Research Paper On Rheumatoid Arthritis
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Definition of the Disease . 3
Signs and Symptoms ... 4
Nursing Diagnosis 5
Musculoskeletal system .. 5
Immune System .. 5
Integumentary System 5
Gastrointestinal System . 6
Cardiovascular System 6
Endocrine System ... 7
Urinary System .. 7 Respiratory System . 7
Nervous System .. 8
Reproductive System 8
Bibliography .. 9
Definition of the Disease Process
Rheumatoid arthritis is a chronic inflammatory disease initially affecting the small joints of the hands and feet (Shlotzhauer and McGuire). It appears similar to osteoarthritis, but rather than based on normal wear on the joints, it causes the lining of the joint to swell, resulting in joint deformity and erosion of the bone. As an autoimmune disorder, the disease is a result of the patient’s immune system attacks the tissues of his own body. Since rheumatoid arthritis in associated with the immune system, the lungs, blood vessels, eyes, and skin may become involved. The disease is more common in women and both genders after the age of 40.
The patient with rheumatoid arthritis will present with symptoms of swollen, warm, tender joints. He may complain of a fever, fatigue, and weight loss. Rheumatoid nodules will be present under the skin on the arms and morning stiffness may last for hours (Blum and Bender). As the linings of the joint become more inflamed, the bone and cartilage may eventually become destroyed. The joint is held in place with tendons and ligaments; as these stretch, the joint loses its shape and the patient will suffer distortion of the joint.
Diagnosis may be difficult when rheumatoid arthritis is in the early stages. Blood tests will shows an elevated erythrocyte sedimentation rate (ESR, or sed rate) indicating an inflammatory process occurring in the body. Other diagnostic blood tests reveal anti-citrullinate d peptid (anti-CCP) antibodies and the rheumatoid factor. Xrays, while not always helpful in the early stages of the disease, can be used to track the progression of joint inflammation over time.
Complications of rheumatoid arthritis (RA) include osteoporosis, carpal tunnel syndrome, cardiovascular problems, and respiratory disease.
Treatment includes medications for pain relief and to retard inflammation currently present and prevent further involvement. Due to side effects associated with drugs used to treat rheumatoid arthritis, the least strong medications are tried first. Pharmaceuticals include non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief and to lessen inflammation such as Advil, Motrin IB, and Aleve. Corticosteroid drugs such as prednisone are effective, but may thin bones, cause weight gain, or result in diabetes. SMARDs (Disease-Modifying AntiRheumatic Drugs) are commonly Azulfidine, Arava, Plazuenil, and Trexall to slow the RA and save joints from permanent damage. Biologic response modifiers are a more recent class of DMARDs and include Rituxan, Cimzia, Kineret, Orencia, Remicade, Humira, Xeljanz, Actemra, Simponi, and Enbrel. All these drugs increase the risk of infection. The use of biologic DMARDs is enhanced when used with non-biologic DMARDs.
Physical therapists can assist in modification of daily tasks and perhaps a device is recommended. Exercises can help joints stay flexible. In the event medications and physical therapy are ineffective, surgery is an option. Joints can be totally replaces with metal and plastic, tendons around the joint can be repaired, and when replacement is not possible, the joint can be fused for pain relief and stabilization. Home relief can be achieved by regular exercise, application of heat or cold, and relaxation.
Signs and Symptoms
As individual will experience some or all of these symptoms prior to visiting a physician: 1) swollen joints that are tender and warm to the touch, 2) fever and weight loss associated with fatigue, 3) bumps under the skin on the arms (rheumatoid nodules), and 4) stiff joints when first getting out of bed that may last for hours In the beginning, the joints that attach your fingers to your hand and your toes to your feet are usually affected first. Later, the symptoms involve larger joints such as the wrists, hips, knees, elbows, shoulders, and ankles. They usually occur in the same joints on both sides of the body; i.e. both hips or both knees.
The signs of rheumatoid arthritis may come and go or change in severity. Periods called discomfort “flares” may alternate with times when the pain and swelling decrease or disappear. The patient suffering from rheumatoid arthritis may find the joints shifting out of place and becoming deformed.
When a patient suffers from rheumatoid arthritis, most of the systems of the body are affected. The following discussion ranks each system in the order of being most affected.
Musculoskeletal System. Rheumatoid arthritis is a disease of the musculoskeletal system that involves an autoimmune response that results in pain, inflammation, decreased mobility, and a lessened ability to perform activities of daily living. The musculoskeletal system is the primary system involved, demonstrating the initial symptoms in these areas.
Immune System. The second most affected system, the immune system has a close
relationship with rheumatoid arthritis (Kunkel). Synovitis results when invading immune cells coordinate with resident cells. The process promotes dysfunctional immune responses. Medications and treatment are directed toward correcting the function of the immune system, if possible.
Integumentary System. The presence of rheumatoid nodules is one of the first signs of RA. Other common skin conditions are skin infections, eczema, and skin eruptions related to drugs (Wyeth Pharmaceuticals). The most mentioned medications in the research are Humira, Remicade, and Enbrel; these drugs are all biologic DMARDs. They act to inhibit the chemical produced by the body that results in RA inflammation. Some patients will stop taking the medications due to the skin disorders side effects (Levin and Werth). Treatment for resolution or reduction of skin problems is the third major nursing intervention for patients with rheumatoid arthritis.
Gastrointestinal System. Patients with rheumatoid arthritis have an increased risk of gastrointestinal (GI) events, some of which can result in death (Myasoedova et al.). A study by Mayasoedova et al. found the risk of serious upper- and lower-GI events is higher in RA patients as opposed to subjects without the disease. The incidence of upper GI events in RA patients was 70 percent higher than in non-RA subjects; the incidence for lower GI events was 50 percent higher. The upper GI events appear related to the use of NSAIDs medications and the use of inhibitors can correct this problem. Upper GI events in RA patients decrease over time, but not the lower GI tract. Since these conditions remain in need of nursing interventions indefinitely, it is vital scrutiny remains constant.
Cardiovascular System. Rheumatoid arthritis increases the risk of arteries becoming blocked and hardened; the sac around the heart can also become inflamed (Roman and Salmon). The results can be atherosclerosis, arterial stiffening, congestive heart failure, and myocardial infarction. The nursing interventions for cardiac patients are implemented for RA patients although it is not their primary diagnosis. Control of the RA can decrease the cardiac involvement with the disease. Heart problems secondary to rheumatoid arthritis are not as frequent or as intense as those for the gastrointestinal system, but they remain critical in priorities.
Endocrine System. It has become accepted that there is a relationship between the immune system and the neuroendocrine network in the progress of rheumatoid arthritis (Eijsbouts and Murphy). The chronic inflammation associated with RA is triggered by the cytokine TNF-α (Chen and Tsai). Blockage of TNF-α by biologic DMARDs used in treating RA can result in impairment of gut hormones that regulate appetite, energy expenditures, body composition, and nutrition. The interaction of cytokines provide a link between the GI endocrine axis and the immune system. Nursing intervention in the evaluation of gut hormones allows an understanding of the importance of the endocrine system on RA. Family history is important because studies have shown that close relatives to the RA patient are likely to have Type I diabetes mellitus (Thomas et al.). It is theorized the two diseases share a susceptibility to the same HLA-linked immune response gene.
Urinary System. A study found 51 percent of rheumatoid arthritis patient have positive cultures of E. coil in the urine (Puntis et al.) Co-morbidities include the presence of permanent catheters, diabetes, cancer, and vaginal prolapsed. Recurrance of UTI is common and the nursing intervention recommends the avoidance of long-term oral steroids on RA patients and the initiation of DMARDs. The care of UTIs is important, but no to the extent of previous body systems.
Respiratory System. Some rheumatoid arthritis patients suffer from inflammation and scarring of lung tissue resulting in shortness of breath (Wajed). Respiratory complications of RA include susceptibility to respiratory infections, pulmonary arterial obstruction, lung nodules with or without pneumoconiosis, diffuse pulmonary fibrosis, airway obstruction, and pleural effusions and fibrosis. When based on xrays alone, the frequency is only one- to six-percent, but when xrays are combined with lung function tests, the positive tests are over 45 percent. Treatment is generally unrewarding. Since the incidence is lower than with UTIs and treatment is generally ineffective, the respiratory system takes lower precedence that the urinary system for nursing intervention.
Nervous System. Rheumatoid arthritis patients have some association with sensory ganglionopathy and cervical spine disease, but more often manifest less serious complications such a headache (Helfgott and Bhattacharyya). However, there are not clear indications RA is responsible for these conditions. Neurologic complications are rare for RA.
Reproductive System. There does not appear to be any association of rheumatoid arthritis with the reproductive system (Beydoun et al.). RA does appear in postmenopausal women over 60 years old, but hormones do not seem to play a part in the manifestation of the disease. Women who experience menopause before 40 years of age do seem to be at an increased risk.
Beydoun, Hind A. et al. 'Reproductive History And Postmenopausal Rheumatoid Arthritis
Among Women 60 Years Or Older'. Menopause: The Journal of The North American
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Blum, Susan S, and Michele Bender. The Immune System Recovery Plan. 2013. Print.
Chen, C.-Y., and C.-Y. Tsai. 'From Endocrine To Rheumatism: Do Gut Hormones Play Roles In
Rheumatoid Arthritis?'. Rheumatology 53.2 (2013): 205-212. Web.
Eijsbouts, Agnes M.M., and Evelyn P. Murphy. 'The Role Of The Hypothalamic–Pituitary–
Adrenal Axis In Rheumatoid Arthritis'. Best Practice & Research Clinical Rheumatology
Helfgott, Simon, and Shamik Bhattacharyya. 'Neurologic Complications Of Systemic Lupus
Erythematosus, Sjögren Syndrome, And Rheumatoid Arthritis'. Semin Neurol 34.04
(2014): 425-436. Web.
Kunkel, Henry G. 'Immunologic Aspects Of Rheumatoid Arthritis'. Journal of Chronic Diseases
10.5 (1959): 418-427. Web. 18 Mar. 2015. eb.
Levin, Joshua, and Victoria P. Werth. 'Skin Disorders With Arthritis'. Best Practice & Research
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Myasoedova, E. et al. 'Increased Incidence And Impact Of Upper And Lower Gastrointestinal
Events In Patients With Rheumatoid Arthritis In Olmsted County, Minnesota: A
Longitudinal Population-Based Study'. The Journal of Rheumatology 39.7 (2012): 1355-
Puntis, D. et al. 'Urinary Tract Infections In Patients With Rheumatoid Arthritis'. Clin Rheumatol
32.3 (2012): 355-360. Web. 18 Mar. 2015.
Roman, M. J., and J. E. Salmon. 'Cardiovascular Manifestations Of Rheumatologic Diseases'.
Circulation 116.20 (2007): 2346-2355. Web. 18 Mar. 2015.
Shlotzhauer, Tammi L, and James L McGuire. Living With Rheumatoid Arthritis. Baltimore:
Johns Hopkins University Press, 2003. Print.
Thomas, D J et al. 'Evidence For An Association Between Rheumatoid Arthritis And
Autoimmune Endocrine Disease.'. Annals of the Rheumatic Diseases 42.3 (1983): 297-
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Wajed, M A. 'Points From Letters: Respiratory Complications Of Rheumatoid Disease'. BMJ
1.6128 (1978): 1702-1702. Web.
Weynard, Cprnelia. 'Immunopathologic Aspects Of Rheumatoid Arthritis: Who Is The
Conductor And Who Plays The Immunologic Instrument?'. The Journal of Rheumatology
79 (2015): 9-14. Web.
Wyeth Pharmaceuticals,. Arthritis Research And Therapy. 2005. Web. 18 Mar. 2015.
Rheumatoid Arthritis of the hand . . . of the feet . . . and the knees
Xrays of the hands, feet, and knees
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