Rheumatoid Arthritis Nursing Care Management and Study Guide

Rheumatoid arthritis is a chronic autoimmune disease that inflames joints, drives pain, and threatens function and independence. Care centers on controlling pain, managing fatigue, protecting joints and mobility, and watching for the toxic side effects of the drugs that treat it.

What is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is an autoimmune disease of unknown origin, classified as a diffuse connective tissue disease and chronic in nature. It is characterized by diffuse inflammation and degeneration in the connective tissues.

Pathophysiology

In RA, the autoimmune reaction occurs primarily in the synovial tissue. Phagocytosis produces enzymes within the joint that break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. The pannus destroys cartilage and erodes bone, leading to loss of articular surfaces and joint motion. Muscle fibers undergo degenerative changes, and tendon and ligament elasticity and contractile power are lost.

Statistics and Incidences

Rheumatoid arthritis affects 1% of the population worldwide. The ratio of female to male with RA is between 2:1 and 4:1.

Causes

Diffuse connective tissue diseases have unknown causes but are thought to result from immunologic abnormalities. People with a specific gene marker, the HLA shared epitope, have a fivefold greater chance of developing RA than people without it. Infectious agents such as bacteria and viruses may trigger the disease in a genetically susceptible person. 70% of people with RA are women, attributed to fluctuations in female hormones. Environmental factors include exposure to cigarette smoke, air pollution, and insecticides, and occupational exposures to substances such as silica and mineral oil.

Clinical Manifestations

Manifestations vary with the stage and severity of the disease. Joint pain is a classic sign, and painful joints are not easily moved. Swollen joints limit function. The affected joint is warm and feels spongy or boggy on palpation. Erythema signals inflammation. Pain limits mobility of the affected area. Deformities of the hands and feet may result from misalignment caused by swelling. Rheumatoid nodules, seen in more advanced RA, are nontender and movable in the subcutaneous tissue.

Complications

The drugs used for RA can cause serious adverse effects. Improper use of immunosuppressants can cause bone marrow suppression. Immunosuppressive agents such as methotrexate and cyclophosphamide are highly toxic and can produce anemia. Some NSAIDs cause gastric irritation and ulceration.

Assessment and Diagnostic Findings

Antinuclear antibody (ANA) titer is a screening test for rheumatic disorders, elevated in 25% to 30% of RA patients; followup tests are needed for the specific rheumatic disorders (anti-RNP for differential diagnosis of systemic rheumatic disease). Rheumatoid factor (RF) is positive in more than 80% of cases (Rose-Waaler test). Latex fixation is positive in 75% of typical cases. Agglutination reactions are positive in more than 50% of typical cases. Serum complement C3 and C4 increase in acute onset; immune disorder or exhaustion depresses total complement levels. Erythrocyte sedimentation rate (ESR) is usually greatly increased (80 to 100 mm/hr) and may return to normal as symptoms improve. CBC usually reveals moderate anemia, with WBC elevated when inflammatory processes are present. Immunoglobulin (Ig) elevation (IgM and IgG) strongly suggests an autoimmune process. X-rays of involved joints reveal soft-tissue swelling, erosion of joints, and osteoporosis of adjacent bone in early changes, progressing to bone-cyst formation, narrowing of joint space, and subluxation, with concurrent osteoarthritic changes possible. Radionuclide scans identify inflamed synovium. Direct arthroscopy reveals bone irregularities and degeneration of the joint. Synovial fluid aspirate may show volume greater than normal; an opaque, cloudy, yellow appearance; elevated WBCs and leukocytes; and decreased viscosity and complement (C3 and C4). Synovial membrane biopsy reveals inflammatory changes and development of pannus.

Medical Management

Management is aligned with each phase of RA. Balance rest and exercise. Refer to community agencies such as the Arthritis Foundation for support. Biologic response modifiers are an alternative approach, using a group of agents made of molecules produced by immune system cells that participate in the inflammatory reactions. A formal occupational and physical therapy program teaches joint protection, pacing activities, work simplification, range of motion, and muscle-strengthening exercises. Food selection should meet the daily requirements from the basic food groups, emphasizing foods high in vitamins, protein, and iron for tissue building and repair.

Pharmacologic Therapy

In early RA, NSAIDs and COX-2 medications block the enzyme involved in inflammation while leaving intact the enzyme that protects the stomach lining; methotrexate is the standard treatment because of its success in preventing both joint destruction and long-term disability; and additional analgesia may be prescribed for periods of extreme pain. In moderate, erosive RA, cyclosporine (Neoral), an immunosuppressant, is added to enhance the disease-modifying effect of methotrexate. In persistent, erosive RA, systemic corticosteroids are used for unremitting inflammation and pain or as a bridging medication while waiting for slower DMARDs to take effect. In advanced, unremitting RA, immunosuppressive agents are prescribed for their ability to affect antibody production at the cellular level, and low-dose antidepressants such as amitriptyline, paroxetine, or sertraline may be used short term to reestablish an adequate sleep pattern and manage chronic pain.

Surgical Management

For persistent, erosive RA, reconstructive surgery is often used and is indicated when pain cannot be relieved by conservative measures and loss of independence is imminent. Synovectomy is excision of the synovial membrane. Tenorrhaphy is suturing of a tendon. Arthrodesis is surgical fusion of the joint. Arthroplasty is surgical repair and replacement of the joint.

Nursing Management

Nursing Assessment

The history and physical examination address manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints. Assess for extra-articular changes including weight loss, sensory changes, lymph node enlargement, and fatigue.

Nursing Diagnosis

Based on the assessment data, major nursing diagnoses include acute and chronic pain related to inflammation and increased disease activity, tissue damage, fatigue, or lowered tolerance; fatigue related to increased disease activity, pain, inadequate sleep or rest, deconditioning, inadequate nutrition, and emotional stress or depression; impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, and lack or improper use of ambulatory devices; self-care deficit related to contractures, fatigue, or loss of motion; disturbed body image related to physical and psychological changes and dependency imposed by chronic illness; and ineffective coping related to actual or perceived lifestyle or role changes.

Nursing Care Planning and Goals

The major goals are improvement in comfort level, incorporation of pain management techniques into daily life, incorporation of strategies to modify fatigue as part of daily activities, attainment and maintenance of optimal functional mobility, adaptation to the physical and psychological changes imposed by the rheumatic disease, and use of effective coping behaviors for actual or perceived limitations and role changes.

Nursing Interventions

The patient with RA needs information about the disease to make self-management decisions and to cope with a chronic illness.

Relieving pain and discomfort: provide a variety of comfort measures (heat or cold, massage, position changes, rest, foam mattress, supportive pillow, splints, relaxation techniques, diversional activities); administer anti-inflammatory, analgesic, and slow-acting antirheumatic medications as prescribed; individualize the medication schedule to the patient's need for pain management; encourage verbalization of feelings about pain and chronicity; teach the pathophysiology of pain and rheumatic disease and help the patient recognize that pain often leads to unproven treatment methods; and assess for subjective changes in pain.

Reducing fatigue: instruct about fatigue by describing the relationship of disease activity to fatigue, describing comfort measures while providing them, developing a sleep routine (warm bath and relaxation techniques), and explaining the importance of rest for relieving systemic, articular, and emotional stress; teach energy conservation techniques (pacing, delegating, setting priorities); identify physical and emotional factors that cause fatigue; facilitate an appropriate activity and rest schedule; encourage adherence to the treatment program; refer to and encourage a conditioning program; and encourage adequate nutrition including iron from food and supplements.

Increasing mobility: encourage verbalization about limitations in mobility; assess the need for occupational or physical therapy consultation, emphasizing range of motion of affected joints, use of assistive ambulatory devices, safe footwear, and appropriate positioning and posture; assist the patient to identify environmental barriers; encourage independence in mobility, allowing ample time for activity, providing a rest period afterward, and reinforcing joint protection and work simplification; and initiate referral to a community health agency.

Facilitating self-care: help the patient identify self-care deficits and factors that interfere with self-care; develop a plan based on the patient's perceptions and priorities that incorporates joint protection, energy conservation, and work simplification (provide assistive devices, reinforce their correct and safe use, let the patient control the timing of self-care activities, and explore different ways to perform difficult tasks or enlist help); and consult community health agencies when the patient has reached a maximum level of self-care yet still has deficits, especially regarding safety.

Improving body image and coping skills: help the patient identify elements of control over symptoms and treatment; encourage verbalization of feelings, perceptions, and fears; identify areas of life affected by the disease and answer questions to dispel myths; and develop a plan for managing symptoms and enlisting support of family and friends.

Monitoring and managing potential complications: help the patient recognize and deal with medication side effects; monitor for GI tract bleeding or irritation, bone marrow suppression, kidney or liver toxicity, increased incidence of infection, mouth sores, rashes, and changes in vision, along with bruising, breathing problems, dizziness, jaundice, dark urine, black or bloody stools, diarrhea, nausea and vomiting, and headaches; and monitor closely for systemic and local infections, which can be masked by high doses of corticosteroids.

Teaching points: focus teaching on the disease, possible changes, the prescribed therapeutic regimen, medication side effects, strategies to maintain independence and function, and home safety; encourage the patient and family to verbalize concerns and ask questions; address pain, fatigue, and depression before starting a teaching program, since they interfere with learning; and instruct the patient about basic disease management and necessary lifestyle adaptations.

Continuing care: refer for home care as warranted; assess the home environment for patient safety and management of the disorder; identify barriers to compliance and make appropriate referrals; monitor skin status and provide preventive skin care for patients at risk for impaired skin integrity; assess the need for assistance in the home and supervise home health aides; refer to physical and occupational therapists as problems and limitations increase; alert the patient and family to support services such as Meals on Wheels and local Arthritis Foundation chapters; assess physical and psychological status, adequacy of symptom management, and adherence; and emphasize the importance of followup appointments.

Evaluation

Expected outcomes are improved comfort level, pain management techniques incorporated into daily life, strategies to modify fatigue incorporated into daily activities, optimal functional mobility attained and maintained, adaptation to the physical and psychological changes imposed by the rheumatic disease, and effective coping behaviors used for actual or perceived limitations and role changes.

Discharge and Home Care Guidelines

The patient and family must be able to explain the nature of the disease and the principles of disease management. The patient or caregiver must describe the medication regimen (name, dosage, schedule of administration, precautions, potential side effects, and desired effects). The patient must describe and demonstrate pain management techniques and demonstrate the ability to perform self-care activities independently or with assistive devices.

Documentation Guidelines

Document the client's description of response to pain, specifics of the pain inventory, expectations of pain management, and acceptable level of pain; manifestations of fatigue and other assessment findings; degree of impairment and effect on lifestyle; level of function and ability to participate in desired activities; functional level and specifics of limitations; needed resources and adaptive devices; availability and use of community resources; observations of maladaptive behavior, emotional changes, and level of independence; prior medication use; the plan of care; the teaching plan; response to interventions, teaching, and actions performed; attainment or progress toward desired outcomes; modifications to the plan of care; and long-term needs.