CASE READING RHEUMATOID ARTHRITIS

LENY ALVAREZ BSN IV-I

DEFINITION Rheumatoid arthritis Rheumatoid arthritis (RA) is a long-term disease that leads to inflammation of the joints and surrounding tissues. It can affect any joint but is common in the wrist and fingers. More women than men get rheumatoid arthritis. It often starts between ages 25 and 55. You might have the disease for only a short time, or symptoms might come and go. The severe form can last a lifetime. ETIOLOGY The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have, long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. It is believed that the tendency to develop rheumatoid arthritis may be genetically inherited (hereditary). It is also suspected that certain infections or factors in the environment might trigger the activation of the immune system in susceptible individuals. This misdirected immune system then attacks the body's own tissues. This leads to inflammation in the joints and sometimes in various organs of the body, such as the lungs or eyes. It is not known what triggers the onset of rheumatoid arthritis. Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF, interleukin-1/IL-1, and interleukin-6/IL-6) are expressed in the inflamed areas. Environmental factors also seem to play some role in causing rheumatoid arthritis. For example, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis ANATOMY Joints allow the limbs to bend and the back to flex. There are three different kinds of joints described but the ones of principal interest to us are synovial joints. In addition, joints between adjacent facets of the vertebrae, as well as the junction of pelvis and vertebrae are synovial joints.

The synovial joint consists of two bone ends covered by articular cartilage. The articular cartilage is smooth and resilient and enables frictionless movement of the joint. The joint stability is maintained by a fibrous joint capsule, which attaches to both bones and collateral ligaments, which are at the sides of most joints. Collateral ligaments are important in maintaining stability in joints such as the fetlock, carpus, elbow, hock and stifle. There are also intra-articular ligaments, the best example of which are the cruciate (cross) ligaments maintaining integrity of the femorotibial compartments of the stifle joint. In addition, there are other ligaments (outside the joint cavity) that also support the integrity of joints. The best examples are the distal sesamoidean ligaments and suspensory ligament that together with the sesamoid bones make up the suspensory apparatus and hold the fetlock in its correct position. Disruption of any of these structures leads to a failure of support of the fetlock joint (one of the common catastrophic injuries in the racehorse) (Figure 2). The joint capsule itself is made up of the fibrous capsule (previously mentioned and providing structural integrity) and an inner lining layer called the synovial membrane. The synovial membrane secretes the synovial fluid, which provides lubrication within the joint itself. There are various disease processes that affect the nature of this synovial fluid because of inflammation and disease in the synovial membrane. The most common sign that the horse owner or trainer sees of any kind of arthritis (inflammation in the joint) is excessive fluid production. This is because of inflammation of the synovial membrane (synovitis). The fluid produced by inflamed synovial membrane generally has a lower viscosity (more watery). This is a sign of disturbance in production of hyaluronic acid, which is the key ingredient providing lubrication in the joint fluid. The joint is a very well engineered structure. Frictionless motion is provided by the combination of a smooth articular cartilage surface as well as lubrication of both the articular cartilage and the synovial membrane together which make up the entire surface area of the inside of the joint. Shock absorption to the joint is

provided by a combination of structures, including articular cartilage, subchondral bone (the bone beneath the cartilage), and the soft tissue structures (joint capsule and ligaments). Because of its resilient nature and ability to compress, articular cartilage in itself is a good shock absorber but its thickness and overall volume is far less than bone or soft tissues. Hence, the soft tissues and the bone are the primary shock absorbers in the joint and any disease that affects bone (fractures, etc) or soft tissue (fibrosis due to chronic inflammation) is going to interfere with this shock absorption. Resilience of the soft tissue is important for normal motion as well as shock absorption. It has been alluded to previously that friction comes from both articular cartilage and synovial membrane. Hyaluronic acid provides lubrication to the synovial membrane surface. Until recently it has been felt that it does not provide any lubrication to the articular cartilage but more recently with some new research, it has been shown that hyaluronic acid, in addition to another protein structure called lubricin, is involved in the lubrication of articular cartilage. This substance moving over the surface of the joints is called boundary lubrication. A second mechanism of lubrication of the cartilage is effected by fluid being squeezed out of the cartilage onto the surface when weightbearing occurs. When weightbearing ceases, the fluid is absorbed back into the cartilage, ready for a next cycle of weightbearing. PATHOPHYSIOLOGY aAntigenic Stimulus Antigenic Stimulus to any joint of the to any joint of the body body Presence of genetic factor that increases the persons susceptibility to RA

Immune Responses

T-Cell and B-Cell Proliferation

Macrophages and monocytes migrate to the site of antigenic stimulus (joint)

T Cells produces enzyme that enhances inflammatory response B Cells produce Rheumatoid Factor

RF and macrophages bind with the antigen forming immune complexes

Tumor Necrosis Factor- alpha produced by monocytes cause joint degradation and synovial

Inflammation of the synovial membrane: Localized and Systemic Response to inflammation begins to manifest Formation of rheumatoid nodules Decreased Blood flow to synovial tissues

Fibrosis and synovial tissue hypertrophy and hyperplasia

Pannus formation and invasion of a part of the joint cavity

Joint stiffness

Metabolic acidosis

Synovial tissues release hydrolytic enzyme

Spread of inflammation to supporting tendons and ligaments

Cartilage destruction

Joint deformity

SIGNS AND SYMPTOMS Clinical Manifestation of RA vary, usually reflecting the stage and severity of disease . Joint pain, swell, warmth and lack of function are classic symptoms. When the disease is active, symptoms can include fatigue, loss of energy,lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis). Rheumatoid arthritis usually inflames multiple joints in a symmetrical pattern (both sides of the body affected). Early symptoms may be subtle. The small joints of both the hands and wrists are often involved. Symptoms in the hands with rheumatoid arthritis include difficulty with simple tasks of daily living, such as turning door knobs and opening jars. The small joints of the feet are also commonly involved, which can lead to painful walking, especially in the morning after arising from bed. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, including cartilage and bone. This leads to a loss of cartilage and erosion andweakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint inflamed, it can cause hoarseness of the voice. Joint symptoms in children with rheumatoid arthritis include limping, irritability, crying, and poor appetite. MEDICAL MANAGEMENT The overall management of RA is multifaceted. It includes rest, both systemic and articular; physical therapy; utilization of the techniques and appliances of occupational therapy; drugs, both those that suppress inflammation and those that are capable of altering the disease course itself; a knowledge of specific articular and nonarticular complications; and the ability to refer for appropriate surgical management. Judicious, energetic application of these principles can favorably affect the outcome of rheumatoid disease in most patients. Most people who have rheumatoid arthritis take medications. Some medications are used only for pain relief; others are used to reduce inflammation. Still others, often called disease-modifying antirheumatic drugs (DMARDs), are used to try to slow the course of the disease. The persons general condition, the current and predicted severity of the illness, the length of time he or she will take the drug, and the drugs effectiveness and potential side effects are important considerations in prescribing drugs for rheumatoid arthritis. The table start-ing on page 20 shows currently used rheumatoid arthri-tis medications, along with their uses and effects, side effects, and monitoring requirements. Biologic

response modifiers are new drugs used for the treatment of rheumatoid arthritis. They can help reduce inflammation and structural damage to the joints by blocking the action of cytokines, proteins of the bodys immune system that trigger inflammation during nor-mal immune responses. Three of these drugs, etanercept(Enbrel*), infliximab (Remicade), and adalimumab(Humira), reduce inflammation by blocking the reac-tion of TNF molecules. Another drug, called anakinra(Kineret), works by blocking a protein called interleukin1 (IL-1) that is seen in excess in patients with rheumatoid arthritis Some people find using a splint for a short time around a painful jointr educes pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help a person choose a splint and make sure it fits properly. Other ways to reduce stress on joints include self-help devices (for example, zipper pullers, long-handled shoe horns); devices to help with getting on and off chairs, toilet seats, and beds; and changes in the ways that a person carries out daily activities. Surgical Intervention Arthroplasty -an operative procedure of orthopedic surgery performed, in which the arthritic or dysfunctional joint surface is replaced with something better or by remodeling or realigning the joint by osteotomy or some other procedure. Possibly, the advent of widely accessible magnetic resonance imaging (MRI), together with improved surgical and anaesthetic practices, may have altered surgical outcome. It is currently unclear which patients may require MRI and which will benefit from surgical intervention. Our large clinical centre serves a stable population of approximately 3800 patients with rheumatoid arthritis. This allowed us to re-examine the outcome of cervical spine disease in all patients in whom MRI was performed over six years, and to compare these data with those relating to outcome obtained 10 years previously. Nursing management of patients with Rheumatoid Arthritis (RA)

The main objective of Nursing Management program are as follows:

To relieve pain and inflammation To maintain joint function and the maximum ability of the patient To prevent and or correct deformity that occurs in joints Maintaining independence so as not to depend on others. There are several ways the management to achieve the goals mentioned above,namely:

Education The first step of this management program is to provide adequate education about the disease to patients, families and anyone associated with the patient. Education will include understanding the pathophysiology (disease course), the causes and estimated journey (prognosis) of the disease, all components of program management including complex drug regimens, sources of help to overcome this illness and effective method of management provided by health teams . This educational process must be Rest It is important because rheumatic usually accompanied by severe fatigue. Although fatigue may arise every day, but there are times when patients feel better or heavier. Patients should be divided into several time a day time activity which was followed by a period of rest. done continuously.

PhysicalExercise Specific exercises can be useful in maintaining joint function. This exercise includes active and passive movement on all the joints are sore, at least twice a day. Drugs for pain relief should be given before starting the exercise. Hot compresses on the sore and swollen joints may reduce pain. Paraffin bath with temperature can be regulated and shower with hot and cold temperatures can be done at home. Exercise and termoterapi is best regulated by the health workers who have received specialized training, such as a physical therapist or occupational therapist. Excessive exercise can damage the supporting structure of the joints that are already weakened Diet/Nutrition Rheumatic Patients do not require a special diet. There are a number of ways with a variety of diets that vary, but all of them unsubstantiated. The general principle for obtaining a balanced diet is important. by the disease.

Drugs Administration of drugs is an important part of all rheumatic disease management programs. Drugs used to reduce pain, relieve inflammation and to try to change the course of the disease

Online: http://www.medicinenet.com/rheumatoid_arthritis/article.htm http://www.nlm.nih.gov/medlineplus/rheumatoidarthritis.html www. Scribd.com journal: Improved medical and surgical management of cervical spine disease in patients with rheumatoid arthritis over 10 years Book: Brunner and Suddarth, Medical-Surgical Nursing Texbook