Rheumatoid Arthritis

What is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a chronic autoimmune disease that mostly affects joints causing pain, swelling, stiffness and loss of functions in the joint. It occurs when the body`s own immune system attack the tissue lining of the joints. It usually affects both sides of the body, thus, when it affects one side, the other side may get affected as well. Affecting same joint at both sides distinguish RA from other types of arthritissuch as osteoarthritis.The exact cause of RA is unknown. RA can damage the cartilage (joint shock absorbers) when inflammation is left uncontrolled and can further leads to bone erosion and joint deformity. RA can also affect other body parts such as the heart, skin, lungs, eyes and mouth in addition to the joints.

What Causes Rheumatoid Arthritis?

The exact cause of RA is unknown but it is thought to be caused by a combinations of factors such as genetics, hormonal and environmental factors. Specific cells in the immune system triggers the attack and they are produce in the joints. Other factors such as smoking, infections, stressors may also trigger the attack and cause symptoms.

Types of Rheumatoid Arthritis

Seropositive rheumatoid arthritis:This is the most common type of RA. As the name suggest, the real form of RA. It may involve in genetics factor that run in families. Symptoms are more severe than seronegative RA.

Seronegative RA:This is when you have tested negative for rheumatoid factor (RF) and the antibody called cyclic citrullinated peptides (CCP), but you’re still experiencing symptoms of RA. Symptoms are milder in this type.

Juvenile idiopathic arthritis (JIA):As the name suggests, this is a form of RA in occurs in kids and teens below age 16.

Pathophysiology of Rheumatoid Arthritis

A combination of factors including genetics and environmental factors aid the process of RA development. The immune system is thought to protect the body against diseases and infections. In the processes of RA, the immune system attacks the tissues of the body and end up in the joints causing inflammation in the inner lining of the joint synovium. As inflammation progresses, the synovium thickens due to several factors in the joint such as increased in cells and protein productions, causing pain, swelling, redness and warmth. As a result, the inflamed and thickened synovium pushes into the joint and destroy the bone and cartilage within the joint capsule. The surrounding structures (ligaments, tendons and muscles) stabilizing the joint become weak overtime. This further leads to intense pain and further damages as the joint moves during activities.

Signs & Symptoms of Rheumatoid Arthritis

Signs and symptoms of RA may vary from mild to severe, they are;

• Fever as a result of infection
• Pain, tenderness, swelling and stiffness in one or more joints
• Pain that worse with joint movement
• Stiffness after sitting for long periods
• Stiffness in the morning
• Pain and stiffness in the same joints at both sides of the body
• Fatigue
• Loss of appetite
• Decreases movement as a result of weakness

Diagnostic Investigations & Test

• Physical examination
• History taking
• Blood test for the following investigation to look out for inflammation and proteins
• Rheumatoid factor (RF) antibodies
• Cyclic citrullinated peptide (CCP) antibodies
• Erythrocyte sedimentation rate (ESR)
• C-Reactive protein (CRP)
• Imaging studies such as X-Ray, ultrasound, MRI
• Joint aspiration - a small fluid sample is taken from a swollen joint to look for signs of infection or gout.
• Nodule biopsy - tissue samples are taken to look out for cancer or other abnormal cells.

Rheumatoid Arthritis Treatment

There is no cure for RA. However, early diagnosis and treatment options (medications and therapies) can help manage symptoms and control inflammation responses to eliminate painful episodes and improve quality of life. The goal of treatment is to reduce joint pain and swelling. Medications include;

• Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, hydroxychloroquine, and sulfasalazine
• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Corticosteroids
• Biologics
• Splints to help protect the joints and strengthen weak joints.
• Physical therapy to help increase the strength and movement of the affected joints

Nursing Management of Rheumatoid Arthritis

The subsequent measures are essential for effectively caring for patients with Rheumatoid Arthritis

• Cradle to take the weight of the bed clothes off the affected limb
• Ensure patient conserves enough energy
• Keep the legs straight if involved with a pillow behind the knees
• Adequate rest during the acute episode, well ventilated room and a comfortable bed devoid of creases
• Firm back support during the day
• Immobilize acute painful joint with light plastic splint

• Encourage patient to use prescribed mobility aids
• Ensure both general and therapeutic exercises
• Assist patient to perform active exercises to maintain muscle strength and joint mobility
• Inform the physiotherapist after pain and swelling have subsided
• Teach patient proper positioning to prevent flexion contractures of hips, knees and neck.

• Serve nutritious diet high in omega III fatty acids from fish oils e.g. salmon, high protein, iron and vitamin C
• Give vitamin and iron to correct anaemia
• Encourage weight loss if patient is obese

• Monitor Temperature, Pulse, Respiration, Blood pressure and record.
• Report deviations promptly to the nurse in - charge or physician.
• Look out for possible side effects and drug reaction and treat them promptly
• Check for toxic reactions of drugs such as dermatitis, agranulocytosis or nephritis

• Serve drugs as prescribed e.g. Gold salt.
• Serve initial dose to 10mg to check for drug reaction.
• Give injection of 50mg weekly to a total of 1g
• Repeat after some months
• Test urine for protein before each injection is given

• Give wax bath to reduce stiffness
• Give warm bath
• Ensure other personal hygiene for your client

• Maintain a supportive relationship
• Discuss nature of disease and positive expectations of treatment
• Encourage patient to set goals and assist him with the long term management
• Adopt a positive but realistic attitude towards your patient
• Do all you can to modify or adapt to stressors
• Ensure much independent in your patient during activities of daily living
• Encourage patient to participate in social activities such as hobbies and family activities
• Allow patient to take part in decision making involving treatment plan.

• Reassure patient that a severe disability is unlikely and can play a full part in the community.
• Teach patient and family on the disease condition for their understanding
• Advise on alteration of periods of work with exercise and rest
• Ensure maintenance of independence in patient
• Adhere to drug schedule
• Perform exercise
• Try to conserve energy
• Protect joints from further damage
• Advise patient on diet, activity, sex, drugs and variety of other issues
• Provide booklets on the condition to patient
• Assist client to join self - helped groups and welfare organization

Preventions of Rheumatoid Arthritis

Differential Diagnosis

• Psoriatic Arthritis
• Osteoarthritis
• Polymyalgia Rheumatic
• Chronic Gouty Arthritis
• Systemic Lupus Erythematosus