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Medical Surgical Exam 4 > Rheumatoid Arthritis > Flashcards

Rheumatoid Arthritis Flashcards

1
Q

Rheumatoid Arthritis (RA)

A

Chronic, systemic autoimmune disease
Inflammation of connective tissue in synovial joints
Periods of remission and exacerbation
Extraarticular manifestations- Rheumatoid nodules, Sjogren’s syndrome, felty syndrome , depression

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2
Q

Etiology and Pathophysiology of RA

A

Autoimmune etiology
Combination of genetics and environmental triggers
Antigen triggers formation of abnormal immunoglobulin G (IgG)
Autoantibodies develop against the abnormal IgG
Rheumatoid factor (RF)

Rheumatoid factor combines with IgG immune complexes → deposit on synovial membranes or cartilage in joints → activates complement → inflammatory response
Neutrophils → proteolytic enzymes → damage cartilage and thicken synovial lining

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3
Q

Pathologic Changes in Rheumatoid Arthritis Picture

A
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4
Q

Clinical Manifestations Joints

A

Onset typically insidious
Fatigue, anorexia, weight loss, generalized stiffness
May report history of precipitating event
Infection, stress, exertion, childbirth, surgery

Specific articular involvement
Pain, stiffness, limitation of motion, and signs of inflammation
Symptoms occur symmetrically
Most often affects small joints
Larger joints and cervical spine may be involved

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5
Q

Other Clinical Manifestations Joints

A

Joint stiffness after inactivity

Morning stiffness 60 minutes to several hours or longer

MCP and PIP joints typically swollen-metacarpal and peripheral

Fingers spindle shaped

Joints tender, painful, warm to touch

Pain ↑ with motion, intensity varies

Tenosynovitis

Deformity and disability

Subluxation

Walking disability

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6
Q

What is Tenosynovitis

A

inflammation of the tendon sheath, flexor and extender and cartlidge. Similar to carpal tunnel

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7
Q

What is Subluxation

A

Dislocation and they over lap

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8
Q

Typical Deformities of Rheumatoid Arthritis

A

A. Ulnar drift
B. Boutonnière deformity
C. Hallux valgus
D. Swan neck deformity

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9
Q

Clinical Manifestations Extraarticular-outside joints Manifestations

A

Rheumatoid nodules can be in both eyes

Sjögren’s syndrome

Felty syndrome

Flexion contractures

Nodular myositis

Cataracts- Can cause blindeness with these patients

Depression

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10
Q

What is Sjögren’s syndrome

A

decrease secretion of the salivary glands and eye gland- give over the counter eye drops

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11
Q

Diagnostic Studies in RA

A

Laboratory studies
Rheumatoid factor (RF)
Erythrocyte sedimentation rate (ESR)
C-reactive protein (CRP)
Antinuclear antibody (ANA)
Anti-citrullinated protein antibody (ACPA)-
Synovial fluid analysis
X-rays of involved joints
Bone scan

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12
Q

Why is Anti-citrullinated protein antibody (ACPA) important

A

Very important in Dx of RA most definitive

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13
Q

What does Synovial fluid analysis show

A

It would be cloudy and increased WBC’s

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14
Q

Collaborative Care

A

Patient teaching
Drug therapy
Disease process
Home management strategies
NSAIDs
Physical therapy
Occupational therapy
Individualized treatment plan

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15
Q

What is DMARDS

A

Disease Mofifying Antirheumatic Drugs

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16
Q

Drug Therapy: DMARDs

A

↓ Permanent effects of RA- Why we give these meds
Methotrexate (Rheumatrex)
Sulfasalazine (Azulfidine)
Hydroxychloroquine (Plaquenil)- Can cause retinopathy-teach regular eye exams- also a antimalarial drug
Leflunomide (Arava)
Monitor for bone marrow suppression and hepatotoxicity
Teratogenic-Can be harmful to babies, careful in women of childbearing age

17
Q

Drug Therapy: Biologic/Targeted Therapies

A

Tumor necrosis factor (TNF) inhibitors-Prevent inflammation, at high risk for infection due topreventing S/S of inflammation-Do not give live vaccinations
Etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab (Cimzia), and golimumab (Simponi)
Bind with TNF, inhibiting inflammation

18
Q

Tumor necrosis factor (TNF) inhibitors

A

TB test and chest x-ray before start of therapy
Monitor for infection
Avoid live vaccinations

19
Q

Drug Therapy

A

Antibiotics (minocycline [Minocin])
Immunosuppressants (azathioprine [Imuran])
Penicillamine (Cuprimine)
Gold preparations (auranofin [Ridaura])-injections used

20
Q

Drug Therapy CorticosteroidsHow would you know therapy was affective?

A

Look at CRP and ESR. Must be tapered off
Intraarticular injections
Low-dose oral for limited time

21
Q

Drug Therapy NSAIDS

A

Anti-inflammatory, analgesic, and antipyretic
May take 2 to 3 weeks for full effectiveness

22
Q

Nutritional Therapy

A

Balanced nutrition important

Loss of appetite or inability to shop for and prepare food → weight loss

Corticosteroid therapy → weight gain

23
Q

Surgical Therapy

A

Relieve severe pain
Improve function
Synovectomy-Removal of joint lining to improve movement
Total joint replacement (arthroplasty)-Common in elderly. How to prevent infection. Aseptic technique

24
Q

Nursing Assessment Subjective Data

A

Recent infections, presence of precipitating factors, pattern of remissions and exacerbations
Use of aspirin, NSAIDs, corticosteroids, DMARDs
Any joint surgery

Family history
Malaise
Ability to participate in therapeutic regimen
Impact on functional ability
Anorexia, weight loss
Dry mucous membranes of mouth and pharynx

Stiffness and joint swelling, muscle weakness, difficulty walking, fatigue
Paresthesia of hands and feet
Loss of sensation
Symmetric joint pain and aching that ↑ with motion or stress on joint

25
Q

Nursing Assessment Objective Data

A

Lymphadenopathy, fever
Keratoconjunctivitis- Cornea inflamed due to dryness
Rheumatoid nodules
Skin ulcers
Shiny, taut skin over joints
Peripheral edeRaynaud’s phenomenon- fingers and feet numb and cold
Distant heart sounds, murmurs
Dysrhythmias
Chronic bronchitis, tuberculosis
Histoplasmosis-fungal infection of lung, fibrosing alveolitis
Splenomegaly (Felty syndromemaSymmetric joint involvement
Swelling, erythema
Heat, tenderness
Deformities
Joint enlargement
Limitation of movement
Muscle contractures; atrophy

26
Q

Nursing Assessment Objective Data Diagnostic Findings

A

+ Rheumatoid factor
↑ESR
↑ WBCs in synovial fluid
X-ray findings
Joint space narrowing
Bony erosion
Deformity
Osteoporosis

27
Q

Nursing Diagnoses

A

Impaired physical mobility
Chronic pain
Disturbed body image

28
Q

Overall goals

A

Satisfactory pain management
Minimal loss of functional ability
Participate in therapeutic regimen
Maintain positive self-image
Perform self-care

29
Q

Nursing Implementation Health Promotion

A

Prevention not possible at this time
Early treatment to prevent further joint damage
Community education programs
Symptom recognition to promote early diagnosis and treatment
Arthrititis.org

30
Q

Nursing Implementation Acute Intervention

A

Primary goals in managing RA???? Decrease inflammation to improve pain management, maintain function tha tis left, prevent any other complications or deformities

Comprehensive program

Drug therapy

Balance of rest and activity- Sitting is better to protect joints

Joint protection

Heat and cold applications-cold is better for acute inflammation, heat is used for stiffness

Exercise- range of motion

Patient and caregiver teaching

Multidisciplinary team- PT, OT,& SS

Usually treated on an outpatient basis

Start with assessment

Physical

Psychosocial

Identify problems

Coordinate program for rehabilitation and education

Multidisciplinary team

31
Q

Nursing Implementation Acute Intervention Medications

A

Suppression of inflammation
NSAIDs
DMARDs
Biologic/targeted therapies
Patient teaching about medications
Timing of administration
Action and side effects
Compliance

32
Q

Nursing Implementation Acute Intervention Non drug relief for pain

A

Therapeutic heat and cold
Rest
Relaxation techniques
*Joint protection- soft splints to preserve joint function
Biofeedback- electrodes to the body to see how the body is responding*
Transcutaneous electrical stimulation
Hypnosis

33
Q

Nursing Implementation Acute Intervention Light weight splints

A

preserve joint function
Removed at regular intervals
Perform ROM exercises
Reapply as prescribed

Occupational therapist → additional self-help devices

34
Q

Nursing Implementation Acute Intervention Planning routine

A

Plan care around morning stiffness- go slowly to allow stiffness to decrease
To relieve joint stiffness and ↑ ability to perform ADLs
Sit or stand in warm shower
Sit in tub with warm towels around shoulders
Soak hands in warm water

35
Q

Etanercept (Enbrel) is prescribed for a patient with stage II rheumatoid arthritis. The nurse determines that the medication is effective if what is observed?

A

Decreased lymphocyte count
Absence of Rh factor in the blood
Decreased C-reactive protein (CRP)
Increased serum immunoglobulin G

Medical Surgical Exam 4 (11 decks)

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