Rheumatoid arthritis (RA) facts Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body. It can affect people of all ages. The cause of rheumatoid arthritis is not known. In rheumatoid arthritis, multiple joints are usually, affected in a symmetrical pattern.

1. Rheumatoid arthritis
RN Arpana Bhusal
BNS

2. Rheumatoid arthritis (RA) facts
• Rheumatoid arthritis is an autoimmune
disease that can cause chronic inflammation
of the joints and other areas of the body.
• It can affect people of all ages.
• The cause of rheumatoid arthritis is not
known.
• In rheumatoid arthritis, multiple joints are
usually, affected in a symmetrical pattern.

3. • Chronic inflammation of rheumatoid arthritis can
cause permanent joint destruction and deformity.
• Damage to joints can occur early and does not
correlate with the severity of symptoms.
• The "rheumatoid factor" is an antibody that can
be found in the blood of 80% of people with
rheumatoid arthritis.
• There is no known cure for rheumatoid arthritis.
• The treatment of rheumatoid arthritis optimally
involves a combination of patient education, rest
and exercise, joint protection, medications, and
occasionally surgery.
• Early treatment of rheumatoid arthritis results in
better outcomes.

4. Causes:
1.Unknown
2.Genetic factors
3.Other predisposing factors
•Fatigue
•Cold
•Emotional stress
•Infection

5. Pathophysiology
• Affected joints progress through four stages of
deterioration; synovitis, pannus formation,
fibrous ankylosis and bony ankylosis.
• Pathological changes begin with inflammatory
changes in the synovial membrane. The synovial
cells and subsynovial tissue undergo a reactive
hyperplasia, vasodilation and increased blood
flow- warmth, redness. Inflammatory process---
Increased capillary permeability---swelling

6. • The development of a destructive vascular
granulation tissue—pannus, which extends from
the synovium to involve the articular cartilage.
• The pannus development between the joint
margins, leading to reduced joint motion and the
possibility of eventual ankylosis.
• Pannus destroys cartilage and erodes the bone.
The consequence is loss of articular surfaces and
joint motion. Muscle fibers undergo degenerative
changes. Muscle elasticity and contractile power
are lost.

9. Clinical manifestations:
• Inflammation, tenderness and stiffness of the joint
• Moderate to severe pain and morning stiffness
lasting longer then 30 minute
• Joint deformities, muscle atrophy and decrease
ROM
• Rheumatoid nodules- elbow, occiput, sacrum
• Low grade fever, fatigue, weakness, anorexia,
weight loss, anaemia, muscle weakness
• Some client have addition extra articular
manifestations eg; vasculitis, pleural effusion,
pericarditis etc

10. Pathologic flexion at the proximal interphalangeal (PIP) joint and hyperextension at
the distal interphalangeal (DIP) join.t
Swan neck deformity is a deformed position of the finger, in which the joint closest to
the fingertip is permanently bent toward the palm while the nearest joint to the palm
is bent away from it (DIP flexion with PIP hyperextension).

11. Diagnosis:
• CBC- anaemia, ESR high
• RH factor positive 70-80%
• ANA (antinuclear antibody) may be positive
• C-reactive protein elevated
• X-ray shows various stages of joint disease
• Synovial fluid analysis
• Synovial biopsy
• MRI

14. The American College of Rheumatology has developed a
system for classifying rheumatoid arthritis that is primarily
based upon the X-ray appearance of the joints.
Stage I
• no damage seen on X-rays, although there may be signs of bone
thinning
Stage II
• on X-ray, evidence of bone thinning around a joint with or without
slight bone damage
• slight cartilage damage possible
• joint mobility may be limited; no joint deformities observed
• atrophy of adjacent muscle
• abnormalities of soft tissue around joint possible

15. Stage III
• on X-ray, evidence of cartilage and bone damage and bone thinning
around the joint
• joint deformity without permanent stiffening or fixation of the joint
• extensive muscle atrophy
• abnormalities of soft tissue around joint possible
Stage IV
• on X-ray, evidence of cartilage and bone damage and osteoporosis
around joint
• joint deformity with permanent fixation of the joint (referred to as
ankylosis)
• extensive muscle atrophy
• abnormalities of soft tissue around joint possible

16. Rheumatologists also classify the functional status of
people with rheumatoid arthritis as follows
• Class I: completely able to perform usual activities of daily living
• Class II: able to perform usual self-care and work activities but
limited in activities outside of work (such as playing sports)
• Class III: able to perform usual self-care activities but limited in
work and other activities
• Class IV: limited in ability to perform usual self-care, work, and
other activities

17. • Arthralgias
• >3 inflamed joints
• Mild functional limitation
• Minimally elevated ESR & CRP
• No erosions/cartilage loss
• No extraarticular disease i.e. anemia
Moderate Disease
• 6-20 Inflamed joints
• Moderate functional limitation
• Elevated ESR/CRP
• Radiographic evidence of inflammation
• No extraarticular disease
Mild Disease

18. Severe Disease
• >20 persistently inflamed joints
• Rapid decline in functional capacity
• Radiographic evidence of rapid progession of bony erosions & loss of
cartilage
• Extraarticular disease

19. Management
• Early and aggressive disease control
– Rheumatologist Referral
• Early/Undiagnosed: NSAIDs, short course Corticosteroids
• Late/Uncontrolled: DMARD (disease modified anti-rheumatoid
drugs) therapy
- Azathioprine
- Leflunomide
- Cyclophosphamide
- Sulfasalazine
It helps to prevent from joint destruction.

20. Management:
1.Pharmacologic:
•NSAIDs to relieve pain and inflammation
•Aspirin- mainstay of treatment has both
analgesic and anti-inflammatory effect
•Gold compounds eg solganal, auranofin to
induce remission and decrease pain and
inflammation
•Corticosteroids
•Antineoplastic medication eg Methotraxate ,
Cytoxan to suppress immune response

21. 2.Local comfort measures:
•Application of heat and cold
•Use of spints
•Use of TENS
3.Non-pharmacologic modalities:
•Behavioral modification- relaxation
technique
4.Surgery:
•Synovectomy
•Arthrodesis-joint fusion
•Total joint replacement

22. Nursing interventions:
Goals:
•Controlling pain
•Promoting self-care
•Optimizing mobility
•Strengthening coping
•Providing education and maintaining health

23. 1.Assess joints for pain, swelling, tenderness, limitation of motion.
2.Promote maintenance of joint mobility and muscle strength:
•Perform ROM exercises several times a day; use of heat prior to
exercise may decrease discomfort, stop exercise at the point of apin.
•Use isometric or other exercise to strengthen muscles
3.Change position frequently; alternate sitting, standing and lying
4.Promote comfort and relieg/control pain:
•Ensure balance between activity and rest
•Provide 1 to 2 scheduled rest periods through out day
•Rest and suppost inflamed joints, if splint used remove 1-2 tiems per
day for gentle ROM exercise

24. 5.Ensure bed rest if ordered for acute exacerbation;
•Provide firm mattress
•Maintain proper body alignment
•Have client lie prone for ½ hour twice a day
•Avoid pillows under knees
•Keep joints mainly in extension, not flexion
•Prevent complications of immobility
6.Provide heat treatment (warm bath, shower, warm, moist compresses,
paraffin dips) as ordered; y be more effective in chronic pain by
educe stiffness, pain and muscle spasm
7.Provide cold treatment as ordered; most effective during acute
episodes

25. 8.Provide psychological support and encourage client to express feelings
9.Assist client in setting realistic goals; focus on client’s strength
10.Provide teaching:
– Use of prescribed medications and side effects
– Importance of maintaining a balance between activity and rest
– Energy conversation methods
– Performance of ROM, isometric and prescribed exercise

26. Thank you