Rheumatoid Arthritis

Arthritis

Arthritis

Arthritis is the swelling and tenderness of one or more joints.

Inflammatory arthritis includes a large number of arthritic conditions in which the predominant feature is a synovial inflammation.
This includes post viral arthritis, rheumatic arthritis, seronegative spondyloarthropathy, / arthritis and Lyme arthritis.

  •  Disease presenting as an inflammatory mono arthritis include crystal arthritis e.g. gout, pseudo gout.
    Septic arthritis and arthritis due to Juxta – articular bone tumors
  •  Disease presenting as an inflammatory polyarthritis include rheumatoid arthritis, reactive arthritis and Seronegative arthritis associated with psoriasis.

Types of arthritis

  1.  Rheumatoid arthritis
  2.  Osteoarthritis
  3.  Goutily arthritis
  4.  Traumatic arthritis
  5.  Septic arthritis
  6.  Hemophilic arthritis
  7.  Gonococcal arthritis
  8.  Syphilitic arthritis
  9.  Tubercular arthritis

Etiology of arthritis

  •  Trauma
  •  Infection like staphylococci and streptococci
  •  Extrapulmonary TB
  •  Late syphilis
  •  Deposition of crystal like urate crystals in uric acid metabolic disorder arthritis, reactive
  • Degeneration of articular parts like cartilages
  • Autoimmunity due to rheumatic fever
  • Hemorrhage into the joint

Predisposing factor

  •  Gender – women before the menopause are affected three times more often than men
  •  Familial – history
  •  Genetic factors
  •  Age
  •  Renal failure

Rheumatoid Arthritis

Rheumatoid arthritis an autoimmune inflammatory disorder of unknown origin that primarily involves the synovial membrane of the joints

Rheumatoid arthritis is a chronic inflammatory joint condition of un known origin characterized by persistent bilateral proportional small joints involvement resulting in cartilage destruction and bony erosion
with subsequent joint deformities.

The disease affects many systems including articular and non articular structures
It is called seropositive arthritis because of rheumatoid factor that is present in 80% of the cases.
Rheumatology deals with a heterogeneous group of disorder of joint, bones and connective  tissues.
Rheumatic diseases affect people of all sexes, ethnic groups, and ages.

The frequency increases with age so that as many as 40% of persons over the age of 50 years have Rheumatic complaints.

Pathophysiology of rheumatoid arthritis

Rheumatoid arthritis is an autoimmune disease where by body tissues are destroyed by its own immune system. The exact cause is not yet known. The disease target the synovium and involves two pathological changes i.e. inflammation and proliferation
The joints are acutely inflamed due to inflammatory changes in the synovial membrane. The synovium becomes thicker, very vascular and the site of increased cell infiltration which may cause an effusion within the joint that manifests as a swollen tender and painful joint with
restriction of its movements. Extra-articular structures lead to rheumatoid nodules (subcutaneous nodules)
The proliferative tissue spreads as pannus over the articular cartilage leading to its slow erosion.

Systemic inflammatory changes can affect many body organs leading to pericarditis, pleuritis, bowel vasculitis, general malaise and anemia
The condition can occur in children less than 16 years as juvenile rheumatoid arthritis or still disease presenting with poly articular arthritis assuming a flexed position, refusing to work, lymphadenopathy, hepatosplenomegaly, pericarditis and pleuritis.

Summary of pathophysiology.

The pathophysiology of rheumatoid arthritis is brief and concise.

  • Autoimmune reaction. In RA, the autoimmune reaction primarily occurs in the synovial tissue.
  • Phagocytosis. Phagocytosis produces enzymes within the joint.
  • Collagen breakdown. The enzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation.
  • Damage. Pannus destroys cartilage and erodes the bone.
  • Consequences. The consequences are loss of articular surfaces and joint motion.
  • Degenerative changes. Muscle fibers undergo degenerative changes, and tendon and ligament elasticity and contractile power are lost.

Signs and symptoms of rheumatoid arthritis

  • Joint pain. One of the classic signs, joints that are painful are not easily moved.
  • Swelling. Limitation in function occurs as a result of swollen joints.
  • Warmth. There is warmth in the affected joint and upon palpation, the joints are spongy or boggy.
  • Erythema. Redness of the affected area is a sign of inflammation.
  • Lack of function. Because of the pain, mobilizing the affected area has limitations.
  • Deformities. Deformities of the hands and feet may be caused by misalignment resulting in swelling.
  • Rheumatoid nodules. Rheumatoid nodules may be noted in patients with more advanced rheumatoid arthritis, and they are nontender and movable in the subcutaneous tissue.

Other signs and symptoms include;

  •  Gradual onset of pain and morning stiffness
  • Loss of appetite and weight
  • Swelling and progressive loss of joint function
  • Mild pyrexia and fatigue
  • Other prodromal signs like anorexia, weakness and vague joint pains that persist for weeks or months followed by pain, tender swollen joints
  • Inflammation involves three or more joints including small joints
  • Symmetrical bilateral arthritis involving ankles, knee, wrists, elbows, shoulders, spine and temporomandibular joints
  • Pain increases with joint movement and may disturb sleep
  • Subcutaneous nodule
  • Extra articular manifestation includes splenomegaly, lymphadenopathy, pericarditis, carpal tunnel syndrome, neuropathy, ulcers, pancytopenia and nephritic syndrome
  • Erythmatous boggy joints
  • The condition is precipitated by stress, emotions, infections and physical exertion
  • The condition is characterized by relapses and remissions
  • There may be hemorrhagic infarcts in the nails and finger pulps.
  • Inflammation in the eye and ulceration of the white portion of the eye.
  • Axial joint leading to fetal cervical cord compression.

Assessment and Diagnostic Findings

  • Physical examination.
  • History taking.
  • X-rays of involved joints: Reveals soft-tissue swelling, erosion of joints, and osteoporosis of adjacent bone (early changes) progressing to bone-cyst formation.
  • Rheumatoid factor (RF): Positive in more than 80% of cases (Rose-Waaler test).
  • Synovial membrane biopsy: Reveals inflammatory changes and development of pannus (inflamed synovial granulation tissue).
  • Synovial/fluid aspirate: May reveal volume greater than normal; opaque, cloudy, yellow appearance (inflammatory response, bleeding, degenerative waste products).
  • Erythrocyte sedimentation rate (ESR): Usually greatly increased (80–100 mm/hr). May return to normal as symptoms improve.
  • CBC: Usually reveals moderate anemia. WBC is elevated when inflammatory processes are present.
  • Immunoglobulin (Ig) (IgM and IgG): Elevation strongly suggests autoimmune process as cause for rheumatoid arthritis.
  • Direct arthroscopy: Visualization of area reveals bone irregularities/degeneration of joint.

Management of rheumatoid arthritis

Aims

  • To control pain
  • To prevent joint damage
  • Control systemic symptoms
  • Stop inflammation[put disease in remission] wellbeing
  • Restore physical function and overall
  • Reduce long term complications
  • Relieve symptoms

There is no specific cure for Rheumatoid arthritis

Nursing care

  1. Provide adequate rest of the painful swollen joints in acute phase. Use a bed cradle to lift linen from affected joints
  2. Firm back support should be used during the day
  3. The legs must be kept straight and the pillow placed behind the knees, this prevents flexion deformities
  4. Encourage the patient to do active exercise under the guidance of a physiotherapist.
  5. Diet should hence a high protein content with aplenty of milk and eggs
  6. Iron should be given to correct anemia which is common.
  7. Vitamin D, calcium supplements may help to reduce osteoporosis
  8. Should be immobilized in light plastic splints on even plaster of paris.
  9. Relieve pain and discomfort. Provide comfort measures like application of heat or cold massage, position changes, supportive pillows etc
  10. Encourage verbalization of pain. Administer anti inflammatory and analgesic as prescribed.
  11. FACILITATING SELF CARE, Assist patient to identify self care deficit. Develop a plan based on patient perception and priorities.
  12. IMPROVING BODY IMAGE AND COPING SKILLS, Identify areas of life affected by the disease and answer questions., Develop a plan for managing symptoms and enlisting support of family and friends to promote daily function
  13. INCREASING MOBILITY, Asses need for occupational or physical therapy consultation., Encourage independence in mobility and assist as needed
  14. REDUCING FATIGUE, Encourage adherence on treatment programs., Encourage adequate nutrition, Encourage on how to use energy conservation techniques like delegation, setting prioties etc
  15. PROMOTE HOME AND COMMUNITY BASED CARE, Focus on teaching on the disease and possible changes related to it, prescribed drugs and their side effect ., Strategies to maintain independence and safety at home.

MEDICAL MANAGEMENT

There is no cure for rheumatoid arthritis. But recent discoveries indicate that remission of symptoms is more likely when treatment begins early with strong medications known as disease-modifying antirheumatic drugs (DMA). The types of medications recommended will depend on the severity of your symptoms and how long you’ve had rheumatoid arthritis.

  1. NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) can relieve pain and reduce inflammation. Over-the-counter
    NSAIDs include ibuprofen (Advil, Motrin IB) and naproxen sodium (Aleve). 
    • Acetyl salicylic acid (aspirin) 80 – 100mg/kg daily 4-60
    •  Other alternative to aspirin, Indomethacin, Naproxen
    , Diclofenac Piroxicam. Stronger NSAIDs are available by prescription. Side effects may include ringing in your ears, stomach irritation, heart problems, and liver and kidney damage.
  2. Steroids. Corticosteroid medications, such as prednisone, reduce inflammation and pain and slow joint damage. Side effects may include thinning of bones, weight gain and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
  3. Disease-modifying antirheumatic drugs (DMARDs). These drugs can slow the progression of rheumatoid arthritis and save the joints and other tissues from permanent damage. Common DMARDs include methotrexate (Trexall, Otrexup, Rasuvo), leflunomide (Arava), hydroxychloroquine (Plaquenil) and sulfasalazine (Azulfidine). Side effects vary but may include liver damage, bone marrow suppression and severe lung infections.
  4. Biologic agents. Also known as biologic response modifiers, this newer class of DMARDs includes abatacept (Orencia), adalimumab (Humira), anakinra (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi), infliximab (Remicade), rituximab (Rituxan), tocilizumab (Actemra) and tofacitinib (Xeljanz). These drugs can target parts of the immune system that trigger inflammation that causes joint and tissue damage. These types of drugs also increase the risk of infections. Biologic DMARDs are usually most effective when paired with a non biologic DMARD, such as methotrexate.

Surgical Management.

SURGERY

If medications fail to prevent or slow joint damage, you and your doctor may consider surgery to repair damaged joints. Surgery may help restore your ability to use your joint. It can also reduce pain and correct deformities.

Rheumatoid arthritis surgery may involve one or more of the following procedures:

  1. Synovectomy. Surgery to remove the inflamed synovium (lining of the joint). Synovectomy can be performed on knees, elbows, wrists, fingers and hips.
  2. Tendon repair. Inflammation and joint damage may cause tendons around your joint to loosen or rupture. Your surgeon may be able to repair the tendons around your joint.
  3. Joint fusion. Surgically fusing a joint may be recommended to stabilize or realign a joint and for pain relief when a joint replacement isn’t an option.
  4. Total joint replacement. During joint replacement surgery, your surgeon removes the damaged parts of your joint and inserts a prosthesis made of metal and plastic.
  5. Osteotomy. 
  6. Tenorrhaphy. Tenorrhaphy is the suturing of a tendon.
  7. Arthrodesis. Arthrodesis is the surgical fusion of the joint.
  8. Arthroplasty. Arthroplasty is the surgical repair and replacement of the joint.

Conservative measures

  • Weight reduction
  • Joint rest
  • Avoidance of joint over use
  • Orthotic devices to support inflamed joints[braces and splits].
  • Isometric and postural exercises and aerobic exercises
  • Occupation and physical therapy.

Nursing Diagnosis

  1. Acute and chronic pain related to inflammation and increased disease activity, tissue damage, fatigue, or lowered tolerance level.
  2. Fatigue related to increased disease activity, pain, inadequate sleep/rest, inadequate nutrition, and emotional stress/depression
  3. Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack or improper use of ambulatory devices.
  4. Self-care deficit related to contractures, fatigue, or loss of motion.
  5. Disturbed body image related to physical and psychological changes and dependency imposed by chronic illness.
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