Rheumatoid Arthritis/Test 4 Flashcards Preview

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Flashcards in Rheumatoid Arthritis/Test 4 Deck (38):

Rheumatoid Arthritis:

*a chronic, systemic diease
*inflammation of connective tissue in the diarthrodial (synovial) joints
*remission and exacerbation periods
-it affects all ethnic groups, occur at any time of life, women are affected more frequently than men.
*thought to be an autoimmune disease
*environment and familial factors may affect it.
*Smoking appears to be linked to both disease development and severity



*A triggering event starts the process-some report history of precipitating stressful event: Infection, work stress, physical exertion, childbirth, surgery, emotional upset
*formation of abnormal immunoglobulin G (IgG)
*Autoantibodies (Rheumatoid factor) form in response to IgG
*RF and IgG form immune complexes that deposit on synovial membranes or articular cartilage in joints
*As this process attracks more WBC's the process becomes chronic


4 Stages of RA

1- early- synovitis (inflammation)
2- moderate- pannus formation (granulation)
3- severe- fibrous ankylosis (adhesions, union of joint surface)
4- terminal- bony ankylosis (must prevent)



*early, progressive and late- correlate with stages
-generalized systemic


RA usually affects joints...

symmetrically (on both sides equally), may initially begin in a couple of joints only, and most frequently attacks the wrists, hands, elbows, shoulders, knees and ankles


Clinical Manifestations: Early/progressive/articular signs:

*onset insidious
*without treatment, joint destruction begins as early as the first year of disease


S/S of RA

-warmth, swelling, tenderness
*multiple symmetrical joint involvement
*joint stiffness after periods of inactivity
*Morning stiffness
*Joint pain, stiffness, limitation of motion
*joint pain with motion
*difficulty grasping objects


Later Articular Signs RA:

*color changes of digits (bluish, rubor, pallor)
*decreased joint mobility
*Contracture (flexion usually)
*subluxation (a partial or incomplete dislocation)
*Increasing pain
*Rheumatoid nodules
*Deformity and disability -swan neck- boutonniere


Generalized Systemic Signs: Early-

(May precede the onset of arthritic complaints)- non-specific manifestations- fatigue, anorexia, weight loss, generalized stiffness


Generalize systemic signs: late-

*muscle weakness and atrophy


Siogren's ("Show Grins")

*Diminished lacrimal and salivary gland secretion


Felty Sydrome:

*Inflammatory eye disorders


Other Systemic Signs

*Burning, gritty, itchy eyes
*Pulmonary disease
*Blood dyscrasias


Complications of RA:

*Without treatment, joint destruction begins as early as the first year of the disease
*Flexion contractures and hand deformities
*Nodular myositis and muscle fiber degeneration (pain)
*Cataract development and loss of vision
*Rheumatoid nodule ulceration
*nodules on vocal cords


Cardiopulmonary effects:

*pleural effusion
*pericardial effusion and cardiomyopathy
*Carpal tunnel syndrome (neuromuscular involvement)


Diagnostic studies- 4 of 7 s/s

*Morning stiffness- greater than one hour and lasting at least 6 weeks
*Symmetric joint swelling
*Swelling in 3 or more joints
*Swelling in hand joints
*Rheumatoid nodules
*Erosions or decalcification seen on hand xray
*Presence of serum RF- 80% of cases


Other diagnostics

*Synovial tissue biopsy-inflammatory changes



*anemia is common
*mild leukocytosis
*elevated rate (remember the inflammation process)
*Positive C-reactive protein (during the acute phase)
*Positive Antinucleic antibody (ANA)



*not specifically diagnostic
*may show joint space narrowing malalignment, ankylosis
*Erosion of articular surface
*Dislocation or subluxation



*increased turbidity and decreased viscosity of synovial fluid
*Presence of immune complexes and WBC's


Outcomes for RA patients:

*Reduction of inflammation
*Satisfactory pain relief
*Maintain functional abilities
*Symptomatic relief
*Compliance with multimodality therapy
*Cope with chronic disease impact on lifestyle
*Prevent complications


Interdisciplinary approach:

*Joint protection
*Heat (usually) and cold application
*Complementary and alternative therapy


Joint Protection:

-Assistive devices for twisting motion: i.e. jar lid
-moderately firm mattress
-avoid flexion
-firm pillow
-no pillow under knees


*Maintain joint motion and mobility

-alternate rest/activity
-exercise to reduce stress (ROM)
-splints and braces tostabilize, support and protect a joint-mechanically correct a dysfunction



-purpose to reduce or prevent swelling
-reduce pain and relieves stiffness



-increase iron for anemia
-calcium and vitamin D: reduces bone reabsorption
-adequate calories and balance nutrition to prevent fatigue and increase energy
-fish oil; decreases prostaglandins, leukotrienes, and cytokines that cause inflammation


Complementary and alternative therapy:

-herbal products
-movement therapies


Heath and cold applications can help

relieve stiffness, pain and muscle spasm. Application of ice is especially beneficial during periods of disease exacerbation, whereas moist heat appears to offer better relief of chronic stiffness. The treatment modality should be selected according to disease severity, ease of application, and cost. Superficial heat sources such as heating pads, moist hot packs, paraffin baths, whirlpool baths, and warm baths or showers can relieve stiffness to allow participation in therapeutic exercises. Plastic bags of frozen vegetables, peas or corn, which can easily mold around the shoulder, wrist, or knees are an easy home treatment. The pt can also use ice cubes or small paper cups of frozen water to massage proximal or distal to a painful joint. Heat and cold can be used as often as desired; however the heat application should not exceed 20 minutes at one time, and the cold application should not exceed 15 to 20 minutes at one time. Alert the pt. to the possibility of a burn, and to avoid use of a heat producing cream i.e., capsaicin, with another external heat device.


Anti-inflammatory Drugs:

-modify the inflammatory process by inhibiting the prostaglandin
-does not prevent bone erosion


Cox 2 inhibitors (NSAIDs but different classification)

-less potential for SE
-controversy: possible effects on the heart


DMARDS- disease modifying anti-rheumatic drugs

**inhibits DNA, RNA protein synthesis
*Methotrexate (gold standard)
*SE as serious NSAIDs- monitor renal and liver labs
*Starting earlier now for- less functional disability, less pain, joint tenderness, swelling
*Most are expensive



*decrease inflammation
*Intraarticular injections


Biologic agents:

-very expensive cost of $17 to 25,000
-stops the diease process (binds TNF)
-enbriel is given SQ and the patient can self administer if taught



Plaquenil (hydroxychloroquine)


Biologic Therapy

-Enebrel (etanercept) sub q once weekly, Remicade (infliximab) IV every 2 months after 3 initial injections, Kineret (anakinra) sub q daily



Minocin (minocycline)


Patient Education:

*importance of rest-activity balance
*Work simplification and use of correct body mechanics
*Safety measures in work and house environment
*exercise program and use of splints
*maintaining ADLs
*Well fitted shoes
*Avoid flexed positions
*Use assistive devices
*Sensible weight loss
*Fall prevention
*Stress management
*Energy conservation measures
*support groups


Gerontologic Considerations:

*high incidence of OA expected in older adults often keeps the health care provider from considering the presence of other types of arthritis
*Age alone causes changes in serologic profiles, making interruption of lab values such as RF and ESR more difficult
*Polypharmacy in the older adult can result in iatrogenic arthritis
*Nonorganic musculoskeletal pain syndromes and weakness may be related to depressive reactions and physical inactivity.
*Diseases such as SLE, which commonly occur in younger adults, can develop in a milder form in older adults
*Increased risk for drug toxicity (after dosing)
*Skeletal effects of corticosteroid therapy