RHEUMATOID ARTHRITIS Rheumatoid Arthritis A chronic autoimmune disease
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RHEUMATOID ARTHRITIS
Rheumatoid Arthritis “A chronic autoimmune disease characterized by the inflammation of the synovial joints” (The Arthritis Society, 2012; Gulanick & Myers, 2011; Firth, 2011)
Def • Rheumatoid arthritis is an autoimmune disease in which the normal immune response is directed against an individual's own tissue, including the synovial joints, tendons, and bones, resulting in inflammation and destruction of these tissues.
Causes • Exact cause Is unknown • AUTOIMMUNITY – abnormal Ig. G is being developed due to some reasons. Antibodies will produce against this abnormal Ig. G. This antibody is termed as rhemuatoid factors (RF). RF combine with Ig. G and deposits in the joints, blood vessels • Smoking • Infection -helicobacter pylori, epstein-bar virus, parvovirus and mycobacteria can trigger the process • Vitamin D deficiency, Genetic predisposition
Pathophysiology • Etiological factors (infectious microorganism) • Antigen –antibody response (production of normal immunoglobulins against the antigen) • Transformation of Ig. G and Ig. M into rheumatoid factors (RF) -{prolonged exposure to the antigen causes normal antibodies to become autoantibodies and attack host tissues }
• Formation of immune complexes in blood and synovial membrane (Normally synovial tissue secretes synovial fluid that both lubricate the joint and is the medium through which nutrients are supplied to articular cartilage) • Due to inflammation -Edema, vascular congestion, fibrin exudate and cellular infiltration occurs • Activated macrophages release cytokines and interleukins and tumor necrosis factor
• PANNUS (inflammatory granular tissues) forms at junctions of synovial tissues and articular cartilage, it interfere with nutrition transport • Articular cartilage becomes necrotic • Pannus invades subchondral bone and supporting soft tissues (ligaments, tendons) and destroys it
• Fibrous tissues replace pannus leads to occluding the joint movements • As fibrous tissues calcifies, total bone joint immobilization occurs
Stages of RA First stage – the unknown etiologic factor initiates joints inflammation –synovitis, with swelling of the synovial lining membrane and production of excess synovial fluid Second stage – pannus (inflammatory granular tissue) is formed at the juncture of the synovium and cartilage. This extends over the surface of the articular cartilage and eventually invades the joint capsule and subchondral bone. Third stage – tough fibrous connective tissue replaces pannus, occluding the joint space. Fibrous ankylosis results in decreased joint motion and leads to deformity Fourth stage – as fibrous tissue calcifies, bony ankylosis may result in total joint immobilization
Signs and Symptoms Joint involvements • Begin with small joints in hands, wrists and feet • Palpation of joints reveals spongy tissue • Progressively involves knees, shoulders, hips, elbows, ankles etc • Symptoms usually acute in onset, bilateral and symmetric • Joints may be hot, swollen and painful (not relieved by rest), morning stiffness lasts more than 30 min • Deformities of hands and feet.
• Deformities due to RA – boutonniere deformity, swan neck deformity, ulnar deviation and hallux valgus
Extra articular features • • • pallor • Fever • Weight loss Paresthesias • Fatigue Contractures • Anemia Atrophy • Lymph node enlargement Color changes of digits (bluish, rubor) Rheumatoid nodules (nontender and movable, found in subcutaneous tissues over bony prominences)
Rhematoid Nodules
Systemic manifestations • Cardiovascular – pericarditis, valvular lesions, myocarditis, vasculitis, raynauds phenomenon • Pulmonary – pleurisy, rheumatoid nodules on lungs, pul. fibrosis, pul. hypertension • Neurologic – neuropathy, myelopathy • Hematologic – anemia, leukopenia
• Renal – rheumatoid nodules on kidney • Dermatologic – rheumatoid nodules, brown lesions, ulcers and fistulas • Ophthalmologic – scleritis, keratoconjuncitivitis (sjogren’s syndrome), glaucoma • Other – fever, malaise, weakness
Diagnosis • CBC • Radiographs of involved joints • CT/MRI scans • Direct arthroscopy • Synovial Fluid aspirate/ Arthrocentesis - cloudy, milky, or dark yellow containing leukocytes • Synovial membrane biopsy
• ESR and C-reactive protein will be elevated • Antinuclear Antibody test to find out rheumatoid factor
X-Ray
Diagnostic criteria –ARA(american rheumatism association) • Morning stiffness lasting more than 1 hour for atleast 6 weeks duration • Swelling of wrist, metacarpophalangeal, or interphalangeal joints for atleast 6 weeks • Symmetric soft tissue swelling • Rheumatoid nodules • Positive serum rheumatoid factor test • Radiographic changes • Elevated ESR, c reactive protein
Management • The major goal is to relieve pain and inflammation and prevent further joint damage • To reduce Anxiety, depression, and maintain self esteem because these factors commonly accompanies Rheumatoid Arthritis
Medications • There are four types of medications used to treat RA: – Non-steroidal anti-inflammatory drugs (NSAIDs) – Disease-modifying anti-rheumatic drugs(DMARDs). – Corticosteroids – Biologic Response Modifiers (“Biologics”)
Non-steroidal anti-inflammatory drugs (NSAIDs) Examples General Use Aspirin, ibuprofen, • antinaproxen, inflammatory: propionic acid Used in the management inflammatory conditions • Antipyretic: used to control fever • Analgesic: Control mild to moderate pain Side Effects Nursing Considerations • Nausea • Vomiting • Diarrhea • Constipation • Dizziness • Drowsiness • Edema • Kidney failure • Liver failure • Prolonged bleeding • Ulcers • Use cautiously in patients with hx of bleeding disorders • Encourage pt to avoid concurrent use of alcohol • NSAIDs may decrease response to diuretics or antihypertensive therapy
Corticosteroids Examples General Use Side Effects Nursing Considerations Cortisone, hydrocortisone, prednisone, betamethasone, dexa -methasone • Used in the management inflammatory conditions • When NSAIDS may be contraindicated • Increased appetite • Weight gain • Water/salt retention • Increased blood pressure • Thinning of skin • Depression • Mood swings • Muscle weakness • Osteoporosis • Delayed wound healing • Take medications as directed (adrenal suppression) • Used with caution in diabetic patients • Encourage diet high in protein, calcium, potassium and low in sodium and carbohydrates
Disease-modifying anti-rheumatic drugs(DMARD) Examples General Use Side Effects Nursing Considerations Methotrexate (the gold standard) , gold salts, cyclosporine, sulfasalazine, azathioprine • immunosuppressive activity • Reduce inflammation of rheumatoid arthritis • Slows down joint destruction • Preserves joint function • Dizziness, drowsiness, headache • Pneumonitis • Anorexia • Nausea • Stomatitis • Infertility • Alopecia • Skin ulceration • Leukopenia • Nephropathy • fever • photosensitivity • May take several weeks to months before they become effective • Discuss teratogenicity, should be taken off drug several months prior to conception
Biologic Response Modifiers (“Bioligics”) Examples General Use Etanercept, anakinra, • Used in the abatacipt, adalimumab, management Infliximab (Remicade) inflammatory conditions • When NSAIDS may be contraindicated • Promptly improve symptoms of RA Side Effects Nursing Considerations • Increased appetite • Weight gain • Water/salt retention • Increased blood pressure • Thinning of skin • Depression • Mood swings • Muscle weakness • Osteoporosis • Delayed wound healing • Onset/worsening of diabetes • Take medications as directed (adrenal suppression) • Encourage diet high in protein, calcium, potassium and low in sodium and carbohydrates • Discuss body image • Discuss risk for infection
Supportive devices Braces casts splints walkers crutches • • Support injured joints and weak muscles Improve joint mobility and stability Help to alleviate pain, swelling and muscle spasm May prevent further damage and deformity
• • Spring – loaded braces Resting splints Functional splints Dynamic splints
Application of heat and cold packs Application of HEAT may be applied by means of • Hydrocollator packs (retains heat ) • Paraffin baths • Electric heating pads • Warm soaks or showers Application of cold packs and ice packs (15 to 20 min) will reduce swelling, pain and stiffness.
Exercise • Walking • Light jogging • Water aerobics • Cycling • Yoga • Tai chi • stretching 4 times a week for 30 minutes
Nutrition The most commonly observed vitamin and mineral deficiencies in patients with RA are: o folic acid o vitamin C o vitamin D o vitamin B 6 o vitamin B 12 o vitamin E o calcium o magnesium o zinc
Alternative Medicine Olive leaf extract Aloe Vera Green Tea Omega 3 Ginger Root Extract
Surgical management Goals • Prevention or correction of deformity • Relief from pain • To relieve symptoms • Prevent joint destruction • Maintain joint and muscle function • Promote quality of life
Procedure Definition Indication Arthroscopy Endoscopic examination of a joint Diagnosis of RA, synovectomy, removal of bone osteophytes Arthrotomy Opening of joint Exploration of joint, drainage of joint and removal of damaged tissues
ARTHROPLASTY Reconstruction of joint • Interposition Replacement of part of joint with prosthesis or with soft tissue • Hemiarthroplasty Replacement of one articular surface • Total Replacement Complete joint is replaced Restore motion, relieve pain, correct deformity
Synovectomy Removal of part or all synovial membrane Osteotomy Cutting bone to change its alignment • Increases function of the joint, Decreases pain and inflammation
Arthordesis Surgical fusion of joint by removal of articular hyaline cartilage, introduction of bone grafts, and stabilization with internal or external fixation devices Tendon Moving tendon from transplants its anatomic position
Nursing management • Pain r/d inflammation, tissue damage • Fatigue related to pain , emotional stress • Impaired physical mobility related to weakness, lack of improper use of ambulatory devices • Deficient self care related to contractures • Disturbed sleep pattern • Disturbed body image • Ineffective coping
Interventions • • • Relieving pain and discomfort Reducing fatigue Increasing mobility Self care Improving sleep Improving body image and coping skills Monitoring and managing complications Increasing knowledge of disease management Follow up care
Osteoarthritis (OA) Osteoarthritis is defined as “a degenerative joint disease characterized by destruction of the articular cartilage, inflammation of joints and overgrowth of bone”
CAUSES or risk factors • Idiopathic – primary OA • Resulted from previous joint injury or inflammation – secondary OA • Age – elderly, Usually seen in the 50 -70 years • Obesity • Excessive weight • Family history
• Congenital structural defects – (leg clave perthes disease – osteochondritis of head of the femur in children) • Metabolic disturbances (diabetes mellitus, acromegaly, pagets disease) • Repeated intra articular hemorrhage (hemophilia) • Neuropathic arthropathy (charcot’s joints) • Excessive use of stress on joints (knees of football players)
Pathophysiology OA affects the articular cartilage and leads to chondrocyte response , subchondral bone (bony plate that supports cartilage) and synovium the articular
Pathologic changes • Erosion of articular cartilage • Thickening of subchondral bone • Formation of osteophytes or bone spurs
• Due to etiological factors • Degenerative changes cause the normally smooth, white joint cartilage to become yellow and opaque with rough surfaces • Chondrocyte response – release of cytokines and proteolytic enzymes due to inflammation • As cartilage become thinner the bony surfaces are drawn closer together • Cartilage break down and fissures may develop • As cartilage is thinned, the subchondral bone increases in density and become sclerotic • New bone outgrowth (osteophytes) will forms at
Signs & Symptoms of OA • Joint pain – sharp pain is caused by inflamed joint, stretching of the joint or irritation of nerve endings • Crackling noise - crepitus • Spasms and contractions • Stiff joints in the morning • Joint swelling • Loss of joint flexibility or strength
• Heberdens nodes – hard bony enlargements on distal interphalangeal joints • Bouchards nodes – hard bony enlargements on proximal interphalangeal joints • Stiffness is most common – morning and lasts about 30 min • Coxarthrosis – pain in the hip on weight bearings progressing to groin and knee
Diagnosis Physical examination History collection X-rays - osteophytes MRIs Joint Aspirate Lab tests- ESR
Management Aim • Symptomatic relief and control of pain • Prevention of progression and disability and restoration of joint function
Non-Pharmacological Management • Exercise (isometric and aerobic exercise) • Weight reduction • Heat & Cold Therapy • Use of assistive devices • Prevention of injuries • Perinatal screening
• Massage, yoga, Tai-chi • Transcutaneous electrical nerve stimulation (TENS) • pulsed electromagnetic fields • Accupunture , Acupressure • Wearing copper bracelets or magnets
Pharmacological Management • Goal – symptom management and pain control
Acetaminophen 1 g four times daily NSAIDs Opioids Corticosteroids Topical analgesics – capsaicin and methyl salicylate Glucosamine and chondroitin – drugs which helps in cartilage development and pain relief • Viscosupplementation – injection into the joint (intra articular injection) with gel like substance (hyaluronates) – have properties of synovial fluid. • • •
Surgical Management • Osteotomy • Arthrodesis • Arthroplasty – Total knee replacement – Total hip replacement
Nursing management Post operative care of patient with total hip replacement Positioning • Flexion is avoided to 60 degrees for 6 -7 days, then 90 degrees for 2 -3 months. • No adduction is permitted beyond midline for 2 – 3 months. Therefore, no sidelying on operative side • Leg maintained in abduction when lying supine • No extreme internal or external rotation is permitted.
Wound care • Drains are inserted in wound to prevent formation of hematoma and left in place for 24 to 48 hrs • Note amount and types of drainage • Use aseptic techniques • Following initial dressing, change dressing once daily using sterile technique • Observe the incision line for signs of infection • Wound kept open if no drains • Staples are removed 7 -10 days postoperatively
Activity • Encourage periodic elevation and lowering of head of bed to provide motion at hip (follow restrictions) • Instruct patient in use of overhead trapeze to shift weight and lift for bedpan and change linen • Encourage active dorsi/plantar flexion exercise of ankles • Patient may turned to unoperative side with operative leg maintained to abduction and extension
• Begin ambulation as early as possible , If tolerated • Observe flexion and adduction restrictions • Observe weight- bearing restrictions (only partial weight bearing with crutches is allowed)
Medication • Prophylactic anticoagulant drug to decrease risk of thrombus formation • Control pain
Discharge instructions • Patient must use ambulatory aid, avoid adduction, and avoid hip flexion to 90 degree for about 2 -3 months • A raised toilet seat is to be obtained • Explain about the life long antibiotic prophylaxis after prosthesis implantation to prevent infections
Postoperative care of person with total knee replacement Positioning • The operative leg is elevated in pillows to enhance venous return for the first 48 hours • Pillows are place with caution not to flex the knees • The patient may turned from side to back to side
Wound care • Same as hip replacement • Assess for loss of blood if bulky compression dressing is used (it can hold large quantities of drainage) • Bulky dressing are removed before the patient begins active flexion • Assess wound for healing and signs of infection
Activity • Passive flexion in a CPM (continuous passive motion)machine within prescribed flexion – extension limits • Patients leg may remain in machines as much as tolerated (up to 12 -15 hrs per day ) • Encouraged to perform active dorsi/plantar flexion of the ankles and after the drain is removed, straight leg raising exercises • Partial weight bearing with assistive devices is allowed
• Sitting in chair with legs elevated • Encouraged to wear resting knee extension splint (immobilizer) on the operative extremity
Pain control • Initial control with medications • Ice is usually applied to the knee to reduce swelling and pain • Patient encouraged to apply ice to knee for 20 to 30 min before and after active flexion exercise
Discharge instructions • Patient must observe partial weight bearing restriction • Use ambulatory aid for min 2 months • Continue active flexion and straight leg raising exercises at home • Aware of life long need of antibiotic prophylaxis
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