Rheumatoid Arthritis.pdf

Rheumatoid Arthritis Rheumatoid arthritis (RA) - an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body. RA mainly attacks the joints, usually many joints at...

Rheumatoid Arthritis Rheumatoid arthritis (RA) - an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation (painful swelling) in the affected parts of the body. RA mainly attacks the joints, usually many joints at once. ○ Characteristics: Chronic - chronic condition is usually long-lasting and does not easily or quickly go away Inflammatory - an innate, nonspecific, immediate, defensive mechanism that helps protect the body against infections and injuries. Progressive - it’s ongoing Systemic - not localized to one region ○ Pathophysiology: Rheumatoid factors (Transformed autoantibodies) attack the healthy tissue of the synovium, causing inflammation. Synovium - connective tissue that lines the inside of the joint capsule Articular cartilage, joint capsule, ligaments and tendons become involved Cartilage breaks down Fluid accumulates in joint space Pannus forms. Pannus - vascular granulation tissue made of inflammatory cells that erodes cartilage and can destroy bone ○ Risk Factors: FE Female (2-3x more likely than men) Euro-Americans more than other groups ○ Concepts Affected: Mobility Pain Immunity ○ Signs and Symptoms: Early Signs: JEW BF L Joint inflammation Early morning stiffness Weight loss (2–3 pounds) Bilateral joints of upper extremities involved (hands/wrist) Fatigue and weakness Low grade fever Late Signs: JOM WASS VP Joint deformities Osteoporosis - A condition in which bones become weak and brittle. Moderate/severe pain (exacerbations/remissions) Weight loss (more severe) Anemia - low RBCs Subcutaneous nodules - deep-seated lesions in the skin Sjogren’s Syndrome - An immune system disorder characterized by dry eyes and dry mouth. Vasculitis/Pericarditis/myocarditis → inflammation of vessels and heart Peripheral neuropathy - Weakness, numbness, and pain from nerve damage, usually in the hands and feet ○ Impact on People: Limits exercise Diminished quality of life Affects a person’s work Ex: a police officer can’t go back to work Presentations of RA ○ Joint swelling ○ Swelling of PIP, MCP joints, nodules Proximal interphalangeal joint (PIP) - middle joint of each of your fingers Metacarpophalangeal (MCP) - Knuckle joint ○ Ulnar deviation - occurs when inflammation in your hand, wrist, or fingers leads to your fingers bending toward your pinky ○ Boutonnière Deformity - middle finger joint is bent in a fixed position inward (toward the palm) and the outermost finger joint is bent excessively outward (away from the palm). ○ Swan Neck Deformity - bending in (flexion) of the base of the finger, a straightening out ○ (extension) of the middle joint, and a bending in (flexion) of the outermost joint ○ Hitchhiker’s Thumb - thumb joint is hypermobile. Ulnar Division Boutonnière Deformity Swan Neck Deformity Hitchhiker's Thumb Interventions: X-Ray, CBC….| HAP FUR CC JR ○ Antinuclear attacks nucleus of healthy cells ○ Arthrocentesis - joint aspiration. used to diagnose and treat musculoskeletal conditions. ○ Invasive, done under local anesthetic ○ Used only if excessive fluid in joint ○ Steps: HCP inserts needle and removes fluid Fluid goes to lab to check for inflammatory cells/immune complexes (RF) Abnormal results = Increased WBC’s, cloudiness, increased volume = consistent with RA. ○ For procedural after care: Ice and rest for 24 hours Monitor site for bleeding/leakage of fluid ○ Secondary Prevention: X-Ray/CT, CBC, ESR, CRP, Antibodies X Ray/CT scan → Looking for joint changes, deformities, fluid in joint CBC → looking for an increase in WBC’s ESR (Sed Rate) - measures inflammation. C-Reactive Protein (CRP) - measures inflammation/infection in the body. Antibody Tests: Rheumatoid Factor - checks for antibodies of immunoglobulins in connective tissue disease (A positive test is not diagnostic) Anti CCP (Anti Cyclic Citrullinated Peptide) Antibodies autoantibodies (proteins) made by the immune system attacking the body’s cells. ○ New test to detect early RA ANA (Antinuclear Antibodies) - checks for tissue death in autoimmune disease ○ Tertiary Prevention: HAP FuR CC Jr Hot or cold packs → use of microwave at home, frozen vegetable packs Adequate nutrition: Avoid obesity → Obesity puts pressure/weight on the joints ○ Watch for anemia Promote mobility: ○ Physical/Occupational Therapy ○ Only when don’t have a flare up ○ Regular activity: ROM daily ○ Dynamic and aerobic exercises/low impact aerobics may be ordered ○ Learn to balance rest/exercise Avoid rushing and stress/Don’t overdo Fall prevention Use of assistive devices → Canes, walkers, rollers, etc. Rest: Joints always rested during exacerbations Complementary medicine (Hypnosis, acupuncture, massage, aromatherapy) Community supports Joint replacement Pharmacology (see below) Medications for RA NSAIDS - Decrease pain and inflammation Example Drugs: ○ Ibuprofen [Motrin, Advil] ○ Celecoxib [CeleBREX] Often given with H2 blocking agent (antihistamine): Famotidine DMARDS (Disease Modifying Anti-Rheumatic Drugs) Methotrexate - immunosuppressant/takes 4-6 weeks to control inflammation, decreases joint pain and swelling ○ Cannot take while pregnant. ○ Contraception must be used. ○ Causes bone marrow suppression (decrease in WBC’s, platelets) Hydroxychloroquine - antimalarial drug which suppresses immune response ○ Decreases skin lesions because it decreases UV ray absorption ○ Implications: Toxicity → Can cause retinitis that can lead to loss of central vision/irreversible Perform frequent eye exams BIORESPONSE MODIFIERS (Immunomodulators) - Newest type of DMARD but gives patient impaired immunity so need for infection control. STEROIDS: Prednisone - Cuts inflammation Cortisone ○ Implications Monitor glucose → DM a concern Impaired immunity → perform Infection control Hypertension → Regular B/P checks Osteoporosis: Role of Vitamin D & Calcium ○ D3 makes sure calcium is absorbed ○ Take Vitamin D3 because it is already broken down partially. Supplements/foods: ○ High calcium food = dairy products Glaucoma → checks by ophthalmologist Electrolyte imbalances → check for fluid retention, check blood work for hypernatremia, hypokalemia Implications for Immunosuppressive Drugs: INFECTION CONTROL!!!! ○ Hand hygiene ○ Need for adult immunizations ○ Avoiding crowds ○ How to deal with tissues during a respiratory infection ○ Avoid sharing cups/utensils at home ○ Monitoring for signs of infection: animal scratches/falls/cuts with kitchen knives, etc. ○ Let dentist know before dental procedures Systemic Lupus Erythematosus (SLE) Systemic Lupus Erythematosus (SLE) - Chronic, progressive autoimmune disorder ○ Progressive loss of tissue integrity through excessive inflammation and overactive immunity. ○ Exacerbations/remissions → Sun exposure exacerbates symptoms ○ Similar to RA → both affects joints and has symmetrical symptoms (ex: pain in both wrists as opposed to one) ○ About 1,600,000 people in North America have SLE Pathophysiology: ○ Inflammation and immune cells precipitate and deposit cells in organs affected → cause vasculitis which lessens blood flow to organs ○ Affects multiple tissues and organs → can do permanent organ damage Risk Factors: FAFA I ○ Strong genetic connection (Family history) ○ Female 9:1 ○ Starts usually between ages of 15-45 ○ African American and Hispanic 2-3 times more likely to get than Caucasian women ○ Infection, injury, drugs, hormones, exposure to environmental substances, such as UV rays (tanning beds) can be a trigger Concepts Affected: ○ Immunity ○ Inflammation ○ Pain ○ Fatigue ○ Reproduction Impact on people ○ SLE affects multiple systems: Other: Mouth and nose ulcers Hair loss High fever Abnormal headache Severe abdominal pain Lungs: Pleuritis - Inflammation of pleura. Causes sharp chest pain (pleuritic pain) that worsens during breathing Pleura - two large, thin layers of tissue that separate your lungs from your chest wall Pneumonitis - lung inflammation Pulmonary emboli - A condition in which one or more arteries in the lungs become blocked by a blood clot. Pulmonary hemorrhage - the extravasation of blood into the alveoli, that is, bleeding into the lower respiratory tract Kidneys → Hematuria - Blood in urine Skin → Butterfly rash and red patches Heart: Endocarditis - inflammation of the inside lining of the heart chambers and heart valves (endocardium) Atherosclerosis Inflammation of the fibrous sac Blood: Anemia HTN Muscle and Joints: Pain Arthritis Aches ○ Maternal Problems: Preterm delivery Increased preeclampsia Increased miscarriages Fetal Problems: ○ Preterm Births ○ Stillbirths ○ IUGR (Intrauterine growth restriction) Signs and Symptoms BLA MAMA FS ○ Early Signs: Butterfly rash or other rash/skin changes (Malar Rash) Low grade fever Alopecia - Hair loss Myositis - rare group of diseases characterized by inflamed muscles, which can cause prolonged muscle fatigue and weakness Arthritis - inflammation or swelling of one or more joints Muscle aches usually bilateral Arthralgia - joint pain Fatigue, weakness Sun or light sensitivity KMS CLM (clam) PantoRS (panthers) ○ Late Signs: Kidney changes → proteinuria, lupus nephritis Moderate/severe pain (exacerbations/remissions) Cardiac change → pericarditis (inflammation) Lung involvement → pleural effusions Musculoskeletal Manifestations Polyarthritis Pancytopenia - low counts RBCs, WBCs, and platelets Anemia - low RBCs. Thrombocytopenia - low platelets Lymphopenia - low lymphocytes (WBCs) Raynaud’s Phenomenon - smaller arteries that supply blood to the skin constrict excessively in response to cold, limiting blood supply to the affected area. Sjogren’s Syndrome - An immune system disorder characterized by dry eyes and dry mouth. Seizures Interventions: X-Ray, CBC… C-U X-Ray, CBC, ESR, Antibodies, Creatine, Urinalysis ○ Secondary Prevention: No single lab test definitive Xray only if a joint is involved Complete Blood Count (CBC) → elevated WBC’s ESR (Sed Rate) → Elevated ESR Antibody tests: Rheumatoid Factor Anti-dsDNA → found in 30% of pts with SLE Anti-ssDNA (Anti‐Single-Stranded DNA Test) Antinuclear Antibodies (ANA) - Antibodies that target the nucleus of healthy cells. ○ 97 % of patients have elevated ANA’s, but the test is not specific. Creatinine → high creatinine indicates kidney problems. Urinalysis → Blood and urine tests to see if kidney involvement or involvement of other major organs. Tertiary Prevention: LP CSF | Meds ○ Lessen sun exposure → No tanning beds/clothing that covers/sunscreen/skin care ○ Pain control ○ Fatigue management → Exercise and rest periods/no exercise during flares ○ Consult with OB/GYN for high-risk pregnancy care ○ Stress management for patient and family ○ Pharmacology (see below) Medications for SLE ○ NSAIDS/DMARDS - Control inflammation/suppress immune system Methotrexate ○ ANTIMALARIALS: Hydroxychloroquine - immunomodulating and anticlotting effects Decreases skin lesions because it decreases UV ray absorption Implications: ○ Toxicity → Can cause retinitis that can lead to loss of central vision/irreversible Perform frequent eye exams ○ Immunomodulators: Monoclonal antibodies = “-mab” Janus kinase inhibitors - inhibits the activity of one or more of the Janus kinase family of enzymes, thereby interfering with the JAK-STAT signaling pathway in lymphocytes (inhibits JAK/STAT pathway which controls inflammation) CORTICOSTEROIDS - Control inflammation and suppress immune system ○ Example = Prednisone