NRU 5200 Advanced Practice Presentation Rheumatoid Arthritis Erin Whitley, BSN, RN.

NRU 5200 Advanced Practice Presentation

Rheumatoid ArthritisErin Whitley, BSN, RN

Rheumatoid Arthritis (RA)

Obj

ectiv

e 1 Identify the

classic presentation of RA.

Obj

ectiv

e 2 State the

benefit of early diagnosis and treatment of RA.

Obj

ectiv

e 3 Discuss

treatment options related to disease severity.

Objectives

- A chronic, autoimmune disease which involves inflammation of the joints

- Morning stiffness is a common finding

- Deformities form with disease progression


Introduction

Description

Introduction

Community Impact

Why selected

http://www.youtube.com/watch?v=BaUkvTScQ6Y

The Faces (and Hands) of Rheumatoid Arthritis- Occurs in approximately 1%- 2% of the population

- More common in women than men

- Onset is usually between ages 20-50

.





Pathophysiology

-Cause is unknown

-Antibody formation in the joint area results in inflammation in the joint area” (Cash 2011, pp 508).

-Not limited to joint issues


Subjective Findings:

Typical first signs:-Symmetrical joint pain and swelling-Morning stiffness for longer that 30 min-Small joints of the hands and feet-Fatigue


Patient Presentation

(Papadakis 2013 pp 826)

Subjective Findings continued:

Other findings-Rheumatoid Nodules-Dryness of the eyes, mouth and other mucous membranes-Interstitial lung disease-Pericarditis and pleural disease-Palmar erythema-Depression



(Papadakis 2013 pp 826)

Objective Findings:

-Observe patient’s movements-Watch for signs of depression-”Inspect all joints, noting deformities, erythema, and temperature” (Cash, 2011, pp 509).-Assess skin for edema and lesions-Auscultate the lungs



Objective Findings:

-Patellar tap to evaluate effusion of the knee-Palpate all joints to look for tenderness with pressure-Assess grip



American College of Rheumatology Criteria

Five of the following seven symptoms must be present:A. Morning stiffness longer that 1 hour

for more than 6 weeksB. Arthritis of at least 3 joint groups

with soft tissue swelling or fluid longer than 6 weeks


Criteria/Diagnostic Guidelines

(Cash 2011, pp 508)

American College of Rheumatology Criteria (continued)

C. Swelling of at least one of the following joints longer than 6 weeks: -proximal interphalangeal-metacarpophalaneal-wristsD. Symmetrical joint swelling longer

than 6 weeks


(Cash 2011, pp 508)


American College of Rheumatology Criteria (continued)

E. Subcutaneous nodulesF. Positive rheumatoid factor testG. Radiographic changes consistent with RA


(Cash 2011, pp 508)


Stage 1: No symptoms or signs, normal activity. Antigen Present

Stage 2: Morning stiffness, warmth at joint, normal activities of daily living, minimal limitation in joint use. Increase T cells, B cells, antibody production, and synovial cells.


Stages

(Cash 2011, pp 508)

Stage 3: Morning stiffness, warmth at joint, and extra articular manifestations. Marked limitation in activities of daily living. Increase T cells, B cells, antibody production, and synovial cells.

Stage 4: Same as 3 plus proliferating synovial membrane involved causing injury to the bone, tendons, and cartilage. Incapacitated or confined to wheelchair.


Stages

(Cash 2011, pp 508)

The primary goal is to decrease inflammation and prevent further damage.PharmacologicDisease-modifying antirheumatic drugs (DMARDs) should be started as soon as the diagnosis is made

-Methotrexate-Plaquenil


Interventions

DMARDs have a delayed onset of action and therefore should be accompanied by administration of a glycocorticosteroid (GC) such as Prednisone.

-Shown to have an immediate impact to stop disease progression and aid in the goal of remission.

-Due to side effects they should only be used short term.


Interventions

(Schneider 2013, pp 6)

Those patients that don’t respond to treatment with one or a combination of DMARDs may be trialed on biologic therapies.

-Humira, Remicade, etc.-used in those with moderate to severe RA.

Usually administered by the patient or a caregiver on a weekly or every other week schedule.


Interventions

Non-PharmacologicTreat Pain:

-Hot-Cold

Splints

Exercise/Activity


Interventions

Patient Education

Focus on:

Population involved

Treatment Options

Living with RA

Seeking early treatment from a Rheumatologist

www.rheumatology.org


http://www.rheumatology.org/

Conclusion

-Can be seen in any population

-Treatment focuses on preventing further damage

-New pharmacologic treatment options (biologics) make early treatment more effective in preventing disease progression

“Clinical remission, defined as the absence of significant signs and symptoms of inflammation with or without additional treatment, occurs in 20% or less of patients. In contrast, remission or achievement of low disease activity (LDA) , usually with continuing treatment, may be achieved in up to 75% of patients.” (Gibofsky 2012, pp 7)


References:Cash, J.C. & Glass, C.A. (2011). Chapter 19 Endocrine Guidelines. In

M. Zuccarini & G. Lee(Eds.). Family Practice Guidelines (pp. 508-510). New York, NY: Springer Publishing Company.

Gibofsky, A. (2012). Overview of Epidemiology, Pathophysiology, and Diagnosis of Rheumatoid Arthritis. The American journal of Managed Care, 18, 1-9. doi:S295-S302

Papadakis, M.A. & McPhee, S.J. (2013). Chapter 20 Musculoskeletal and Immunologic Disorders. In C. Diedrich, H. Lebowitz, B. Holton, & M.W. Rabow (Eds.). 2013 Current Medical Diagnosis & Treatment (pp. 826-830). New York, NY: McGraw-Hill

Companies.


References:Rheumatoid Patient Foundation. The Faces of Rheumatoid Disease-

Rheumatoid Arthritis. Available from http://www.youtube.com/watch?v=BaUkvTScQ6Y

Ruderman, E. & Tambar, S. (2012). In American College Of Rheumatology. Retrieved from http://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Rheumatoid_Arthritis/

Schneider, M. & Krüger, K. (2013). Rheumatoid Arthritis-Early Diagnosis and Disease Management. Deutsches Ärzteblatt International, 110, 1-10. doi:10.3238/arztebl.2013.0477



http://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Rheumatoid_Arthritis/





NRU 5200 Advanced Practice Presentation Rheumatoid Arthritis Erin Whitley, BSN, RN.

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