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 Rheumatoid Arthritis (RA)

Rheumatoid Arthritis (RA) is a chronic inflammatory disease that affects joints and other organ systems. RA affects 0.5% to 1% of the population worldwide.

What are the Causes and Pathophysiology of Rheumatoid Arthritis (RA)?

1. Immunologic processes result in inflammation of the synovium, producing antigens and inflammatory by-products that lead to the destruction of articular cartilage, oedema, and production of a granular tissue called pannus.

2. Granulation tissue forms adhesions that lead to decreased joint mobility.

3. Similar adhesions can occur in supporting structures, such as ligaments and tendons, and cause contractures and ruptures that further affect joint structure and mobility.

4. The aetiology is unknown but is probably a combined effect of environmental, epidemiologic, infectious, and genetic factors.

5. An infectious agent has not been identified, but many infectious processes can produce a polyarthritis similar to RA.

6. Women are affected more frequently than men.

Signs and Symptoms of Rheumatoid Arthritis (RA)

1. Arthritis 2010 criteria include synovitis in any joint, rather than symmetrical joints in the 1987 criteria.

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2. Skin manifestation

• Rheumatoid nodules-elbows, occiput, sacrum.
• Vasculitic changes- brown, splinterlike lesions in fingers or nail folds.

3. Cardiac manifestation

• Acute pericarditis
• Conduction defects
• Valvular insufficiency
• Coronary arthritis
• Cardiac tamponade-rare
• Myocardial Infarction, sudden death-rare

4. Pulmonary Manifestation

• Asymptomatic pulmonary disease
• Pleural effusion, pleurisy.
• Interstitial fibrosis.
• Laryngeal obstruction caused by involvement of the cricoarytenoid-rare.
• Pulmonary nodules.

5. Neurologic Manifestations

• Mononeuritis multiplex-wrist drop, foot drop.
• Carpal tunnel syndrome.
• Compression of spinal nerve roots.
• Distal sensory neuropathy.

6. Other Manifestation

• Fever.
• Fatigue.
• Weight loss.
• Episcleritis.

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Diagnostic Evaluation of Rheumatoid Arthritis (RA)

1. Complete blood count--normochromic, normocytic anaemia of chronic disease; may also have iron-deficiency anaemia (hypochromic, microcytic); platelets may be elevated with inflammation.

2. RF- positive in up to 70% to 80% of patients with RA; CCP is more specific for RA than RF testing.

3.ESR and CRP- often elevated due to active inflammation.

4. Synovial fluid analysis

5. X- rays- changes develop within 2 years.

• Hands/wrists- marginal erosions of the proximal interphalangeal (PIP), metacarpophalangeal, and carpal joints; generalized osteopenia.
• Cervical spine- erosions that produce atlantoaxial subluxation (generally after many years).

6. Magnetic resonance imaging (MRI)- detects spinal cord compression that results from C1 to C2 subluxation and compression of surrounding vascular structures. Also detects erosions earlier than x-ray.

7. Bone scan-increased uptake in the joints involved in RA.

8. Ultrasound-detects synovitis and erosion ( very user-dependent). Musculoskeletal ultrasound is widely used in Europe, but more sporadic use in the United States.

9. Synovial biopsy.

• Inflammatory cells associated with RA.
• Excludes other causes of polyarthritis by noting the lack of other pathologic findings, such as crystals.

Treatment of Rheumatoid Arthritis (RA)

1. NSAIDs to relieve pain and inflammation.

2. DMARDs to reduce disease activity.

• Monotherapy or combination of older agent, such as methotrexate or hydroxychloroquine, with newer agent, such as tumor necrosis factor (TNF) inhibitor or other biologic agents.
• Combination of TNF inhibitor and methotrexate has shown greater benefit in improving signs and symptoms, preventing radiologic deterioration of the joint, and improving physical function in comparison with monotherapy.
• Goal is to have long-term impact on the joints and to prevent disability.

3. Corticosteroids (by mouth or intra-articular administration) to reduce inflammatory process. Generally used for short periods, due to multiple side effects.

4. Local comfort measures

1. Application of heat and cold did not show benefit in a meta-analysis, but treatment can be individualized.
2. Use of splints to support painful, swollen joints.
3. Use of transcutaneous electrical nerve stimulation (TENS) unit for 15 minutes three times a week may provide some benefit.
4. Iontophoresis-delivery of medication through the skin using direct electrical current.
5. Parrafin wax baths with exercise may be of some benefit.

5. Non pharmacologic modalities 

• Behaviour modification.
• Relaxation techniques.

6. Surgery.

• Synovectomy.
• Arthrodesis-joint fusion.
• Total joint replacement.

Complications of Rheumatoid Arthritis (RA)

1. Loss of joint function because of bony adhesions and damage of supporting structures- 70% of patients become disabled within 5 years of onset; 32% cannot work after 10 years.

2. Anemia of chronic disease.

3. Felty's syndrome-neutropenia, splenomegaly and deformity; occurs in 1% of patients.

Nursing Assessment of Rheumatoid Arthritis (RA)

1. Perform joint examination, if indicated, including which joints are affected; ROM of each joint; presence of heat, redness, swelling; and possible joint effusion.

2. Note presence of deformities

• Swan neck- PIP joints hyperextend.
• Boutonniere- PIP joints flex.
• Ulnar deviation-fingers point toward ulna.

3. Assess pain using a pain measurement scale such as visual analogue scale.

4. Assess functional status using the ACR revised criteria for classification for global functional status.

• Class 1- Completely able to perform usual activities of daily living (ADLs).
• Class ll- able to perform usual self-care and vocational activities, but limited in avocational activities.
• Class lll- able to perform usual self-care activities, but limited in vocational and avocational activities.
• Class lV- limited ability to perform usual self-care, vocational, and avocational activities.

5. Assess for adherence to treatment plan, any complementary methods used, and any adverse reactions to medications.

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Nursing Diagnosis of Rheumatoid Arthritis (RA)

1. Chronic pain related to disease process.

2. Impaired physical mobility related to pain and limited joint motion.

3. Risk of injury related to side effects/toxicities of DMARD therapy.

4. Dressing or Grooming self-care deficit related to limitations secondary to disease process.

5. Ineffective coping related to pain, physical limitations, and chronicity of RA.

Nursing Interventions of Rheumatoid Arthritis (RA)

Controlling Pain 

1. Apply local heat or cold to affected joints for 15 to 20 minutes, three to four times per day. Avoid temperatures likely to cause skin or tissue damage by checking the temperature of warm soaks or by covering cold packs with a towel.

2. Administer or teach self-administration of pharmacologic agents. 

• Advise patient when to expect pain relief, based on mechanism of action of the drug.

3. Encourage the use of adjunctive pain-control measures.

• Progressive muscle relaxation.
• TENs.
• Biofeedback.
• Meditation.
• Acupuncture or similar therapies.

Optimising Mobility

1. Encourage warm bath or shower in the morning to decrease morning stiffness.

2. Encourage measures to protect affected joints.

• Perform gentle ROM exercises
• Use splints 
• Assist with ADLs if necessary.

3. Encourage exercise consistent with degree of disease activity.

4. Refer to physical therapy and occupational therapy.

Preventing Serious Adverse Reactions to Drug Therapy.

1. Review drug information before administration to ensure that baseline bloodwork, such as CBC and liver function tests have been done; there are no drug interactions, and you understand reconstitution and administration information.

2. Ensure that a tuberculin test has been done prior to starting biologics. If positive, treatment for latent tuberculosis (TB) and biologic may be started simultaneously.

• In immunocompromised individuals, including those with autoimmune diseases, greater than 5 mm reaction to tuberculin skin test is considered positive.
• Interferon-gamma release assays for tuberculosis screening are newer blood tests that are commonly used. These are more sensitive and specific than the purified protein derivative skin test and maybe either substituted or done in conjunction with skin testing.

3. Make sure that no live vaccine have been administered in the past 2 to 3 weeks before initiating biologic therapy because infection with vaccine agent could result. Oral DMARDs may be used safely.

4. Ensure that the patient has no active or untreated infections. Be aware that suppressed viral infections, such as hepatitis, herpes, and varicella, can result from immune therapy.

5. Administer or teach patient to administer medication subcutaneously by rotating sites of abdomen , thigh, and upper arm, as directed.