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  1. Baljinder singh M. Sc (MSN) Assistant Professor PIMS , Panipat
  2. ⦿ Rheumatoid arthritis is autoimmune disorder in which Immune system identifies the synovial membrane as "foreign" and begins attacking it. ⦿ Synovial membrane shown in picture
  3. ⦿ Rheumatoid Arthritis (RA) is a chronic inflammatory disorder that may affect many tissues and organs, but mainly attacks the joints producing an inflammatory synovitis.
  4. ⦿ Idiopathic ⦿ Positive family history ⦿ Inherited tissue type major histocompatibility complex (MHC) antigen ⦿ Smoking ⦿ Bacterial and Fungal Infection ⦿ Herpes simplex virus infections ⦿ Epstein-Barr virus (EBV) ⦿ Vitamin D deficiency
  5. ⦿ RA affects 0.5-1.0% of population in USA ⦿ Females > males 3:1 ⦿ but people of any age can be affected ⦿ Peak age 45-65 but onset early from age 20-45 yrs ⦿ About 75% of these are women. ⦿ The disease strikes women three times more often than men
  6. ⦿ Presentation of antigen to T cells ⦿T- and B-cell Proliferation Angiogenesis in synovial lining ⦿ Neutrophil accumulation in synovial fluid. ⦿ Synovitis. ⦿ Early pannus Formation(The pannus is a sheet of inflammatory granulation tissue that spreads from the synovial membrane and invades the joint)
  7. ⦿ Subchondral bone erosion. ⦿ Pannus invasion of cartilage Chondrocyte proliferation. ⦿ Laxity of ligaments ⦿ Joint instability , contractures, decreased ROM, systemic complications
  8. Sign and Symptoms
  9. ⦿The joints of the hands are often the very first joints affected by rheumatoid arthritis. These joints are swollen red and tender when squeezed. ⦿ Swelling due to synovitis
  10. ⦿The deformity arises from hyperextension of the proximal interphalangeal joint, while the distal interphalangeal joint is flexed.
  11. ⦿Mallet finger is a simple flexion deformity of the distal interphalangeal joint preventing extension.
  12. ⦿ Severe hyperextension of the interphalangeal joint of the thumb
  13. ⦿ Fatigue ⦿ Joint pain ⦿ Joint tenderness ⦿ Joint swelling ⦿ Joint redness ⦿ Joint warmth
  14. ⦿ Joint stiffness ⦿ Loss of joint range of motion ⦿ Many joints affected (polyarthritis) ⦿ Limping ⦿ Joint deformity ⦿ Both sides of the body affected (symmetric)
  15. Diagnosis
  16. ⦿ X Rays ◾X rays of hands and feet are generally performed in people with RA. ⦿ Magnetic Resonance Imaging (MRI) ⦿ Ultrasounds
  17. ⦿ Blood Tests ◾Rheumatoid Factor (RF)  RF is a specific antibody in the blood.  A negative RF does not rule out RA. The arthritis is then called seronegative, most common during the first year of illness and converting to seropositive status over time. ◾Anti-citrullinated Protein Antibodies (ACPAs)  Like RF , this testing is only positive in a proportion of all RA cases.  Unlike RF , this test is rarely found positive if RA is NOT present, giving it a specificity of about 95%.
  18. ◾Other blood tests performed when RA is suspected:  Erythrocyte Sedimentation Rate (ESR) ⚫The rate at which red blood cells precipitate in a 1 hour period.  C-Reactive Protein ⚫A protein found in the blood in response to inflammation.  Full Blood Count ⚫Gives information about all blood cells.  Renal Function ⚫Kidney Function  Liver Enzymes ⚫Gives information on the state of a patient’s liver
  19. ⦿ Salicylates ⦿ Acetylated ◾aspirin ⦿ Nonacetylated ◾choline magnesium ◾trisalicylate (Trilisate) ◾choline salicylate (Arthropan) ⦿Nonsteroidal Anti- inflammatory Drugs (NSAIDs) ◾diclofenac (Voveran) ◾etodolac (Lodine) ◾flurbiprofen (Ansaid) ◾ibuprofen ◾meclofenamate (Meclomen) ◾meloxicam ◾nabumatone (Relafen)
  20. ⦿ Disease-Modifying Antirheumatic Drugs (DMARDs) ⦿ Antimalarials  Action: Anti-inflammatory, inhibits lysosomal enzymes ◾hydroxychloroquine ◾chloroquine ⦿ Gold-containing compounds  Action: Inhibits T- and B-cell activity, suppresses synovitis during active stage of rheumatoid ◾aurothioglucose (Solganol) ◾gold sodium thiomalate ◾auranofin (Ridaura) ◾sulfasalazine (Azulfidine) ◾penicillamine (Cuprimine) ◾Immunosuppressives
  21. ⦿ Action: Immune suppression, effects DNA synthesis and other cellular effects  methotrexate (Rheumatrex)  azathioprine (Imuran)  cyclophosphamide (Cytoxan) ⦿ Corticosteroids ⦿ Action: Anti-inflammatory, analgesic Used for shortest duration and at lowest dose possible to minimize adverse effects ◾prednisone ◾prednisolone ◾hydrocortisone ◾intra-articular injections ⦿ Topical Analgesics ◾capsaicin (Zostrix)
  22. Surgeries considered for people who have severe rheumatoid arthritis include: ⦿ Arthroplasty , to replace part or all of a joint, such as the hip or knee. ⦿Arthroscopy, which uses a small lighted instrument to remove debris or inflamed tissue from a joint. ⦿ Carpal tunnel release, to relieve pressure on the median nerve in the wrist.
  23. ⦿ Cervical spinal fusion, to treat severe neck pain and nerve problems. ⦿ Finger and hand surgeries, to correct joint problems in the hand. ⦿ Foot surgery such as phalangeal head resection. ⦿ Synovectomy , to remove inflamed joint tissue.
  24. ⦿ NURSING DIAGNOSES • 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, emotional stress/depression • Disturbed sleep pattern related to pain, depression, and medications • • Self-care deficits related to contractures, fatigue, or loss of motion
  25. ⦿ Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack of or improper use of ambulatory devices ⦿ 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
  26. • Nursing Considerations Patient education on how to protect and Ensure adequate pain relief Address sleep disturbance, fatigue and Small nutritious meals, vitamins, iron Encourage informed decisions on self- Counselling/ emotional support for patient