Rheumatoid arthritis

Rheumatoid arthritis

®  A type of chronic systemic inflammatory arthritis and connective tissue disorder affecting more women (ages 35-45)  than men

®  Rheumatoid arthritis

FACTORS:

à  Genetic

à  Auto-immune connective tissue disorders

à  Fatigue, emotional stress, cold, infection

®  Rheumatoid arthritis

Pathophysiology

®  Immune reaction in the synovium à attracts neutrophils à releases enzymes àbreakdown of collagen à irritates the synovial liningàcausing synovial inflammationedema and pannus formation and joint erosions and swelling

ASSESSMENT FINDINGS

®  1. PAIN

®  2. Joint swelling and stiffness-SYMMETRICAL, Bilateral

®  3. Warmth, erythema and lack of function

®  4. Fever, weight loss, anemia, fatigue

®  5. Palpation of join reveals spongy tissue

®  6. Hesitancy in joint movement

ASSESSMENT FINDINGS

®  Joint involvement is SYMMETRICAL and BILATERAL

®  Characteristically beginning in the hands, wrist and feet

®  Joint STIFFNESS occurs early morning, lasts MORE than 30 minutes, not relieved by movement, diminishes as the day progresses

®  Rheumatoid arthritis

®  Joints are swollen and warm

®  Painful when moved

®  Deformities are common in the hands and feet causing misalignment

®  Rheumatoid nodules may be found in the subcutaneous tissues

®  Rheumatoid arthritis

Diagnostic test

1. X-ray

®  Shows bony erosion

2. Blood studies reveal (+) rheumatoid factor, elevated ESR and CRP and ANTI-nuclear antibody

3. Arthrocentesis shows synovial fluid that is cloudy, milky or dark yellow containing numerous WBC and inflammatory proteins

MEDICAL MANAGEMENT

®  1. Therapeutic dose of NSAIDS and Aspirin to reduce inflammation

®  2. Chemotherapy with methotrexate, antimalarials, gold therapy and steroid

®  3. For advanced cases- arthroplasty, synovectomy

®  4. Nutritional therapy

GOLD THERAPY:

®  IM or Oral preparation

®  Takes several months (3-6)  before effects can be seen

®  Can damage the kidney and causes bone marrow depression

Nursing MANAGEMENT

1. Relieve pain and discomfort

®  USE splints to immobilize the affected extremity during acute stage of the disease and inflammation to REDUCE DEFORMITY

®  Administer prescribed medications

®  Suggest application of COLD packs during the acute phase of pain, then HEAT application as the inflammation subsides

2. Decrease patient fatigue

®  Schedule activity when pain is less severe

®  Provide adequate periods of rests

3. Promote restorative sleep

4. Increase patient mobility

®  Advise proper posture and body mechanics

®  Support joint in functional position

®  Advise ACTIVE ROME

5. Provide Diet therapy

®  Patients experience anorexia, nausea and weight loss

®  Regular diet with caloric restrictions because steroids may increase appetite

®  Supplements of vitamins, iron and PROTEIN

6. Increase Mobility and prevent deformity:

®  Lie FLAT on a firm mattress

®  Lie PRONE several times to prevent HIP FLEXION contracture

®  Use one pillow under the head because of risk of dorsal kyphosis

®  NO Pillow under the joints because this promotes flexion contractures

Hot versus Cold

Hot

Use to RELIEVE joint stiffness, pain and muscle spasm

After acute attack

Cold

 Use to control inflammation and pain

ACUTE ATTACK

Juvenile rheumatoid Arthritis

Definition:

à  AUTO-IMMUNE inflammatory joint disorder of UNKNOWN cause

à  SYSTEMIC chronic disorder of connective tissue

à  Diagnosed BEFORE age 16 years old

PATHOPHYSIOLOGY : unknown

®  Affected by stress, climate and genetics

®  Common in girls 2-5 and 9-12 y.o.

®  Symptoms may decrease as child enters adulthood

®  With periods of remissions and exacerbations

Juvenile rheumatoid Arthritis

Systemic JRA	Pauci-articular	Polyarticular
FEVER	MILD joint pain and swelling	Morning joint stiffness and fever
Salmon-pink rash	IRIDOCYCLITIS	Weight Bearing joints
Five or more joints	Less than 4 joints	Five or more joints
Anorexia, anemia, fatigue	Very Good prognosis	Poor prognosis

Medical Management

1.       ASPIRIN and NSAIDs- mainstay treatment

2.       Slow-acting anti-rheumatic drugs

3.       Corticosteroids

Nursing Management

1.       Encourage normal performance of daily activities

2.       Assist child in ROM exercises

3.       Administer medications

4.       Encourage social and emotional development

During acute attack:

®  SPLINT the joints

®  NEUTRAL positioning

®  Warm or cold packs