Rheumatoid Arthritis (RA)

  1. General information
    1. Chronic systemic disease characterized by inflammatory changes in joints and related structures
    2. Occurs in women more often than men (3:1); peak incidence between ages 35-45
    3. Cause unknown, but may be an autoimmune process; genetic factors may also play a role.
    4. Predisposing factors include fatigue, cold, emotional stress, infection.
    5. Joint distribution is symmetric (bilateral); most commonly affects smaller peripheral joints of hands and also commonly involves wrists, elbows, shoulders, knees, hips, ankles, and jaw.
    6. If unarrested, affected joints progress through four stages of deterioration: synovitis, pannus formation, fibrous ankylosis, and bony ankylosis.
  2. Medical management
    1. Drug therapy
      1. Aspirin: mainstay of treatment, has both analgesic and anti-inflammatory effect.
      2. Nonsteroidal anti-inflammatory drugs (NSAIDs): ibuprofen (Motrin), indomethacin (Indocin), fenoprofen (Nalfon), mefenamic acid (Ponstel), phenylbutazone (Butazolidin), piroxicam (Feldene), naproxen (Naprosyn), sulindac (Clinoril); relieve pain and inflammation by inhibiting the synthesis of prostaglandins
      3. Gold compounds (chrysotherapy)
        1. injectable form: sodium thiomalate (Myochrysine); aurothioglucose (Solganal); given IM once a week; take 3-6 months to become effective; side effects include proteinuria, mouth ulcers, skin rash, aplastic anemia; monitor blood studies and urinalysis frequently.
        2. oral form: auranofin (Ridaura); smaller doses are effective; take 3-6 months to become effective; diarrhea also a side effect with oral form; blood and urine studies should also be monitored.
      4. Corticosteroids
        1. intra-articular injections temporarily suppress inflammation in specific joints.
        2. systemic administration used only when client does not respond to less potent anti-inflammatory drugs.
      5. Methotrexate, Cytoxan given to suppress immune response; side effects include bone marrow suppression
    2. Physical therapy to minimize joint deformities
    3. Surgery to remove severely damaged joints (e.g., total hip replacement; knee replacement)
  3. Assessment findings
    1. Fatigue, anorexia, malaise, weight loss, slight elevation in temperature
    2. Joints are painful, warm, swollen, limited in motion, stiff in morning and after periods of inactivity, and may show crippling deformity in long-standing disease
    3. Muscle weakness secondary to inactivity
    4. History of remissions and exacerbations
    5. Some clients have additional extra-articular manifestations: subcutaneous nodules; eye, vascular, lung, or cardiac problems.
    6. Diagnostic tests
      1. X-rays show various stages of joint disease
      2. CBC: anemia is common
      3. ESR elevated
      4. Rheumatoid factor positive
      5. ANA may be positive
      6. C-reactive protein elevated
  4. Nursing interventions
    1. Assess joints for pain, swelling, tenderness, limitation of motion.
    2. Promote maintenance of joint mobility and muscle strength.
      1. Perform ROM exercises several times a day; use of heat prior to exercise may decrease discomfort; stop exercise at the point of pain.
      2. Use isometric or other exercise to strengthen muscles.
    3. Change position frequently; alternate sitting, standing, lying.
    4. Promote comfort and relief/control of pain.
      1. Ensure balance between activity and rest.
      2. Provide 1-2 scheduled rest periods throughout day.
      3. Rest and support inflamed joints; if splints used, remove 1-2 times/day for gentle ROM exercises.
    5. Ensure bed rest if ordered for acute exacerbations.
      1. Provide firm mattress.
      2. Maintain proper body alignment.
      3. Have client lie prone for 1/2 hour twice a day.
      4. Avoid pillows under knees.
      5. Keep joints mainly in extension, not flexion.
      6. Prevent complications of immobility.
    6. Provide heat treatments (warm bath, shower, or whirlpool; warm, moist compresses; paraffin dips) as ordered.
      1. May be more effective in chronic pain.
      2. Reduce stiffness, pain, and muscle spasm.
    7. Provide cold treatments as ordered; most effective during acute episodes.
    8. Provide psychologic support and encourage client to express feelings.
    9. Assist client in setting realistic goals; focus on client strengths.
    10. Provide client teaching and discharge planning concerning
      1. Use of prescribed medications and side effects
      2. Self-help devices to assist in ADL and to increase independence
      3. Importance of maintaining a balance between activity and rest
      4. Energy conservation methods
      5. Performance of ROM, isometric, and prescribed exercises
      6. Maintenance of well-balanced diet
      7. Application of resting splints as ordered
      8. Avoidance of undue physical or emotional stress
      9. Importance of follow-up care