Rheumatoid arthritis is a chronic autoimmune disease that causes inflammation of the joints. It affects around 1% of the adult population globally. The disease is characterized by destruction and proliferation of the synovial membrane that lines the joints, causing pain, swelling, stiffness and limited range of motion. Diagnosis involves assessing symptoms, laboratory tests showing inflammation, and x-rays that can reveal bone erosion over time. Treatment aims to reduce inflammation, slow joint damage, and improve function through medications, exercise, joint protection, and nutritional support. Nursing care focuses on pain management, maintaining mobility and independence with daily activities.

2. Rheumatoid Arthritis
Presented by
Taghreed hamza hawsawi

3. LEVEL
1
LEVEL
2
LEVEL
3
LEVEL
4
LEVEL
5
Describe the medical management of
rheumatoid arthritis .
Illustrate the symptoms of rheumatoid arthritis.
Describe the assessment relevant diagnostic
tests.
Mention the clinical manifestation.
Explain the pathophysiology of rheumatoid arthritis .
Learning Objectives

4. LEVEL
6
LEVEL
7
Discuss the nursing interventions based on nursing diagnosis that
commonly occur in rheumatoid arthritis
Describe the role of nutritional support in rheumatoid arthritis management.
Learning Objectives

5. Rheumatoid arthritis (RA) is an autoimmune
disease that causes chronic inflammation of the
joints.
in developed countries the 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).
Introduction

6. Pathophysoilogy
Systemic inflammatory process originating in
the synovium or synovial fluid involving
connective tissue .
characterized by destruction and proliferation
of synovial membrane.

7. Step 1 Step 2 Step 3 Step 4 Step 5
Phagocytosis
produces
enzymes within
the joint,
causing
inflammation.
Collagen is
destroyed over
time and pannus
formations occur,
narrowing the
joint space.
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.

8. Clinical Manifestations

9. Clinical Manifestations

10. Clinical Manifestations
Around the joints
 warmth
 redness
 swelling
 pain
 limitations in joint motion
General
 sickness
 tiredness
 fever

11. Assessment and Diagnostic Findings
 Patient history
- questions about the intensity of pain symptoms
- frequency of symptoms
- what makes the pain better or worse
 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.

12. Complications
 Joint destruction begins as early as first year of disease without treatment
 Flexion contractures and hand deformities
 Cause diminished grasp strength
 Affect patient’s ability to perform self-care tasks

13. Medical management
Take 1
capsule
Every 6 hours
paracetamol
Take with water
Treatments can:
 Relieve pain
 Reduce swelling
 Slow down or help prevent joint damage
 Increase ability to function
 Improve sense of well-being

14. Medical management
Early-stage RA
1- Patient education, a balance of rest and exercise.
2-Salicylates or NSAIDs (Anti inflammatory drug).
3- Several COX-2 (cyclo-oxygenase) inhibitors, another
class of NSAIDs, block the enzyme involved in
inflammation.
4-Antirheumatic agents (antimalarials, gold,
penicillamine, or sulfasalazine) are initiated early in
treatment.
5-Methotrexate is currently the gold standard in the
treatment of RA.

15. Medical management
 Persistent, erosive RA
 Surgical procedures include
synovectomy (excision of the synovial
membrane) .
 tenorrhaphy (suturing a tendon) .
 arthroplasty (surgical repair and
replacement of the joint).

16. Medical management
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.

17. Medical management
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).

18. Nonpharmacologic relief of pain
Therapeutic heat and cold
Rest
Relaxation techniques
Joint protection
Biofeedback
Transcutaneous electrical stimulation
Hypnosis

19. 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.

20. Nursing management
Nurse must also
Evaluate psychosocial needs and
environmental concerns
After problem identification,
coordinate a carefully planned
program for rehabilitation and
education for interdisciplinary
health care team

21. Nursing management

22. 22
Nursing Care Plan
Nursing Diagnosis: Acute Pain related to distension of tissues by accumulation of fluid/inflammatory process, destruction of joint
Expected Outcome (Objectives): Patient reports pain is relieved/controlled.
Nursing Intervention Rational Evaluation
1. Consider reports of pain, noting location
and intensity (scale of 0–10). Note
precipitating factors and nonverbal pain
cues.
2. Recommend or provide firm mattress or
bed board, small pillow. Elevate linens
with bed cradle as needed.
3. Suggest patient assume position of
comfort while in bed or sitting in chair.
Promote bed rest as indicated.
4. Encourage frequent changes of position.
Assist patient to move in bed, supporting
affected joints above and below, avoiding
jerky movements.
5. Monitor the duration, not the intensity, of
morning stiffness.
1. Favorable in determining pain management needs and
effectiveness of program.
2. Soft and sagging mattress, large pillows prevent
maintenance of proper body alignment, placing stress
on affected joints. Elevation of bed linens reduces
pressure on inflamed or painful joints.
3. In severe disease or acute exacerbation, total bed rest
may be necessary (until objective and subjective
improvements are noted) to limit pain or injury to joint.
4. Prevents general fatigue and joint stiffness. Stabilizes
joint, decreasing joint movement and associated pain.
5. Duration more accurately reflects the disease’s severity.
Patient verbalized reduce
pain.

23. 23
Nursing Care Plan
Nursing Diagnosis: Impaired Physical Mobility related to Pain, discomfort and intolerance to activity.
Expected Outcome (Objectives): Reluctance to attempt movement/inability to purposefully move within the physical
environment
Nursing Intervention Rational Evaluation
1. Assess and continuously monitor degree
of joint inflammation and pain.
2. Maintain bed rest or chair rest when
indicated. Schedule activities providing
frequent rest periods and uninterrupted
nighttime sleep.
3. Assist with active and passive ROM and
resistive exercises and isometrics when
able.
4. Encourage patient to maintain upright and
erect posture when sitting, standing,
walking.
5. Position with pillows, sandbags,
trochanter roll. Provide joint support with
splints, braces.
1. Level of activity and exercise depends on progression
and resolution of inflammatory process.
2. Systemic rest is mandatory during acute exacerbations
and important throughout all phases of disease to
reduce fatigue, improve strength.
3. Maintains and improves joint function, muscle strength,
and general stamina. Note: Inadequate exercise leads
to joint stiffening, whereas excessive activity can
damage joints.
4. Maximizes joint function, maintains mobility.
5. Promotes joint stability (reducing risk of injury) and
maintains proper joint position and body alignment,
minimizing contractures.
The patient can move within
the physical environment

24. 24
Nursing Care Plan
Nursing Diagnosis: Disturbed Body Image related to changes in ability to perform usual tasks.
Expected Outcome (Objectives): Verbalize increased confidence in ability to deal with illness, changes in lifestyle, and possible
limitations.
Nursing Intervention Rational Evaluation
1. Encourage verbalization about concerns of
disease process, future expectations.
2. Encouraged a balanced diet, but make
sure the patient understands that special
diets won’t cure RA. Stress the need for
weight control.
3. Ascertain how patient views self in usual
lifestyle functioning, including sexual
aspects.
4. Discuss patient’s perception of how SO
perceives limitations.
5. Involve patient in planning care and
scheduling activities.
6. Assist with grooming needs as necessary.
7. Give positive reinforcement for
accomplishments.
1. Provides opportunity to identify fears and
misconceptions and deal with them directly.
2. Obesity adds further stress to joints.
3. Identifying how illness affects perception of self and
interactions with others will determine need for further
intervention and counseling.
4. Verbal and nonverbal cues from SO may have a major
impact on how patient views self.
5. Enhances feelings of competency and self-worth,
encourages independence and participation in therapy.
6. Maintaining appearance enhances self-image.
7. Allows patient to feel good about self. Reinforces
positive behavior. Enhances self-confidence.
Patient showed more
confidence and able to deal
with illness, changes in
lifestyle, and possible
limitations.

25. 25
Nursing Care Plan
Nursing Diagnosis: Self Care Deficit related to Musculoskeletal impairment and pain on movement
Expected Outcome (Objectives): Perform self-care activities at a level consistent with individual capabilities.
Nursing Intervention Rational Evaluation
1. Ascertain usual level of functioning (0–4) before
onset or exacerbation of illness and potential
changes now anticipated.
2. Maintain mobility, pain control, and exercise
program.
3. Urge the patient to perform activities of daily
living (ADLs), such as practicing good hygiene,
dressing and feeding himself.
4. Prepares for increased independence, which
enhances self-esteem.
5. Allow patient sufficient time to complete tasks
to fullest extent of ability. Capitalize on
individual strengths.
6. Consult with rehabilitation specialists
(occupational therapist).
1. May be able to continue usual activities with
necessary adaptations to current limitations.
2. Support physical and emotional independence.
3. ADLs that can be done should be encouraged to
maximize function.
4. Assess barriers to participation in self-care.
Identify and plan for environmental
modifications.
5. May need more time to complete tasks by self
but provides an opportunity for greater sense of
self-confidence and self-worth.
6. Helpful in determining assistive devices to meet
individual needs (buttonhook, long-handled
shoehorn, reacher, hand-held shower head).
Patient can perform some
self-care activities at a level
consistent according to his
capabilities.

26. 26
Nursing Care Plan
Nursing Diagnosis: Deficient Knowledge related to information misinterpretation
Expected Outcome (Objectives): Verbalize understanding of condition/prognosis, and potential complications.
Nursing Intervention Rational Evaluation
1. Review disease process, prognosis, and
future expectations.
2. Discuss patient’s role in management of
disease process through nutrition,
medication, and balanced program of
exercise and rest.
3. Identify individually appropriate exercise
program components (swimming,
stationary bike, nonimpact aerobics)
4. Stress importance of continued pharmaco
therapeutic management.
5. Suggest taking medications, such as
NSAIDs, with meals, milk products, or
antacids and at bedtime.
1. Provides knowledge base from which patient can make
informed choices.
2. Goal of disease control is to suppress inflammation in
joints and other tissues to maintain joint function and
prevent deformities.
3. Can increase patient’s energy level and mental
alertness, minimize functional limitations. Program
needs to be customized based on joints involved and
patient’s general condition to maximize effect and
reduce risk of injury.
4. Benefits of drug therapy depend on correct
dosage (aspirin must be taken regularly to sustain
therapeutic blood levels of 18–25 mg per dL).
5. Limits gastric irritation. Reduction of pain at hs
enhances sleep, and increased blood level decreases
early-morning stiffness.
Patient verbalized
understanding of
condition/prognosis, and
potential complications.

27. 27

28. 28
Rheumatoid arthritis is:
a. Temporary
b. Chronic
c. Both
Rheumatoid arthritis is a disease caused by abnormalities
in which system of the body?
a. Nervous system
b. Immune system
c. Digestive system
d. Respiratory system
Manifestations of rheumatoid arthritis:
A) inflammatory synovitis
B) cartilage destruction
C) bone erosion
D) changes in joint integrity
E) progressive, relentless polyarthritis with functional
impairment
Which of these is not a feature of rheumatoid arthritis?
a. Swollen joints
b. Painful joints
c. limitations in joint motion
d. Headache

29. 29
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.
American Academy of Orthopaedic Surgeons. (2012) . Arthritis. Retrieved
from http://orthoinfo.aaos.org/menus/arthritis.cfm
Arthritis Foundation. (2012). Common Myths. Retrieved from
http://www.arthritis.org/aam-common-myths.php
Arthritis Society. (2010). Lupus. Retrieved from
http://http://www.arthritis.ca/document.doc?id=327
Arthritis Society. (2011). Osteoarthritis: Know Your Options. Retrieved from
http://www.arthritis.ca/document.doc?id=328
Arthritis Society. (2012). About Arthritis. Retrieved from
http://www.arthritis.ca/aboutarthritis
References

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