Rheumatoid Arthritis

1. Rheumatoid Arthritis Dr. Belal M. Hijji, RN. PhD March 19, 2012

2. At the end of this lecture, students will be able to: • Discuss the clinical picture of RA. • Discuss assessment of health history and identify relevant diagnostic tests. • Describe the medical management of RA. • Describe the role of nutritional support in RA management. • Focus on applying the nursing process in addressing a nursing problem related to RA.

3. Introduction • Rheumatoid arthritis (RA) is a common chronic inflammatory disease in developed countries with a prevalence from 0.7% to 3%, with an average of 1% in the adult population. In the Kingdom of Saudi Arabia, one study identified a prevalence of RA to be 2.2 per thousand people in Al Qassim (Al-Dalaan et al. 1998).

4. Clinical Manifestations • Joint pain, swelling, warmth, erythema, and lack of function are classic. Palpation of the joints reveals spongy tissue. • Initially, the small joints in the hands, wrists, and feet are involved. The patient has limitation in function, and he tends to guard the joints through immobilization, which can lead to contractures [تقلص], creating soft tissue deformity. • As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints are involved. • Symptoms are usually bilateral and symmetric. • RA is a systemic disease with multiple extra-articular [خارج المفاصل] features (fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud’s phenomenon (cold- and stress-induced vasospasm causing episodes of digital blanching or cyanosis).

6. Other extra-articular features of RA include arteritis, neuropathy, scleritis, pericarditis, splenomegaly, and Sjogrens’ syndrome (dry eyes and dry mucous membranes). • Rheumatoid nodules may be noted in patients with advanced RA.

7. Assessment and Diagnostic Findings • Rheumatoid nodules, joint inflammation detected on palpation. • laboratory findings (Presence of rheumatoid factor, high erythrocyte sedimentation rate (ESR), C-reactive protein and antinuclear antibody may be positive). Arthrocentesis shows synovial fluid that is cloudy, milky, or dark yellow. X-ray studies show characteristic bony erosions.

8. Medical Management • Early-stage RA • Patient education, a balance of rest and exercise. • Salicylates or NSAIDs. • Several COX-2 (cyclo-oxygenase) inhibitors, another class of NSAIDs, block the enzyme involved in inflammation. • Antirheumatic agents (antimalarials, gold, penicillamine, or sulfasalazine) are initiated early in treatment. • Methotrexate is currently the gold standard in the treatment of RA.

9. Moderate, erosive RA • Patients need to participate in a formal program of education about principles of joint protection, pacing activities, range of motion, and exercises. • Cyclosporine enhances the disease modifying effect of methotrexate. • Persistent, erosive RA • Reconstructive surgery (indicated when conservative measure to control pain fail) is frequently used. Surgical procedures include synovectomy (excision of the synovial membrane), tenorrhaphy (suturing a tendon), arthrodesis (surgical fusion of the joint), and arthroplasty (surgical repair and replacement of the joint).

10. Persistent, erosive RA • Systemic low-dose corticosteroid is used for the shortest duration when the patient has unresolved inflammation and pain. • Joints that are severely inflamed and fail to respond promptly to the measures outlined previously may be treated by local injection of a corticosteroid.

11. Advanced, unremitting RA • High dose immunosuppressive agents such as methotrexate and azathioprine are prescribed because of their ability to affect the production of antibodies at the cellular level. • Depression and sleep deprivation may require the short-term use of low-dose antidepressant medications, such as amitriptyline (Elavil).

12. Nutrition Therapy • Patients with RA frequently experience anorexia, weight loss, and anemia. • Food selection should include the daily requirements from the basic food groups. • For the extremely anorexic patient, small, frequent feedings with increased protein supplements may be prescribed. • Patients may need diet counselling.

13. An Example of Applying the Nursing Process to Resolve a Nursing Problem for Patient With RA • Nursing Diagnosis: Acute and chronic pain related to inflammation and increased disease activity, tissue damage, or lowered tolerance level. • Goal: Improvement in comfort level; incorporation of pain management techniques into daily life.

14. Nursing Interventions • Providing a variety of comfort measures. • Application of heat or cold. • Massage, position changes, rest. • Foam mattress, supportive pillow, splints. • Relaxation techniques, activities that divert attention away from pain. Pain may respond to these non-pharmacologic interventions. • Administering slow-acting anti-rheumatic, anti-inflammatory and analgesic medications as prescribed. This is because pain responds to individual or combination medication regimens. • Encouraging verbalization of feelings about pain to promote coping.

15. Expected Outcomes The patient: • Identifies factors that exacerbate or influence pain response. • Identifies and uses pain management strategies. • Verbalizes decrease in pain. • Reports signs and symptoms of side effects in timely manner. • Verbalizes that pain is characteristic of rheumatic disease. • Establishes realistic pain-relief goals.

16. References • Al-Dalaan A, Al Ballaa S, Bahabri S, Biyari T, Al Sukait M, Mousa M. The prevalence of rheumatoid arthritis in the Qassim region of Saudi Arabia. Annals of Saudi Medicine 1998;18(5):396-397.