COLLEGE OF NURSING, ILBS

INSTITUTE OF LIVER AND BILIARY SCIENCES

SEMINAR
ON
EVIDENCE BASED IN
RHEUMATOID ARTHRITIS

SUBMITTED TO : MS TARIKA SHARMA

LECTURER, CON
ILBS

SUBMITTED BY: B SUPRIYA CHHETRY

MSc NURSING 1st year
ILBS COLLEGE OF NURSING
SUBMITTED ON :

CASE SCENARIO

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50 years old man with no significant past medical history develops progressive pain and swelling
of the small joints of both his hands. He complains about morning stiffness of several hours’
duration. He finds it increasingly difficult to engage in activities that require him to use his hands
(cigarettes rolling, painting). During the next 4 years his shoulders, knees, ankles and feet begin
to be affected by arthritis, with his hands begin to deform.

INTRODUCTION

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by inflammatory arthritis and
extra-articular involvement. It is a chronic inflammatory disorder caused in many cases by the interaction
between genes and environmental factors, including tobacco, that primarily involves synovial joints. It
typically starts in small peripheral joints, is usually symmetric, and progresses to involve proximal joints
if left untreated Joint inflammation over time leads to the destruction of the joint with loss of cartilage and
bone erosions. Rheumatoid arthritis with a symptom duration of fewer than six months is defined as early
Rheumatoid arthritis, and when the symptoms have been present for more than six months, it is defined
as established Rheumatoid arthritis. Rheumatoid arthritis if untreated, is a progressive disease with
morbidity and increased mortality.

There is no pathognomonic laboratory test for rheumatoid arthritis, which makes the diagnosis of this
disease challenging in the early stages. A comprehensive clinical approach is required to make the
diagnosis and prevent debilitating joint damage. The treatment of patients with rheumatoid arthritis
requires both pharmacological and non-pharmacological therapy. Today, the standard of care is early
treatment with disease-modifying anti-rheumatic drugs. Despite treatment, many patients progress to
disability and suffer significant morbidity over time. A comprehensive pharmacological and non-
pharmacological treatment (physical therapy, counseling, and patient education) is required to improve
clinical outcomes.

DEFINITION

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Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease characterized by
inflammation of connective tissue in the diarthrodial (synovial) joints, typically with periods of
remission and exacerbation.

EPIDEMIOLOGY:

The worldwide prevalence of RA in the Global Burden of Disease 2010 Study is about 0.24%. The
prevalence of RA is higher in Western and Northern Europe, North America, and other regions with
people of European descent, such as Australia. The prevalence is lower in Central and South America and
even lower in East Asia and Africa. The annual incidence of RA in the United States and other western
nations of northern Europe is about 40 per 100,000 persons. According to epidemiologic data, RA is
more prevalent in women compared to men, with a lifetime risk of RA of 3.6% in women compared to
1.7% in men. RA risk also increases with age, with a peak incidence between age 65 to 80 years of
age. A systematic review of population-based studies (including 60 studies) showed a worldwide period
prevalence of RA of 0.51% (1955-2015).

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Prevalence of RA (period prevalence 1955-2015)

Continent/Number of Studies/RA Pooled Prevalence (95%CI)

North America 10 0.70% (0.57-0.86)

Europe 26 0.54% (0.50-0.59)

Africa 3 0.52% (0.00-1.74)

Asia 26 0.30% (0.23-0.37)

South America 2 0.30% (0.09-0.62)

Global 67 0.46% (0.39-0.54)

ETIOLOGY:

The exact cause of rheumatic arthritis is unknown

There are several things that may increase risk of developing rheumatoid arthritis, including:

GENES – There's some evidence that rheumatoid arthritis can run in families, although the risk
of inheriting it is thought to be ls genes are only thought to play a small role in the condition

HORMONES – Rheumatoid arthritis is more common in women than men, which may be
because of the effects of the hormone oestrogen, although this link has not been proven

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 SMOKING – Some evidence suggests that people who smoke have an increased risk of
developing rheumatoid arthritis

RISK FACTORS FOR RHEUMATOID ARTHRITIS

Researchers have studied a number of genetic and environmental factors to determine if they
change a person’s risk of developing Rheumatoid arthritis.

 Age. can begin at any age, but the chance of developing rheumatoid arthritis increases with age.
The onset of rheumatoid arthritis is highest among adults in their sixties.

 Sex. Women are two to three times more likely to develop rheumatoid arthritis than men.

 Smoking. Multiple studies show that people who smoke have a higher risk of developing
rheumatoid arthritis. It can also make the disease worse.

 History of live births. Women who have never given birth may have a greater risk of
developing rheumatoid arthritis.

 Early Life Exposures. Some early life exposures may increase risk of developing rheumatoid
arthritis in adulthood. For example, one study found that children whose mothers smoked had
double the risk of developing rheumatoid arthritis when they were adults. Adults whose parents
had a lower income are at increased risk of developing rheumatoid arthritis.

 Obesity. Being obese can increase the risk of developing rheumatoid arthritis . Studies
examining the role of obesity also found that the more overweight a person was, the higher his or
her risk of developing rheumatoid arthritis became.

 Genetics/inherited traits. People born with specific genes are more likely to develop
rheumatoid arthritis . Also, these genes, called HLA (human leukocyte antigen) class II

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genotypes, can also make your arthritis worse. The risk of RA may be highest when people with
these genes also smoke or have obesity.
PATHOPHYSIOLOGY

STAGES OF RHEUMATOID ARTHRITIS

Anatomic Stages of Rheumatoid Arthritis
Stage 1: Early:
No destructive changes on X-ray, possible X-ray evidence of osteoporosis

Stage 2: Moderate:
X-ray evidence of osteoporosis, with or without slight bone or cartilage destruction; no joint
deformities (although possibly limited joint mobility); adjacent muscle atropi possible
presence of extra-articular soft tissue lesions (eg, nodules, tenosynovitis)

Stage 3: Severe
X-ray evidence of cartilage and bone destruction in addition to osteoporosis; joint deformity,
such as subluxation, ulnar deviation, or hyperextension, without fibrous or bony ankylosis;

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 extensive muscle atrophy; possible presence of extra-articular soft tissue lesions (eg, nodules,
tenosynovitis)

Stage4: Terminal
Fibrous or bony ankylosis, stage 3 criteria

Rheumatoid arthritis A:
Early pathologic change in theumatoid arthritis is rheumatoid synovitis. The synovium is
inflamed. There is a great inc lymphocytes and plasma cells.

Rheumatoid arthritis B
With time, there is articular cartilage destruction: vascular granulation tissue grows are the
surface of the cartilage ( from the edges of the joint, and the articular surface shows loss of
cartilage beneath the extending pannus, most marked at the joint margins.

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Rheumatoid arthritis C:
Inflammatory pannus causes focal destruction of bone. At the edges of the joint there is
osteolytic destruction of bone, responsible for erosions seen on X-rays. This p associated with
joint deformity.
Rheumatoid arthritis D:
Characteristic deformity and soft tissue swelling associated with long-standing rheumatoid
disease of the hands. With Rheumatoid arthritis there are times when symptoms get worse,
known as flares, and times when symptoms get better, known as remission.

COMPARISON OF RHEUMATOID ARTHRITIS AND

OSTEOARTHRITIS
PARAMETER RHEUMATOID OSTEOARTHRITIS
ARTHRITIS

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Age at onset Gender Young to middle age Usually >40 yr of age

Female/male ratio is 2:1 or Before age 50, more men

3:1; less marked gender than women; after age 50,
difference after age 60 more women than men

Weight Lost or maintained weight Often overweight

Disease Systemic disease with Localized disease with

exacerbations and remissions variable, progressive course

Small joints first (PIPS, Weight-bearing joints of

Affected joints MCPS, MTPs), wrists, knees and hips, small joints
elbows, shoulders, knees; (MCPS, DIPs, PIPS), cervical
usually bilateral, symmetric and lumbar spine; often
asymmetric Stiffness occurs
Pain characteristics Stiffness lasts 1 hr to all day on arising but usually
and may decrease with use, subsides after 30 min, pain
pain is variable, may disrupt gradually worsens with joint
sleep use and time, lessens with
rest
Effusions Common
Uncommon
Nodules Present, especially on
extensor surfaces Heberden's (DIPs) and
Bouchard's (PIPS) nodes
Synovial fluid
WBC count>20,000/μl with WBC count <2000/μl (mild
mostly neutrophils leukocytosis)
X-rays
Joint space narrowing and Joint space narrowing,
erosion with bony osteophytes, subchondral
overgrowths, subluxation cysts, sclerosis
with advanced disease;
osteoporosis related to
corticosteroid use
Laboratory findings
Rheumatoid fever positive
in 80% of patients Elevated Rheumatoid negative
ESR, CRP indicative of Transient elevation in ESR
active inflammation related to synovitis
Common Signs and symptoms of RA include:

 Pain or aching in more than one joint

 Stiffness in more than one joint
 Tenderness and swelling in more than one joint

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  The same symptoms on both sides of the body (such as in both hands or both knees)
 Weight loss
 Fever
 Fatigue or tiredness
 Weakness

Medical History

 About patient symptoms, when and how they started, and how it has changed over time.

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 What limitations in activities may have, such as difficulty with work, leisure, or activities
around the house
 About other medical problems.
 If patient have any family members with similar symptoms or if any family members have
rheumatoid arthritis.
 What medications patient take.

Physical Examination

In physical examination a physical exam that may include:

 Examining joints for

 Watching how patient walk, bend, and carry out activities of daily living.
 Looking for a rash or nodules on your skin.
 Listening to chest for signs of inflammation in the lungs.

Laboratory Tests

Lab tests may help to diagnose rheumatoid arthritis. Some common tests include:

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 Rheumatoid factor (RF):

This Blood Test Checks For Rheumatoid Factor. An Antibody That Many People With
Rheumatoid Arthritis Can Eventually Have In Their Blood. An Antibody Is A Special Protein
Made By The Immune System That Normally Helps Fight Invaders In The Body. Not All People
With Rheumatoid arthritis test Positive For RF; Some People Test Positive For RF But Never
Develop The Disease; And Some People Test Positive But Have Another Disease. However,
Doctors Can Use This Test, Along With Other Test Results And Evaluations, To Diagnose
Rheumatoid Arthritis

 Anti-cyclic citrullinated peptide antibody (anti-CCP):

This blood test checks for anti-CCP antibodies, which appear in many people with rheumatoid
arthritis. In addition, anti-CCP can appear before RA symptoms develop, which can help doctors
diagnose the disease early. This test’s results, along with the results from RF blood tests, are very
useful in confirming a rheumatoid arthritis diagnosis. However, it is important to know that some
people have rheumatoid arthritis even with normal blood tests.

 Complete blood count:

This blood test measures different blood cell counts and can help diagnose anemia, which is
common in people with Rheumatoid arthritis.

 Erythrocyte sedimentation rate (often called the sed rate):

This test measures inflammation in the body and monitors disease activity and response to
treatments.

 C-reactive protein:

This is another common test for inflammation that can help diagnose rheumatoid arthritis and
monitor disease activity and response to treatments.

Other blood tests.

It may also use other tests to check like kidney function, electrolytes, liver function, thyroid
function, muscle markers, other autoimmune markers, and markers of infection to evaluate for
overall health and evaluate for other diagnoses. Other specific tests for rheumatoid arthritis, are
sometimes considered.

IMAGING TESTS
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 To check for joint damage, doctors may use imaging tests such as:

 X-rays:

It help check for RA; however, they are not generally abnormal in the early stages of rheumatoid
arthritis, before joint damage occurs. Doctors may use x-rays to monitor the progression of the
disease or to rule out other causes for the joint pain.

 Magnetic resonance imaging (MRI) and ultrasound :

It may help diagnose rheumatoid arthritis in the early stages of the disease. In addition, these
imaging tests can help evaluate the amount of damage in the joints and the severity of the
disease.

 Other imaging tests sometimes considered for rheumatoid arthritis include computed
tomography (CT) scanning, positron emission tomography (PET) scan, bone scan, and dual-
energy X-ray absorptiometry (DEXA).

Evidence-based recommendations for the diagnosis and management of rheumatoid

arthritis for non-rheumatologists: Integrating systematic literature research and expert
opinion of the Thai Rheumatism Association
Wanruchada Katchamart 1, Pongthorn Narongroeknawin 2, Parawee Chevaisrakul 3, Pornchai
Dechanuwong 4, Ajanee Mahakkanukrauh 5, Nuntana Kasitanon 6, Rattapol
Pakchotanon 2, Kittiwan Sumethkul 7, Parichat Ueareewongsa 8, Sittichai Ukritchon 9, Thitirat
Bhurihirun 1, Kittikorn Duangkum 5, Porntip Intapiboon 8, Samanan Intongkam 2, Wimol
Jangsombatsiri 3, Kanon Jatuworapruk 6, Naravadee Kositpesat 9, Pawinee
Leungroongroj 3, Wiyanoot Lomarat 2, Chonachan Petcharat 1, Siriluck
Sittivutworapant 7, Patcharawan Suebmee 5, Pongchirat Tantayakom 1, Worakan Tipsing 4, Paijit
Asavatanabodee 2, Praveena Chiowchanwisawakit 1, Chingching Foocharoen 5, Ajchara
Koolvisoot 1, Worawit Louthrenoo 6, Boonjing Siripaitoon 8, Kitti Totemchokchyakarn 3, Tasanee
Kitumnuaypong 7; Thai Rheumatism Association

Abstract
Aim: Rheumatoid arthritis (RA) is a chronic inflammatory joint disease leading to joint damage,
functional disability, poor quality of life and shortened life expectancy. Early diagnosis and
aggressive treatment are a principal strategy to improve outcomes. To provide best practices in
the diagnosis and management of patients with RA, the Thai Rheumatism Association (TRA)
developed scientifically sound and clinically relevant evidence-based recommendations for
general practitioners, internists, orthopedists, and physiatrists.
Methods: Thirty-seven rheumatologists from across Thailand formulated 18 clinically relevant
questions: three for diagnosis, 10 for treatments, four for monitoring, and one for referral. A
bibliographic team systematically reviewed the relevant literature on these topics up to
December 2013. A set of recommendations was proposed based on the results of systematic

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 reviews combined with expert opinions. Group consensus was achieved for all statements and
recommendations using the nominal group technique.
Results: A set of recommendations was proposed. For diagnosis, either American College of
Rheumatology (ACR) 1987 or ACR/European League Against Rheumatism 2010 classification
criteria can be applied. For treatment, nonsteroidal anti-inflammatory drugs, glucocorticoid, and
disease-modifying antirheumatic drugs, including antimalarials, methotrexate and sulfasalazine
are recommended. Physiotherapy should be suggested to all patients. Tight control strategy and
monitoring for efficacy and side effects of treatments, as well as indications for referral to a
rheumatologist are provided.
Conclusions: These evidence-based recommendations provide practical guidance for diagnosis,
fundamental management and referral of patients with RA for non-rheumatologists. However, it
should be incorporated with clinical judgments and decisions about care for each individual
patient.

TREATMENT OF RHEUMATOID ARTHRITIS

Treatment of rheumatoid arthritis continues to improve, which can give many people relief from
symptoms, improving their quality of life. The following options to treat Rheumatoid Arthritis
are :

1. Medications management
2. Physical therapy and occupational therapy.
3. Surgery.
4. Routine monitoring and ongoing care.
5. Complementary therapies.
6. Nursing management

It may recommend a combination of treatments, which may change over time based on
symptoms and the severity of disease. No matter which treatment plan recommends, the overall
goals are to help:

 Relieve pain.
 Decrease inflammation and swelling.
 Prevent, slow, or stop joint and organ damage.
 Improve your ability to participate in daily activities.

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Rheumatoid arthritis may start causing joint damage during the first year or two that a person has
the disease. Once joint damage occurs, it is generally cannot be reversed, so early diagnosis and
treatment are very important.

MEDICATIONS MANAGEMENT

Most people who have treatment of rheumatoid arthritis

Treatment of rheumatoid arthritis continues to improve, which can give many people relief from
symptoms, improving their quality of life. It may recommend a combination of treatments, which
may change over time based on your symptoms and the severity of disease. No matter which
treatment plan recommends, the overall goals are to help:

 Relieve pain.
 Decrease inflammation and swelling.
 Prevent, slow, or stop joint and organ damage.
 Improve your ability to participate in daily activities.

Rheumatoid arthritis may start causing joint damage during the first year or two that a person has
the disease. Once joint damage occurs, it is generally cannot be reversed, so early diagnosis and
treatment are very important.

MEDICATIONS

Most people who have Rheumatoid arthritis take medications. Studies show that early treatment
with combinations of medications, instead of one medication alone, may be more effective in
decreasing or preventing joint damage. Many of the medications that prescribe to treat
Rheumatoid arthritis help decrease inflammation and pain, and slow or stop joint damage. They
may include:

 Anti-inflammatory medications to provide pain relief and lower inflammation.

 Corticosteroids that can help decrease inflammation, provide some pain relief, and slow joint
damage. Because they are potent drugs and have potential side effects, will prescribe the
lowest dose possible to achieve the desired benefit.
 Disease-modifying anti-rheumatic drugs (DMARDs) that can help to slow or change the
progression of the disease.
 Biologic response modifiers, which are also DMARDs, if disease does not respond to
initial therapies. These medications target specific immune messages and interrupt the
signal, helping to decrease or stop inflammation.
 Janus kinase (JAK) inhibitors, which are also DMARDs, send messages to specific cells to
stop inflammation inside the cell. These medications may also be considered if disease
does not respond to initial therapies.

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 Physical Therapy and Occupational Therapy

 It may recommend physical therapy and occupational therapy. Physical therapy can help to
regain and maintain overall strength and target specific joints that bother .
 Occupational therapy can help develop, recover, improve, as well as maintain the skills needed
for daily living and working.
 Sometimes, assistive devices or braces may be helpful to optimize movement, reduce pain, and
help to maintain the ability to work.

SURGERY

It may recommend surgery if patient have permanent damage or pain that limits patient ability
to perform day-to-day activities. Surgery is not for everyone.

It will consider the following before recommending surgery:

 overall health.
 The condition of the affected joint or tendon.
 The risks and benefits of the surgery.

Types of surgery

JOINT REPAIRSJoint reconstruction surgery is a medical procedure that involves the repair of a
damaged joint. It ranges from minor repairs to total joint replacement, and it can provide pain relief and
permanent solutions to joint disorders. Most of the time, this surgical procedure involves the hips, knees,
ankles, elbows, shoulders, or fingers

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 ARTHROSCOPY

Arthroscopy is procedure which is minor repairs to joints through a small incision and with the
use of a tiny fiber-optic camera function. It is a minimally invasive treatment option. This
procedure enables the surgeon to alleviate pressure in a stiff joint, to remove bone spurs, and to
trim tissues that are causing harm to the joint. This type of surgical procedure common involves
the knees, hips, and shoulders.

JOINT REPLACEMENTS:
Joint replacement surgeries may either be total or partial, depending on your condition. With this
type of surgery, replaces damaged joint with a prosthesis. The prosthetic joint is a specially made
artificial joint that consists of medical-grade plastic, metal, and/or ceramic parts designed to
move like a regular joint. Unlike the other reconstructive surgeries, this surgical procedure is
more complicated and is for treating severe joint pain or dysfunction in the hip, shoulder, or
knee.

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 LIVING WITH JOINT REPLACEMENT

 Following a relatively short period of recovery after surgery, patients undergoing joint
replacement surgery typically return to a high level of activity.

 Speed of recovery following surgery depends on your level of activity before surgery,
general health and overall physical fitness, degree and duration of physical impairment

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 before surgery, the type of surgery you had, and your expectations and motivation.
Physical therapy and occupational therapy after joint replacement are very important.

 Long term physical limitations after surgery are nearly always due to other orthopedic or
rheumatologic problems (significant arthritis in other joints, chronic low back pain) or
major health problems (heart, breathing, other chronic illnesses) rather than due to any
limitations of the joint replacement.

 In general, those undergoing hip and knee replacements can return to unlimited low
impact activities such as swimming, water exercise, walking, biking, low impact
aerobics, golf, and doubles tennis.

 Most orthopedic surgeons advise against high impact and joint overloading activities that
involve heavy lifting, running, and jumping. However, many patients resume their
normal activities of daily living following hip or knee replacement without limitation.

 Although patients typically obtain a functional amount of motion following hip

replacement surgery, occasionally the limits of motion of a total hip replacement can be
exceeded, resulting in dislocation out of its normal position. Patient education and an
understanding of the limitations of total hip replacement, especially regarding the
potential for dislocation and range of motion restrictions, can help minimize the
occurrence of this complication. Patients should be encouraged to discuss specific
limitations, precautions, and activity restrictions following total joint replacement with
their surgeons

ROUTINE MONITORING AND ONGOING CARE

Regular medical care is important because it can:

 Monitor how the disease is progressing.

 Determine how well the medications are working.
 Talk to patient and family members about any side effects from the medications.
 Adjust treatment as needed.

Monitor pf patient condition it also may include blood and urine tests, and x-rays or other
imaging tests. Having rheumatoid arthritis increases risk of developing osteoporosis,
particularly if patient take corticosteroids. Osteoporosis is a bone disease that causes the bones
to weaken and easily break. Need to explain patient about your risk for the disease and the
potential benefits of calcium and vitamin D supplements or other osteoporosis treatments.

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 Since rheumatoid arthritis can affect other organs, it is also necessary to monitor for
cardiovascular or respiratory health. Many of the medications used to treat rheumatoid
arthritis may increase the risk of infection. Patient may monitor for infections. Vaccines may
be recommended to lower the risk and severity of infections.

LIVING WITH RHEUMATOID ARTHRITIS

Research shows that people who take part in their own care report less pain and make fewer
doctor visits. They also enjoy a better quality of life.

Self-care can help play a role in managing your Rheumatoid arthritis and improving the
patient health. Patient can:

 Learn about rheumatoid arthritis and its treatments.

 Use exercises and relaxation techniques to reduce pain and help stay active.
 Communicate well with health care team so can have more control over disease.
 Reach out for support to help cope with the physical emotional, and mental effects of
rheumatoid arthritis.

Participating in care can help build confidence in ability to perform day-to-day activities,
allowing to lead a full, active, and independent life.

LIFESTYLE CHANGES

Certain activities can help improve ability to function on their own and maintain a positive
outlook.

REST AND EXERCISE.

Balance rest and exercise, with more rest when Rheumatoid arthritis is active and more
exercise when it is not. Rest helps to decrease active joint inflammation, pain, and fatigue. In
general, shorter rest breaks every now and then are more helpful than long times spent in bed.
Exercise is important for maintaining healthy and strong muscles, preserving joint mobility,
and maintaining flexibility. Exercise can help:

 Improve sleep.
 Decrease pain.
 Keep a positive attitude.
 Maintain a healthy weight.

Patient may sometimes recommend low-impact exercises, such as water exercise programs.

JOINT CARE.

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Some people find wearing a splint for a short time around a painful joint reduces pain and
swelling. People use splints mostly on wrists and hands, but also on ankles and feet. Patient must
provide knowledge before wearing a splint. Other ways can protect joints include:

 Using self-help devices, such as items with a large grip, zipper pullers, or long-handled
shoehorns.
 Using tools or devices that help with activities of daily living, such as an adaptive
toothbrush or silverware.
 Using devices to help get on and off chairs, toilet seats, and beds.
 Choosing activities that put less stress on joints, such as limiting the use of the stairs or
taking rest periods when walking longer distances.
 Maintaining a healthy weight to help lower the stress on joints.

MONITORING OF SYMPTOMS.

It is important to monitor symptoms for any changes or the development of new symptoms.
Patient Understanding symptoms and how they may change can help to manage pain when
patient have a flare.
 Stress management. The emotions may feel fear, anger, and frustration, along with any
pain, physical limitations, and the unpredictable nature of flares – can increase patient
stress level. Stress can make living with the disease more difficult. Stress also may affect
the amount of pain feel. Ways to cope with stress can include:
o Regular rest periods.
o Relaxation techniques such as deep breathing, meditating, or listening to quiet
sounds or music.
o Movement exercise programs, such as yoga and tai chi.

MENTAL HEALTH MANAGEMENT.

 Living with Rheumatoid arthritis can be hard and isolating. Patient may feel alone, anxious,
or depressed about having the disease, advised patient to hyperventilated,their feeling to
their family and friends
 To seek for knowledge from health professional.

HEALTHY DIET.

A healthy and nutritious diet that includes a balance of calories, protein, and calcium is
important for maintaining overall health. Limiting about drinking alcoholic beverages
because they may interact with the medications patient take for rheumatoid arthritis.

NURSING MANAGEMENT :

Nursing management include nursing assessment, nursing diagnosis , outcome and intervention

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Subjective Data

Important Health Information

Past health history: Recent infections; presence of precipitating factors such as emotional
upset, infections, overwork, childbirth, surgery, pattern of remissions and exacerbations

Medications: Use of aspirin, NSAIDs, corticosteroids, DMARDs

Surgery or other treatments: Any joint surgery

Health Patterns

Health perception-health management: Positive family history for rheumatoid arthritis or

other autoimmune disorders; malaise, ability to participate in therapeutic regimen

Nutritional-metabolic: Anorexia, weight loss; dry mucous membranes of mouth and

pharynx

Activity-exercise: Stiffness and joint swelling, muscle weakness, difficulty walking,

fatigue

Cognitive-perceptual: Paresthesias of hands and feet; numbness, tingling, loss of

sensation; symmetric joint pain and aching that increases with motion or stress on joint

Objective Data

General

Lymphadenopathy, fever

Integumentary

Keratoconjunctivitis; subcutaneous rheumatoid nodules on forearm, elbows; skin ulcers;

shiny, taut skin over involved joints; peripheral edema

Cardiovascular

Symmetric pallor and cyanosis of fingers (Raynaud's phenomenon); distant heart sounds,
murmurs, dysrhythmias

Respiratory

Chronic bronchitis, tuberculosis, histoplasmosis, fibrosing alveolitis

Gastrointestinal

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 Splenomegaly (Felty syndrome)

Musculoskeletal

Symmetric joint involvement with swelling, erythema, heat, tenderness, and deformities;
enlargement of proximal phalangeal and metacarpophalangeal joints; limitation of joint
movement; muscle contractures, muscle atrophy

Possible Finding Positive rheumatoid factor, ↑ ESR, anemia; ↑ WBC in synovial fluid;
evidence of joint space narrowing, and bony erosion and deformity on X-ray
(osteoporosis with advanced disease)

NURSING CARE PLAN

NURSING DIAGNOSIS GOALS OUTCOME INTERVENTIONS

AND RATIONALES
NURSING  Effectively Pain Control  Perform a
DIAGNOSIS :Chronic uses comprehensive
pain related to joint analgesics  Uses assessment of
inflammation, overuse and preventive pain to include
of joints, and nonanalge measures location,
ineffective pain and/or sic relief  Uses characteristics,

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comfort measures a measures nonanalge onset/ duration,
communication of pain  Verbalizes sic relief frequency,
descriptors, guarding satisfactor measures quality,
behavior, and limited y pain  Uses intensity or
joint function; hot, control analgesics severity of
swollen, painful joints appropriat pain, and
ely precipitating
 Reports factors to
uncontroll establish a
ed pattern and
symptoms baseline
to health assessment and
care to plan
profession appropriate
al interventions.
 Report  Evaluate, with
pain patient and
controlled health care
team,
effectiveness
of past pain-
control
measures that
have been used
to determine
what has
helped and not
helped in the
past.
 Reduce or
eliminate
factors that
precipitate or
increase the
pain
experience
(e.g., fear,
fatigue, and
lack of
knowledge) to
minimizenegati
ve stimuli that
may increase
pain.
 Teach use of
nonpharmacolo

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 gic techniques
(e.g.,
relaxation,
distraction,
hot/cold
applications,
and massage)
before pain
occurs or
increases, and
along with
other pain
relief
measures, to
promote
muscle
relaxation and
decrease
tension.

 Provide the
person with
optimal pain
relief with
prescribed
analgesics to
help decrease
pain and
inflammation.

Impaired physical mobility  Performs Mobility  Exercise

related to joint pain, stiffness, prescribed Therapy: Joint
and deformity as evidenced by joint Joint movement Mobility
limitation of joint motion, exercises  Determine
strength, and endurance; to Muscle limitations of
inability to perform routine maintain movement joint
activities of daily living and movement and
improve Moves with ease effect on
joint function to
function Endurance establish
 Uses joint baseline for
protection Performance of plan of care.
measures usual routine  Collaborate
to prevent with physical

25
increased therapy in
joint Muscle endurance developing and
inflammati executing an
on Activity exercise
program to
maintain and
improve joint
function.
 Explain to
patient/family
the purpose
and plan for
joint exercises
to provide
information
and support for
the patient.
Initiate pain-
control
measures
before
beginning joint
exercise
(e.g..hot packs,
warm shower)
to relieve
stiffness and
increase
mobility.
 Assist patient
to optimal
body position
for
passive/active
joint
movement
(e.g., with
correct
application of
resting splints,
selection of
properly fitting
footwear, and
selection and
use of assistive
devices) to

26
 prevent or limit
joint deformity

Disturbed body image related  Discusses Body Image Identity effects of

to chronic disease activity, feelings patient's culture,
long-term treatment, about the Internal picture of religion, race, sex, and
deformities, stiffness, and meaning self age in terms of body
inability to perform usual of in image to determine
activities as evidenced by physical Congruence extent of problems and
social withdrawal, flat affect,  Verbalizes between body plan appropriate
altered self-concept, and acceptance reality, body interventions.
reduced sexual interest of body ideal, and body
appearanc presentation
e and
function Description of Adjustment to changes
 Identifies affected body part in physical appearance
communit Adjustment to changes
y Adjustment to in body function
resources changes in
for sexual physical Assist patient to
counseling appearance discuss changes
for self caused by illness or
and Adjustment to surgery to identify
partner change in body problems and plan
function appropriate
interventions.

Assist patient to
separate physical
appearance from
feelings of personal
worth so a positive
body image is fostered
in spite of physical
manifestations

Facilitate contact with

individuals with
similar changes in
body image to
promote sharing and
socialization for
patient.

27
 Sexual Counseling

Refer patient to sex

therapist as sexual
problems and concerns
can

have a serious impact

on body image.
Include spouse/sexual
partner in counseling
as much as possible to
encourage
communication.

SUMMARY AND CONCLUSION:

Rheumatoid arthritis is a debilitating, chronic, inflammatory disease, capable of causing joint

damage as well as long-term disability. Early diagnosis and intervention are essential for the
prevention of serious damage and loss of essential bodily functions. Furthermore, early referral
to a specialist can help to ensure better treatment outcomes. With advances in the field of
molecular medicine, we have a better understanding of disease mechanisms which can aid in the
designing of more effective treatments of Patients with Rheumatoid arthritis also benefit from
physical and occupational therapy. It is recommended that they perform exercise regularly to
maintain joint mobility and strengthen the muscles around the joints. Movement exercises that
are less traumatic for joints but good for muscle strength include swimming, yoga, and tai chi.
Applying heat- and cold-packs before and after exercise minimizes painful symptoms.

RECENT ADVANTAGEMENT

Recent Advances in the Treatment of Rheumatoid

Arthritis
Tina D. Mahajan, M.D.1 and Ted R. Mikuls, M.D., M.S.P.H.1,2

Author information Copyright and License information Disclaimer

28
The publisher's final edited version of this article is available at Curr Opin
Rheumatol

Abstract

Purpose of Review:

Therapies for rheumatoid arthritis (RA) continue to expand rapidly. The purpose of this review is
to discuss novel treatment options, including biosimilars, that are available, as well as to
highlight promising agents in development. The purpose is also to discuss new emerging safety
signals associated with these drugs and to discuss strategies in tapering therapy.

Recent Findings:

There are several novel RA therapies. These include the interleukin 6 receptor blocker sarilumab,
which was approved in 2017. In aggregate, the sarilumab studies show that it is effective in RA,
including patients with incomplete responses to methotrexate and anti-tumor necrosis factor
inhibitor, showing superior efficacy when used in higher dose (200 mg every two weeks) to
standard-dose adalilumab. The two biosimilar drugs currently approved are CT-P13 and SB2,
which are based on the reference product infliximab. Other drugs that are currently being studied
include the interleukin-6 cytokine blocker sarikumab, the small targeted molecule filgotinib, and
many new biosimilars. Baracitinib failed to achieve approval by the FDA primarily over
perceived safety concerns. Although this review summarizes trials examining biologic tapering,
additional data is needed to guide clinicians in regards to treatment de-escalation in RA.

Summary:

With the greatly expanded armamentarium of RA treatment options available, it is important for
clinicians to understand the data regarding drug efficacy and safety. With remission increasingly
attainable, effective drug tapering strategies are needed. While tapering trials do exist, more
studies will be needed to help guide clinical practice.

Keywords: rheumatoid arthritis, treatment, biosimilar, sarilumab, tapering

Accelerated nodulosis and systemic manifestations during methotrexate therapy for rheumatoid
arthritis

29
 B Combe 1, C Didry, M Gutierrez, J M Anaya, J Sany
Affiliations expand

 PMID: 8261056

Abstract

Objectives: Methotrexate is successfully used in the treatment of arthritis but little is known
about its effects on extra-articular manifestations of rheumatoid arthritis. We focused this work
on the incidence and clinical course of extra-articular manifestations during long-term treatment
with methotrexate.

Methods: The effect of methotrexate on extra-articular manifestations was investigated in 176

patients with rheumatoid arthritis who had obtained, in a prospective study, a good clinical
response to methotrexate (10 mg/week) taken for 33 months (range 4-68).

Results: Before taking methotrexate, 44 patients (25.1%) had extra-articular manifestations:

nodules (n = 40) and vasculitis (n = 9). With methotrexate, nodulosis and vasculitis were stable
in 31 cases, improved in 3 and worsened in 10 (23%). Among the 132 patients without extra-
articular manifestations before methotrexate therapy, 15 (11%) developed accelerated nodulosis
preferentially located on the fingers, 7 had a vasculitis and 3 a pericarditis during methotrexate
therapy. Extra-articular manifestations occurred between 1 and 24 months of initiating
methotrexate therapy. Rheumatoid factor was positive in 88% of the patients with extra-articular
manifestations. No relationship was noted between extra-articular manifestations and HLA type
or antinuclear antibodies. In 3 out of 4 patients who developed accelerated nodulosis while
taking methotrexate, the addition of hydroxychloroquine (400 mg/day) resulted in a significant
reduction in the number and size of the nodules within 3 to 10 months after starting combined
therapy.

Conclusion: These data suggest that methotrexate is not effective in the treatment of extra-
articular manifestations in rheumatoid arthritis and that nodulosis may occur in about 11% of
patients taking methotrexate therapy for rheumatoid arthritis. The combination of
hydroxychloroquine and methotrexate may have a beneficial effect on nodulosis that needs to be
evaluated

References

1. l.lewis, s. (2011). medical surgical nursing. texas: elsevier.

30
2. Mahajan, T. D., & Mikuls, T. R. (2018). Recent advances in the treatment of rheumatoid
arthritis. Current opinion in rheumatology, 30(3), 231–237.
https://doi.org/10.1097/BOR.0000000000000496

3. Combe, B., Didry, C., Gutierrez, M., Anaya, J. M., & Sany, J. (1993). Accelerated
nodulosis and systemic manifestations during methotrexate therapy for rheumatoid
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