Nursing Self-Study, Continue Education Topic reg/ Patient with Rheumatoid Arthritis (Pathophysiology, Treatment, and Nursing Management, and etc.)

Continue nursing education reading:

Chu, A. & Ng, B. (2017). Caring for patients with rheumatoid arthritis in the community: Aggressive treatment and expert nursing care can improve patients’ quality of life

Rheumatoid arthritis is a chronic systemic inflammatory disease that affects joints and other organ systems. It can lead to severe functional disability and poor quality of life, imposing substantial burdens on patients and their caregivers. It affects 0.5% to 1% of the population worldwide. Evidence suggests that both genetics and environmental factors play a role in rheumatoid arthritis, others are including infections and epidemiologic factors.

(Retrieved from Chu & Ng, 2017)

Clinical Manifestations

• Immunologic processes results in inflammation of synovium, producing antigens and inflammatory by-products that lead to destruction of articular cartilage, edema, and production of a granular tissue call pannus
  • Swelling, tenderness, and synovial joint destruction /deformities – rheumatoid nodules 
  • Arthritis: bilateral, symmetric arthritis affects any diarthrodial joint, but most commonly involves the hands, wrists, knees, and feet
• Granulation tissue forms adhesions that lead to decreased join mobility. Similar adhesions can occur in supporting structure, such as ligaments and tendons, and cause contractures and ruptures that further affect joint structure and mobility. 
• Joint erosion on X-ray

 

Diagnostic Evaluation

• Complete Blood Count (CBC)
• Rheumatoid Factor (RF)- positive in up to 70% to 75% of patient with rheumatoid arthritis.
• Cyclic citrullinated peptide (CCP), Antibodies against citrullinated peptides test (ACPA), may be ordered along with RF test to help diagnose rheumatoid arthritis, promote early accurate diagnosis of rheumatoid arthritis
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) – elevated due to active inflammation
• Synovial fluid analysis
• X-rays: changes develop within 2 years
• Magnetic resonance imaging (MRI)
• Bone scan
• Ultrasound
• Synovial biopsy

With no gold standard, early diagnosis is challenging, but early diagnosis (within 6 months of rheumatoid arthritis symptom onset) with early treatment are essential in reducing the risk of joint damage and maintain quality of life.

 

Management

• Relieve pain and inflammation: NSAIDs and Corticosteroids
• Current rheumatoid arthritis treatment recommendation:
  • initiate DMARDs (preferably methotrexate) immediately after diagnosis, to reduce disease activity
    • Monotherapy
    • Combination (for patients who don’t respond to traditional DMARD monotherapy)
  • Drug alert:
    • do no give DMARDs within 2 to 3 weeks of any live vaccine.
    • watch for signs of infection, including reactivation of viral infection, while patients are receiving DMARDs
      • for example, methotrexate is associated with hypatotoxicity and bone marrow suppression, so patients taking this drug should undergo complete blood counts and liver enzyme tests every 2 to 3 months
      • Before combination of TNF (tumor necrosis factor) inhibitor and methotrexate (benefit in improving signs and symptoms, preventing radiologic deterioration of joint, and improving physical function), because the immunomodulating actions of biologics that increase the risk of certain infection, patient may benefit for laten tuberculosis test, receive pneumococcal, zoster, and influenza vaccinations before beginning treatment.
• Local comfort measures:
  • application of heat and cold- apply local heat or cold to affected joins for 15 to 20 minutes, three to four times per day.
    • Avoid temperatures likely to cause skin or tissue damage by checking temperature of warm soaks or by covering cold packs with a towel.
    • Encourage warm bath or shower in the morning to decrease morning stiffness to promote mobility
  • use of splints, and perform gentle ROM exercise to encourage measures to protect affected joints.
    • encourage exercise consistent with degree of disease activity
    • refer to physical therapy and occupational therapy
  • use of transcutaneous electrical nerve stimulation (TENS) units
  • Iontophoresis – delivery of medication through the skin using direct electrical current
• Nonpharmacologic modalities:
  • behavior modification
  • relaxation techniques
• Surgery:
  • synovectomy
  • arthrodesis -joint fusion
  • total joint replacement

 

Nursing Diagnoses

• Pain and discomfort- Chronic pain r/t disease process
• Activity intolerance and Impaired mobility – r/t pain and limited joint motion
• Self-care deficits – r/t limitation secondary to disease process
• Fall risks – Risk for injury r/t DMARD therapy
• Ineffective coping – Nonadherence to the therapeutic regimen r/t pain, physical limitations, and chronicity of rheumatoid arthritis
• Altered body image or role performance
• Ineffective health maintenance
• caregiver role strain

 

Nursing Interventions (refer to Management)

• Controlling pain
• Optimizing Mobility
• Preventing serious adverse reactions to drug therapy
• promoting self care
  • provide pain relief before self-care activities
  • schedule adequate rest periods
• strengthening coping skills
  • be aware of potential job, child care, home maintenance, and social and family functioning problems that may result from rheumatoid arthritis
  • encourage patient to vocalized problems and feelings
  • assist with problem-solving approach to explore options and to gain control of problems areas
  • reinforce effective coping mechanisms
  • refer to social worker or mental health counselor as needed

 

Myth or Fact?

Exercise helps ease joint stiffness caused by rheumatoid arthritis. Patient who did light exercise- walking and stretching- for as little as 3 hours over a six-week period reported a significant reduction in stiffness.

 

 

Other Resources Retrieved from

Lippincott manual of nursing practice (9th ed.)

Porth’s pathophysiology: Concepts of altered health states (9th ed.)