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At the end of this lecture, students will be able to:
• Discuss the clinical picture of RA.
• Discuss assessment of health history and identify relevant
diagnostic tests.
• Describe the medical management of RA.
• Describe the role of nutritional support in RA management.
• Focus on applying the nursing process in addressing a nursing
problem related to RA.
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Introduction
• Rheumatoid arthritis (RA) is a common chronic inflammatory
disease in developed countries with a prevalence from 0.7% to
3%, with an average of 1% in the adult population. In the
Kingdom of Saudi Arabia, one study identified a prevalence of
RA to be 2.2 per thousand people in Al Qassim (Al-Dalaan et
al. 1998).
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Clinical Manifestations
• Joint pain, swelling, warmth, erythema, and lack of function
are classic. Palpation of the joints reveals spongy tissue.
• Initially, the small joints in the hands, wrists, and feet are
involved. The patient has limitation in function, and he tends
to guard the joints through immobilization, which can lead to
contractures []تقلص, creating soft tissue deformity.
• As the disease progresses, the knees, shoulders, hips, elbows,
ankles, cervical spine, and temporomandibular joints are
involved.
• Symptoms are usually bilateral and symmetric.
• RA is a systemic disease with multiple extra-articular [ خارج
]المفاصل features (fever, weight loss, fatigue, anemia, lymph
node enlargement, and Raynaud’s phenomenon (cold- and
stress-induced vasospasm causing episodes of digital
blanching or cyanosis).
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– Other extra-articular features of RA include arteritis,
neuropathy, scleritis, pericarditis, splenomegaly, and
Sjogrens’ syndrome (dry eyes and dry mucous
membranes).
– Rheumatoid nodules may be noted in patients with
advanced RA.
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Assessment and Diagnostic Findings
• Rheumatoid nodules, joint inflammation detected on palpation.
• laboratory findings (Presence of rheumatoid factor, high
erythrocyte sedimentation rate (ESR), C-reactive protein and
antinuclear antibody may be positive). Arthrocentesis shows
synovial fluid that is cloudy, milky, or dark yellow. X-ray
studies show characteristic bony erosions.
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Medical Management
• Early-stage RA
– Patient education, a balance of rest and exercise.
– Salicylates or NSAIDs.
– Several COX-2 (cyclo-oxygenase) inhibitors, another class
of NSAIDs, block the enzyme involved in inflammation.
– Antirheumatic agents (antimalarials, gold, penicillamine, or
sulfasalazine) are initiated early in treatment.
– Methotrexate is currently the gold standard in the treatment
of RA.
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• Moderate, erosive RA
– Patients need to participate in a formal program of education
about principles of joint protection, pacing activities, range of
motion, and exercises.
– Cyclosporine enhances the disease modifying effect of
methotrexate.
• Persistent, erosive RA
– Reconstructive surgery (indicated when conservative
measure to control pain fail) is frequently used. Surgical
procedures include synovectomy (excision of the synovial
membrane), tenorrhaphy (suturing a tendon), arthrodesis
(surgical fusion of the joint), and arthroplasty (surgical repair
and replacement of the joint).
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• Persistent, erosive RA
– Systemic low-dose corticosteroid is used for the shortest
duration when the patient has unresolved inflammation and
pain.
– Joints that are severely inflamed and fail to respond promptly
to the measures outlined previously may be treated by local
injection of a corticosteroid.
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• Advanced, unremitting RA
– High dose immunosuppressive agents such as methotrexate
and azathioprine are prescribed because of their ability to
affect the production of antibodies at the cellular level.
– Depression and sleep deprivation may require the short-
term use of low-dose antidepressant medications, such as
amitriptyline (Elavil).
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Nutrition Therapy
• Patients with RA frequently experience anorexia, weight loss,
and anemia.
• Food selection should include the daily requirements from the
basic food groups.
• For the extremely anorexic patient, small, frequent feedings
with increased protein supplements may be prescribed.
• Patients may need diet counselling.
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An Example of Applying the Nursing Process to
Resolve a Nursing Problem for Patient With RA
• Nursing Diagnosis: Acute and chronic pain related to
inflammation and increased disease activity, tissue damage, or
lowered tolerance level.
• Goal: Improvement in comfort level; incorporation of pain
management techniques into daily life.
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Nursing Interventions
• Providing a variety of comfort measures.
1. Application of heat or cold.
2. Massage, position changes, rest.
3. Foam mattress, supportive pillow, splints.
4. Relaxation techniques, activities that divert attention away
from pain. Pain may respond to these non-pharmacologic
interventions.
• Administering slow-acting anti-rheumatic, anti-inflammatory
and analgesic medications as prescribed. This is because pain
responds to individual or combination medication regimens.
• Encouraging verbalization of feelings about pain to promote
coping.
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Expected Outcomes
The patient:
• Identifies factors that exacerbate or influence pain response.
• Identifies and uses pain management strategies.
• Verbalizes decrease in pain.
• Reports signs and symptoms of side effects in timely manner.
• Verbalizes that pain is characteristic of rheumatic disease.
• Establishes realistic pain-relief goals.
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References
• Al-Dalaan A, Al Ballaa S, Bahabri S, Biyari T, Al Sukait M,
Mousa M. The prevalence of rheumatoid arthritis in the
Qassim region of Saudi Arabia. Annals of Saudi Medicine
1998;18(5):396-397.
