Nursing Care and Pathophysiology for Rheumatoid Arthritis (RA)

So this lesson is going to cover Rheumatoid Arthritis, or RA. This is something that affects a surprising number of our patients and usually it’s something they’ll have already been diagnosed with by the time they get to you. They may come to the hospital for something completely unrelated, but we have to deal with managing their RA as well.

First of all, Rheumatoid Arthritis is a Chronic, Systemic, Autoimmune Inflammatory disorder affecting the joints. So autoimmune means the body is actually attacking the joints and the joint fluid - that’s what causes the inflammation. It’s chronic, meaning long-lasting and usually lifelong, and it’s systemic which means it can affect ANY joint in the body. We most often look at the hands, though, because one of the major signs of RA is joint deformity. This inflammation around the joints, like you can see here on the second finger, causes the joints to get weak. They can even dislocate or pop out of place. But most commonly this weakness and inflammation begins to cause deformities of the joints, they may bulge out or turn sideways like you see here.

So, what are we going to assess in our patients? Well, with all the inflammation in the joints, they’re going to be very stiff and they’re going to lose a lot of strength. They struggle just trying to change positions because of the stiffness. We also see the joints get spongy or weak and deformed. One of the most common deformities in RA is called Ulnar Deviation. This is when the fingers begin to deviate out to the ulnar side of the hand. Remember your ulna is the bone in your arm, here on the pinky side. So that’s why it’s called Ulnar Deviation. This is pretty classic for Rheumatoid Arthritis. We also find that most RA patients also suffer with anemia because the prolonged inflammation causes their body’s ability to produce red blood cells to decrease. Make sure you check out the Anemia lesson in the Hematology Course to learn more about that. The big thing it causes in these cases is just more fatigue. We’ll also see their ESR and CRP levels increase - that’s Erythrocyte Sedimentation Rate and C-Reactive Protein - both of those are markers in our blood that indicate inflammation. And, we’ll also see the presence of Rheumatoid Factor in their blood. This is how we would differentiate RA from something like Osteoarthritis. The big thing here is to assess the patient’s reaction to the changes in their body and their ability to perform ADL’s. Imagine trying to get dressed or hold a fork when you have this kind of deformity in your hands. It’s not easy, so we need to help them out with some of those things.

As far as therapeutic management, one of the things we can use to help ease joint pain is paraffin baths. This is a type of wax that the patient will stick their hands in. It’s hot when they first put their hands in the little bath, but then as the wax cools, it cools their joints as well. So it’s basically a form of hot/cold therapy that doesn’t require them to hold an ice pack or anything like that. We can also give medications. Remember this is an inflammatory disorder, so we want to give anti-inflammatory medications like NSAIDs or Corticosteroids. But remember, both of these can cause problems when taken long-term so we need to be looking out for that. Review those drugs in the Pharmacology course if you need to learn more. We can also give what are called DMARDs. That’s Disease Modifying Anti-Rheumatic Drugs. Essentially they will help to slow the progression of the disease, which can help minimize the amount of anti-inflammatories they need and decrease the frequency of exacerbations or flare ups. As far as nursing care, like I said we can provide heat/cold therapy. We want them to alternate hot and cold about every 15 minutes. We’ll schedule rest times which will help alleviate some of that fatigue. We also want to do Range of Motion exercises - this helps to keep the joints flexible and moving and prevent stiffness. Don’t forget to get PT or OT involved to help! And, of course, we want to assist with any ADL’s that the patient struggles to do on their own.

There are also a couple of procedures we could do for a patient with RA. One is an arthroscopy - remember that Arthro means joint, and the scopy part is a camera. So we’re inserting a camera into the joints to evaluate them. We can also take a sample of the joint fluid. With all the inflammation - the joint fluid may come out more orange, whereas normally it would be yellow. In severe cases, patients could also have an arthroplasty - where the joint is replaced altogether. This is most common in hips and knees. Just keep in mind that it’s not curative because this is an autoimmune disease. It will only help to alleviate severe symptoms. With both of these procedures, we want to make sure we assess distal neurovascular status post-op. Pulses, pain, numbness or tingling, etc. We also are concerned about positioning after hip replacement - we’ll talk in more detail about that in the Osteoporosis lesson.

Our top priority nursing concepts for a patient with Rheumatoid Arthritis are going to be mobility, comfort, and functional ability. Hopefully that makes sense based on what we’ve already talked about. Keep those joints moving, give anti-inflammatories and hot/cold packs to relieve pain, and make sure we help them with any ADL’s they aren’t able to perform.

So, let’s recap. RA is a chronic, systemic, autoimmune inflammatory disorder of the joints that causes stiffness, weakness, dislocation, and joint deformities. We want to give anti-inflammatory treatments like NSAIDs, Corticosteroids, and hot/cold packs. We want to optimize their mobility with range of motion exercises and consulting PT/OT. And if they do have a procedure like an arthroscopy or arthroplasty, we want to make sure we’re assessing perfusion and nerve function distal to that joint and using proper positioning.

So that’s it for Rheumatoid Arthritis. Check out all the resources attached to this lesson to learn more. Now, go out and be your best selves today. And, as always, happy nursing!