Rheumatoid, Psoriatic Arthritis & Gout PDF

Rheumatoid, Psoriatic Arthritis & Gout Learning Objectives Recognize the symptoms and characteristics of rheumatoid arthritis (RA), psoriatic arthritis and gout Compare and contrast available pharmacologic therapies for RA, psoriatic arthritis and gout Design individualized nursing ca...

Rheumatoid, Psoriatic Arthritis & Gout Learning Objectives Recognize the symptoms and characteristics of rheumatoid arthritis (RA), psoriatic arthritis and gout Compare and contrast available pharmacologic therapies for RA, psoriatic arthritis and gout Design individualized nursing care and monitoring plans for patients with RA, psoriatic arthritis and gout Describe the etiology and socioeconomic and psychosocial burden of RA, psoriatic arthritis and gout and the importance of early  Rheumatoid Arthritis (RA)  Chronic, Periods of remissions (still have it, just not active) & systemic exacerbation (gets worse) disease Extraarticular manifestations  Inflammation of – (happens outside the connective tissue joint) in the – Fatigue (subjective) – Anorexia (objective) diarthrodial – Weight loss (objective (synovial) joint – Low-grade fever  Generalized (objective aching and – Anemia (objective) stiffness Criteria for Rheumatoid Arthritis Morning stiffness (most complaint) at least 1 hour for at least 6 weeks Swelling of three or more joints for at least 6 weeks Swelling of wrist, metacarpophalangeal or proximal interphalangeal joints for 6 or more weeks Systemic joint swelling Hand X-ray changes typical of RA can include: – Rheumatoid nodules – Serum rheumatoid factor Results of Progressive Joint Destruction May lead to subluxation (dislocation of the joint resulting in misalignment of the bone ends) Instability of the joint Limitation of movement  Rheumatoid Arthritis (RA) Etiology &  Cause Pathophysiology  Unknown  Autoimmune  Most widely accepted theory  Antigen/abnormal Immunoglobulin G (IgG)  Presence of autoantibodies  Rheumatoid factor Rheumatoid Arthritis (RA) Etiology & Pathophysiology IgG + rheumatoid factor form deposits on synovial membranes & articular cartilage  Inflammation results  Pannus (granulation tissue at the joint margins) leads to articular cartilage destruction  Genetic  Predisposition/familial occurrence of “human leukocyte antigen (HLA) in Caucasian RA patients  Rheumatoid Arthritis Joint Deformities Boutonniere deformity of thumb Ulnar deviation of metacarpophalange al joints Swan-neck deformity of fingers  Rheumatoid Arthritis Anatomic 4 Stages  Stage 1 – Early  No destructive changes on x-ray  Possible osteoporosis  Stage II – Moderate  X-ray osteoporosis  No joint deformities  Possible presence of extra-articular soft tissue lesions Rheumatoid Arthritis Anatomic 4 Stages  Stage III – Severe  X-ray evidence of cartilage and bone destruction  Osteoporosis  Joint deformity  Subluxation (dislocation)  Ulnar deviation, hyperextension  Bony ankylosis  Abnormal stiffening and immobility of a joint due to fusion of the bones. Bone is making more bone bone so joints fuse  Muscle atrophy (because you aren’t Rheumatoid Arthritis Anatomic 4 Stages Stage IV – Terminal (end of life) – Fibrous or bony ankylosis – Criteria of Stage III  Rheumatoid Arthritis Clinical Manifestations  Insidious (can look like other stuff especially early on Fatigue Anorexia weight loss generalized stiffness  “Morning Stiffness” 60+ mins to several hours depending on disease progression Rheumatoid Arthritis Clinical Manifestations Joints – Stiffness becomes localized – Pain – Edema – Limited motion – Inflammation – Joints warm to touch – Fingers become spindle-shaped Rheumatoid Arthritis Extraarticular Manifestations Sjögren’s Raynaud’s Syndrome Phenomenon  Decreased – Cold fingers, toes, lacrimal secretion and tip of nose  Burning, gritty, – Color changes in the itchy eyes  Decreased tearing skin in response to and cold or stress photosensitivity – Numb, prickly feeling  Dry mouth or stinging pain upon warming or stress relief  Rheumatoid Arthritis Extraarticular Manifestations Valvular lesions/pericarditis Interstitial pulmonary fibrosis or pleuritis – Lungs lose elasticity Lymphadenopathy (lymph node enlargement Peripheral neuropathy and edema – Cant feel feet= fall risk ”killer of old people” Myositis (muscle inflammations  Rheumatoid Arthritis Clinical Manifestations  Rheumatoid Arthritis Diagnostic Studies  Lab Studies C-Reactive Protein  Rheumatoid (CRP) – Marker or Factor inflammation  Positive in 80% of – Increased is patients associated with  Erythrocyte inflammation sedimentation Increase in WBCs rate (ESR) Synovial biopsy (marker of – Inflammation inflammation)  Increased is Bone Scan associated with Areas of increased bone inflammation activity (buildup in joint) Rheumatoid Arthritis Treatment Goals Reduce pain Minimize stiffness and swelling Maintain mobility Become an informed health care consumer  Rheumatoid Arthritis Drug Therapy  NSAIDs Plaquenil (hydroxychloroquine  Disease- : antimalarial drug) modifying Methotrexate antirheumatic Gold salt therapy drugs (DMARDS) – Given by injection  Anti-inflammatory Corticosteroid action Therapy Nutrition Balanced diet Rheumatoid Arthritis Drug Therapy Biologics – Target the molecules that cause inflammation in rheumatoid arthritis Must be tested for latent TB prior to initiation of therapy – Quantiferon Gold test Most accurate blood test for TB Psoriatic Arthritis (PsA) Psoriatic arthritis is a chronic inflammatory arthritis condition If left untreated, patients with psoriatic arthritis may suffer from: – Pain – Reduced quality of life – Joint damage – Disability Etiology Pre-existing psoriasis or family history of psoriasis – 30% of people with psoriasis develop PsA in addition to their skin condition Affects males and females equally Onset is usually ages 30-55 Signs and Symptoms Pain Stiffness Swelling of: – Joints – Surrounding tendons – Ligaments Frequently associated with low back pain Signs and Symptoms Dactylitis Peripheral – “Sausage digits” Arthritis Lack of definition – 95% of patients of joints experience First clinical sign inflammation, of PsA pain, and/or Enthesitis tenderness in – Inflammation peripheral joints adjacent to joints of the hands at tendon, and/or feet ligament, or joint- – Affected joints capsule insertions may also display Signs and Symptoms Skin and nail changes Axial PsA typically presents as asymmetric sacroiliitis or spondylitis – Leads to lower back pain Over time, some of the vertebrae in the spinal column spontaneously fuse  Pathophysiology Characterized by body not being able to distinguish cell from non cell Pathogenesis of PsA is complex and poorly understood Occurs in a genetically susceptible individual in whom there has been a trigger (whether environmental or otherwise) The immune system receives a message  Pathophysiology This autoimmune response results in psoriatic arthritis T-cells become activated and drive the immune response that results in the development of inflammatory cytokines and mediators – From inflammatory process Ultimately cause erosive (erosion of joints and surrounding tissue) changes and reactive bony growth in the joints and surrounding tissue. Treatment Physical therapy Hot and cold compresses Topical steroids for skin and nails Gout Acute gouty arthritis with recurrent attacks of severe articular and peri-articular inflammation Tophi or the accumulation of crystalline deposits in articular surfaces, bones, soft tissue, and cartilage Gouty nephropathy or renal impairment Uric acid kidney stones Types of Gout Primary gout – Designate cases in which the cause of the disorder is unknown or an inborn error in metabolism – Characterized primarily by hyperuricemia (high uric acid levels) and gout Secondary gout – The cause of the hyperuricemia is known but the gout is not the main disorder Treatment of Gout Termination and prevention of the acute attacks of gouty arthritis Correction of hyperuricemia with drugs Inhibition of further precipitation of sodium urate (sodium + uric acid= crystals) Absorption of urate crystal deposits already in the tissues Rheumatoid, Psoriatic Arthritis & Gout Nursing Diagnoses  Chronic pain related to joint inflammation  Impaired physical mobility  Disturbed body image related to chronic disease  Ineffective therapy regimen management related to complexity of chronic health problem  Self-care deficit related to disease progression Rheumatoid, Psoriatic Arthritis & Gout Nursing Management Goals  Satisfactory pain relief  Minimal loss of functional ability of affected joints  Patient participation in planning and carrying out therapeutic regimen  Positive-self image  Self-care to the maximum capability Rheumatoid, Psoriatic Arthritis & Gout  Rest alternating Psychological with activity as Therapy tolerated – Individual &  Energy conservation family support  Joint protection system  Joint protective devices (braces)  Heat / Cold Therapy  Relieve stiffness, pain, and muscle spasm  Exercise  Individualized  Aquatic Therapy  Gerontologic Considerations  Sensitivity to  Challenges to medication Self-Care &  NSAIDs Decisions  GI Bleed (tough  Autonomous on stomach)  Assisted Living  Corticosteroid therapy  Osteopenia (bone tissue thinning) adds to inactivity- related loss of bone density  Pathological Practice Question A physician suspects a patient may have rheumatoid arthritis due to the patient's presenting symptoms. What diagnostic testing can be ordered to help a physician diagnose rheumatoid arthritis? Select all that apply: a) Rheumatoid factor b) Erythrocyte sedimentation rate c) Dexa-Scan d) X-ray imaging e) Cardiac markers Practice Question Which statement is FALSE concerning rheumatoid arthritis? a) Rheumatoid arthritis most commonly affects the fingers and wrist. b) Rheumatoid arthritis is different from osteoarthritis in that it doesn't affect other systems of the body. c) Rheumatoid arthritis can occur at any age (30-50 year old most commonly). d) Ankylosis can occur in severe cases of rheumatoid arthritis.