cold may be used to decrease pain. Teach the client to flex muscle groups when pain is felt in an extremity.

teach the client that both heat and cold may be used to decrease pain. Rationale: Heat and cold applications can provide analgesia and relieve muscle spasms. Pain medications are taken on a regular schedule if the client has chronic pain so that relief is maintained at a constant level. Exercising during pain exacerbates the pain. Flexing muscles in a painful extremity is not related to pain control.

the synovial membrane is damaged by:

the inflammatory and immune process. it swells from infiltration of leukocytes and it thickens as cells proliferate and abnormally enlarge

activity intolerance

• Assess for signs and symptoms of activity intolerance: • Implement measures to improve activity tolerance: • perform actions to promote rest and/or conserve energy: • discourage smoking and excessive intake of beverages high in caffeine such as coffee, tea, and colas (nicotine and caffeine can increase cardiac workload and myocardial oxygen utilization, thereby decreasing oxygen availability) • perform actions to improve breathing pattern (in order to decrease dyspnea and improve tissue oxygenation

Disturbed body image

• Demonstrate a caring, accepting attitude toward the client • Encourage the client to talk about the effects of the disease, both the physical and the effects on life roles • Encourage the client to maintain self-care and usual roles to the extent as possible • Provide positive feedback for self-care activities and adaptive • Refer the client to support groups

Ineffective role performance

• Discuss the effects of the disease on the client's career and other life roles. • Encourage the client to identify changes brought on by the disease • Encourage the client and family to discuss their feelings about role changes and to grieve over lost roles or abilities • Listen actively to concerns expressed by the client and family members, and acknowledge the validity of concerns • Help the client and family to identify strengths they can use to cope with role changes

Fatigue

• Encourage a balance of periods of activity with periods of rest • Stress the importance of planned rest periods during the day • Help the client to prioritize activities • Encourage regular physical activity • Refer the client to support group

Chronic Pain

• Monitor the level of pain and duration of morning stiffness • Encourage the client to relate pain to activity level and adjust his or her activities accordingly • Teach the use of heat and cold applications to provide pain relief • Teach about the use of prescribed anti-inflammatory medications • Encourage use of other nonpharmacologic pain relief

impaired mobility

• Promote general health by encouraging a well-balanced diet

Gold Salts

• Unknown mode of action, but it may produce clinical remission and decrease new bony erosions • Weekly therapy • Dermatitis, stomatitis, bone marrow depression, proteinuria • Mild skin reactions • CBC and urinalysis are monitored throughout treatment

anxiety

• orient client to environment, equipment, and routines; explain the purpose for and operation of a kinetic bed if indicated • introduce client to staff who will be participating in care; if possible, maintain consistency in staff assigned to his/her care • maintain a calm, supportive, confident manner when interacting with client • encourage verbalization of fear and anxiety; provide feedback • provide a calm, restful environment • instruct client in relaxation techniques and encourage participation in diversional activities • assist client to identify specific stressors and ways to cope with them • encourage significant others to project a caring, concerned attitude without obvious anxiousness • include significant others in orientation and teaching sessions and encourage their continued support of the client • administer prescribed antianxiety agents if indicated.