RHEUMATOID ARTHRITIS

Rheumatoid arthritis, or RA, is an

autoimmune and inflammatory disease, which
means that your immune system attacks healthy
cells in your body by mistake, causing inflammation
(painful swelling) in the affected parts of the body.
It mainly attacks the joints, usually many joints at
once. RA commonly affects joints in the hands,
wrists, and knees. In a joint with RA, the lining of
the joint becomes inflamed, causing damage to
joint tissue. This tissue damage can cause long-
lasting or chronic pain, unsteadiness (lack of
balance), and deformity (misshapenness). RA can
also affect other tissues throughout the body and
cause problems in organs such as the lungs, heart,
and eyes.

Four Stages of Rheumatoid Arthritis

Stage 1: in early-stage rheumatoid arthritis, the tissue around your joint(s) is inflamed.
You may have some pain and stiffness. If your provider ordered x-rays, they wouldn’t
see destructive changes in your bones.
Stage 2: the inflammation has begun to damage the cartilage in your joints. You might
notice stiffness and a decreased range of motion.
Stage 3: the inflammation is so severe that it damages your bones. You’ll have more
pain, stiffness and even less range of motion than in stage 2, and you may start to see
physical changes.
Stage 4: in this stage, the inflammation stops but your joints keep getting worse. You’ll
have severe pain, swelling, stiffness and loss of mobility.

Physiology/Pathophysiology
 The exact mechanism of action for the etiology of RA is unknown. Evidence
points to a genetic predisposition and the development of immunologically mediated
joint inflammation. An autoimmune reaction occurs in the synovial tissue. RA synovium
breaks down collagen, causing edema, proliferation of the synovial membrane, and
ultimately pannus formation. Pannus destroys cartilage and erodes the bone. The
consequence is the loss of articular surfaces and joint motion. Muscle fibers undergo
degenerative changes. Tendon and ligament elasticity and contractile power are lost.
The RA inflammatory process has also been implicated in other disease
processes (i.e., arteriosclerosis). It is hypothesized that the RA disease process
somehow interferes with the production of high-density lipoprotein cholesterol, which is
the form of cholesterol responsible for decreasing cellular lipids and, therefore, is
considered antiatherosclerotic.
The nervous system is also affected by the RA inflammatory process. The
synovial inflammation can compress the adjacent nerve, causing neuropathies and
paresthesias. Axonal degeneration and neuronal demyelination are also possible due to
the infiltration of polymorphonuclear leukocytes, eosinophils, and mononuclear cells,
causing necrotizing or occlusive vasculitis.

Signs and Symptoms

With RA, there are times when symptoms get worse, known as flares, and times
when symptoms get better, known as remission. Signs and symptoms of RA include:

 Pain or aching in more than one joint.

 Stiffness in more than one joint
 Tenderness and swelling in more than one joint.
 The same symptoms on both sides of the body (such as in both hands or both
knees)
 Weight loss
 Fever
 Fatigue or tiredness
 Weakness

Causes

RA is the result of an immune response in which the body’s immune system

attacks its own healthy cells. The specific causes of RA are unknown, but some factors
can increase the risk of developing the disease.

Risk Factors

Researchers have studied a number of genetic and environmental factors to

determine if they change person’s risk of developing RA.

Characteristics that increase risk

 Age. RA can begin at any age, but the likelihood increases with age. The onset
of RA is highest among adults in their sixties.
 Sex. New cases of RA are typically two-to-three times higher in women than
men.
 Genetics/inherited traits. People born with specific genes are more likely to
develop RA. These genes, called HLA (human leukocyte antigen) class II
genotypes, can also make your arthritis worse. The risk of RA may be highest
when people with these genes are exposed to environmental factors like smoking
or when a person is obese.
 Smoking. Multiple studies show that cigarette smoking increases a person’s risk
of developing RA and can make the disease worse.
 History of live births. Women who have never given birth may be at greater risk
of developing RA.
  Early Life Exposures. Some early life exposures may increase risk of
developing RA in adulthood. For example, one study found that children whose
mothers smoked had double the risk of developing RA as adults. Children of
lower income parents are at increased risk of developing RA as adults.
 Obesity. Being obese can increase the risk of developing RA. Studies examining
the role of obesity also found that the more overweight a person was, the higher
his or her risk of developing RA became.

Characteristics that can decrease risk

Unlike the risk factors above which may increase risk of developing RA, at least one
characteristic may decrease risk of developing RA.

 Breastfeeding. Women who have breastfed their infants have a decreased risk
of developing RA.

Complications

Rheumatoid arthritis (RA) has many physical and social consequences and can
lower quality of life. It can cause pain, disability, and premature death.

 Premature heart disease. People with RA are also at a higher risk for
developing other chronic diseases such as heart disease and diabetes. To
prevent people with RA from developing heart disease, treatment of RA also
focuses on reducing heart disease risk factors. For example, doctors will advise
patients with RA to stop smoking and lose weight.
 Obesity. People with RA who are obese have an increased risk of developing
heart disease risk factors such as high blood pressure and high cholesterol.
Being obese also increases risk of developing chronic conditions such as heart
disease and diabetes. Finally, people with RA who are obese experience fewer
benefits from their medical treatment compared with those with RA who are not
obese.
 Employment. RA can make work difficult. Adults with RA are less likely to be
employed than those who do not have RA. As the disease gets worse, many
people with RA find they cannot do as much as they used to. Work loss among
people with RA is highest among people whose jobs are physically demanding.
Work loss is lower among those in jobs with few physical demands, or in jobs
where they have influence over the job pace and activities.

Assessment and Diagnostic Procedures & Findings

To diagnose rheumatoid arthritis (RA), healthcare professionals typically use a

combination of clinical evaluation, medical history assessment, and specific diagnostic
procedures. Here are some common diagnostic procedures and findings used in the
diagnosis of RA:
1. Physical Examination: A healthcare provider will examine the joints for swelling,
tenderness, warmth, and range of motion. They may also look for other signs of
inflammation, such as nodules or redness of the skin.
2. Medical History: The healthcare provider will ask about symptoms, including the
duration and pattern of joint pain, stiffness, and other associated symptoms.
They will also inquire about family history, previous medical conditions, and
exposure to risk factors.
3. Blood Tests: Several blood tests can aid in the diagnosis and evaluation of RA,
including:
- Rheumatoid Factor (RF): RF is an antibody that can be present in the
blood of individuals with RA. However, it is not specific to RA and can be
found in other conditions or even in healthy individuals.
 - Anti-Cyclic Citrullinated Peptide (anti-CCP) Antibodies: These antibodies
are more specific to RA and are often present in individuals with the
disease.
- Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP):
These blood markers indicate the presence of inflammation in the body,
although they are not specific to RA and can be elevated in other
conditions as well.
4. Imaging Tests: X-rays, ultrasound, and magnetic resonance imaging (MRI)
scans may be used to assess joint damage, inflammation, and changes in the
affected joints. These tests can help determine the severity of RA and monitor
disease progression.
5. Synovial Fluid Analysis: In some cases, a joint aspiration procedure may be
performed to obtain synovial fluid from an affected joint. The fluid can be
analyzed for signs of inflammation and the presence of certain cells and proteins
associated with RA.
Nursing Diagnosis
1. Acute and chronic pain related to inflammation and Increased disease activity,
tissue damage, fatigue, or lowered tolerance level.
2. Fatigue related to increased disease activity, pain, inadequate sleep/rest,
deconditioning, inadequate nutrition, and emotional stress/depression.
3. Impaired physical mobility related to decreased range of motion, muscle
weakness, pain on movement, limited endurance, lack or improper use of
ambulatory devices.
Nursing Management
1. Reducing fatigue
 Provide instruction about fatigue: describe relationship of disease activity to
fatigue; describe comfort measures while providing them.
 Develop and encourage a sleep routine (warm bath and relaxation techniques
that promote sleep);
 Explain importance of rest for relieving systematic, articular, and emotional
stress.
 Explain how to use energy conservation techniques (pacing, delegating, setting
priorities).
 Identify physical and emotional factors that can cause fatigue. Facilitate
development of appropriate activity/rest schedule.
 Encourage adherence to the treatment program.
 Refer to and encourage a conditioning program. Encourage adequate nutrition,
including source of iron from food and supplements.
2. Increasing mobility
 Encourage verbalization regarding limitations in mobility.
 Assess need for occupational or physical therapy consultation: emphasize range
of motion of affected joints; promote use of assistive ambulatory devices; explain
use of safe footwear; use individual appropriate positioning/posture.
 Assist to identify environmental barriers. Encourage independence in mobility
and assist as needed: allow ample time for activity; provide rest period after
activity; reinforce principles of joint protection and work simplification.
 Initiate referral to community health agency.
3. Relieving pain and discomfort
 Provide a variety of comfort measures (e.g., application of heat or cold; massage,
position changes, rest; foam mattress, supportive pillow, splints; relaxation
techniques, diversional activities).
  Administer anti-inflammatory, analgesic, and slow- acting antirheumatic
medications as prescribed.
 Individualize medication schedule to meet patient’s need for pain management.
 Encourage verbalization of feelings about pain and chronicity of disease.
 Teach pathophysiology of pain and rheumatic disease, and
 Assist patients to recognize that pain often leads to unproven treatment methods.
Assist in identification of pain that leads to use of unproven methods of
treatment.
 Assess for subjective changes in pain.
Medical Management
1. Rest and exercise. There should be a balance of rest and exercise planned for a
patient with RA.
2. Biologic response modifiers. An alternative treatment approach for ra, biologic
response modifiers, has emerged, wherein a group of agents that consist of molecules
produced by cells of the immune system participate in the inflammatory reactions.
3. Therapy. A formal program with occupational and physical therapy is prescribed to
educate the patient about the principles of joint protection, pacing activities, work
simplification, range of motion, and muscle-strengthening exercises. Nutrition. Food
selection should include the daily requirements from the basic food groups, with
emphasis on foods high in vitamins, protein, and iron for tissue building and repair.
Surgical Management
1. Reconstructive surgery. It is indicated when pain cannot be relieved by conservative
measures and the threat of loss of independence is eminent.
2. Synovectomy. It is the excision of the synovial membrane.
3. Tenorrhaphy. It is the suturing of a tendon.
4. Arthrodesis. It is the surgical fusion of the joint. Arthroplasty. Arthroplasty is the
surgical repair and replacement of the joint.
Pharmacologic Intervention
1. Early rheumatoid arthritis.
NSAIDS. COX-2 medications block the enzyme involved in inflammation while
leaving intact the enzyme involved in protecting the stomach lining. Methotrexate.
Methotrexate is currently the standard treatment of RA because of its success in
preventing both joint destruction and long- term disability. Analgesics. Additional
analgesia may be prescribed for periods of extreme pain.
2. Moderate erosive rheumatoid arthritis.
Cyclosporine. Neoral, An immunosuppressant is added to enhance the disease
modifying effect of methotrexate.
3. Persistent, erosive rheumatoid arthritis.
Corticosteroids. Systemic corticosteroids are used when the patient has
unremitting inflammation and pain or needs a “bridging” medication while waiting for
slower dmards to begin taking effect.
4. Advanced, unremitting rheumatoid arthritis.
Immunosuppressants. Immunosuppressive agents are prescribed because of
their ability to affect the production of antibodies at the cellular level. Antidepressants.
For most patients with ra, depression and sleep deprivation may require the short-term
use of low-dose antidepressants such as amitriptyline, paroxetine, or sertraline, to
reestablish an adequate sleep pattern and to manage chronic pain.
References
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of medical-surgical nursing. 15th edition. Philadelphia, Wolters Kluwer Health.
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