Rheumatoid

Arthritis
Presented By: John Winston A. Baje
Anatomy and
Physiology
 What is
rheumatoid
arthritis?
+Key Facts

• Chronic inflammatory disorder that most typically

affects the small joints
• An autoimmune disorder of unknown origin
• A systemic disease
• Two-three times more common in women than men
• Can occur at any age, but generally occurs in ages
between 40-60 years old
• In most cases, symptoms occur symmetrically
• About 1% of the world’s population is affected by RA
• Formation of granulation tissue filled with inflammatory
cells at the edges of the synovial lining (Pannus
formation)
 Signs and symptoms
• Joint pain
• Joint swelling
• Joints that are tender to the touch
• Red and puffy hands
• Firm bumps of tissue under the skin on your
arms (rheumatoid nodules)
• Fatigue
• Morning stiffness that may last for hours
• Fever
• Weight loss
 Symptoms may come and go
• Rheumatoid arthritis signs and symptoms may
vary in severity and may even come and go.

• Periods of increased disease activity — called

flare-ups or flares — alternate with periods of
relative remission, during which the swelling,
pain, difficulty sleeping and weakness fade or
disappear.
 Factors that may increase your risk of
rheumatoid arthritis include:
• Sex. 

• Age. 

• Family history. If a member of your family has rheumatoid

arthritis, you may have an increased risk of the disease. Doctors
don't believe you can directly inherit rheumatoid arthritis.
Instead, it's believed that you can inherit a predisposition to
rheumatoid arthritis.

• Smoking. 
Pathophysiology
 Predisposing Precipitating
factors: factors:
• Sex (two-three times • Environmental
more common in exposure
women than men)
• Age (can occur at
any age but most
commonly begin at
ages 40-60 years
old )
• Family history (If a
member of your
family has
rheumatoid arthritis,
you may have an
increased risk of the
disease).
• Smoking
 Presentation of antigen to the T-cells

T-cells activates the B-cells to release IgE

antibodies

IgE antibodies sit on the surface of the mast cells

and trigger the release of chemical mediators.
 Mast cells release chemical mediators (cytokines,
bradykinin, and prostaglandins) into the surrounding
tissues (synovium)

Cell proliferation in the synovium causing inflammation

(synovitis)

• Swelling in small joints associated

Early and aggressive treatment with with pain, stiffness and fatigue
anti-inflammatory and anti-rheumatic
drugs.

Proliferation of newly formed synovial tissue infiltrated with

inflammatory cells (Pannus formation)
Complete joint destruction
 Rheumatologists also classsify the
functional status of persons with RA :
• Class I: completely able to perform usual activities of daily living

• Class II: able to perform usual self-care and work activities but
limited in activities outside of work (such as playing sports,
household chores)
 
• Class II: able to perform usual self-care activities but limited in
work and other activities
 
• Class IV: limited in ability to perform usual self-care, work, and
other activities
Laboratory exams:
 Blood tests:
• Decreased in hematocrit can be seen on patient having chronic
inflammtion.

• Normal values: Men 42%-52%, Women 35%-37%

 Blood tests:
• Tends to have elevated erythrocyte sedimentation rate (ESR).

• An increase indicates rising inflammation, resulting in clustering

of RBCs, which make them heavier than normal. The higher the
ESR, the greater the inflammatory activity.

• Normal values: Men 0-15 mm/hour, women 0-25 mm/hour

 Blood tests:
• Presence of Rheumatoid factor (RF, a non-specific antibody). A
negative RF does not rule out RA; rather, the arthritis is
called sero-negative. This is the case in about 15% of patients.
During the first year of illness, rheumatoid factor is more likely to
be negative with some individuals converting to sero-positive
status over time.
 Blood tests:
• Presence of the anti-citrullinated protein antibodies (ACPAs) or
anti-CCP. Like RF, these tests are positive in only a proportion
(67%) of all RA cases, but are rarely positive if RA is not present,
giving it a specificity of around 95%. As with RF, there is
evidence for ACPAs being present in many cases even before
onset of clinical disease.
 Arthrocentesis
• A sterile needle and syringe are used to drain joint fluid out of
the joint for study in the laboratory.

• Analysis of the joint fluid in the laboratory can help to exclude

other causes of arthritis. Arthrocentesis can also be helpful in
relieving joint swelling and pain.

• Occasionally, cortisone medications are injected into the joint

during the arthrocentesis in order to rapidly relieve joint
inflammation and further reduce symptoms.
 Blood tests:
• C – reactive protein test (CRP) shows presence of abnormal
glycoprotein due to inflammatory process.

• Positive reading indicates active inflammation

• Normal values: < 1 mg/dL

 X-rays:
• Helps tract the progression of rheumatoid arthritis in your joints
over time.
 Medical and surgical
management:
• There is no cure for rheumatoid arthritis.

• Medications can reduce inflammation in your joints in order to

relieve pain and prevent or slow joint damage.

• Occupational and physical therapy can help you protect your

joints

• If your joints are severely damaged by RA, surgery maybe

necessary.
 The goal of the treatment:
• The goal of treatment in rheumatoid arthritis is to
reduce joint inflammation and pain, maximize joint
function, and prevent joint destruction and deformity
Pharmacologic
management:
Non-steroidal anti-inflammatory
drugs (NSAIDs)
 Steroids
• Corticosteroid medications, such as prednisone and
methylprednisolone (Medrol), reduce inflammation and pain and
slow joint damage.

• Side effects may include easy bruising, thinning of bones,

cataracts, weight gain, a round face and diabetes.

• Doctors often prescribe a corticosteroid to relieve acute

symptoms, with the goal of gradually tapering off the medication.
 Disease-modifying anti-
rheumatic 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 (Rheumatrex, Trexall),

leflunomide (Arava), hydroxychloroquine (Plaquenil),
sulfasalazine (Azulfidine) and minocycline (Dynacin, Minocin).

• Side effects vary but may include liver damage, bone marrow
suppression and severe lung infections.
 Immunosupressants:
• These medications act to tame your immune system, which is
out of control in rheumatoid arthritis.

• Examples include azathioprine (Imuran, Azasan), cyclosporine

(Neoral, Sandimmune, Gengraf) and cyclophosphamide
(Cytoxan).

• These medications can increase your susceptibility to infection.

 TNF-alpha inhibitors:
• Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory
substance produced by your body.

• TNF-alpha inhibitors can help reduce pain, morning stiffness,

and tender or swollen joints — usually within one or two weeks
after treatment begins.

• Examples include etanercept (Enbrel), infliximab (Remicade)

and adalimumab (Humira).

• Potential side effects include injection site irritation, congestive

heart failure, blood disorders, lymphoma, demyelinating
diseases and increased risk of infection.
 Surgical
interventions:
 Total joint replacement
(arthroplasty):
• During joint replacement surgery, your surgeon removes the
damaged parts of your joint and inserts a prosthesis made of
metal and plastic.
 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.
 Removal of the joint lining
(synovectomy)

• If the lining around your joint (synovium) is inflamed and causing

pain, your surgeon may recommend removing the lining of the
joint.
 Joint fusion (arthrodesis):

• 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.
 Therapy:
• An occupational therapist can help you find different ways to
approach everyday tasks in order to take stress off your painful
joint .

• For instance, if your fingers are sore, pick up an object using

your forearms. Lean into a glass door to force it open, rather
than pushing on the door with sore arms.
 Therapy:
• Assistive devices can make it easier to go about your day
without stressing your painful joints. For instance, using specially
designed gripping and grabbing tools may make it easier to work
in the kitchen if you have pain in your fingers. Try a cane to help
you get around.

• Your doctor or occupational therapist may have ideas about

what sorts of assistive devices may be helpful to you. Catalogs
and medical supply stores also may be places to look for ideas.
 Exercise regularly
• If you're just getting started, begin by taking a walk. Try
swimming or gentle water aerobics.

• Avoid exercising tender, injured or severely inflamed joints. If

you feel new joint pain, stop. New pain that lasts more than two
hours after you exercise probably means you've overdone it. If
pain persists for more than a few days, call your doctor.
 Apply heat or cold
• Heat can help ease your pain and relax tense, painful muscles.
One of the easiest and most effective ways to apply heat is to
take a hot shower or bath for 15 minutes. Other options include
using a hot pack or an electric heating pad set on its lowest
setting.

• Cold may dull the sensation of pain. Cold also has a numbing
effect and decreases muscle spasms. Don't use cold treatments
if you have poor circulation or numbness. Techniques may
include using cold packs, soaking the affected joints in cold
water and ice massage.

• Many people with rheumatoid arthritis find relief by soaking their

aching joints in warm water for four minutes and then in cool
water for a minute. Repeat the cycle for a half-hour, ending with
a warm-water soak.
 Relaxation:

• Find ways to cope with pain by reducing stress in your life.

• Techniques such as hypnosis, guided imagery, deep breathing

and muscle relaxation can all be used to control pain.
Nursing Care Plan:
 Cues Nursing Objective Intervention Rationale
diagnosis

Subjective: Acute pain Within 30- Independent:

“nitukar na pod related to minute-  Perform comprehensive assessment  To assess
akong rheuma sir. accumulation of nursing of pain including location, etiology/precipitating
Sakit kaayo” as excess fluid in intervention, characteristics, onset/duration, contributory factors and for
verbalized by the the synovium the client will frequency, quality and severity (pain baseline data for evaluation
client. secondary to be able to scale) and precipitating/aggravating purposes.
With pain scale of inflammatory demonstrate factors  To provide non-pharmacologic
9/10 process as and verbalize  Provide variety of comfort measure: management of pain
evidenced by relief or at • application of heat or cold
guarding/protec least • massage, position changes, rest
Objective: tive behavior reduction of • Foam mattress, supportive pillows
and client’s pain from • relaxation techniques and
 Guarding/prot verbalization of pain scale: diversional activities
ective pain with pain 9/10  To promote client’s rest and
behavior scale: 9/10  Promote quite and restful environment. comfort.
 Joint swelling
 Joints that are Dependent:
red and  To reduce inflammation and
tender to  Administer NSAIDs as ordered. relieve pain
touch • To reduce inflammation and to
 Limited  Administer DMARDs as ordered. slow the progression of joint
movement damage.
 Joint stiffness  To gather additional baseline
 Do laboratory exams as ordered objective information of the
(CBC, ESR, CRP, Rheumatoid factor client’s condition for
and radiologic studies) evaluation.
 Prognosis:

• The course of the disease varies greatly. Some people have

mild short-term symptoms, but in most the disease is
progressive for life.

• Around 20%-30% will have subcutaneous nodules (known as

rheumatoid nodules); this is associated with a poor prognosis.
 Prognosis:
• A lifespan reduction of 5 to 10 years.

• According to the UK's National Rheumatoid Arthritis Society,

"Young age at onset, long disease duration, the concurrent
presence of other health problems (called co-morbidity), and
characteristics of severe RA—such as poor functional ability or
overall health status, a lot of joint damage on x-rays, the need
for hospitalization or involvement of organs other than the joints
—have been shown to associate with higher mortality“. 

• Positive responses to treatment may indicate a better prognosis.

 Journal

Regular alcohol consumption may

reduce the severity of rheumatoid
arthritis, according to the study
conducted by researchers from the
University of Sheffield, England
 Journal

 "We found that patients who had drunk alcohol

most frequently had symptoms that were less
severe than those who had never drunk alcohol
or only drank it infrequently," lead author James
Maxwell said.
 Journal

 Researchers questioned 873 people with RA

and 1,004 people who did not have the disease
about their alcohol consumption in the month
prior to the study. All participants then
underwent X-ray and blood screening to
determine the severity of inflammation in their
bodies. Pain, swelling and disability were also
measured.
 Journal

 The researchers found that people who drank on

more than 10 days per month were four times less
likely to develop the condition than those who did
not drink. Likewise, people with RA who drank
more regularly suffered less inflammation, joint
pain, swelling and disability than those who drank
less often.
 None of the study participants consumed more
than the maximum recommended 10 drinks per
week.
 Journal

 It remains unclear what role alcohol might play in

preventing or alleviating the disease.

"There is some evidence to show that alcohol

suppresses the activity of the immune system, and
that this may influence the pathways by which RA
develops," Maxwell said. "Once someone has
developed [rheumatoid arthritis], it's possible that
the anti-inflammatory and analgesic effects of
alcohol may play a role in reducing the severity of
symptoms.
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