2.11.2007

NCP Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease involving connective tissue and characterized by destruction and proliferation of the synovial membrane, resulting in joint destruction, ankylosis, and deformity.

Although the cause is unknown, researchers speculate that a virus may initially trigger the body’s immune response, which then becomes chronically activated and turns on itself (autoimmune response). Immunologic mechanisms appear to play an important role in the initiation and perpetuation of the disease in which spontaneous remissions and unpredictable exacerbations occur. RA is a disorder of the immune system and, as such, is a whole-body disease that can extend beyond the joints, affecting other organ systems, such as the skin and eyes.

CARE SETTING

Community level unless surgical procedure is required.

RELATED CONCERNS

Psychosocial aspects of care

Total joint replacement

Patient Assessment Database

Data depend on severity and involvement of other organs (e.g., eyes, heart, lungs, kidneys), stage (i.e., acute exacerbation or remission), and coexistence of other forms of arthritis/autoimmune diseases.

ACTIVITY/REST

May report: Joint pain and tenderness worsened by movement and stress placed on joint; morning stiffness (duration often l hr or more), usually occurs symmetrically

Functional limitations affecting ADLs, desired lifestyle, leisure time, and occupation

Fatigue; sleep disturbances

May exhibit: Malaise

Impaired ROM of joints; particularly hand (fingers and wrist), hips, knees, ankles, elbows, and shoulders

Muscle atrophy; joint and muscle contractures/deformities

Decreased muscle strength, altered gait/posture

CARDIOVASCULAR

May report: Intermittent pallor, cyanosis, then redness of fingers/toes before color returns to normal (Raynaud’s phenomenon)

EGO INTEGRITY

May report: Acute/chronic stress factors (e.g., financial, employment, disability, relationship factors)

Hopelessness and powerlessness (incapacitating situation)

Threat to self-concept, body image, personal identity (e.g., dependence on others)

FOOD/FLUID

May report: Inability to obtain/consume adequate food/fluids (temporomandibular joint [TMJ] involvement)

Anorexia, nausea

May exhibit: Weight loss

Dryness of oral mucous membranes, decreased oral secretions; dental caries (Sj√∂gren’s syndrome)

HYGIENE

May report: Varying difficulty performing self-care activities; dependence on others

NEUROSENSORY

May report: Numbness/tingling of hands and feet, loss of sensation in fingers

May exhibit: Symmetrical joint swelling

PAIN/DISCOMFORT

May report: Acute episodes of pain (may/may not be accompanied by soft-tissue swelling in joints)

Chronic aching pain and stiffness (mornings are most difficult)

May exhibit: Red, swollen, hot joints (during acute exacerbations)

SAFETY

May report: Difficulty managing homemaker/maintenance tasks

Persistent low-grade fever

Dryness of eyes and mucous membranes

May exhibit: Pale, shiny, taut skin; subcutaneous rounded, nontender nodules; lesions, leg ulcers

Skin/periarticular local warmth, erythema

Decreased muscle strength, altered gait, reduced ROM

SEXUALITY

May report: Deficulty engaging in sexual activity as desired/abstinence

SOCIAL INTERACTION

May report: Impaired interactions with family/others; change in roles; isolation

TEACHING/LEARNING

May report: Familial history of RA (in juvenile onset)

Usual onset between ages 25 and 50, ratio of women to men 3:1

Use of health foods, vitamins, untested arthritis “cures”

History of pericarditis, valvular lesions; pulmonary fibrosis, pleuritis

Discharge plan

DRG projected mean length of inpatient stay: 5.4 days

May require assistance with transportation, self-care activities, and homemaker/maintenance tasks; changes in physical layout of home

Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

Antinuclear antibody (ANA) titer: Screening test for rheumatic disorders, elevated in 25%–30% of RA patients.

Follow-up tests are needed for the specific rheumatic disorders, e.g., anti-RNP is used for differential diagnosis of systemic rheumatic disease.

Rheumatoid factor (RF): Positive in more than 80% of cases (Rose-Waaler test).

Latex fixation: Positive in 75% of typical cases.

Agglutination reactions: Positive in more than 50% of typical cases.

Serum complement: C3 and C4 increased in acute onset (inflammatory response). Immune disorder/exhaustion results in depressed total complement levels.

Erythrocyte sedimentation rate (ESR): Usually greatly increased (80–100 mm/hr). May return to normal as symptoms improve.

CBC: Usually reveals moderate anemia. WBC is elevated when inflammatory processes are present.

Immunoglobulin (Ig) (IgM and IgG): Elevation strongly suggests autoimmune process as cause for RA.

X-rays of involved joints: Reveals soft-tissue swelling, erosion of joints, and osteoporosis of adjacent bone (early changes) progressing to bone-cyst formation, narrowing of joint space, and subluxation. Concurrent osteoarthritic changes may be noted.

Radionuclide scans: Identify inflamed synovium.

Direct arthroscopy: Visualization of area reveals bone irregularities/degeneration of joint.

Synovial/fluid aspirate: May reveal volume greater than normal; opaque, cloudy, yellow appearance (inflammatory response, bleeding, degenerative waste products); elevated levels of WBCs and leukocytes; decreased viscosity and complement (C3 and C4).

Synovial membrane biopsy: Reveals inflammatory changes and development of pannus (inflamed synovial granulation tissue).

NURSING PRIORITIES

1. Alleviate pain.
2. Increase mobility.
3. Promote positive self-concept.
4. Support independence.
5. Provide information about disease process/prognosis and treatment needs.

DISCHARGE GOALS

1. Pain relieved/controlled.
2. Patient is dealing realistically with current situation.
3. Patient is managing ADLs by self/with assistance as appropriate.
4. Disease process/prognosis and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.