Rheumatoid arthritis

2. ⦿ Rheumatoid arthritis is
autoimmune disorder in
which Immune system
identifies the synovial
membrane as "foreign"
and begins attacking it.
⦿ Synovial membrane shown in
picture

3. ⦿ Rheumatoid Arthritis (RA) is a chronic
inflammatory disorder that may affect many
tissues and organs, but mainly attacks the
joints producing an inflammatory synovitis.

6. ⦿ Idiopathic
⦿ Positive family history
⦿ Inherited tissue type major
histocompatibility complex (MHC) antigen
⦿ Smoking
⦿ Bacterial and Fungal Infection
⦿ Herpes simplex virus infections
⦿ Epstein-Barr virus (EBV)
⦿ Vitamin D deficiency

7. ⦿ RA affects 0.5-1.0% of population in USA
⦿ Females > males 3:1
⦿ but people of any age can be affected
⦿ Peak age 45-65 but onset early from age 20-45
yrs
⦿ About 75% of these are women.
⦿ The disease strikes women three times more
often than men

8. ⦿ Presentation of antigen to T cells
⦿T- and B-cell Proliferation Angiogenesis in
synovial lining
⦿ Neutrophil accumulation in synovial fluid.
⦿ Synovitis.
⦿ Early pannus Formation(The pannus is a
sheet of inflammatory granulation tissue that
spreads from the synovial membrane and
invades the joint)

9. ⦿ Subchondral bone erosion.
⦿ Pannus invasion of cartilage Chondrocyte
proliferation.
⦿ Laxity of ligaments
⦿ Joint instability
, contractures, decreased
ROM, systemic complications

10. Sign and Symptoms

11. ⦿The joints of the
hands are often the
very first joints
affected by
rheumatoid arthritis.
These joints are
swollen red and
tender when
squeezed.
⦿ Swelling due to synovitis

14. ⦿The deformity arises
from hyperextension
of the proximal
interphalangeal joint,
while the distal
interphalangeal joint
is flexed.

16. ⦿Mallet finger is a
simple flexion
deformity of the
distal
interphalangeal
joint preventing
extension.

17. ⦿ Severe
hyperextension of
the interphalangeal
joint of the thumb

18. ⦿ Fatigue
⦿ Joint pain
⦿ Joint tenderness
⦿ Joint swelling
⦿ Joint redness
⦿ Joint warmth

19. ⦿ Joint stiffness
⦿ Loss of joint range of motion
⦿ Many joints affected (polyarthritis)
⦿ Limping
⦿ Joint deformity
⦿ Both sides of the body affected (symmetric)

20. Diagnosis

21. ⦿ X Rays
◾X rays of hands and feet are generally performed in
people with RA.
⦿ Magnetic Resonance Imaging (MRI)
⦿ Ultrasounds

22. ⦿ Blood Tests
◾Rheumatoid Factor (RF)
 RF is a specific antibody in the blood.
 A negative RF does not rule out RA. The arthritis is then called
seronegative, most common during the first year of illness and
converting to seropositive status over time.
◾Anti-citrullinated Protein Antibodies (ACPAs)
 Like RF
, this testing is only positive in a proportion of all RA
cases.
 Unlike RF
, this test is rarely found positive if RA is NOT present,
giving it a specificity of about 95%.

23. ◾Other blood tests performed when RA is suspected:
 Erythrocyte Sedimentation Rate (ESR)
⚫The rate at which red blood cells precipitate in a 1
hour period.
 C-Reactive Protein
⚫A protein found in the blood in response to
inflammation.
 Full Blood Count
⚫Gives information about all blood cells.
 Renal Function
⚫Kidney Function
 Liver Enzymes
⚫Gives information on the state of a patient’s liver

24. Goals of treatment
• Relief of pain
• Reduction of inflammation
• Protection of articular structures
• Maintenance of function
• Control of systemic involvement

25. There are 3 major groups of therapy for RA
• Physical therapy/treatment
• Medical therapy/treatment
•Surgical therapy/treatment

26. Physical therapy
•Rest is very important
•Splinting to reduce unwanted motion of inflamed joints is
useful.
• Exercise directed at maintaining muscle strength and joint
mobility without exacerbating joint inflammation is very
important.
•Orthotic and assistive devices can be helpful in supporting
and aligning deformed joints to reduce pain and improve
function.
• Education of the patients and family – to made changes in
lifestyle to minimize stress on joints.

27. ⦿ Salicylates
⦿ Acetylated
◾aspirin
⦿ Nonacetylated
◾choline magnesium
◾trisalicylate (Trilisate)
◾choline salicylate (Arthropan)

28. ⦿Nonsteroidal Anti-inflammatory Drugs
(NSAIDs)
◾diclofenac (Voveran)
◾etodolac (Lodine)
◾flurbiprofen (Ansaid)
◾ibuprofen
◾meclofenamate (Meclomen)
◾meloxicam
◾nabumatone (Relafen)

29. • ⦿ Disease-Modifying Antirheumatic Drugs
(DMARDs).
Reduce bone and cartilage destruction. The evidence suggests that
DMARDs retard the development of bony erosions and facilitates
their healing.
 Methotrexate is considered the DMARD of first choice
to treat rheumatoid arthritis.
 Methotrexate is a folic acid antagonist.
 Action: Anti-inflammatory, inhibits lysosomal enzymes
◾hydroxychloroquine
◾chloroquine

30. ⦿ Gold-containing compounds
 Action: Inhibits T- and B-cell activity, suppresses
synovitis during active stage of rheumatoid
◾aurothioglucose (Solganol)
◾gold sodium thiomalate
◾auranofin (Ridaura)
◾sulfasalazine (Azulfidine)
◾penicillamine (Cuprimine)

31.  Immunosuppressives
⦿ Action: Immune suppression, effects DNA
synthesis and other cellular effects
 methotrexate (Rheumatrex)
 azathioprine (Imuran)
 cyclophosphamide (Cytoxan)

32. ⦿ Corticosteroids
⦿ Action: Anti-inflammatory, analgesic Used
for shortest duration and at lowest dose
possible to minimize adverse effects
◾prednisone
◾prednisolone
◾hydrocortisone
◾intra-articular injections

33. ⦿ Topical Analgesics
◾capsaicin (Zostrix)

34. Surgeries considered for people who
have severe rheumatoid
arthritis include:
⦿ Arthroplasty
, to replace part or all of a joint, such
as the hip or knee.
⦿Arthroscopy, which uses a small lighted instrument
to remove debris or inflamed tissue from a joint.
⦿ Carpal tunnel release, to relieve pressure on the
median nerve in the wrist.

35. ⦿ Cervical spinal fusion, to treat severe neck
pain and nerve problems.
⦿ Finger and hand surgeries, to correct joint
problems in the hand.
⦿ Foot surgery such as phalangeal head
resection.
⦿ Synovectomy
, to remove inflamed joint
tissue.

36. ⦿ NURSING DIAGNOSES
• Acute and chronic pain related to inflammation
and increased disease activity, tissue damage,
fatigue, or lowered tolerance level
• Fatigue related to increased disease activity,
pain, inadequate sleep/rest, deconditioning,
inadequate nutrition, emotional
stress/depression
• Disturbed sleep pattern related to pain,
depression, and medications
•
• Self-care deficits related to contractures,
fatigue, or loss of motion

37. ⦿ Impaired physical mobility related to
decreased range of motion, muscle
weakness, pain on movement, limited
endurance, lack of or improper use of
ambulatory devices
⦿ Disturbed body image related to physical and
psychological changes and dependency
imposed by chronic illness
• Ineffective coping related to actual or
perceived lifestyle or role changes