Autoimmune Disorders:Rheumatoid Arthritis, Osteoarthritis, &          Gouty Arthritis     Maria Carmela L. Domocmat, RN, M...
Rheumatic DisordersComprise autoimmune and inflammatorydisorders‘the primary crippling disease”Inflammation of jointPrimar...
What causes autoimmune disease?                   http://www.medscape.com/content/2000/00/40/87/408750/art-mrc4856.lymp.fi...
Reaction to SelfOccurs when the immune system sees “self”antigens as “nonself”may be due to genetic factors, infectious ag...
Reaction to Self~ 3.5 % of people have autoimmune diseases  On average, women are 2.7 times more likely to  develop these ...
Why does the immune system attack the body thatit’s supposed to protect? failure to recognize some cells as “self”    in r...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Rheumatoid Arthritis (RA)chronic systemic autoimmune disease - anti-self antibodies that react with the constant regions o...
Rheumatoid arthritis (RA) affects peripheraljoints and may cause destruction of both cartilageand bone. The disease affect...
TreatmentMaria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
ACR Clinical ClassificationCriteria for Rheumatoid Arthritisusing history, physical examination, laboratoryand radiographi...
ACR Clinical ClassificationCriteria for Rheumatoid Arthritis          Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
ACR Clinical Classification Criteria for Juvenile Rheumatoid ArthritisGENERAL CLASSa. Persistent arthritis of at least six...
ACR Classification Criteria for Determining Progression of    Rheumatoid Arthritis *These criteria describe either spontan...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3415/images/moreland/slide07.gif                          ...
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Initial Laboratory work-upComplete blood countComprehensive metabolic panelUrinalysisSedimentation RateRheumatoid FactorAn...
Chemistriesnormalwith the exception of a slight decrease in albuminand increase in total protein reflecting the chronicinf...
Hematologymild anemia with hematocrit values in the range of 30 - 34%   occurs in approximately 25 to 35% of patients   In...
Hematologywhite cell count                       platelet count  usually normal                          usually normal  c...
HematologyIncreased erythrocyte sedimentation rate (ESR)              Maria Carmela L. Domocmat, RN, MSN
Serology(+) RFRheumatoid factors  are autoantibodies directed against IgGA positive test for rheumatoid factor (RF)  patho...
Radiologyearly in the disease  show nothing other than soft tissue swelling.periarticular osteopenia may develop.With prog...
Clinical manifestations    Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
http://nobelprize.org/medicine/laureates/1996/illpres/implications.htmlMaria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Typical visible changesinclude ulnar deviation ofthe fingers at the MCPjoints, hyperextension orhyperflexion of the MCPand...
Extra-Articular DiseaseRheumatoid NodulesCardiopulmonary DiseaseOcular DiseaseNeurologic DiseaseFeltys SyndromeRheumatoid ...
Rheumatoid Nodulessubcutaneous nodule the most characteristic extra-articular lesion of the disease. occur in 20 to 30% of...
Rheumatoid Nodules               http://images.rheumatology.org/vi               ewphoto.php?imageId=3011201              ...
Rheumatoid Nodules                         Rheumatoid nodules                         commonly form near the              ...
Caplan’s Syndrome    Presence of rheumatoid nodules in lungs    pneumococcus (noted in among coal miners and    asbestos w...
Cardiopulmonary DiseaseThere are several pulmonary manifestations ofrheumatoid arthritis,including pleurisy with or withou...
Cardiopulmonary DiseaseOn pulmonary function testing,  there commonly is a restrictive ventilatory defect with  reduced lu...
Neurologic Diseasemost common - is a mild, primarily sensoryperipheral neuropathy, usually more marked in thelower extremi...
Neurologic DiseaseCervical myelopathy secondary to atlantoaxialsubluxation is an uncommon but particularlyworrisome compli...
Feltys Syndromeis characterized by  splenomegaly  leukopenia - predominantly granulocytopenia.rare complicationRecurrent b...
Rheumatoid Vasculitismost common clinical manifestations are smalldigital infarcts along the nailbeds.              Maria ...
Sjogrens Syndromea chronic inflammatory disorder characterized bylymphocytic infiltration of lacrimal and salivaryglands.l...
Criteria for Diagnosis of       Sjögrens SyndromeFour ormore ofthefollowingcriteriamust bepresent            Maria Carmela...
Ocular DiseaseKeratoconjunctivitis of Sjogrens syndrome is themost common ocular manifestation of rheumatoidarthritis.Sicc...
Keratoconjunctivitis, Sicca      Maria Carmela L. Domocmat, RN, MSN
PROGNOSIS      Maria Carmela L. Domocmat, RN, MSN
Disability is higher among patients withrheumatoid arthritis with 60% being unable towork 10 years after the onset of thei...
Patients at higher risk for shortened survival arethose with  systemic extra-articular involvement,  low functional capaci...
ACR Guidelines for MedicalManagement of Rheumatoid        Arthritis      (updated April, 2002)
Maria Carmela L. Domocmat, RN, MSN
http://rezidentiat.3x.ro/eng/pareng.files/image015.gif                                     Maria Carmela L. Domocmat, RN, ...
ManagementMaria Carmela L. Domocmat, RN, MSN
The goal of treatment now aims towardachieving thelowest possible level of arthritis disease activityand remission if poss...
Reduce pain and inflammationProtect Articular surface› Reduction of joint stressMaintain function› ROM exercises› Physical...
REDUCE PAIN ANDINFLAMMATION       Maria Carmela L. Domocmat, RN, MSN
Pharmacologic treatment1. Non-steroidal Anti-inflammatory Agents   (NSAIDs)2. Corticosteroids3. Disease Modifying Anti-rhe...
http://www.medscape.com/content/2004/00/48/77/487710/art-487710.fig9.jpg                                       Maria Carme...
NSAIDs and corticosteroidshave a short onset of action while DMARDs cantake several weeks or months to demonstrate aclinic...
NON-STEROIDAL ANTI-INFLAMMATORY AGENTS(NSAIDS)      Maria Carmela L. Domocmat, RN, MSN
NSAIDsmajor effect - reduce acute inflammation therebydecreasing pain and improving function.have mild to moderate analges...
OTC NSAIDsAspirinibuprofen (Advil ®, Motrin®, Nuprin ®)naproxen (Alleve®, Flanax)ketoprofen (Actron, Orudis KT)           ...
Aspirin - oldest drug of the non-steroidal class  but because of its high rate of GI toxicity, a narrow  window between to...
Prescription NSAIDs includemeloxicam (Mobic®),                    diclofenac (Cataflam®,etodolac (Lodine®),               ...
Maria Carmela L. Domocmat, RN, MSN
Drugs for Prevention NSAID-         Induced UlcersIf NSAID-induced ulcers are identified, thefollowing steps have been sug...
Drugs for Prevention NSAID-         Induced Ulcersproton-pump inhibitors (PPIs).  Can reduce NSAID-ulcer rates by as much ...
Drugs for Prevention NSAID-          Induced UlcersTry misoprostol or Arthrotec.   If other agents are inappropriate, miso...
L-arginine supplement  an amino acid found in health stores  may help protect against damage from NSAIDs.  an alternative ...
Topical NSAIDsdelivered in gels, creams, or patches are provingto reduce arthritic pain and pose less of a risk forgastroi...
$63.07Maria Carmela L. Domocmat, RN, MSN
NSAIDS: COX-2 inhibitorincludes COX-2 inhibitorsalso effective in controlling inflammation.Only one of these agents is cur...
or COX-2 medications            Maria Carmela L. Domocmat, RN, MSN
COX-2 inhibitors designed to decrease the gastrointestinal risk of NSAIDS, but concerns of possible increases in cardiovas...
CORTICOSTEROIDS      Maria Carmela L. Domocmat, RN, MSN
Corticosteroidsanti-inflammatory & immunoregulatory activity.PO, IV, IM or can be injected directly into the joint.useful ...
Corticosteroids Maria Carmela L. Domocmat, RN, MSN
Corticosteroidsalso useful as chronic adjunctive therapy inpatients with severe disease that is not wellcontrolled on NSAI...
cushingoid appearance    Maria Carmela L. Domocmat, RN, MSN
Prevent osteoporosis due to steroid               useadequate calcium and vitamin D supplementationBisphosphonates  alendr...
Intra-articular corticosteroids  (e.g., triamcinolone or  methylprednisolone and others) are effective for controlling a l...
http://www.mayoclinicproceedings.com/conMaria Carmela L. Domocmat, RN, MSN    tent/84/9/831.full
DISEASE MODIFYING ANTI-RHEUMATIC DRUGS(DMARDS)       Maria Carmela L. Domocmat, RN, MSN
Disease Modifying Anti-rheumatic       Drugs (DMARDs)Can alter the disease course and improveradiographic outcomes.DMARDs ...
DMARDsMethotrexate (Rheumatrex®, Trexall®)Hydroxychloroquine (Plaquenil ®)Sulfasalazine (Azulfidine®)Leflunomide (Arava®)T...
DMARDsB cell Depleting Agents  rituximab (Rituxan®)Interleukin-1 (IL-1) Receptor Antagonist Therapy  anakinra (Kineret®)In...
Methotrexatethe first-line DMARD agentHas rapid onset of action at therapeutic doses (6-8 weeks)good efficacyfavorable tox...
http://www.muabannhadat123.com/forum/showthread.php?p=3477Maria Carmela L. Domocmat, RN, MSN
Hydroxychloroquinean antimalarial drugrelatively safe and well-tolerated agent for thetreatment of rheumatoid arthritis.ha...
Hydroxychloroquineis sometimes combined with methotrexate foradditive benefits for signs and symptoms or aspart of a regim...
Sulfasalazine Azulfidine®effectiveness - somewhat less thanthat methotrexate,reduce signs and symptoms andslow radiographi...
Leflunomide (Arava®)efficacy is similar to methotrexate in terms of signsand symptomsviable alternative - failed or are in...
Tumor necrosis factor (TNF)           inhibitorsTumor necrosis factor alpha (TNF)  is a pro-inflammatory cytokine produced...
TNF antagonistsfirst of the biological DMARDS to be approved forthe treatment of RA andhave also been referred to as biolo...
TNFs or Biological Response       Modifiers (BRMs)Etanercept (Enbrel®)Infliximab(Remicade®)Adalimumab (Humira®)           ...
Etanercept (Enbrel®)Etanercept is effective in reducing the signs andsymptoms of RA, as well as in slowing or haltingradio...
Infliximab(Remicade®)Infliximab, in combination with methotrexate, isapproved for the treatment of RA, and for thetreatmen...
Adalimumab (Humira®)Adalimumab is a fully human anti-TNF monoclonalantibody with high specificity for TNF.             Mar...
Anakinra (Kineret™)a human recombinant IL-1 receptor antagonist (hurIL-1ra)can be used alone or in combination withDMARDs ...
T-cell Costimulatory blockadeAbatacept (Orencia®)first of a class of agents known as T-cellcostimulatory blockers.interfer...
Intramuscular GoldMyochrysine® and Solganal®IMhave been replaced byMethotrexate and other DMARDSas the preferred agents to...
Plasmapheresis Maria Carmela L. Domocmat, RN, MSN
Alternative treatments  glucosamine sulfate  chondroitin sulfateare   are dietary supplements usually taken in pill form t...
NURSING MANAGEMENT      Maria Carmela L. Domocmat, RN, MSN
Chronic pain r/t inflammation and swelling frompressure on surrounding tissues, joint deformityand joint destruction  Teac...
Promote comfort withnonpharmacologic measures       Maria Carmela L. Domocmat, RN, MSN
Manage stiffness Maria Carmela L. Domocmat, RN, MSN
Promote sleep and restEncourage to sleep at least 8 hrs at night, takedaily napsPromote a quiet envtProvide warm beverages...
REDUCTION OF JOINTSTRESS       Maria Carmela L. Domocmat, RN, MSN
Reduction of joint stressBecause obesity stresses the musculoskeletalsystem, ideal body weight should be achieved andmaint...
Readiness for enhanced self-care r/t complexmedication schedules, high risk of S/E of meds,health maintenance, and self-ca...
Self-careUse china or heavy plastic cup with handlewhich is easier to manipulate rather thanstyrofoam or paper cup which m...
Reduction of joint stressurge to maintain a modest level of activity toprevent joint laxity and muscular atrophy.Splinting...
Assistive devices      Computer Keyboard Aid                                      Arthritics Pen Maria Carmela L. Domocmat...
Phone & Cup Holder withHook and Loop Strap               Maria Carmela L. Domocmat, RN, MSN
Arthritis in your hands                       causes your finger joints                       and knuckles to become      ...
Instead, use a grasp that                       aligns your knuckles                       evenly along the handle        ...
For tasks that require you to                       pinch objects tightly, look for                       assistive device...
Use assistive devices tohelp you open jars. Thisspares your fingers fromthe twisting motionrequired to open a jar.        ...
To protect your finger joints,avoid tightly pinching withyour fingers.For example, use a buttonaid to help you grasp andfa...
Promote balanced dietGood oral hygiene b4 and after mealsSmall, frequent feedingsHigh-caloric snacksIf with xerostamia – m...
Promote decision-makingExercise healthy control over the disease  Client should be able to verbalize cause of illness  Edu...
Promote hopeAvoid false reassuranceHelp set realistic goalsPraise for accomplishments (no matter howsmall)Active listening...
Promote copingThe client would be able to integrate diseaseinto the demands of daily livingSign that the client has health...
Signs of less adaptive strategies  Avoidance strategies – ex: denial  Excessive sleeping  Other passive behaviors  Depress...
FATIGUE          Maria Carmela L. Domocmat, RN, MSN
Management of Fatigue:For muscle atrophy – aggressive PT tostrengthen muscle and prevent further atrophy             Maria...
Management of FatiguePrinciples of energy conservation  Pacing activities- do not plan too much activity for one  day  All...
BODY IMAGE DISTURBANCE      Maria Carmela L. Domocmat, RN, MSN
Enhance body imageBody image may be affected by both the diseaseprocess and drug therapy  Ulnar deviation, swan-neck defor...
Let the client wear own clothes rather than thehosp gown, brush own hair, use make-up ifdesiredUse colored hair accessorie...
SURGICAL INTERVENTIONS       Maria Carmela L. Domocmat, RN, MSN
Surgical interventionsTendon transfer and osteotomySynovectomyArthrodesisJoint arthroplasty or replacement             Mar...
Tendon transfer and osteotomyNodules or benign bony tumors (exostoses) –surgically removed and flexion contracturessurgica...
SynovectomySurgical removal of synovia – elbow, wrist, fingers,knees               Maria Carmela L. Domocmat, RN, MSN
Synovectomyordinarily not recommended for patients withrheumatoid arthritis, primarily because relief isonly transient.syn...
SynovectomyMaria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
ArthrodesisOperation that produce bony fusion of jointused for clients with bone loss after jointinfection , tumors, muscu...
Joint arthroplasty or replacement particularly of the knee, hip, wrist, and elbow, are highly successful. Arthroplasty of ...
Hip Replacement         Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Surgical intervention   Maria Carmela L. Domocmat, RN, MSN
Surgical interventionOther operations include  release of nerve entrapments (e.g., carpal tunnel  syndrome)  arthroscopic ...
Complementary/ Alternative          therapiesPain relief – hypnosis, acupuncture, magnetGood nutrition  Omega-3 fatty acid...
Complementary/ Alternative        therapiesAntioxidant vitamins (A,C, E) to help maintain normalfunction of the immune sys...
Osteoarthritisassociated with theaging process andcan affect any joint.The cartilage of theaffected joint isgradually worn...
WHAT’S THE DIFFERENCEBETWEEN RA AND OA?       Maria Carmela L. Domocmat, RN, MSN
Maria Carmela L. Domocmat, RN, MSN
Osteoarthritis is a deterioration of cartilage andovergrowth of bone often due to "wear and tear."Rheumatoid arthritis is ...
Known as the “wear-and-tear” kind of arthritisa chronic condition characterized by thebreakdown of the joint’s cartilage. ...
AKA degenerative joint disease, ostoarthrosis, hypertrophic arthritis degenerative arthritis.               Maria Carmela ...
stages of osteoarthritisCartilage loses elasticity and is more easilydamaged by injury or use.Wear of cartilage causes cha...
stages of osteoarthritisBits of bone or cartilage float loosely in the jointspace.The joint lining, or the synovium, becom...
The main problem inknee OA is degenerationof the articular cartilage.Articular cartilage is thesmooth lining that coversth...
The articular cartilage is                      kept slippery by joint fluid                      made by the joint lining...
An important substance                      present in articular                      cartilage and synovial              ...
When the articularcartilage degenerates, orwears away, the boneunderneath is uncoveredand rubs against bone.Small outgrowt...
Changes in the cartilage and bones of the jointcan lead to pain, stiffness and use limitations.Deterioration of cartilage ...
Maria Carmela L. Domocmat, RN, MSN
Causes and Risk factorsthere is no single known cause of osteoarthritis(OA),there are several risk factors that should bec...
Maria Carmela L. Domocmat, RN, MSN
TreatmentAcetaminophenNonsteroidal anti-inflammatory drugs (NSAIDs) orCOX-2 medicationsCapsaicinTramadolNarcotic pain reli...
Acetaminophen Tylenol, Anacin-3, Panadal, Phenaphen,Valadol, and others)for mild to moderate osteoarthritis.usually the fi...
Nonsteroidal anti-inflammatory       drugs (NSAIDs)for moderate to severe arthritic pain.OTC NSAIDsPrescription NSAIDs inc...
Drugs for Prevention NSAID-         Induced UlcersIf NSAID-induced ulcers are identified switch toalternative pain relieve...
Topical NSAIDs           $63.07 Maria Carmela L. Domocmat, RN, MSN
Capsaicin (Zostrix)is an ointment prepared from the activeingredient in hot chili peppers that has beenhelpful for relievi...
SALONPAS PAIN PATCH WITH CAPSAICIN          Maria Carmela L. Domocmat, RN, MSN
Tramadol (Ultram)is a pain reliever that has some properties thatare similar to narcotics.not as addictive, however, and m...
Maria Carmela L. Domocmat, RN, MSN
Narcotic pain relieversoxycodone, oxymorphone, or morphinemay be necessary for severe pain that does notrespond to less po...
http://differncebetween.infoloommedia.netdna-cdn.com/wp-content/uploads/2009/11/oxycodone.png                             ...
ManagementSame with RA           Maria Carmela L. Domocmat, RN, MSN
Let’s Exercisehttp://www.medicinenet.com/rheumatoid_arthritis_exercises_slideshow/article.htm             Maria Carmela L....
Maria Carmela L. Domocmat, RN, MSN
Gouty arthritisis a disease characterized by an abnormalmetabolism of uric acid, resulting in an excess ofuric acid in the...
Gouty arthritis2 major types  Primary  Secondary                Maria Carmela L. Domocmat, RN, MSN
Gouty arthritisPrimary  Inherited X-lined trait  Caused by several inborn errors of purine metabolism    Uric acid- is the...
Gouty arthritisSecondary  Hyperuricemia     Excessive uric acid in blood casued by anoterh disease  Affects all ages     R...
Four Stages Of Gouty ArthritisAsymptomatic HyperuricemiaAcute Gout / Acute Gouty ArthritisInterval / IntercriticalChronic ...
Four Stages Of Gouty ArthritisAsymptomatic Hyperuricemia:  Asypmptomatic but with elevated blood uric acid  levels Serum u...
Four Stages Of Gouty ArthritisAcute Gout / Acute Gouty Arthritis  hyperuricemia has caused deposits of uric acid  crystals...
Maria Carmela L. Domocmat, RN, MSN
http://cdn.nursingcrib.com/wp-content/uploads/gouty-arthritis.jpg                                   Maria Carmela L. Domoc...
http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3689/images/cohen/slide019.gif                            ...
Four Stages Of Gouty ArthritisInterval / Intercritical  the periods between acute gouty attacks – may be  months or years ...
Tophi        Tophi – deposits of sodium urate crystals               May occur anywhere; common in outer earhttp://www.hop...
http://www.cdaarthritis.com/images_slides/40_gout_b_toe1_360.jpg        Maria Carmela L. Domocmat, RN, MSN
http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3689/images/cohen/slide019.gif                     Maria C...
http://img.medscape.com/slide/migr                                     ated/editorial/cmecircle/2004/3689/i               ...
http://msnbcmedia1.msn.com/i/ms                                     nbc/Components/Interactives/Healt                     ...
http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3689/images/cohen/slide019.gif            Maria Carmela L....
Dx testsSynovial fluid analysis (shows uric acid crystals)Uric acid - bloodJoint x-rays (may be normal)Synovial biopsyUric...
Maria Carmela L. Domocmat, RN, MSN
ManagementDrug therapyDiet therapy               Maria Carmela L. Domocmat, RN, MSN
ManagementDrug therapy  acute gouty arthritis – inflammation subsides  spontaneously within 3 to 5 days  But if cannot tol...
ManagementDrug therapy  Chronic or repeated acute episodes     Allopurinol (Zyloprim)        A xanthine oxidase inhibitor ...
Maria Carmela L. Domocmat, RN, MSN
Febuxostat (Uloric)               first new medication developed specifically for the               control of gout in ove...
Maria Carmela L. Domocmat, RN, MSN
Management        Diet therapy               Avoid alcohol, anchovies, sardines, oils, herring,              organ meat (l...
Limit meat        Avoid fatty foods such as salad dressings, ice        cream, and fried foods.        Eat enough carbohyd...
http://s1.hubimg.com/u/1184832_f496.jpg                                          Maria Carmela L. Domocmat, RN, MSN
Avoid all forms of aspirin and diuretics – mayprecipitate attackExcessive physical or emotional stress- canexacerbate dise...
Prevention of kidney stone            formationIncrease fluid intake – prevent stone formation  Dilute urine and prevent s...
ComplicationsChronic gouty arthritisKidney stonesDeposits in the kidneys, leading to chronickidney failure             Mar...
Autoimmune disorders.RA, OA, Gout
Autoimmune disorders.RA, OA, Gout
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Autoimmune disorders, rheumatoid arthritis, osteoarthritis, gout, gouty arthritis

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Autoimmune disorders.RA, OA, Gout

  1. 1. Autoimmune Disorders:Rheumatoid Arthritis, Osteoarthritis, & Gouty Arthritis Maria Carmela L. Domocmat, RN, MSN Instructor, Curative and Rehabilitative Nursing Care II School of Nursing Northern Luzon Adventist College
  2. 2. Rheumatic DisordersComprise autoimmune and inflammatorydisorders‘the primary crippling disease”Inflammation of jointPrimary reason for work-related disabilityLeading cause of disability among 65 yrs oldand above Maria Carmela L. Domocmat, RN, MSN
  3. 3. What causes autoimmune disease? http://www.medscape.com/content/2000/00/40/87/408750/art-mrc4856.lymp.fig2.gif Certain variants or mutations in the MHC genes may result in abnormal MHCDomocmat, RN, MSN Maria Carmela L. proteins
  4. 4. Reaction to SelfOccurs when the immune system sees “self”antigens as “nonself”may be due to genetic factors, infectious agents,gender, and agethe autoimmune response results in tissuedamage Some damage occurs in only one or a few organs, in other cases it may be body-wide (systemic) Maria Carmela L. Domocmat, RN, MSN
  5. 5. Reaction to Self~ 3.5 % of people have autoimmune diseases On average, women are 2.7 times more likely to develop these diseases than menmost have no known cause or curetreatment is aimed at controlling symptoms Maria Carmela L. Domocmat, RN, MSN
  6. 6. Why does the immune system attack the body thatit’s supposed to protect? failure to recognize some cells as “self” in rheumatic fever, the streptococcus antigen is very similar to a protein in heart tissue, so the body mistakenly identifies heart tissues as foreign cells seen as foreign are attacked and destroyed may be only a few select cells or organs (organ-specific) – e.g., multiple sclerosis, juvenile diabetes, rheumatic fever may be systemic - e.g., systemic lupus erythematosus, rheumatoid arthritis Maria Carmela L. Domocmat, RN, MSN
  7. 7. Maria Carmela L. Domocmat, RN, MSN
  8. 8. Maria Carmela L. Domocmat, RN, MSN
  9. 9. Rheumatoid Arthritis (RA)chronic systemic autoimmune disease - anti-self antibodies that react with the constant regions of other antibodies (rheumatoid factor)onset of disease occurs most often between the ages of25-55 women are 3 times more likely to develop this than mensymptoms include weakness, fatigue, and joint paininfections, hormones and genetic factors may be involved X-ray shows severe arthritis affecting the joints and limiting mobility Maria Carmela L. Domocmat, RN, MSN
  10. 10. Rheumatoid arthritis (RA) affects peripheraljoints and may cause destruction of both cartilageand bone. The disease affects mainly individualscarrying the DR4 variant of MHC genes. Maria Carmela L. Domocmat, RN, MSN
  11. 11. TreatmentMaria Carmela L. Domocmat, RN, MSN
  12. 12. Maria Carmela L. Domocmat, RN, MSN
  13. 13. Maria Carmela L. Domocmat, RN, MSN
  14. 14. Maria Carmela L. Domocmat, RN, MSN
  15. 15. ACR Clinical ClassificationCriteria for Rheumatoid Arthritisusing history, physical examination, laboratoryand radiographic findings: Maria Carmela L. Domocmat, RN, MSN
  16. 16. ACR Clinical ClassificationCriteria for Rheumatoid Arthritis Maria Carmela L. Domocmat, RN, MSN
  17. 17. Maria Carmela L. Domocmat, RN, MSN
  18. 18. ACR Clinical Classification Criteria for Juvenile Rheumatoid ArthritisGENERAL CLASSa. Persistent arthritis of at least six weeks durationin one or more jointsb. Exclusion of other causes of arthritis (see list ofexclusions+)onset subtypes-determined by manifestationsduring the first six months of disease althoughmanifestations more closely resembling anothersubtype may appear later Maria Carmela L. Domocmat, RN, MSN
  19. 19. ACR Classification Criteria for Determining Progression of Rheumatoid Arthritis *These criteria describe either spontaneous remission or a state of drug-induced disease suppression.
  20. 20. Maria Carmela L. Domocmat, RN, MSN
  21. 21. Maria Carmela L. Domocmat, RN, MSN
  22. 22. http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3415/images/moreland/slide07.gif Maria Carmela L. Domocmat, RN, MSN
  23. 23. Maria Carmela L. Domocmat, RN, MSN
  24. 24. Maria Carmela L. Domocmat, RN, MSN
  25. 25. Maria Carmela L. Domocmat, RN, MSN
  26. 26. Maria Carmela L. Domocmat, RN, MSN
  27. 27. Initial Laboratory work-upComplete blood countComprehensive metabolic panelUrinalysisSedimentation RateRheumatoid FactorAnti-nuclear Antibody Maria Carmela L. Domocmat, RN, MSN
  28. 28. Chemistriesnormalwith the exception of a slight decrease in albuminand increase in total protein reflecting the chronicinflammatory process.Renal and liver function should be checked priorto instituting therapy. Maria Carmela L. Domocmat, RN, MSN
  29. 29. Hematologymild anemia with hematocrit values in the range of 30 - 34% occurs in approximately 25 to 35% of patients In most cases, the reduced red cell mass is caused by the anemia of chronic disease, a normocytic-normochromic process characterized by a low concentration of serum iron, a low serum iron-binding capacity, and a normal or increased serum ferritin concentration. occasionally true iron deficiency anemia can develop secondary to intercurrent blood loss often from gastrointestinal (GI) bleeding due to NSAIDS.Patients should be monitored closely for symptoms of GI bleeding andconsideration must also be given to other causes of GI blood loss suchas colonic lesions. Maria Carmela L. Domocmat, RN, MSN
  30. 30. Hematologywhite cell count platelet count usually normal usually normal can be mildly elevated but thrombocytosis secondary to occurs in response to inflammation. inflammation. Drug reactions and Feltys syndrome are rare causes of leukopenia or thrombocytopenia Maria Carmela L. Domocmat, RN, MSN
  31. 31. HematologyIncreased erythrocyte sedimentation rate (ESR) Maria Carmela L. Domocmat, RN, MSN
  32. 32. Serology(+) RFRheumatoid factors are autoantibodies directed against IgGA positive test for rheumatoid factor (RF) pathognomonic of rheumatoid arthritis Maria Carmela L. Domocmat, RN, MSN
  33. 33. Radiologyearly in the disease show nothing other than soft tissue swelling.periarticular osteopenia may develop.With progression of disease narrowing of the joint space is caused by loss of cartilage, and juxta-articular erosions appear, generally at the point of attachment of the synovium.end-stage disease large cystic erosions of bone may be seen. Bony proliferation may occur because of degenerative changes that follow inflammation. Maria Carmela L. Domocmat, RN, MSN
  34. 34. Clinical manifestations Maria Carmela L. Domocmat, RN, MSN
  35. 35. Maria Carmela L. Domocmat, RN, MSN
  36. 36. http://nobelprize.org/medicine/laureates/1996/illpres/implications.htmlMaria Carmela L. Domocmat, RN, MSN
  37. 37. Maria Carmela L. Domocmat, RN, MSN
  38. 38. Maria Carmela L. Domocmat, RN, MSN
  39. 39. Typical visible changesinclude ulnar deviation ofthe fingers at the MCPjoints, hyperextension orhyperflexion of the MCPand PIP joints, flexioncontractures of theelbows, and subluxationof the carpal bones andtoes (cocked -up). Maria Carmela L. Domocmat, RN, MSN
  40. 40. Extra-Articular DiseaseRheumatoid NodulesCardiopulmonary DiseaseOcular DiseaseNeurologic DiseaseFeltys SyndromeRheumatoid VasculitisSjogrens Syndrome Maria Carmela L. Domocmat, RN, MSN
  41. 41. Rheumatoid Nodulessubcutaneous nodule the most characteristic extra-articular lesion of the disease. occur in 20 to 30% of cases, almost exclusively in seropositive patients. located most commonly on the extensor surfaces of the arms and elbows but are also prone to develop at pressure points on the feet and knees. Maria Carmela L. Domocmat, RN, MSN
  42. 42. Rheumatoid Nodules http://images.rheumatology.org/vi ewphoto.php?imageId=3011201 &albumId=75692 Maria Carmela L. Domocmat, RN, MSN
  43. 43. Rheumatoid Nodules Rheumatoid nodules commonly form near the extensor surface of the elbow. They can be fixed to the underlying periosteum or can be freely mobile. Maria Carmela L. Domocmat, RN, MSN
  44. 44. Caplan’s Syndrome Presence of rheumatoid nodules in lungs pneumococcus (noted in among coal miners and asbestos workers)http://images.rheumatology.org/image_dir/album75692/md_99-05-0096_1.tif.jpg Maria Carmela L. Domocmat, RN, MSN
  45. 45. Cardiopulmonary DiseaseThere are several pulmonary manifestations ofrheumatoid arthritis,including pleurisy with or without effusion,intrapulmonary nodules,rheumatoid pneumoconiosis (Caplans syndrome),diffuse interstitial fibrosis, and rarely,bronchiolitis obliterans pneumothorax. Maria Carmela L. Domocmat, RN, MSN
  46. 46. Cardiopulmonary DiseaseOn pulmonary function testing, there commonly is a restrictive ventilatory defect with reduced lung volumes and a decreased diffusing capacity for carbon monoxide.Although mostly asymptomatic, of greatestconcern is distinguishing these manifestationsfrom infection and tumor.Pericarditis is the most common cardiacmanifestation. Maria Carmela L. Domocmat, RN, MSN
  47. 47. Neurologic Diseasemost common - is a mild, primarily sensoryperipheral neuropathy, usually more marked in thelower extremities.Entrapment neuropathies (e.g., carpal tunnelsyndrome and tarsal tunnel syndrome) sometimesoccur because of compression of a peripheralnerve by inflamed edematous tissue. Maria Carmela L. Domocmat, RN, MSN
  48. 48. Neurologic DiseaseCervical myelopathy secondary to atlantoaxialsubluxation is an uncommon but particularlyworrisome complication potentially causingpermanent, even fatal neurologic damage. Maria Carmela L. Domocmat, RN, MSN
  49. 49. Feltys Syndromeis characterized by splenomegaly leukopenia - predominantly granulocytopenia.rare complicationRecurrent bacterial infections and chronicrefractory leg ulcers are the major complications. Maria Carmela L. Domocmat, RN, MSN
  50. 50. Rheumatoid Vasculitismost common clinical manifestations are smalldigital infarcts along the nailbeds. Maria Carmela L. Domocmat, RN, MSN
  51. 51. Sjogrens Syndromea chronic inflammatory disorder characterized bylymphocytic infiltration of lacrimal and salivaryglands.leads to impaired secretion of saliva and tears andresults in the sicca complex: dry mouth (xerostomia) dry eyes (keratoconjunctivitis sicca) dry vagina (rare) Maria Carmela L. Domocmat, RN, MSN
  52. 52. Criteria for Diagnosis of Sjögrens SyndromeFour ormore ofthefollowingcriteriamust bepresent Maria Carmela L. Domocmat, RN, MSN
  53. 53. Ocular DiseaseKeratoconjunctivitis of Sjogrens syndrome is themost common ocular manifestation of rheumatoidarthritis.Sicca (dry eyes) is a common complaint. Episcleritis occurs occasionally and is manifestedby mild pain and intense redness of the affectedeye.Scleritis and corneal ulcerations are rare but moreserious problems. Maria Carmela L. Domocmat, RN, MSN
  54. 54. Keratoconjunctivitis, Sicca Maria Carmela L. Domocmat, RN, MSN
  55. 55. PROGNOSIS Maria Carmela L. Domocmat, RN, MSN
  56. 56. Disability is higher among patients withrheumatoid arthritis with 60% being unable towork 10 years after the onset of their disease.Recent studies have demonstrated an increasedmortality in rheumatoid patients.Median life expectancy was shortened an averageof 7 years for men and 3 years for womencompared to control populations. Maria Carmela L. Domocmat, RN, MSN
  57. 57. Patients at higher risk for shortened survival arethose with systemic extra-articular involvement, low functional capacity, low socioeconomic status, low education, and prednisone use. Maria Carmela L. Domocmat, RN, MSN
  58. 58. ACR Guidelines for MedicalManagement of Rheumatoid Arthritis (updated April, 2002)
  59. 59. Maria Carmela L. Domocmat, RN, MSN
  60. 60. http://rezidentiat.3x.ro/eng/pareng.files/image015.gif Maria Carmela L. Domocmat, RN, MSN
  61. 61. ManagementMaria Carmela L. Domocmat, RN, MSN
  62. 62. The goal of treatment now aims towardachieving thelowest possible level of arthritis disease activityand remission if possible,the minimization of joint damage, andenhancing physical function and quality of life. Maria Carmela L. Domocmat, RN, MSN
  63. 63. Reduce pain and inflammationProtect Articular surface› Reduction of joint stressMaintain function› ROM exercises› Physical and occupational therapySurgical intervention Maria Carmela L. Domocmat, RN, MSN
  64. 64. REDUCE PAIN ANDINFLAMMATION Maria Carmela L. Domocmat, RN, MSN
  65. 65. Pharmacologic treatment1. Non-steroidal Anti-inflammatory Agents (NSAIDs)2. Corticosteroids3. Disease Modifying Anti-rheumatic Drugs (DMARDs) Maria Carmela L. Domocmat, RN, MSN
  66. 66. http://www.medscape.com/content/2004/00/48/77/487710/art-487710.fig9.jpg Maria Carmela L. Domocmat, RN, MSN
  67. 67. NSAIDs and corticosteroidshave a short onset of action while DMARDs cantake several weeks or months to demonstrate aclinical effect Maria Carmela L. Domocmat, RN, MSN
  68. 68. NON-STEROIDAL ANTI-INFLAMMATORY AGENTS(NSAIDS) Maria Carmela L. Domocmat, RN, MSN
  69. 69. NSAIDsmajor effect - reduce acute inflammation therebydecreasing pain and improving function.have mild to moderate analgesic propertiesindependent of their anti-inflammatory effect.Note: these drugs alone do not change the courseof the disease of rheumatoid arthritis or preventjoint destruction. Maria Carmela L. Domocmat, RN, MSN
  70. 70. OTC NSAIDsAspirinibuprofen (Advil ®, Motrin®, Nuprin ®)naproxen (Alleve®, Flanax)ketoprofen (Actron, Orudis KT) Maria Carmela L. Domocmat, RN, MSN
  71. 71. Aspirin - oldest drug of the non-steroidal class but because of its high rate of GI toxicity, a narrow window between toxic and anti-inflammatory serum levels, and the inconvenience of multiple daily doses, aspirins use as the initial choice of drug therapy has largely been replaced by other NSAIDs. Maria Carmela L. Domocmat, RN, MSN
  72. 72. Prescription NSAIDs includemeloxicam (Mobic®), diclofenac (Cataflam®,etodolac (Lodine®), Voltaren®, Arthrotec®),nabumetone (Relafen®), diflusinal (Dolobid®),sulindac (Clinoril®), indomethicin (Indocin®),tolementin (Tolectin®), ketoprofen (Orudis®,choline magnesium Oruvail®),salicylate (Trilasate®), oxaprozin (Daypro®),flurbiprofen (Ansaid), piroxicam (Feldene®).dexibuprofen (Seractil) Maria Carmela L. Domocmat, RN, MSN
  73. 73. Maria Carmela L. Domocmat, RN, MSN
  74. 74. Drugs for Prevention NSAID- Induced UlcersIf NSAID-induced ulcers are identified, thefollowing steps have been suggested:Switch to alternative pain relievers. proton-pump inhibitors (PPIs). misoprostol or Arthrotec. L-arginineIf cannot change drugs, then should use lowestNSAID dose possible Maria Carmela L. Domocmat, RN, MSN
  75. 75. Drugs for Prevention NSAID- Induced Ulcersproton-pump inhibitors (PPIs). Can reduce NSAID-ulcer rates by as much as 80% compared with no treatment. omeprazole (Prilosec) esomeprazole (Nexium) lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprozole (Protonix). Maria Carmela L. Domocmat, RN, MSN
  76. 76. Drugs for Prevention NSAID- Induced UlcersTry misoprostol or Arthrotec. If other agents are inappropriate, misoprostol protects against the major intestinal toxicity of NSAIDs. the first drug approved for preventing NSAID-induced ulcers. It is equally or even more effective than some of the PPIs, but it does not heal existing ulcers and has more side effects than PPIs. Patients tend to stop using it.Arthrotec - a combination of an ulcer protectiveagent called misoprostol and the NSAIDdiclofenac. Maria Carmela L. Domocmat, RN, MSN
  77. 77. L-arginine supplement an amino acid found in health stores may help protect against damage from NSAIDs. an alternative agent not government regulated and more research is needed to confirm its benefits. Maria Carmela L. Domocmat, RN, MSN
  78. 78. Topical NSAIDsdelivered in gels, creams, or patches are provingto reduce arthritic pain and pose less of a risk forgastrointestinal complications associated withoral NSAIDs.diclofenac (Pennsaid, Oxa Sat)eltenac, ibuprofen, or ketoprofen. Maria Carmela L. Domocmat, RN, MSN
  79. 79. $63.07Maria Carmela L. Domocmat, RN, MSN
  80. 80. NSAIDS: COX-2 inhibitorincludes COX-2 inhibitorsalso effective in controlling inflammation.Only one of these agents is currently available inthe United States (celecoxib, Celebrex®) whileadditional compounds are available in othercountries (etoricoxib, Arcoxia®; lumiracoxib,Prexige®). Maria Carmela L. Domocmat, RN, MSN
  81. 81. or COX-2 medications Maria Carmela L. Domocmat, RN, MSN
  82. 82. COX-2 inhibitors designed to decrease the gastrointestinal risk of NSAIDS, but concerns of possible increases in cardiovascular risk with these agents has led to the withdrawal of two of these drugs from the market (rofecoxib, Vioxx®; valdecoxib, Bextra®). Maria Carmela L. Domocmat, RN, MSN
  83. 83. CORTICOSTEROIDS Maria Carmela L. Domocmat, RN, MSN
  84. 84. Corticosteroidsanti-inflammatory & immunoregulatory activity.PO, IV, IM or can be injected directly into the joint.useful in early disease as temporary adjunctivetherapy while waiting for DMARDs to exert theirantiinflammatory effects. Maria Carmela L. Domocmat, RN, MSN
  85. 85. Corticosteroids Maria Carmela L. Domocmat, RN, MSN
  86. 86. Corticosteroidsalso useful as chronic adjunctive therapy inpatients with severe disease that is not wellcontrolled on NSAIDs and DMARDs.Weight gain and a cushingoid appearance(increased fat deposition around the face, rednessof the cheeks, development of a “buffalo hump”over the neck) is a frequent problem and source ofpatient complaints Maria Carmela L. Domocmat, RN, MSN
  87. 87. cushingoid appearance Maria Carmela L. Domocmat, RN, MSN
  88. 88. Prevent osteoporosis due to steroid useadequate calcium and vitamin D supplementationBisphosphonates alendronate (Fosamax®) risedronate (Actonel®) ibandronate (Boniva®)Patients with and without osteoporosis risk factorson low dose prednisone should undergo bonedensitometry (DEXA Scan) to assess fracture risk. Maria Carmela L. Domocmat, RN, MSN
  89. 89. Intra-articular corticosteroids (e.g., triamcinolone or methylprednisolone and others) are effective for controlling a localflare in a joint without changing theoverall drug regimen. Maria Carmela L. Domocmat, RN, MSN
  90. 90. http://www.mayoclinicproceedings.com/conMaria Carmela L. Domocmat, RN, MSN tent/84/9/831.full
  91. 91. DISEASE MODIFYING ANTI-RHEUMATIC DRUGS(DMARDS) Maria Carmela L. Domocmat, RN, MSN
  92. 92. Disease Modifying Anti-rheumatic Drugs (DMARDs)Can alter the disease course and improveradiographic outcomes.DMARDs have an effect upon rheumatoid arthritisthat is different and may be more delayed in onsetthan either NSAIDs or corticosteroids.when the diagnosis of rheumatoid arthritis isconfirmed, DMARD agents should be started. Maria Carmela L. Domocmat, RN, MSN
  93. 93. DMARDsMethotrexate (Rheumatrex®, Trexall®)Hydroxychloroquine (Plaquenil ®)Sulfasalazine (Azulfidine®)Leflunomide (Arava®)Tumor Necrosis Factor Inhibitors etanercept (Enbrel®, adalimumab (Humira ®), and infliximab (Remicade®)T-cell Costimulatory Blocking Agents abatacept (Orencia®) Maria Carmela L. Domocmat, RN, MSN
  94. 94. DMARDsB cell Depleting Agents rituximab (Rituxan®)Interleukin-1 (IL-1) Receptor Antagonist Therapy anakinra (Kineret®)Intramuscular GoldOther Immunomodulatory and Cytotoxic agents— azathioprine (Imuran®), cyclophosphamide, and cyclosporine A(Neoral®, Sandimmune®) Maria Carmela L. Domocmat, RN, MSN
  95. 95. Methotrexatethe first-line DMARD agentHas rapid onset of action at therapeutic doses (6-8 weeks)good efficacyfavorable toxicity profileease of administrationand relatively low cost. Maria Carmela L. Domocmat, RN, MSN
  96. 96. http://www.muabannhadat123.com/forum/showthread.php?p=3477Maria Carmela L. Domocmat, RN, MSN
  97. 97. Hydroxychloroquinean antimalarial drugrelatively safe and well-tolerated agent for thetreatment of rheumatoid arthritis.have limited ability to prevent joint damage ontheir own, their use should probably be limited topatients with very mild and nonerosive disease. Maria Carmela L. Domocmat, RN, MSN
  98. 98. Hydroxychloroquineis sometimes combined with methotrexate foradditive benefits for signs and symptoms or aspart of a regimen of “triple therapy” withmethotrexate and sulfasalazine. Maria Carmela L. Domocmat, RN, MSN
  99. 99. Sulfasalazine Azulfidine®effectiveness - somewhat less thanthat methotrexate,reduce signs and symptoms andslow radiographic damage.given in conjunction withmethotrexate andhydroxychloroquine as part of aregimen of “triple therapy” Maria Carmela L. Domocmat, RN, MSN
  100. 100. Leflunomide (Arava®)efficacy is similar to methotrexate in terms of signsand symptomsviable alternative - failed or are intolerant tomethotrexate. Maria Carmela L. Domocmat, RN, MSN
  101. 101. Tumor necrosis factor (TNF) inhibitorsTumor necrosis factor alpha (TNF) is a pro-inflammatory cytokine produced by macrophages and lymphocytes. found in large quantities in the rheumatoid joint and is produced locally in the joint by synovial macrophages and lymphocytes infiltrating the joint synovium. TNF is one of the critical cytokines that mediate joint damage and destruction due to its activities on many cells in the joint as well as effects on other organs and body systems. Maria Carmela L. Domocmat, RN, MSN
  102. 102. TNF antagonistsfirst of the biological DMARDS to be approved forthe treatment of RA andhave also been referred to as biologicalresponse modifiers or “biologics” todifferentiate them from other DMARDS such asmethotrexate, leflunomide, or sulfasalazine. Maria Carmela L. Domocmat, RN, MSN
  103. 103. TNFs or Biological Response Modifiers (BRMs)Etanercept (Enbrel®)Infliximab(Remicade®)Adalimumab (Humira®) Maria Carmela L. Domocmat, RN, MSN
  104. 104. Etanercept (Enbrel®)Etanercept is effective in reducing the signs andsymptoms of RA, as well as in slowing or haltingradiographic damage, when used either asmonotherapy or in combination with methotrexate. Maria Carmela L. Domocmat, RN, MSN
  105. 105. Infliximab(Remicade®)Infliximab, in combination with methotrexate, isapproved for the treatment of RA, and for thetreatment of psoriatic arthritis, and ankylosingspondylitis, as well as psoriasis and Crohn’sdisease. Maria Carmela L. Domocmat, RN, MSN
  106. 106. Adalimumab (Humira®)Adalimumab is a fully human anti-TNF monoclonalantibody with high specificity for TNF. Maria Carmela L. Domocmat, RN, MSN
  107. 107. Anakinra (Kineret™)a human recombinant IL-1 receptor antagonist (hurIL-1ra)can be used alone or in combination withDMARDs other than TNF blocking agents(Etanercept, Infliximab, Adalimumab). Maria Carmela L. Domocmat, RN, MSN
  108. 108. T-cell Costimulatory blockadeAbatacept (Orencia®)first of a class of agents known as T-cellcostimulatory blockers.interfere with the interactions between antigen-presenting cells and T lymphocytes and affectearly stages in the pathogenic cascade of eventsin rheumatoid arthritis. Maria Carmela L. Domocmat, RN, MSN
  109. 109. Intramuscular GoldMyochrysine® and Solganal®IMhave been replaced byMethotrexate and other DMARDSas the preferred agents to treat RA.rarely used now due to theirnumerous side effects andmonitoring requirements, theirlimited efficacy, and very slowonset of action. Maria Carmela L. Domocmat, RN, MSN
  110. 110. Plasmapheresis Maria Carmela L. Domocmat, RN, MSN
  111. 111. Alternative treatments glucosamine sulfate chondroitin sulfateare are dietary supplements usually taken in pill form that are thought to protect and possibly help repair cartilage cells. Maria Carmela L. Domocmat, RN, MSN
  112. 112. NURSING MANAGEMENT Maria Carmela L. Domocmat, RN, MSN
  113. 113. Chronic pain r/t inflammation and swelling frompressure on surrounding tissues, joint deformityand joint destruction Teach about meds Promote comfort with nonpharmacologic measures Manage stiffness Promote sleep and rest Maria Carmela L. Domocmat, RN, MSN
  114. 114. Promote comfort withnonpharmacologic measures Maria Carmela L. Domocmat, RN, MSN
  115. 115. Manage stiffness Maria Carmela L. Domocmat, RN, MSN
  116. 116. Promote sleep and restEncourage to sleep at least 8 hrs at night, takedaily napsPromote a quiet envtProvide warm beverages before retiring to sleepAdminister hypnotics or relaxants as prescribed Maria Carmela L. Domocmat, RN, MSN
  117. 117. REDUCTION OF JOINTSTRESS Maria Carmela L. Domocmat, RN, MSN
  118. 118. Reduction of joint stressBecause obesity stresses the musculoskeletalsystem, ideal body weight should be achieved andmaintained.Rest, in general, is an important feature ofmanagement.When the joints are actively inflamed, vigorousactivity should be avoided because of the dangerof intensifying joint inflammation or causingtraumatic injury to structures weakened byinflammation. Maria Carmela L. Domocmat, RN, MSN
  119. 119. Readiness for enhanced self-care r/t complexmedication schedules, high risk of S/E of meds,health maintenance, and self-care Promote balanced diet Promote decision-making Promote hope Promote coping Maria Carmela L. Domocmat, RN, MSN
  120. 120. Self-careUse china or heavy plastic cup with handlewhich is easier to manipulate rather thanstyrofoam or paper cup which may bend orcollapseWhen fine motor activities become impossible –use larger joints or body surfaces Ex: use palm of hand to press the toothpaste to toothbrush rather than the fingers Use devices – long-handed brushes to brush hair or dressing sticks for facilitite wearing of pants Maria Carmela L. Domocmat, RN, MSN
  121. 121. Reduction of joint stressurge to maintain a modest level of activity toprevent joint laxity and muscular atrophy.Splinting of acutely inflamed joints, particularly atnight and the use of walking aids (canes, walkers)are all effective means of reducing stress onspecific joints. Maria Carmela L. Domocmat, RN, MSN
  122. 122. Assistive devices Computer Keyboard Aid Arthritics Pen Maria Carmela L. Domocmat, RN, MSN
  123. 123. Phone & Cup Holder withHook and Loop Strap Maria Carmela L. Domocmat, RN, MSN
  124. 124. Arthritis in your hands causes your finger joints and knuckles to become stiff and sometimes painful and swollen. Protect your hands by avoiding pushing, pulling and twisting motions. Avoid making a tight fist or pinching objects tightly.Maria Carmela L. Domocmat, RN, MSN
  125. 125. Instead, use a grasp that aligns your knuckles evenly along the handle of the tool or utensil. This makes grasping the tool more comfortable and requires less effort to use the tool. For instance, a built-up handle made of foam can make it easier for you to grasp your toothbrush.Maria Carmela L. Domocmat, RN, MSN
  126. 126. For tasks that require you to pinch objects tightly, look for assistive devices that can help you hold the object with less force. For instance, using a special key holder may help you turn keys more comfortably without putting strain on your hand. This type of holder aligns your knuckles evenly along the handle of the tool or utensil, allowing you to use a larger grip to turn the key.Maria Carmela L. Domocmat, RN, MSN
  127. 127. Use assistive devices tohelp you open jars. Thisspares your fingers fromthe twisting motionrequired to open a jar. Maria Carmela L. Domocmat, RN, MSN
  128. 128. To protect your finger joints,avoid tightly pinching withyour fingers.For example, use a buttonaid to help you grasp andfasten buttons on yourclothes. Choose clothes witheasy-to-close fasteners,such as zippers, largebuttons or hooks. Maria Carmela L. Domocmat, RN, MSN
  129. 129. Promote balanced dietGood oral hygiene b4 and after mealsSmall, frequent feedingsHigh-caloric snacksIf with xerostamia – moisten foods, extra fluids withmealsEliminate spicy or acidic foodsSit upright to eatTake all meds with food and full glass of water – toameliorate GI distressUse assistive device if with stiffness Maria Carmela L. Domocmat, RN, MSN
  130. 130. Promote decision-makingExercise healthy control over the disease Client should be able to verbalize cause of illness Educate the clientIncrease participation in decision-making allow as many choices as possible Decide on own ADL Maria Carmela L. Domocmat, RN, MSN
  131. 131. Promote hopeAvoid false reassuranceHelp set realistic goalsPraise for accomplishments (no matter howsmall)Active listeningBe sensitive to changes in mind and affect Maria Carmela L. Domocmat, RN, MSN
  132. 132. Promote copingThe client would be able to integrate diseaseinto the demands of daily livingSign that the client has healthy approachstrategies Seek out info and assistance Find strength through spiritual support Verbalize feelings and concerns Set goals Express positive thoughts Maintain realistic independence Maria Carmela L. Domocmat, RN, MSN
  133. 133. Signs of less adaptive strategies Avoidance strategies – ex: denial Excessive sleeping Other passive behaviors Depression Maria Carmela L. Domocmat, RN, MSN
  134. 134. FATIGUE Maria Carmela L. Domocmat, RN, MSN
  135. 135. Management of Fatigue:For muscle atrophy – aggressive PT tostrengthen muscle and prevent further atrophy Maria Carmela L. Domocmat, RN, MSN
  136. 136. Management of FatiguePrinciples of energy conservation Pacing activities- do not plan too much activity for one day Allow rest periods Set priorities – determine which activities are most important and do them first Obtain assistance when needed – delegate responsibilities balance activity and rest Plan ahead to prevent last minute rushing and stress Learn own activity tolerance and do not exceed it Maria Carmela L. Domocmat, RN, MSN
  137. 137. BODY IMAGE DISTURBANCE Maria Carmela L. Domocmat, RN, MSN
  138. 138. Enhance body imageBody image may be affected by both the diseaseprocess and drug therapy Ulnar deviation, swan-neck deformity, boutonnière deformity, rheumatoid nodules Steroid side effect – cushingoid syndromeDetermine client’s perception of the changesand impact of reaction of the SOMost impt Ix – communicate acceptance of theclient ; establish and maintain trustingrelationship to encourage the client to expressfeelings Maria Carmela L. Domocmat, RN, MSN
  139. 139. Let the client wear own clothes rather than thehosp gown, brush own hair, use make-up ifdesiredUse colored hair accessories , nail polish,perfume Maria Carmela L. Domocmat, RN, MSN
  140. 140. SURGICAL INTERVENTIONS Maria Carmela L. Domocmat, RN, MSN
  141. 141. Surgical interventionsTendon transfer and osteotomySynovectomyArthrodesisJoint arthroplasty or replacement Maria Carmela L. Domocmat, RN, MSN
  142. 142. Tendon transfer and osteotomyNodules or benign bony tumors (exostoses) –surgically removed and flexion contracturessurgically relievedOsteotomies Excision or cutting through bones Maria Carmela L. Domocmat, RN, MSN
  143. 143. SynovectomySurgical removal of synovia – elbow, wrist, fingers,knees Maria Carmela L. Domocmat, RN, MSN
  144. 144. Synovectomyordinarily not recommended for patients withrheumatoid arthritis, primarily because relief isonly transient.synovectomy of the wrist - an exception recommended if intense synovitis is persistent despite medical treatment over 6 to 12 months. Persistent synovitis involving the dorsal compartments of the wrist can lead to extensor tendon sheath rupture resulting in severe disability of hand function. Maria Carmela L. Domocmat, RN, MSN
  145. 145. SynovectomyMaria Carmela L. Domocmat, RN, MSN
  146. 146. Maria Carmela L. Domocmat, RN, MSN
  147. 147. ArthrodesisOperation that produce bony fusion of jointused for clients with bone loss after jointinfection , tumors, musculoskeletal trauma,paralysisImmobilize the joint but eliminate somediscomfort or arthritic processAnkle - most common Maria Carmela L. Domocmat, RN, MSN
  148. 148. Joint arthroplasty or replacement particularly of the knee, hip, wrist, and elbow, are highly successful. Arthroplasty of the metacarpophalangeal (knuckle) joints also can reduce pain and improve function. Maria Carmela L. Domocmat, RN, MSN
  149. 149. Hip Replacement Maria Carmela L. Domocmat, RN, MSN
  150. 150. Maria Carmela L. Domocmat, RN, MSN
  151. 151. Surgical intervention Maria Carmela L. Domocmat, RN, MSN
  152. 152. Surgical interventionOther operations include release of nerve entrapments (e.g., carpal tunnel syndrome) arthroscopic procedures removal of a symptomatic rheumatoid nodule. - occasionally Maria Carmela L. Domocmat, RN, MSN
  153. 153. Complementary/ Alternative therapiesPain relief – hypnosis, acupuncture, magnetGood nutrition Omega-3 fatty acids Found in coldwater fish (salmon, sea bass, tuna) May help reduce inflam But amount needed is impractical to human consumption Fish oil capsules Maria Carmela L. Domocmat, RN, MSN
  154. 154. Complementary/ Alternative therapiesAntioxidant vitamins (A,C, E) to help maintain normalfunction of the immune systemTrace elements for joint health Zinc, Selenium, Copper, Iron Maria Carmela L. Domocmat, RN, MSN
  155. 155. Osteoarthritisassociated with theaging process andcan affect any joint.The cartilage of theaffected joint isgradually worndown, eventuallycausing bone to rubagainst bone. Bonyspurs develop onthe unprotectedbones, causing painand inflammation. Maria Carmela L. Domocmat, RN, MSN
  156. 156. WHAT’S THE DIFFERENCEBETWEEN RA AND OA? Maria Carmela L. Domocmat, RN, MSN
  157. 157. Maria Carmela L. Domocmat, RN, MSN
  158. 158. Osteoarthritis is a deterioration of cartilage andovergrowth of bone often due to "wear and tear."Rheumatoid arthritis is the inflammation of ajoints connective tissues, such as the synovialmembranes, which leads to the destruction ofthe joints cartilage. Maria Carmela L. Domocmat, RN, MSN
  159. 159. Known as the “wear-and-tear” kind of arthritisa chronic condition characterized by thebreakdown of the joint’s cartilage. Cartilage is thepart of the joint that cushions the ends of thebones and allows easy movement of joints. Thebreakdown of cartilage causes the bones to rubagainst each other, causing stiffness, pain andloss of movement in the joint. Maria Carmela L. Domocmat, RN, MSN
  160. 160. AKA degenerative joint disease, ostoarthrosis, hypertrophic arthritis degenerative arthritis. Maria Carmela L. Domocmat, RN, MSN
  161. 161. stages of osteoarthritisCartilage loses elasticity and is more easilydamaged by injury or use.Wear of cartilage causes changes to underlyingbone. The bone thickens and cysts may occurunder the cartilage. Bony growths, called spurs orosteophytes, develop near the end of the bone atthe affected joint. Maria Carmela L. Domocmat, RN, MSN
  162. 162. stages of osteoarthritisBits of bone or cartilage float loosely in the jointspace.The joint lining, or the synovium, becomesinflamed due to cartilage breakdown causingcytokines (inflammation proteins) and enzymesthat damage cartilage further. Maria Carmela L. Domocmat, RN, MSN
  163. 163. The main problem inknee OA is degenerationof the articular cartilage.Articular cartilage is thesmooth lining that coversthe ends of bones wherethey meet to form thejoint. The cartilage givesthe knee joint freedom ofmovement by decreasingfriction. Maria Carmela L. Domocmat, RN, MSN
  164. 164. The articular cartilage is kept slippery by joint fluid made by the joint lining (the synovial membrane). The fluid, called synovial fluid, is contained in a soft tissue enclosure around synovial joints called the joint capsule.Maria Carmela L. Domocmat, RN, MSN
  165. 165. An important substance present in articular cartilage and synovial fluid is called hyaluronic acid. Hyaluronic acid helps joints collect and hold water, improving lubrication and reducing friction. It also acts by allowing cells to move and work within the joint.Maria Carmela L. Domocmat, RN, MSN
  166. 166. When the articularcartilage degenerates, orwears away, the boneunderneath is uncoveredand rubs against bone.Small outgrowths calledbone spurs,or osteophytes, may formin the joint. Maria Carmela L. Domocmat, RN, MSN
  167. 167. Changes in the cartilage and bones of the jointcan lead to pain, stiffness and use limitations.Deterioration of cartilage can: Affect the shape and makeup of the joint so it doesn’t function smoothly. - limp when walk or have trouble going up and down stairs. Cause fragments of bone and cartilage to float in joint fluid causing irritation and pain. Cause bony spurs, called osteophytes, to develop near the ends of bones Mean the joint fluid doesn’t have enough hyaluronan, which affects the joint’s ability to absorb shock. Maria Carmela L. Domocmat, RN, MSN
  168. 168. Maria Carmela L. Domocmat, RN, MSN
  169. 169. Causes and Risk factorsthere is no single known cause of osteoarthritis(OA),there are several risk factors that should beconsidered Age Obesity Injury or Overuse Genetics or Heredity Muscle Weakness Other Diseases and Types of Arthritis Maria Carmela L. Domocmat, RN, MSN
  170. 170. Maria Carmela L. Domocmat, RN, MSN
  171. 171. TreatmentAcetaminophenNonsteroidal anti-inflammatory drugs (NSAIDs) orCOX-2 medicationsCapsaicinTramadolNarcotic pain relieversglucosamine sulfate and chondroitin sulfate Maria Carmela L. Domocmat, RN, MSN
  172. 172. Acetaminophen Tylenol, Anacin-3, Panadal, Phenaphen,Valadol, and others)for mild to moderate osteoarthritis.usually the first choice Maria Carmela L. Domocmat, RN, MSN
  173. 173. Nonsteroidal anti-inflammatory drugs (NSAIDs)for moderate to severe arthritic pain.OTC NSAIDsPrescription NSAIDs include Maria Carmela L. Domocmat, RN, MSN
  174. 174. Drugs for Prevention NSAID- Induced UlcersIf NSAID-induced ulcers are identified switch toalternative pain relievers. Maria Carmela L. Domocmat, RN, MSN
  175. 175. Topical NSAIDs $63.07 Maria Carmela L. Domocmat, RN, MSN
  176. 176. Capsaicin (Zostrix)is an ointment prepared from the activeingredient in hot chili peppers that has beenhelpful for relieving painful areas in otherdisorders. Maria Carmela L. Domocmat, RN, MSN
  177. 177. SALONPAS PAIN PATCH WITH CAPSAICIN Maria Carmela L. Domocmat, RN, MSN
  178. 178. Tramadol (Ultram)is a pain reliever that has some properties thatare similar to narcotics.not as addictive, however, and may be analternative for patients who do not respond toNSAIDs or less potent agents. Maria Carmela L. Domocmat, RN, MSN
  179. 179. Maria Carmela L. Domocmat, RN, MSN
  180. 180. Narcotic pain relieversoxycodone, oxymorphone, or morphinemay be necessary for severe pain that does notrespond to less potent pain relievers. Maria Carmela L. Domocmat, RN, MSN
  181. 181. http://differncebetween.infoloommedia.netdna-cdn.com/wp-content/uploads/2009/11/oxycodone.png Maria Carmela L. Domocmat, RN, MSN
  182. 182. ManagementSame with RA Maria Carmela L. Domocmat, RN, MSN
  183. 183. Let’s Exercisehttp://www.medicinenet.com/rheumatoid_arthritis_exercises_slideshow/article.htm Maria Carmela L. Domocmat, RN, MSN
  184. 184. Maria Carmela L. Domocmat, RN, MSN
  185. 185. Gouty arthritisis a disease characterized by an abnormalmetabolism of uric acid, resulting in an excess ofuric acid in the tissues and blood causinginflammationPeople with gout either produce too much uricacid, or more commonly, their bodies have aproblem in removing it.AKA gout the disease of kings the king of diseases Maria Carmela L. Domocmat, RN, MSN
  186. 186. Gouty arthritis2 major types Primary Secondary Maria Carmela L. Domocmat, RN, MSN
  187. 187. Gouty arthritisPrimary Inherited X-lined trait Caused by several inborn errors of purine metabolism Uric acid- is the end-product of purine metabolism; excreted in urine Production of uric acid exceeds the excretion capability of kidneys Sodium urate is deposited in the synovium and other tissues which results in inflammation Males, 30’s and 40’s Maria Carmela L. Domocmat, RN, MSN
  188. 188. Gouty arthritisSecondary Hyperuricemia Excessive uric acid in blood casued by anoterh disease Affects all ages Renal insufficiency Diuretic therapy Multiple myeloma Carcinomas Causes: decreased normal excretion of uric acid and other waste products Increased production of uric acid Maria Carmela L. Domocmat, RN, MSN
  189. 189. Four Stages Of Gouty ArthritisAsymptomatic HyperuricemiaAcute Gout / Acute Gouty ArthritisInterval / IntercriticalChronic Tophaceous Gout Maria Carmela L. Domocmat, RN, MSN
  190. 190. Four Stages Of Gouty ArthritisAsymptomatic Hyperuricemia: Asypmptomatic but with elevated blood uric acid levels Serum uric acid level (mg/dl) Incidence of gout >9.0 7.0-8.9 7.0-8.9 0.5-0.37 <7.0 0.1% Maria Carmela L. Domocmat, RN, MSN
  191. 191. Four Stages Of Gouty ArthritisAcute Gout / Acute Gouty Arthritis hyperuricemia has caused deposits of uric acid crystals in joint spaces, leading to gouty attacks. Excruciating pain and inflammation of one or more joints – esp metatarsophalangeal joints of the great toe (podagra) Increased ESR, WBC Maria Carmela L. Domocmat, RN, MSN
  192. 192. Maria Carmela L. Domocmat, RN, MSN
  193. 193. http://cdn.nursingcrib.com/wp-content/uploads/gouty-arthritis.jpg Maria Carmela L. Domocmat, RN, MSN
  194. 194. http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3689/images/cohen/slide019.gif Maria Carmela L. Domocmat, RN, MSN
  195. 195. Four Stages Of Gouty ArthritisInterval / Intercritical the periods between acute gouty attacks – may be months or years after the 1st attack Asymptomatic period No abnormality in jointsChronic Tophaceous Gout: the disease has caused permanent damage Deposits or urate crytals under skin and within major organs (i.e., urate kidney stone formation) Maria Carmela L. Domocmat, RN, MSN
  196. 196. Tophi Tophi – deposits of sodium urate crystals May occur anywhere; common in outer earhttp://www.hopkins-arthritis.org/images/gout_fig7.gif Maria Carmela L. Domocmat, RN, MSN
  197. 197. http://www.cdaarthritis.com/images_slides/40_gout_b_toe1_360.jpg Maria Carmela L. Domocmat, RN, MSN
  198. 198. http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3689/images/cohen/slide019.gif Maria Carmela L. Domocmat, RN, MSN
  199. 199. http://img.medscape.com/slide/migr ated/editorial/cmecircle/2004/3689/i mages/cohen/slide019.gifMaria Carmela L. Domocmat, RN, MSN
  200. 200. http://msnbcmedia1.msn.com/i/ms nbc/Components/Interactives/Healt h/MiscHealth/GOUT.gifMaria Carmela L. Domocmat, RN, MSN
  201. 201. http://img.medscape.com/slide/migrated/editorial/cmecircle/2004/3689/images/cohen/slide019.gif Maria Carmela L. Domocmat, RN, MSN
  202. 202. Dx testsSynovial fluid analysis (shows uric acid crystals)Uric acid - bloodJoint x-rays (may be normal)Synovial biopsyUric acid - urine Maria Carmela L. Domocmat, RN, MSN
  203. 203. Maria Carmela L. Domocmat, RN, MSN
  204. 204. ManagementDrug therapyDiet therapy Maria Carmela L. Domocmat, RN, MSN
  205. 205. ManagementDrug therapy acute gouty arthritis – inflammation subsides spontaneously within 3 to 5 days But if cannot tolerate pain Colchicine (Colsalide, Novocolchicine) and NSAIDs Taken for 4-7 days (NSAIDs) -Indomethacin (Indocin), ibuprofen (Advil), and naproxen (Aleve), celecoxib (Celebrex) painkillers such as codeine, hydrocodone, and oxycodone Corticosteroids Maria Carmela L. Domocmat, RN, MSN
  206. 206. ManagementDrug therapy Chronic or repeated acute episodes Allopurinol (Zyloprim) A xanthine oxidase inhibitor – prevents conversion of xanthine to uric acid Probenecid (Benemid, Benuryl) Uricosuric drug – promotes excretion of excess uric acid drink at least 2 liters of fluid a day while taking this medication (to help prevent uric acid kidney stones from forming). Combination drug Probenecid and Colchicine (ColBenemid) Note: avoid aspirin – it inactivates the drug Maria Carmela L. Domocmat, RN, MSN
  207. 207. Maria Carmela L. Domocmat, RN, MSN
  208. 208. Febuxostat (Uloric) first new medication developed specifically for the control of gout in over 40 years. Decreases formation of uric acid by the body and is a very reliable way to lower the blood uric acid level. can be used in patients with mild to moderate kidney impairment. should not be taken with 6-mercaptopurine (6-MP), or azathioprine.http://www.emedicinehealth.com/gout/page7_em.htm#Medications Maria Carmela L. Domocmat, RN, MSN
  209. 209. Maria Carmela L. Domocmat, RN, MSN
  210. 210. Management Diet therapy Avoid alcohol, anchovies, sardines, oils, herring, organ meat (liver, kidney, and sweetbreads), legumes (dried beans and peas), gravies, mushrooms, spinach, asparagus, cauliflower, consommé, and baking or brewers yeast.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/ Maria Carmela L. Domocmat, RN, MSN
  211. 211. Limit meat Avoid fatty foods such as salad dressings, ice cream, and fried foods. Eat enough carbohydrates. If losing weight, lose it slowly. Quick weight loss may cause uric acid kidney stones to form.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001459/ Maria Carmela L. Domocmat, RN, MSN
  212. 212. http://s1.hubimg.com/u/1184832_f496.jpg Maria Carmela L. Domocmat, RN, MSN
  213. 213. Avoid all forms of aspirin and diuretics – mayprecipitate attackExcessive physical or emotional stress- canexacerbate disease Maria Carmela L. Domocmat, RN, MSN
  214. 214. Prevention of kidney stone formationIncrease fluid intake – prevent stone formation Dilute urine and prevent sediment formationAlkaline ash diet Citrus fruits, juices, milk and certain dairy products Uric acid is more soluble in high pH urine – less likely to form urinary stones Maria Carmela L. Domocmat, RN, MSN
  215. 215. ComplicationsChronic gouty arthritisKidney stonesDeposits in the kidneys, leading to chronickidney failure Maria Carmela L. Domocmat, RN, MSN
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