MS121.pdf

11/21/23, 3:13 PM Realizeit for Student Rheumatoid Arthritis Rheumatoid arthritis is an autoimmune disease of unknown origin that affects 1% to 2% of the population worldwide, with females having a three times greater incidence than males. It may occur at any age but the onset commonly occurs betw...

11/21/23, 3:13 PM Realizeit for Student Rheumatoid Arthritis Rheumatoid arthritis is an autoimmune disease of unknown origin that affects 1% to 2% of the population worldwide, with females having a three times greater incidence than males. It may occur at any age but the onset commonly occurs between the third and sixth decade of life. The incidence of RA increases after the sixth decade of life (Norris, 2019). RA that occurs after the age of 65 is referred to as elderly onset RA (Norris, 2019). Additional risks that have been identified include family history, environmental influences such as diet or geographic location, nulliparity, as well as the modifiable factors of smoking and obesity (Mogul, Corsi, & McAuliffe, 2019). Pathophysiology The exact mechanism of action for the etiology of RA is unknown. Evidence points to a genetic predisposition and the development of immunologically mediated joint inflammation (Eliopoulos, 2021; Norris, 2019). An autoimmune reaction (see Fig. 34-1) occurs in the synovial tissue. RA synovium breaks down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroys cartilage and erodes the bone. The consequence is the loss of articular surfaces and joint motion. Muscle fibers undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost. The RA inflammatory process has also been implicated in other disease processes (i.e., arteriosclerosis). It is hypothesized that the RA disease process somehow interferes with the production of high-density lipoprotein cholesterol, which is the form of cholesterol responsible for decreasing cellular lipids and, therefore, is considered antiatherosclerotic. The nervous system is also affected by the RA inflammatory process. The synovial inflammation can compress the adjacent nerve, causing neuropathies and paresthesias. Axonal degeneration and neuronal demyelination are also possible due to the infiltration of polymorphonuclear leukocytes, eosinophils, and mononuclear cells, causing necrotizing or occlusive vasculitis (Norris, 2019). Clinical Manifestations The American College of Rheumatology and the European League Against Rheumatism have collaborated and established criteria for classifying RA. These criteria are based on a point system where a total score of 6 or greater is required for the diagnosis of RA. The scoring system is based on joint involvement (number of joints affected), serology (low positive or high positive rheumatoid factor [RF] or anti-citrullinated peptide antibody [ACPA]), abnormal results of the acute phase reactants (erythrocyte sedimentation rate [ESR] or C-reactive protein [CRP]), and duration of symptoms greater than 6 weeks. Patients diagnosed with RA who are excluded from these diagnostic criteria include: (1) patients who have one joint with synovitis that is not related to any other clinical disease and who also score at least 6 to 10 points on the scale, and (2) patients diagnosed with bony https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 1/3 11/21/23, 3:13 PM Realizeit for Student erosions on x-ray (Aletaha, Neogi, Silman, et al., 2010; Molano-Gonzalez, Olivares-Matinez, Anaya, et al., 2019). The initial clinical manifestations of RA include symmetric joint pain and morning joint stiffness lasting longer than 1 hour. Over the course of the disease, clinical manifestations of RA vary, usually reflecting the stage and severity of the disease. Symmetric joint pain, swelling, warmth, erythema, and lack of function are classic symptoms. Palpation of the joints reveals spongy or boggy tissue. Often, fluid can be aspirated from the inflamed joint. Characteristically, the pattern of joint involvement begins in the small joints of the hands, wrists, and feet (Omma et al., 2018). As the disease progresses, the knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints may be affected. The onset of symptoms is usually acute. Symptoms are usually bilateral and symmetric. In the early stages of disease, even before the presentation of bony changes, limitation in function can occur when there is active inflammation in the joints. Joints that are hot, swollen, and painful are not easily moved. The patient tends to guard or protect these joints by immobilizing them. Immobilization for extended periods can lead to contractures, creating soft tissue deformity. Deformities of the hands (e.g., ulnar deviation and swan neck deformity) and feet are common in RA . The deformity may be caused by misalignment resulting from swelling, progressive joint destruction, or the subluxation (partial dislocation) that occurs when one bone slips over another and eliminates the joint space. Deformities of RA differ from those seen with osteoarthritis (OA), such as Heberden’s and Bouchard’s nodes. RA is a systemic disease with multiple extra-articular features. Most common are fever, weight loss, fatigue, anemia, lymph node enlargement, and Raynaud’s phenomenon (cold- and stress-induced vasospasm causing episodes of digital blanching or cyanosis). Rheumatoid nodules are common in patients with more advanced RA. These nodules are usually nontender and movable in the subcutaneous tissue. They usually appear over bony prominences such as the elbow, are varied in size, and can disappear spontaneously or progress to ulceration (Weber & Kelley, 2019; Young, 2019). Nodules occur only in people who have rheumatoid factor. Other extraarticular features include arteritis, neuropathy, pericarditis, splenomegaly, and Sjögren’s syndrome (dry eyes and dry mucous membranes). Assessment and Diagnostic Findings Several assessment findings are associated with RA: rheumatoid nodules, joint inflammation detected on palpation, and certain laboratory findings. The history and physical examination focus on manifestations, such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints (Weber & Kelley, 2019). The patient is also assessed for extra-articular changes; these often include weight loss, sensory changes, lymph node enlargement, and fatigue. Symptoms and examination findings are often recorded using a disease activity score, a variety of which are in https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 2/3 11/21/23, 3:13 PM Realizeit for Student use, to evaluate disease activity, help guide treatment decisions, and monitor treatment efficacy (Mahmood, van Tuyl, Schoonmade, et al., 2019). Rheumatoid factor is present in many patients with RA, but its presence alone is not diagnostic of RA, and its absence does not rule out the diagnosis. Antibodies to cyclic citrullinated peptide (antiCCP) have a specificity of approximately 95% at detecting RA (Norris, 2019). The ESR and CRP tend to be significantly elevated in the acute phases of RA and are therefore useful in monitoring active disease and disease progression. The complete blood count (CBC) should be assessed to establish a baseline count especially prior to starting medications (Fischbach & Fischbach, 2018). Patients may exhibit anemia, and platelets may be elevated due to the inflammatory process. A tuberculin (TB) skin test should be done prior to the initiation of certain medications to rule out tuberculosis. In the event the patient has latent TB and has never been treated, the infection can be reactivated. The patient should also be assessed for hepatitis B and hepatitis C, which could impact treatment strategies if positive. If the client tests positive for hepatitis, the infection should be treated prior to starting medication. Liver and kidney monitoring are recommended for most DMARD therapy because it can cause elevation of the liver enzymes and can also affect kidney function. X-ray, ultrasound, or both of the hands, wrists, and feet can be useful in establishing a baseline for joint evaluation, and assessing the joints for erosions and synovitis. Joint damage may occur within the first 6 to 12 months of diagnosis and should be followed as indicated. Plain x-ray is the most common radiographic study used to track disease progression as it is inexpensive, reliable, and reproducible (Mahmood et al., 2019). MRI can also be useful to detect small erosions that may not be visible on x-ray or ultrasound. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 3/3