1. rheumatoid
ARTHRITIS

2. RHEUMATOID ARTHRITIS
A chronic, systemic inflammatory disorder characterised by recurrent inflammation of multiple joints and related structures.
It is a disorder that principally affects synovial tissues and frequently accompanied by extraarticular manifestations.
Although the cause of rheumatoid arthritis is unknown, autoimmunity is thought to play a pivotal role in its chronicity and progression.
Most clients exhibit a pattern of symmetric involvement of multiple peripheral joints and periods of remission and exacerbations.

3. Incidence
It affects three times as many women as men. The onset is mostly between the ages of 30 and 50.

4. The actual cause is unknown Hereditary or genetic factors Smoking
Aetiology
The actual cause is unknown
Hereditary or genetic factors
Smoking
Autoimmunity
Infections e.g. EBV
Metabolic or biochemical abnormalities,
Nutritional factors e.g. vit D deficiency,

5. Diagnostic investigations
Rheumatoid factors
FBC
ESR
Synovial fluid analysis
X-ray of the joints

7. Pathophysiology
RA begins when T lymphocytes infiltrate the synovial membrane, following the invasion of the body by antigens. They proliferate in the synovium and initiate an immune response. B cells are also stimulated to produce auto antibodies [rheumatoid factors] to IgG. The antigen-antibody interaction leads to the formation of immune complexes which initiates synovitis, with swelling of the synovial lining membrane and production of excess synovial fluid. Pannus [granulation inflammatory tissue] is formed at the juncture of synovium and cartilage. This extends over the surface of the articular cartilage and eventually invades joint capsule and subchondral bone.

8. PATHOPHYSIOLOGY
Tough fibrous connective tissue replaces the pannus, occluding the joint space. Fibrous ankylosis results in decreased joint motion, mal- alignment and deformity. Finally, as the fibrous tissue calcifies, bony ankylosis may result in total joint immobilisation.

9. Swan neck deformity and ulnar deviation

10. Clinical manifestations
Musculoskeletal
Spine
General
Cervical pain
Symmetric polyarticular joint swelling
Neurologic manifestations
Joint redness, warmth, pain, tenderness
Wrists
Limited range of motion
Morning stiffness
Deformity
Limitation of motion
• Carpal tunnel syndrome

11. Clinical manifestations cont’d
Hands
Ankles
Ulnar deviation
Limited range of motion
Swan-neck deformity [DIP hyperflexion with PIP hyperextension]
Pain on ambulation
Feet
Subluxation
Boutonnière deformity [PIP flexion with DIP hyperextension]
Hallux valgus [deviation of the great toe towards other digits of the foot]
Knees
Joint effusion
Lateral toe deviation
Instability
Cock-up toe

12. Clinical manifestations cont’d
Respiratory • Pleural disease • Pneumonitis Integumentary • Rheumatoid nodules Exocrine glands Sjögren’s syndrome • Dry eyes • Dry mouth Cardiovascular • Vasculitis • Pericarditis Hematologic Felty's syndrome • Splenomegaly • Neutropenia • Anemia

13. Clinical manifestations cont’d
Metabolic Processes • Fatigue • Weakness • Anorexia • Weight loss • Low-grade fever

14. NSAIDs: especially Aspirin: Corticosteroids e.g. prednisolone
management
Pharmacologic
NSAIDs: especially Aspirin:
Corticosteroids e.g. prednisolone
Immunosuppressive or cytotoxic drugs e.g. methotrexate, cyclophosphamide
Disease modifying anti-rheumatic drugs: e.g. methotrexate, gold salts, antimalarial agents e.g. hydroxychoroquine, sulfasalazine and D-penicillamine, leflunomide

15. management Rest and sleep
Complete bed rest is unnecessary and should be avoided to prevent stiffness and immobility
Regularly scheduled rest periods alternated throughout the day help relieve pain and fatigue and minimise excessive weight bearing
Encourage client to sit instead of standing
Teach client good body alignment while resting
Provide a firm mattress or bed board
Encourage position of extension and avoid position of flexion
Never place pillows under client’s knees

16. Joint protection Exercise: management
Help client to identify ways to modify tasks
Encourage periods of rest in-between activity to avoid fatigue
Encourage client to use assistive devices to conserve the joints
Exercise:
ROM exercise,
isometric exercise,
Lying prone and allowing the legs to hang over the end of the mattress will help prevent flexion contractures. The client should be told to do this several times a day.

17. management Pain management: Psychological support:
Assess the level of pain and duration of morning stiffness
Encourage client to relate pain to activity level and adjust activity accordingly
Application of cold or warm compress to relieve pain
Serve prescribed analgesics
Psychological support:
Self image disturbance
Body image disturbance
Monitor the level of pain and duration of morning stiffness. Pain and morning stiffness are indicators of disease activity. Increased pain may necessitate changes in the therapeutic treatment plan.
■ Encourage the patient to relate pain to activity level and adjust activities accordingly. Teach the importance of joint and whole-body rest in relieving pain. Pain is an indicator of excess stress on inflamed joints. Increasing pain indicates a need to decrease activity levels.