Baljinder singh
M. Sc (MSN)
Assistant Professor
PIMS , Panipat

⦿ Rheumatoid arthritis is
autoimmune disorder in
which Immune system
identifies the synovial
membrane as "foreign"
and begins attacking it.
⦿ Synovial membrane shown in
picture

⦿ Rheumatoid Arthritis (RA) is a chronic
inflammatory disorder that may affect many
tissues and organs, but mainly attacks the
joints producing an inflammatory synovitis.

⦿ 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

⦿ 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

⦿ 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)

⦿ Subchondral bone erosion.
⦿ Pannus invasion of cartilage Chondrocyte
proliferation.
⦿ Laxity of ligaments
⦿ Joint instability
, contractures, decreased
ROM, systemic complications

Sign and Symptoms

⦿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

⦿The deformity arises
from hyperextension
of the proximal
interphalangeal joint,
while the distal
interphalangeal joint
is flexed.

⦿Mallet finger is a
simple flexion
deformity of the
distal
interphalangeal
joint preventing
extension.

⦿ Severe
hyperextension of
the interphalangeal
joint of the thumb

⦿ Fatigue
⦿ Joint pain
⦿ Joint tenderness
⦿ Joint swelling
⦿ Joint redness
⦿ Joint warmth

⦿ Joint stiffness
⦿ Loss of joint range of motion
⦿ Many joints affected (polyarthritis)
⦿ Limping
⦿ Joint deformity
⦿ Both sides of the body affected (symmetric)

Diagnosis

⦿ X Rays
◾X rays of hands and feet are generally performed in
people with RA.
⦿ Magnetic Resonance Imaging (MRI)
⦿ Ultrasounds

⦿ 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%.

◾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

⦿ 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)

⦿ 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

⦿ 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)

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.

⦿ 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.

⦿ 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

⦿ 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

• 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