Juvenile arthritis is a common condition in children that causes joint inflammation and pain. It can be classified as acute, sub-acute, or chronic based on the duration of symptoms. The most common type is juvenile idiopathic arthritis, which refers to conditions characterized by chronic joint inflammation. Treatment involves medications like NSAIDs and DMARDs to reduce inflammation and pain, physical or occupational therapy to maintain mobility, and surgery in severe cases to correct joint deformities. Nursing care focuses on alleviating pain, increasing mobility through exercise, promoting independence in self-care, and ensuring patients understand their condition and treatment plan.

1. Juvenile Arthritis
PABITRA SHARMA

3. Introduction
Arthriris is a common complaint in children. It
said to be present if there is swelling or effusion
in a joint or if there are any two of the following
four features
- Limitation of rang of motion
- Pain
- Tenderness
- Increased heat

4. Contd…
• It can be secondary to an underlying illness or
may be primary disease condition in itself.
• Clinical assessment based on a good history
and physical examination would provide more
diagnostic clues than indiscriminate laboratory
tests
• A convenient way to classify arthritis is based
on the duration of illness at the time of
presentation

5. Classification of arthritis
Acute arthritis( usually < 2weeks)
Arthritis associated with acute rheumatic fever
Transient (toxic) synovitis
Arthritis associated with Kawasaki disease,
HSP
Septic arthritis (S. aureus, H. influenza, N.
meningitides)

6. Contd…
Sub-acute arthritis (2-6 weeks)
Associated with SLE,polyarthritis nodosa
Bone pains associated with leukemia or
neuroblastoma
Associated with Lyme disease, Sickle cell
Associated with hypogammaglobulinemia

7. Contd…
Chronic arthritis (>6weeks)
Juvenile idiopathic arthritis
Ankylosing spondylitis
Tubercular arthritis
psoriasis

8. Juvenile idiopathic arthritis
• The term Juvenile idiopathic arthritis(JIA) was
proposed by the Pediatric Standing Committee of
the international League of Association for
Rheumatology(ILAR)
• It refers to a group of condition characterized by
chronic inflammatory changes of the joint
• It is defined as arthritis of one or more joints with
onset below the age of 16 year and persisting for
at least 6 weeks. It has following subtype

9. Subtypes
• Systemic
• Oligoarthritis
- Persistent
- Extended
• Polyarthritis: RFnegative
• Polyarthritis: RF positive
• Psoriatic arthritis
• Enthesitis related arthritis
• Undifferentiated arthritis
- Fits no other category
- Fits more than one category

10. Incidence
• JIA is not a rare disease
• prevalence is increasing trend
• Common in underdeveloped country
• Can occur in 0.4-1.3 per 1000children of below
16 years
• Common cause of disability in children
• Cause of chronic morbidity and school
absenteeism
• Common in girl

11. Etiology
• The immune system is intimately involved in
the evolution of the disease
• Genetic predisposition

12. Pathophysiology
• Systemic inflammatory process originating in
the synovium or synovial fluid involving
connective tissue and characterized by
destruction and proliferation of synovial
membrane.
• Phagocytosis produces enzymes within the
joint, causing inflammation.
• Collagen is destroyed over time and pannus
formations occur, narrowing the joint space.

13. Contd..
• May result in joint destruction, ankylosis and
deformity with loss of articulation and joint
motion.
• Inflammatory process can also affect the spine,
blood vessels, the pleural membrane of the lungs
or the pericardial sac.
• Condition may be short lived and limited or
progressive and severe.
• Spontaneous remissions and unpredictable
exacerbations can occur

14. Clinical features
• Systemic onset JIA
About 5-15% of patient with JIE may have acute onset of
disease with systemic prominent features
Features usually starts with – intermittent fever with
characteristics twice daily peak(quotidian fever), fever in
evening , maculopapular rash prominent in rash (difficult
to identify in dark skinned people),marked
irritability(decrease with fever), hepatosplenomegaly,
lymphadenopathy, moderate neutrophil leukocytosis,
increased ESR with thrombocytosis and RF is negative

15. Contd…
• Oligoarthritis
Most frequent type of JIA, about 60-70% of
patient, four or fewer large joint are affected
during the first 6 month of the disease.
Involvement usually asymmetrical . Joint
swelling rather than joint pain. Two subtype are
described :Persistent (if joint involvement 4 or
less) and extended (if joint involvement is more
than 4)

16. Contd…
It is more common in girl, age of 3-5 years,
small joints of hand and feet are not involved
• Polyarthritis- in 25-30%,common in girl, joint
pain, swelling is more common, fever and
malaise can be significant. Usually two
subtype: RF negative- occur at any age of
childhood. The knee wrist and hip joint are
mostly affected, small joint tent to less
involve, rheumatoid nodules are not seen

17. Contd…
RF positive: onset of age is late childhood and
early adolescence. The arthritis is symmetrical,
deforming usually typical in small joint specially
metatarsophalangeal and proximal
interphalangeal. Cervical spine could also
affected. Rheumatoid nodules also present.

18. Contd…
• Psoriatic arthritis
Present when there is arthritis with association of
psoriasis or any 2 of following criteria/features-
dactylitis, nail pitting and psoriasis in 1st degree
relatives. Involvement of both large and small
joint simultaneously. Or involvement of the
distal interphalangeal joint are important clinical
clue for diagnosis .

19. Contd…
• Enthesitis arthritis- the condition is more
common in boys, older than 8 years, large
joint of lower extremities is usually affected
later ankylosing spondylitis may develop in
adulthood, self limiting acute symptomatic
iritis may occur.

20. Characteristic Pattern of Joint
Involvement
• Begins with small joints in hands, wrists, and feet.
• Progressively involves knees, shoulders, hips,
elbows, ankles, cervical spine, and
temporomandibular joints.
• Symptoms are usually acute in onset, bilateral,
and symmetric.
• Joints may be hot, swollen, and painful; joint
stiffness often occurs in the morning.
• Deformities of the hands and feet can result from
misalignment and immobilization.

21. Laboratory investigation
• Should recognize the differing pattern of joint involvement
in various type of JIA.
• Synovial fluid aspiration for microscopy and culture is
indicated in children with monoarthritis because septic
arthritis need to included
• Complete blood count may required
• Bone marrow aspiration may be needed if use of
glucocorticoids is being contemplated for treatment of JIA.
• CRP
• RA
• RF
• LFT

22. • Antinuclear antibody (ANA) titer: Screening test for rheumatic
disorders, elevated in 25%–30% of RA patients. Follow-up tests
are needed for the specific rheumatic disorders, e.g., anti-RNP is
used for differential diagnosis of systemic rheumatic disease.
• Rheumatoid factor (RF): Positive in more than 80% of cases
(Rose-Waaler test).
• Latex fixation: Positive in 75% of typical cases.
• Agglutination reactions: Positive in more than 50% of typical
cases.
• Serum complement: C3 and C4 increased in acute onset
(inflammatory response). Immune disorder/exhaustion results in
depressed total complement levels.
• Erythrocyte sedimentation rate (ESR): Usually greatly increased
(80–100 mm/hr). May return to normal as symptoms improve.
• CBC: Usually reveals moderate anemia. WBC is elevated when
inflammatory processes are present.

23. • Immunoglobulin (Ig) (IgM and IgG): Elevation strongly
suggests autoimmune process as cause for RA.
• X-rays of involved joints: Reveals soft-tissue swelling, erosion of
joints, and osteoporosis of adjacent bone (early changes)
progressing to bone-cyst formation, narrowing of joint space, and
subluxation. Concurrent osteoarthritic changes may be noted.
• Radionuclide scans: Identify inflamed synovium.
• Direct arthroscopy: Visualization of area reveals bone
irregularities/degeneration of joint.
• Synovial/fluid aspirate: May reveal volume greater than normal;
opaque, cloudy, yellow appearance (inflammatory
response, bleeding, degenerative waste products); elevated levels
of WBCs and leukocytes; decreased viscosity and complement
(C3 and C4).
• Synovial membrane biopsy: Reveals inflammatory changes and
development of pannus (inflamed synovial granulation tissue).

24. Treatment
Multidisciplinary management is needed
• Physiotherapy and occupational therapy is
needed to prevent deformities
• physical therapy helps to reduce pain
,maintenance of posture and joint mobility,
improve muscle strength and prevents fixed
flexion deformities.
• Ophthalmologist consultation to prevent
Uveitis

25. Medical therapy
• NSAID are the mainstay of symptomatic
management , NSAID inhibit both isoforms of
the enzyme cyclo-oxygenase.
• Naproxen and Ibuprofen are used in children
• Indomethacin is believed to use in Enthesitis
arthritis
• Rey syndrome could develop in children
receiving NSAID, if there is recurrent viral
infection

26. Contd…
• Children with NSAID should watch for gastric
adverse effects.
• Dose(4-6wk) – ibuprofen 35-45mg/kg/day,
maximum 700mg/day QID
• Indomethacin- 1-2mg/kg/day, max-150mg/day
TDS
• Diclofenac- 2-3mg/kg/day, max- 150mg/day QID
• Piroxicam- .3-.6mg/kg/day, max- 20mg/day OD
(analgesic dose is usually half the anti-
inflammatory dose)

27. Contd…
• Disease modifying anti-rheumatic
drugs(DMARDs) need to started in almost all
children with polyarthritis. Weekly
methotrexate 15-25mg/m2/week given
subcutaneously or orally for management of
severe illness.
• Methotrexate is better in children than older,
and have fewer adverse effects

28. Contd…
• Hydroxychloroquine is useful with
methotrexate
• Intra- articular glucocorticoids are preferred
therapy for children with oligoarthritis and
who does not respond with initial NSAID
• Local steroid instillation may required for
patient with iridocyclitis
• Systemic glucocorticoid (prednisolone) for
severe arthritis

29. Contd…
• Newer treatment modalities includes
biological.

30. Course
• Oligoarthritis usually has good prognosis but localised
deformities can develop due to asymmetric growth of limb
• Children with RF positive polyarthritis have a disease
pattern similar to adult show erosive and deforming arthritis
• Treatment regime is always not satisfactory. Approximately
50% patient may undergo remission with minor residual
joint involvement.
• Untreated or partially treated JIA may develop flexion
contractures of hips, knee and elbows resulting permanent
disability.
• Neck stiffness is an especially debilitating problem and can
result in torticollis. Temporomandibular joint involvement
result in restricted opening and may require surgical
intervention.

31. Complication
• Anemia- is chronic ongoing inflammation ,is
almost always present in children with
pesistent active arthritis and serial hemoglobin
levels mirror disease activity rather closely.
Blood loss induced by NSAID can also
contributory factor for anemia.
• Chronic anterior Uveitis- may be clinically
silent and potentially blinding.

32. Contd…
• Macrophage activation syndrome with life
threatening condition with icterus, bleeding
tendency, leukopenia, thrombocytopenia, elevated
triglycerides etc.( so prompt intravenous
methylprednisolone administration is needed)
• Growth disturbances
• Secondary amyloidosis is rare complication
present with proteinuria and hypoalbuminemia
and so often irreversible.

33. Nursing management
Assessment
ACTIVITY/REST
• May report: Joint pain and tenderness worsened by movement
and stress placed on joint; morning stiffness (duration often l hr or
more), usually occurs symmetrically
• Functional limitations affecting ADLs, desired lifestyle, leisure time,
and occupation
• Fatigue; sleep disturbances
• May exhibit: Malaise
• Impaired ROM of joints; particularly hand (fingers and wrist), hips,
knees, ankles, elbows, and shoulders
• Muscle atrophy; joint and muscle contractures/deformities
• Decreased muscle strength, altered gait/posture

34. CARDIOVASCULAR
• May report: Intermittent pallor, cyanosis, then redness of
fingers/toes before color returns to normal (Raynaud’s phenomenon)
• EGO INTEGRITY
• May report: Acute/chronic stress factors (e.g., financial,
employment, disability, relationship factors)
• Hopelessness and powerlessness (incapacitating situation)
• Threat to self-concept, body image, personal identity (e.g.,
dependence on others)
FOOD/FLUID
• May report: Inability to obtain/consume adequate food/fluids
(temporomandibular joint [TMJ] involvement)
• Anorexia, nausea
• May exhibit: Weight loss
• Dryness of oral mucous membranes, decreased oral secretions;
dental caries (Sjögren’s syndrome)

35. HYGIENE
• May report: Varying difficulty performing self-care
activities; dependence on others
• NEUROSENSORY
• May report: Numbness/tingling of hands and feet, loss
of sensation in fingers
• May exhibit: Symmetrical joint swelling
PAIN/DISCOMFORT
• May report: Acute episodes of pain (may/may not be
accompanied by soft-tissue swelling in joints)
• Chronic aching pain and stiffness (mornings are most
difficult)
• May exhibit: Red, swollen, hot joints (during acute
exacerbations)

36. SAFETY
• May report: Difficulty managing homemaker/maintenance
tasks
• Persistent low-grade fever
• Dryness of eyes and mucous membranes
• May exhibit: Pale, shiny, taut skin; subcutaneous rounded,
non-tender nodules; lesions, leg ulcers
• Skin/periarticular local warmth, erythema
• Decreased muscle strength, altered gait, reduced ROM
• Sexuality
• May report: Difficulty engaging in sexual activity as
desired/abstinence
SOCIAL INTERACTION
• May report: Impaired interactions with family/others;
change in roles; isolation

37. Nursing Priorities
• Alleviate pain.
• Increase mobility.
• Promote positive self-concept.
• Support independence.
• Provide information about disease
process/prognosis and treatment needs.

38. Nursing diagnosis
• Impaired Physical Mobility related to pain and
restricted joint movement.
• Acute pain related to swollen, inflamed joints and
restricted movement.
• Fatigue related to chronic inflammatory process.
• Risk for Ineffective Therapeutic Regimen
Management related to insufficient knowledge of
condition, pharmacologic therapy, exercise
program, myths and community resources.

39. Relieving Pain and Discomfort
• Provide a variety of comfort measures (eg, application of heat or
cold; massage, position changes, rest; foam mattress, supportive
pillow, splints; relaxation techniques, diversional activities).
• Administer anti-inflammatory, analgesic, and slow-
acting antirheumatic medications as prescribed.
• Individualize medication schedule to meet patient’s need for pain
management.
• Encourage verbalization of feelings about pain and chronicity of
disease.
• Teach pathophysiology of pain and rheumatic disease, and assist
patient to recognize that pain often leads to unproven treatment
methods.
• Assist in identification of pain that leads to use of
unproven methods of treatment.
• Assess for subjective changes in pain.

40. Reducing Fatigue
• Provide instruction about fatigue: Describe relationship
of disease activity to fatigue; describe comfort measures
while providing them; develop and encourage a sleep
routine (warm bath and relaxation techniques that promote
sleep); explain importance of rest for relieving systematic,
articular,
• and emotional stress.
• Explain how to use energy conservation techniques
(pacing, delegating, setting priorities).
• Identify physical and emotional factors that can cause fatigue.
• Facilitate development of appropriate activity/rest schedule.
• Encourage adherence to the treatment program.
• Refer to and encourage a conditioning program.
• Encourage adequate nutrition, including source of iron from food
and supplements.

41. Increasing Mobility
• Encourage verbalization regarding limitations in
mobility.
• Assess need for occupational or physical therapy
consultation: Emphasize range of motion of affected
joints; promote use of assistive ambulatory devices;
explain use of safe footwear; use individual appropriate
positioning/posture.
• Assist to identify environmental barriers.
• Encourage independence in mobility and assist as
needed: Allow ample time for activity; provide rest
period after activity; reinforce principles of joint
protection and work simplification.
• Initiate referral to community health agency.

42. Facilitating Self Care
• Assist patient to identify self care deficits and factors that
• interfere with ability to perform self-care activities.
• Develop a plan based on the patient’s perceptions and
priorities on how to establish and achieve goals to meet self
care needs, incorporating joint protection, energy
conservation, and work simplification concepts: Provide
appropriate assistive devices; reinforce correct and safe use
of assistive devices; allow patient to control timing of self-
care activities; explore with the patient different ways to
perform difficult tasks or ways to enlist the help of someone
else.
• Consult with community health care agencies when
individuals have attained a maximum level of self care yet
still have some deficits, especially regarding safety.

43. Improving Body Image and Coping Skills
• Help patient identify elements of control over
disease symptoms and treatment.
• Encourage patient’s verbalization of feelings,
perceptions, and fears.
• Identify areas of life affected by disease.
Answer questions and dispel possible myths.
• Develop plan for managing symptoms and
enlisting support of family and friends to
promote daily function.

44. • Monitoring and Managing Potential Complications
• Help patient recognize and deal with side effects from
medications.
• Monitor for medication side effects, including GI
tract bleeding or irritation, bone marrow suppression,
kidney or liver toxicity, increased incidence of
infection, mouth sores, rashes, and changes in vision.
Other signs and symptoms include bruising, breathing
problems, dizziness, jaundice, dark urine, black or
bloody stools, diarrhea, nausea and vomiting, and
headaches.
• Monitor closely for systemic and local infections,
which often can be masked by high doses of
corticosteroids

45. Continuing Care
• Refer for home care as warranted (eg, frail patient
with significantly limited function).
• Assess the home environment and its adequacy
for patient safety and management of the disorder.
• Identify any barriers to compliance, and make
appropriate referrals.
• For patients at risk for impaired skin integrity,
monitor skin status and also instruct, provide, or
supervise the patient and family in preventive
skin care measures.
• Assess patient’s need for assistance in the home,
and supervise home health aides.

46. Contd..
• Make referrals to physical and occupational
therapists as problems are identified and
limitations increase.
• Alert patient and family to support services such
as Meals on Wheels and local Arthritis
Foundation chapters.
• Assess the patient’s physical and psychological
status, adequacy of symptom management, and
adherence to the management plan.
• Emphasize the importance of follow up
appointments to the patient and family.

47. THANK YOU