OBJECTIVE:

 at the end of the class the student will be able to:

 define rheumatoid arthritis.
 State the incidence of rheumatic arthritis.
 differentiate the normal joint and the affected joint of rheumatoid arthristis.
 state the differentiation between the osteoporosis and rheumatic arthristis.
 enlist the causes of rheumatoid arthristis
 describe the anatomical stages of rheumatoid arthristis.
 list down the American rheumatoid association classification.
 enumerate the sign and symptoms.
 explain the complication.
 enlist the diagnostic test
 describe the management.

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INTRODUCTION:

Rheumatoid arthritis is a chronic inflammatory disorder that can affect more

than just your joints. In some people, the condition can damage a wide variety of
body systems, including the skin, eyes, lungs, heart and blood vessels. An
autoimmune disorder, rheumatoid arthritis occurs when your immune system
mistakenly attacks your own body's tissues. Unlike the wear-and-tear damage of
osteoarthritis, rheumatoid arthritis affects the lining of your joints, causing a
painful swelling that can eventually result in bone erosion and joint deformity. The
inflammation associated with rheumatoid arthritis is what can damage other parts
of the body as well. While new types of medications have improved treatment
options dramatically, severe rheumatoid arthritis can still cause physical
disabilities.

DEFINITION:

Rheumatoid arthritis (RA) is a disease that leads to inflammation of the joints and
surrounding tissues. It is a long-term disease. It can also affect other organs.

INCIDENCE:

The annual incidence of rheumatoid arthritis (RA) has been reported to be around
40 per 100,000. The disease prevalence is about 1 percent in Caucasians but varies
between 0.1 percent (in rural Africans) and 5 percent (in Pima, Blackfeet, and
Chippewa Indians.

A NORMAL JOINT WORK .

A joint is where two bones meet. Most of our joints are designed to allow the
bones to move in certain directions and within certain limits

For example, the knee is the largest joint in the body and one of the most
complicated. It must be strong enough to take our weight and must lock into
position, so we can stand upright. It also has to act as a hinge, so we can walk, and
needs to twist and turn when we run or play sports. The end of each bone is
covered with cartilage that has a very smooth, slippery surface. The cartilage
allows the ends of the bones to move against each other, almost without rubbing.

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The joint is held in place by the synovium ,which contains thick fluid to protect the
bones and joint. The synovium has a tough outer layer that holds the joint in place
and stops the bones moving too far.

A JOINT AFFECTED BY RHEUMATOID ARTHRITIS:

If you have rheumatoid arthritis, your immune system can cause inflammation
inside a joint or a number of joints. Inflammation is normally an important part of
how your immune system works. It allows the body to send extra fluid and blood
to a part of the body under attack from an infection. For example, if you have a cut
that gets infected, the skin around it can become swollen and a different colour.
However, in the case of rheumatoid arthritis, this inflammation in the joint is
unnecessary and causes problems. When the inflammation goes down, the capsule
around the synovium remains stretched and can’t hold the joint in its proper
position. This can cause the joint to become unstable and move into unusual
positions.

FIG: NORMAL JOINTS AND JOINT AFFECTED WITH RHEUMATOID

ARTHRITIS.

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Causes

 The cause of RA is not known . It is an autoimmune disease. This means the

immune system of the body mistakenly attacks healthy tissue.
 Rheumatoid arthritis can occur at any age, but is more common in middle
age. Women get Rheumatoid arthritis more often than men.
 Infection, genes, and hormone changes may be linked to the disease.
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  Smoking may also be linked to rheumatoid arthritis.
 It is less common than osteoarthritis (OA).
 OA which is a condition that occurs in many people due to wear and tear on
the joints as they age.

The following can play a part in why someone has rheumatoid arthritis:

Age

Rheumatoid arthritis affects adults of any age, although most people are diagnosed
between the ages of 40 and 60.Around three-quarters of people with rheumatoid
arthritis are of working age when they are first diagnosed.

Sex:

Rheumatoid arthritis is two to three times more common among women than men.

Genetics:

Rheumatoid arthritis develops because of a combination of genetic and

environmental factors, such as smoking and diet. It is unclear what the genetic link
is, but it is thought that having a relative with the condition increases your chance
of developing the condition.

Weight:

If you are overweight, you have a significantly greater chance of developing

rheumatoid arthritis than if you are a healthy weight. The body mass index (BMI)
is a measure that calculates if your weight is healthy, using your height and weight.
For most adults:

 An ideal BMI is in the 18.5 to 24.9 range.

 If your BMI is: below 18.5 – you're in the underweight range
 Between 18.5 and 24.9 – you're in the healthy weight range
 Between 25 and 29.9 – you're in the overweight range
 Between 30 and 39.9 – you're in the obese range.
 To work out your BMI, use the healthy weight calculator.

Environmental exposures: Although poorly understood, some exposures such as

asbestos or silica may increase the risk of developing rheumatoid arthritis.
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Emergency workers exposed to dust from the collapse of the World Trade Center
are at higher risk of autoimmune diseases such as rheumatoid arthritis.

Smoking:

Cigarette smoking significantly increases the risk of developing rheumatoid

arthritis.

Diet:

There is some evidence that if you eat a lot of red meat and don’t consume much
vitamin C, you may have an increased risk of developing rheumatoid arthritis.

Pathophysiology:

The pathophysiology of rheumatoid arthritis is brief and concise.

 Autoimmune reaction: In RA, the autoimmune reaction primarily occurs

in the synovial tissue.
 Phagocytosis: Phagocytosis produces enzymes within the joint.
 Collagen breakdown: The enzymes break down collagen, causing edema,
proliferation of the synovial membrane, and ultimately pannus formation.
 Damage: Pannus destroys cartilage and erodes the bone.
 Consequences: The consequences are loss of articular surfaces and joint
motion.
 Degenerative changes: Muscle fibers undergo degenerative changes, and
tendon and ligament elasticity and contractile power are lost.

ANATOMIC STAGES OF RHEUMATOID ARTHRITIS:

STAGE 1: EARLY

No destructive changes on X-ray,possible X-ray evidence of Osteoporosis

STAGE II: MODERATE

X-ray evidence of oseotoporosis,with or without slight bone or cartilage

destruction,no joint deformities,adjacent muscle atrophy,possible presence of
extraarticular soft tissue lesions .

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STAGE III: SEVERE

X-ray evidence of cartilage and bone destruction in addition to osteoporosis,joint

deformity such as subluxation,ulnar deviation or hyper extension ,without fibrous
or bony ankylosis, extensive muscle atrophy, possible presence of extraarticular
soft tissue lesions.

STAGE IV: TERMINAL

Fibrous or bony ankylosis, stage III criteria.

AMERICAN RHEUMATISM ASSOCIATION CLASSIFICATION:

Criteria for rheumatoid arthritis:

 Rheumatoid arthritis is defined as having atleast 4-7 of the following

criteria:
 Morning stiffness that lasts for more or equal to 1hr.
 Swelling in three or more joints.
 Swelling in hands joints.
 Symmetric joints swelling.
 Erosion or decalcification seen on hands X-rays.
 Rheumatoids nodules.
 Presence of serum RF.

Signs and symptoms of rheumatoid arthritis may include:

 Tender, warm, swollen joints

 Joint stiffness that is usually worse in the mornings and after inactivity
 Fatigue, fever and loss of appetite
 Early rheumatoid arthritis tends to affect your smaller joints first —
particularly the joints that attach your fingers to your hands and your toes to
your feet.
 As the disease progresses, symptoms often spread to the wrists, knees,
ankles, elbows, hips and shoulders. In most cases, symptoms occur in the
same joints on both sides of your body.
 Typical distortions of the hands include:
 Ulnar drift (zig-zag) deformity.

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  Boutonniere deformity.
 Hallus valgus.
 Swan neck deformity.

 About 40 percent of the people who have rheumatoid arthritis also

experience signs and symptoms that don't involve the joints. Rheumatoid
arthritis can affect many non joint structures, including:
 Skin
 Eyes
 Lungs
 Heart
 Kidneys
 Salivary glands
 Nerve tissue
 Bone marrow
 Blood vessels
 Rheumatoid arthritis signs and symptoms may vary in severity and may
even come and go. Periods of increased disease activity, called flares,
alternate with periods of relative remission — when the swelling and pain
fade or disappear. Over time, rheumatoid arthritis can cause joints to deform

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 and shift out of place.

FIG. EXTRAARTICULAR MANIFESTATION OF RA.

Complications

Rheumatoid arthritis increases your risk of developing:

Osteoporosis:

Rheumatoid arthritis itself, along with some medications used for treating
rheumatoid arthritis, can increase your risk of osteoporosis — a condition that
weakens your bones and makes them more prone to fracture.

Rheumatoid nodules:

These firm bumps of tissue most commonly form around pressure points, such
as the elbows. However, these nodules can form anywhere in the body, including
the lungs.

Dry eyes and mouth:

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 People who have rheumatoid arthritis are much more likely to experience
Sjogren's syndrome, a disorder that decreases the amount of moisture in your eyes
and mouth.

Infections:

The disease itself and many of the medications used to combat rheumatoid
arthritis can impair the immune system, leading to increased infections.

Abnormal body composition:

The proportion of fat to lean mass is often higher in people who have rheumatoid
arthritis, even in people who have a normal body mass index (BMI).

Carpal tunnel syndrome:

If rheumatoid arthritis affects your wrists, the inflammation can compress the
nerve that serves most of your hand and fingers.

Heart problems:

Rheumatoid arthritis can increase your risk of hardened and blocked arteries, as
well as inflammation of the sac that encloses your heart.

Lung disease:

People with rheumatoid arthritis have an increased risk of inflammation and

scarring of the lung tissues, which can lead to progressive shortness of breath.

Lymphoma:

Rheumatoid arthritis increases the risk of lymphoma, a group of blood cancers

that develop in the lymph system.

DIAGNOSTIC TEST:

There is no test that can determine for sure whether you have RA. Most people
with RA will have some abnormal test results. However, some people will have
normal results for all tests.

 History and physical examination.

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Anti-CCP antibody:

These tests are positive in most patients with RA. The anti-CCP antibody test is
more specific for RA.

LABORATORY TEST:

 Complete blood count.

 C-reactive protein.
 Erythrocyte sedimentation rate.
 Joint x-rays.
 Joint ultrasound or MRI.
 Synovial Joint fluid analysis.

MANAGEMENT:

Rheumatoid arthritis most often requires long-term treatment by an expert in

arthritis called a rheumatologist. Treatment includes:

Medicines:

Early treatment for RA with medicines called disease-modifying antirheumatic

drugs (DMARDS) should be used in all patients. This will slow joint destruction
and prevent deformities. The activity of the RA should be checked at regular visits
to make sure the disease is under control. The goal of treatment is to stop the
progression of the RA.

Anti-inflammatory medicines:

These include aspirin and non-steroidal anti-inflammatory drugs (NSAIDs),

such as ibuprofen, naproxen and celecoxib.

Disease modifying antirheumatic drugs (DMARDs):

These are often the medicines that are tried first in people with RA. They are
prescribed along with rest, strengthening exercise, and anti-inflammatory drugs.
Methotrexate is the most commonly used DMARD for rheumatoid arthritis.
Leflunomide and hydroxyl chloroquine may also be used. Sulfasalazine is a drug
that is often combined with methotrexate and hydroxychloroquine (triple therapy).
It may be weeks or months before you see any benefit from these drugs. These
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drugs may have serious side effects, so you will need frequent blood tests when
taking them.

 Surgical Management:
 Reconstructive surgery: Reconstructive surgery is indicated when pain
cannot be relieved by conservative measures and the threat of loss of
independence is eminent.
 Synovectomy: Synovectomy is the excision of the synovial membrane.
 Tenorrhaphy: Tenorrhaphy is the suturing of a tendon.
 Arthrodesis: Arthrodesis is the surgical fusion of the joint.
 Arthroplasty: Arthroplasty is the surgical repair and replacement of the joint.

APHERESIS:

A blood filtration device used in apheresis called the prosorba column is in

frequently used to treat moderate to severe RA in patients who have failed to
respond or an intolerant to DMARDs . RF is removed from the patients blood as it
passes through the column. Patient are treated once a week for 12 weeks.

NURSING MANAGEMENT:

HEAT AND COLD THERAPY AND EXERCISE:

Heat and cold application can help relieves stiffness, pain, and muscle spasm .
Application of ice is especially beneficial during periods of diseases exacerbation
wheras moist heat appears to offer better relief of chronic stiffness .

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EXERCISE:

Gently ROM exercises are usually done daily to keep the joints functional.The
patient should have the oppurtunity to practice the exercises with supervision .
Aquatic warm water (78-86 degree F) allows easier joints movements.

PSYCHOLOGICAL SUPPORT:

The nurse can help the patients reorganize fears and concerns that are faced by the
patients. Evauluation of the family support system is important .Financial planning
may be necessary .Commmunity resources such as home care nurse, homemakers
services and vocational rehabilitation may be considered .Self help group may be
beneficial for some patients.

NUTRITION:

Some people with RA may have intolerance or allergies to certain foods. A

balanced nutritious diet is recommended. It may be helpful to eat foods rich in fish
oils (omega-3 fatty acids). Smoking cigarettes should be stopped. Excessive
alcohol should also be avoided.

NURSING DIAGNOSIS:

Bases on the assessment data, the major nursing diagnoses appropriate for the
patient are:

 Acute and chronic pain related to inflammation and increased disease

activity, tissue damage, fatigue, or lowered tolerance level.
 Fatigue related to increased disease activity, pain, inadequate sleep/rest,
deconditioning, inadequate nutrition, and emotional stress/depression
 Impaired physical mobility related to decreased range of motion, muscle
weakness, pain on movement, limited endurance, lack or improper use of
ambulatory devices.
 Self-care deficit related to contractures, fatigue, or loss of motion.
 Disturbed body image related to physical and psychological changes and
dependency imposed by chronic illness.
 Ineffective coping related to actual or perceived lifestyle or role changes.

Conclusion

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 Managing people's foot and leg problems that are associated with RA often
will involve the podiatrist working closely with other members of the multi-
disciplinary team. As such the rheumatology team will try to ensure that
problems are addressed in a timely and appropriate manner, reflecting the
needs and wishes of the individual who has RA.

JOURNAL ARTICLE:

Cardiovascular Events in Rheumatoid Arthritis Patients – 6 Year

Follow-up Study(26.OCT.2019.)

Evija Stumbra Stumberga*, Gaida Krumina, Silva Senkane and Liana Ziediņa

Department of Rheumatology, Riga Stradins University, Latvia. Patients with

Rheumatoid Arthritis (RA) have an increased risk of developing cardiovascular
disease when compared to the general population. This case-control prospective
study investigated whether the atherosclerotic lesions in brachiocephalic vessels,
carotid Intima-Media Thickness (cIMT), cerebrovascular, Cardiovascular (CV)
risk factors and smoking, as well as level of disease activity and severity,
seropositivity are associated with the risk of developing clinical cerebrovascular,
cardiovascular events in patients with RA during Cases were patients who
developed their first stroke or MI after diagnosis of RA; controls were patients
with RA without CVD 6 year follow-up. RA disease activity and severity, joint
replacement surgery was not associated with CV events in RA patients in our
study.

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2. Black.M.Joyce, Hawks.H; Medical Surgical Nursing; 8th edition; volume-2
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4. Proj.jain.k.A; Human physiology in nutshell; Arya 1st edition. New Delhi.
5. Remedypublication.com

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