RHEUMATOID ARTHRITIS

INTRODUCTION

RA is a chronic autoimmune disorder whose major distinctive features is chronic symmetrical & erosive inflammation of the synovial tissue of joints.The incidence of RH is estimated to range from 0.5 -1.5%of the population. After age 55

the incidence rates for men & women are est. to be 2% &5% resp.

DEFINITION

Rheumatoid arthritis is a chronic ,systemic, inflammatory disease

involving connective tissue and characterized by destruction and

proliferation of the synovial membrane ,resulting in joint

distraction ,ankylosis and deformity .

RISK FACTORS AND ETIOLOGY

• IMMUNE SYSTEM

• GENDER

• GENETICS

PATHOPHYSIOLOGY• STAGE 1

• STAGE 2

• STAGE 3

• STAGE 4

PATHOPHYSIO;

STAGE 1• SWELLING OF SYNOVIA OF JOINTS• PAIN • STIFFNESS• X-RAY CAN’T DIAGNOSE RA IN

THIS STAGE

STAGE 2• In this stage ,pannus gradually develops.this

layer of granulated tissue derived from synovial memb extending over the articular surface .It appears reddish ,rough and adheres tightly to the underlying cartilage by incision & lysis interfering with cartilage nutrition

STAGE 3• Fibrous ankylosis(stiffnes of joint) with

subluxation(dislocation) &distortion(alteration of real shape) of the affected joint .

• Granulation(division of hard tissue into pieces) tissue become invaded with tough fibrous tissue & is converted to scar tissue .It inhibits joint movement.

STAGE 4• Bony ankylosis (firm bony union) developed.• It is developed by the fibrous tissue

calcification.• Then changes into osseous tissue .

SIGN AND SYMPTOMS

• INITIAL SYMP: -malaise -weight loss -stiffness -vague periarticular painJOINT TENDERNESSA SWAN NECK DEFORMITYCARPAL TUNNEL SYNDROME SJOGREN’S SYNDROMEFELTY’S SYNDROME

SWAN NECK DEFORMITY;

• Swan neck deformity is a deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it (DIP hyperflexion with PIP hyperextension). It is commonly caused by injury or inflammatory conditions like rheumatoid arthritis or sometimes familial (congenital, like Ehlers-Danlos syndrome [1]).

BOUTONNIERE’S SYNDROME

• Boutonniere deformity is a deformed position of the fingers or toes, in which the joint nearest the knuckle (PIP) is permanently bent toward the palm while the furthest joint (DIP) is bent back away (PIP flexion with DIP hyperextension). It is commonly caused by injury[1] or by an inflammatory condition…..

CARPAL TUNNEL SYNDROME

• Carpal tunnel syndrome is a condition in which there is pressure on the median nerve -- the nerve in the wrist that supplies feeling and movement to parts of the hand. It can lead to numbness, tingling, weakness, or muscle damage in the hand and fingers.

SJOGREN’S SYNDROME

• Sjögren's syndrome also known as "Sicca syndrome",[1] is a systemic autoimmune disease in which immune cells attack and destroy the exocrine glands[2] that produce tears and saliva.

FELTY’S SYNDROME

• The symptoms of Felty's syndrome are similar to those of rheumatoid arthritis. Patients suffer from painful, stiff, and swollen joints, most commonly in the joints of the hands, feet, and arms. In some affected individuals

CONTD.• COCK UP TOES• NEUROMASCULAR-peripheral

neuropathy.• PULMONARY-pleuritis, bronchiolitis,

& interstitial lung disease. • CARDIAC-

pericarditis,myocarditis,coronary vasculitis.

COCK- UP TOES

CONTD.• HEMATOLOGIC-

anemia,lymphoma.• DERMATOLOGIC-palmar

erythma, subcutaneous nodules, smallvessel vasculitis.• OCULAR-scleritis,retinal

nodules.

SCLERITIS

LAB .DIAGNOSIS• RF an Ig M antibody is seen in the sera of

75% of pt.with RA.• Antinuclear antibody are seen in 20% pt.

with RA.• E.S.R is elevated both in acute & chronic

stages of disease.• A moderate anemia is often present which

is hypochromic normocytic.

Contd.• Slight inc. in W.B.C• Platelet count is elevated.• JOINT FLUID EXAM.-ITt is valuable. The

fluid is translucent to opaque and has between 30,000 – 50,000 W.B.C/microlitr.

• X-RAY- not sensitive .Mostly negative in first 6 mnths.

CONTD.• C-REACTIVE PROTEIN –It is widely used to monitor

disease coarse. Its levels get increasedto >0.7 picograms\ml.

• Hb –slightly decreased.

• LFT –Alkaline phosphatase slightly elevated.

MED . MANAGEMENT• NSAIDS

• COX-2 INHIBITORS

• CORTICOSTEROIDS

• DMARD’S

NSAIDS• Eg.DICLOFENAC ,

IBUPROFEN ,NAPROXEN,OXAPROXEN.

• NSG.CONSIDERATIONS;• Admn.NSAIDS with food .• Monitor for

g.i ,CNS ,cardiovascular,renal,hematologic &dermatologic adverse effects.

• Avoid salcylates-use ecetaminophen for additional analgesia.

• Watch for possible confusion in elderly.

COX-2 INHIBITORS• Eg.

CELOCOXIB,ROFECOXIB ,VALDECOXIB

• NSG.CONSIDERATIONS;• Same monitoring as for other nsaids • Appropriate for the elerly & pt’s who are

at high risk for gastric ulcers

CORTICOSTEROIDS

• Eg. PREDNISONE, PREDNISOLONE ,HYDROCORTISONE.

• NSG. CONSIDERATIONS;• Assess for toxicity –cataract,

G.I,irritation ,hyperglycemia,hypertension,fractures,avascular necrosis psycosis.

• Joints most amenable to injections include ankles, hips, shoulders &hands.

• Repeated injections can cause joint damage.

DMARD’S

• Eg. ANTIMALARIALS (HYDROXYCHLOROQUINE)

• GOLD CONTAINING COMP’S (AUROTHIOGLUCOSE, GOLD SODIUM THIOMALATE)

• PENICILLAMINE

SURGICAL MNG.• SYNOVECTOMY (surgical removal of a

part of the synovial membrane of a synovial joint)• ARTHRODESIS (artificial induction of

joint ossification between two bones via surgery.)

•OSTECTOMY (removal of bone)• ARTHROPLASTY ("surgical

repair of joint)

JOINT PROTECTION & SUPPORTIVE MX

•

PRINCIPLESPain that lasts more than 2 hr indicates joint

damage.• Maintain muscle strength and joint range of

motion .• Wear splints and abraces.• Protect and provide rest to very weak or

unstable joints • During activity ,provide external stability to

an unstable joint.

Contd.• Avoid tight grasp.• Don’t carry heavy bags and pails.• Use adaptive equipments such as jar openers.• Use built up handles or writing stensils,pot handles.• Avoid pressure gainst the radial side of each finger.• Don’t rest your chin on the sides of your fingers

• Avoid prolonged periods of holding the same position.

• Sit,if the task takes more than 10 min.• Stand up after sitting for 20-30 min .• Reposition yourself often.

NSG. MANAGEMENT

• NSG. DIAGNOSIS:

• PAIN R/T INFLAMMATORY AND SWELLING SECONDARY TO THE DISEASE PROCESS.

• IMPAIRED PHYSICAL MOBILITY R/T PAIN,STIFFNESS & JOINT DEFORMITIES.

• SELF CARE DEFICIT R/T LIMITATION SECONDARY TO THE DISEASE PROCESS.

• ALTERED SLEEP PATTERN R/T DISEASED PROCESS .• DISTURBANCES IN SELF-CONCEPT R/T ALTERED BODY

IMAGE AND ROLE PERFORMANCE.