n325 rheumatoid arthritis · 2019. 8. 23. · 2/25/16 6 clinicalmanifestations! joints!!...
Post on 11-Mar-2021
2 Views
Preview:
TRANSCRIPT
2/25/16
1
Rheumatoid Arthritis Chapter 65
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Rheumatoid Arthritis (RA) § Chronic, systemic autoimmune
disease § Inflammation of connective tissue in
diarthrodial (synovial) joints § Periods of remission and exacerbation § Extraarticular manifestations
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Rheumatoid Arthritis (RA) § Affects all ethnic groups § Incidence ↑ with age, peaks 30–50
years old § 1.3 million Americans § Women > men
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
2
Case Study
• T.S. is a 40-‐year-‐old woman who presents to the clinic with fatigue, morning stiffness, and painful swelling of her fingers.
• The health care provider suspects rheumatoid arthritis (RA).
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Case Study
• In preparation for teaching T.S. about this disease process, you decide to quickly review its etiology and pathophysiology.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Case Study
• What causes RA?
• Describe the pathophysiology of RA.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
2/25/16
3
Etiology and Pathophysiology § Autoimmune etiology
§ Combination of genetics and environmental triggers
§ Antigen triggers formation of abnormal immunoglobulin G (IgG)
§ Autoantibodies develop against the abnormal IgG § Rheumatoid factor (RF)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Etiology and Pathophysiology § Rheumatoid factor combines with IgG
immune complexes → deposit on synovial membranes or cartilage in joints → activates complement → inflammatory response
§ Neutrophils → proteolytic enzymes → damage cartilage and thicken synovial lining
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Etiology and Pathophysiology § T helper cells (CD4) activated →
stimulate monocytes, macrophages, and synovial fibroblasts → secrete proinflammatory cytokines § Interleukin-‐1 (IL-‐1) § Interleukin-‐6 (IL-‐6) § Tumor necrosis factor (TNF)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
4
Pathologic Changes in Rheumatoid Arthritis
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Etiology and Pathophysiology § Genetic link
§ Higher incidence in identical twins § HLA-‐DR4 and HLA-‐DR1 antigens § Smoking increases risk in patients
genetically predisposed
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study • The results of T.S.’s hand x-‐rays demonstrate no significant abnormality.
• In what stage would T.S.’s RA be classified?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
2/25/16
5
Etiology and Pathophysiology § Stage I: Early
§ No destructive changes on x-‐ray, possible x-‐ray evidence of osteoporosis
§ Stage II: Moderate § X-‐ray evidence of osteoporosis § No joint deformities, adjacent muscle
atrophy, possible presence of extraarticular soft tissue lesions
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Etiology and Pathophysiology § Stage III: Severe
§ X-‐ray evidence of cartilage and bone destruction in addition to osteoporosis; joint deformity; extensive muscle atrophy; possible presence of extraarticular soft tissue lesions
§ Stage IV: Terminal § Fibrous or bony ankylosis, stage III
criteria Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study • For what additional clinical manifestations of RA will you assess T.S.?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
2/25/16
6
Clinical Manifestations Joints § Onset typically insidious § Fatigue, anorexia, weight loss,
generalized stiffness § May report history of precipitating
event § Infection, stress, exertion, childbirth,
surgery
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Clinical Manifestations Joints § Specific articular involvement
§ Pain, stiffness, limitation of motion, and signs of inflammation
§ Symptoms occur symmetrically § Most often affects small joints § Larger joints and cervical spine may
be involved
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Clinical Manifestations Joints § Joint stiffness after inactivity § Morning stiffness 60 minutes to
several hours or longer § MCP and PIP joints typically swollen § Fingers spindle shaped § Joints tender, painful, warm to touch § Pain ↑ with motion, intensity varies
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
7
Clinical Manifestations Joints § Tenosynovitis § Deformity and disability § Subluxation § Walking disability
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Typical Deformities of Rheumatoid Arthritis
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Clinical Manifestations Extraarticular Manifestations § Rheumatoid nodules § Sjögren’s syndrome § Felty syndrome § Flexion contractures § Nodular myositis § Cataracts § Depression
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
8
Extraarticular Manifestations of Rheumatoid Arthritis
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study • What diagnostic testing would you expect the health care provider to order for T.S.?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Diagnostic Studies
§ Laboratory studies § Rheumatoid factor (RF) § Erythrocyte sedimentation rate (ESR) § C-‐reactive protein (CRP) § Antinuclear antibody (ANA) § Anti-‐citrullinated protein antibody (ACPA)
§ Synovial fluid analysis § X-‐rays of involved joints § Bone scan
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
9
Case Study
• T.S.’s lab results indicate positive RF and ANA.
• Her CRP and ESR are also elevated. • The health care provider tells T.S. she has rheumatoid arthritis.
• What medication(s) would you expect the health care provider to prescribe for T.S.?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Collaborative Care § Patient teaching
§ Drug therapy § Disease process § Home management strategies
§ NSAIDs § Physical therapy § Occupational therapy § Individualized treatment plan
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Drug Therapy: DMARDs § ↓ Permanent effects of RA
§ Methotrexate (Rheumatrex) § Sulfasalazine (Azulfidine) § Hydroxychloroquine (Plaquenil) § Leflunomide (Arava)
§ Monitor for bone marrow suppression and hepatotoxicity
§ Teratogenic Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
10
Drug Therapy: Biologic/Targeted Therapies § Tumor necrosis factor (TNF) inhibitors
§ Etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira), certolizumab (Cimzia), and golimumab (Simponi)
§ Bind with TNF, inhibiting inflammation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Drug Therapy: Biologic/Targeted Therapies § Tumor necrosis factor (TNF) inhibitors
§ TB test and chest x-‐ray before start of therapy
§ Monitor for infection § Avoid live vaccinations
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Drug Therapy: Biologic/Targeted Therapies § IL-‐1 receptor antagonist (IL-‐1Ra)
§ Anakinra (Kineret) § Given SQ; reduces pain and swelling
§ Tocilizumab (Actemra) § Blocks IL-‐6, a proinflammatory cytokine
§ Abatacept (Orencia) § Blocks T-‐cell activation
§ Rituximab (Rituxan) § Targets B cells
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
11
Drug Therapy
§ Antibiotics (minocycline [Minocin]) § Immunosuppressants (azathioprine
[Imuran]) § Penicillamine (Cuprimine) § Gold preparations (auranofin [Ridaura])
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Drug Therapy § Corticosteroid therapy
§ Intraarticular injections § Low-‐dose oral for limited time
§ NSAID and salicylates § Antiinflammatory, analgesic, and
antipyretic § May take 2 to 3 weeks for full
effectiveness
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nutritional Therapy § Balanced nutrition important § Loss of appetite or inability to shop for
and prepare food → weight loss § Corticosteroid therapy → weight gain
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
12
Surgical Therapy § Relieve severe pain § Improve function § Synovectomy § Total joint replacement (arthroplasty)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment § Subjective data
§ Recent infections, presence of precipitating factors, pattern of remissions and exacerbations
§ Use of aspirin, NSAIDs, corticosteroids, DMARDs
§ Any joint surgery
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment § Subjective data
§ Family history § Malaise § Ability to participate in therapeutic
regimen § Impact on functional ability § Anorexia, weight loss § Dry mucous membranes of mouth and
pharynx Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
13
Nursing Assessment § Subjective data
§ Stiffness and joint swelling, muscle weakness, difficulty walking, fatigue
§ Paresthesia of hands and feet § Loss of sensation § Symmetric joint pain and aching that ↑
with motion or stress on joint
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment
§ Objective data § Lymphadenopathy, fever § Keratoconjunctivitis § Rheumatoid nodules § Skin ulcers § Shiny, taut skin over joints § Peripheral edema
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment
§ Objective data § Raynaud’s phenomenon § Distant heart sounds, murmurs § Dysrhythmias § Chronic bronchitis, tuberculosis § Histoplasmosis, fibrosing alveolitis § Splenomegaly (Felty syndrome)
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
14
Nursing Assessment
§ Objective data § Symmetric joint involvement § Swelling, erythema § Heat, tenderness § Deformities § Joint enlargement § Limitation of movement § Muscle contractures; atrophy
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Assessment
§ Objective data § + Rheumatoid factor § ↑ESR § ↑ WBCs in synovial fluid § X-‐ray findings
§ Joint space narrowing § Bony erosion § Deformity § Osteoporosis
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Diagnoses § Impaired physical mobility § Chronic pain § Disturbed body image
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
15
Planning § Overall goals
§ Satisfactory pain management § Minimal loss of functional ability § Participate in therapeutic regimen § Maintain positive self-‐image § Perform self-‐care
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Implementation Health Promotion § Prevention not possible at this time § Early treatment to prevent further
joint damage § Community education programs
§ Symptom recognition to promote early diagnosis and treatment
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Implementation Acute Intervention § Primary goals in managing RA
§ Decrease inflammation § Manage pain § Maintain joint function § Prevent or correct joint deformity
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
16
Nursing Implementation Acute Intervention § Comprehensive program
§ Drug therapy § Balance of rest and activity § Joint protection § Heat and cold applications § Exercise § Patient and caregiver teaching
§ Multidisciplinary team
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Implementation Acute Intervention § Usually treated on an outpatient basis § Start with assessment
§ Physical § Psychosocial
§ Identify problems § Coordinate program for rehabilitation
and education § Multidisciplinary team
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Implementation Acute Intervention § Suppression of inflammation
§ NSAIDs § DMARDs § Biologic/targeted therapies
§ Patient teaching about medications § Timing of administration § Action and side effects § Compliance
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
17
Case Study
• What type of nondrug interventions can you teach T.S. about to help with her joint pain?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Nursing Implementation Acute Intervention § Nondrug relief of pain
§ Therapeutic heat and cold § Rest § Relaxation techniques § Joint protection § Biofeedback § Transcutaneous electrical stimulation § Hypnosis
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Nursing Implementation Acute Intervention § Lightweight splints
§ Removed at regular intervals § Perform ROM exercises § Reapply as prescribed
§ Occupational therapist → additional self-‐help devices
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
18
Nursing Implementation Acute Intervention § Plan care around morning stiffness § To relieve joint stiffness and ↑ ability
to perform ADLs § Sit or stand in warm shower § Sit in tub with warm towels around
shoulders § Soak hands in warm water
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
• What interventions can you teach T.S. related to her fatigue issues?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Ambulatory and Home Care Rest § Alternate rest periods with activity § Helps relieve pain and fatigue § Amount of rest varies § Avoid total bed rest § 8–10 hours of sleep + daytime rest § Modify activities to avoid overexertion
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
19
Ambulatory and Home Care Body Alignment § Firm mattress or bed board § Encourage positions of extension § Avoid flexion positions § No pillows under knees § Small, flat pillow under head and
shoulders
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
• What will you teach T.S. to help her protect her joints from further stress?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Ambulatory and Home Care Joint Protection § Modify tasks for less stress on joints § Energy conservation
§ Work simplification techniques § Pacing and organizing § Use of carts § Joint protective devices § Delegation
§ Occupational therapy § Assistive devices
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
20
Case Study
• T.S. asks you whether she should use ice or heat on her painful joints.
• How will you respond?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
iStockphoto/Thinkstock
Ambulatory and Home Care Heat and Cold Therapy § Relieve pain, stiffness, and muscle
spasm § Ice
§ Especially beneficial during periods of disease exacerbation
§ Application should not exceed 10–15 minutes at one time
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Ambulatory and Home Care Heat and Cold Therapy § Moist heat
§ Heating pads, moist hot packs, paraffin baths, warm baths or showers
§ Relieve stiffness § Should not exceed 20 minutes at a time § Be alert for burn potential
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
21
Ambulatory and Home Care Exercise § Individualized exercise plan to
§ Improve flexibility § Increase strength § Increase overall endurance
§ Reinforce program participation and ensure correct performance
§ Need both recreational and therapeutic exercise
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Ambulatory and Home Care Exercise § Gentle ROM exercises done daily to
keep joints functional § Aquatic exercises in warm water
beneficial § Limit to one or two reps during acute
inflammation
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Ambulatory and Home Care Psychologic Support § Patient teaching important
§ RA § Nature and course of disease § Goals of therapy
§ Consider value system and perception of disease
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
22
Ambulatory and Home Care Psychologic Support § Patient is constantly challenged by
problems of § Limited function and fatigue § Loss of self-‐esteem § Altered body image § Fear of disability or deformity
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Ambulatory and Home Care Psychologic Support § Discuss alterations in sexuality § Patient vulnerable to unproven or
even dangerous remedies § Help patient recognize fears and
concerns
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Ambulatory and Home Care Psychologic Support § Evaluation of family support system § Financial planning § Community resources may be
considered § Self-‐help groups are beneficial for
some patients § Strategies to decrease depression
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
2/25/16
23
Etanercept (Enbrel) is prescribed for a patient with stage II rheumatoid arthritis. The nurse determines that the medication is effective if what is observed? a. Decreased lymphocyte count b. Absence of Rh factor in the blood c. Decreased C-‐reactive protein (CRP) d. Increased serum immunoglobulin G
Audience Response Question
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
top related