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What is RA?
involves the synovial membrane of the joints.
What is PANNUS formation?
Pannus destroys cartilage and erodes the bone.
The consequence is loss of articular surrfaces and joint motion.
What are the classic sx of RA?
- 1. Joint pain
- 2. swelling
- 3. warmth
- 4. erythema
- 5. lack of function
S/sx of RA?
- PALPATION on joints--> SPONGY or BOGGY tissue.
- Fluid can be aspirated from the inflamed joint.
- Inflammation, tenderness and stiffness of the joints.
- Moderate to severe pain.
- Joint deformities, muscle atrophy, and decreased ROM in affected joints.
Characteristic Pattern of Joint involvement:
- BEGINS: small joints in the hands, wrists and feet.
- PROGRESSIVE: knees, shoulder, hips, elbows, ankles, cervical spine, and TMJ.
- SX: acute in onset, bilateral and symmetric.
- JOINTS: hot, swollen and painful; joint stiffness in AM for more than 30 mins.
HANDS- misalignment and immobilized.
Extraarticular features of RA:
- Weight loss
- Sensory changes
- LN enlargement
- Raynaud's phenomenon (cold- and stress- induced vasospasm)
- Rheumatoid nodules, nontender and movable; found in the subcutaneous tissue over bony prominences.
- Arteritis, neuropathy, scleritis, pericarditis, splenomegaly and Sjorgen syndrome (dry eyes and mucous membrane)
Diagnosis of RA:
- *elevated ESR
- *decreased RBC and C4 compliment components.
- *(+)--> ANA and C-reactive protein
- *(+) Rheumatoid factor:VALUES--> Nonreactive: 0-39IU/ml; Weakly reactive:40-79IU/ml; Reactive: higher than 80IU/ml
- Radiographic study--> (+)joint deterioration
- Synovial tissue biopsy--> (+)inflammation
Goal of tx in pts with RA:
Preserve joint function.
Medication therapy USED for RA pt:
- NSAIDs-anti-inflammatory and analgesic effect.
- GLUCOCORTICOIDS-anti-inflammatory effect.
- DMARDs-slow the degenerative effect of the d/o; 1st choice in tx of SEVERE athritis; S/E: Injection site inflammation and pain, ecchymosis and edema, pancytopenia and infection, fatigue, nausea, headache, vomiting and flu-like sx and allergic response; N.I: !HCP-sx of infection and before receiving live vaccines, lab tests (neutrophil counts, WBC and platelets cont) are important BEFORE and DURING tx.
- GOLD SALTS- reduce progression of joint damage; GOLD TOXICITY: pruritis, rash, metallic taste, stomatitis and diarrhea; ANTIDOTE: Dimercaprol (BAL in oil)-enhance gold excretion.
Medications for RA:
- Anakinra (Kineret)-injection site reactions are common.
- Adalimumab (Humira)-injection site reactions are common; associated with neurologic injury
- Auranofin (Ridaura)-oral gold prep; not commonly used.
- Cyclosporine (Neoral)-immunosuppresants and antiinflammatory; cause nephrotoxicity
- Entanercept (Enbrel)-injection site reactions are common;r/f: heart failure, associated with CNS demyelination d/o and hematologic d/o.
- Hydroxychloroquine (Plaqueni)-assoc with RETINAL DAMAGE;(+)visual dist->!HCP
- Leflunomide (Arava)-s/e: diarrhea, resp infxn, reversible alopecia, rash and nausea; is hepatotoxic.
- Methotrexate (Rheumatrex, Trexall)-can cause hepatic fibrosis, BM suppression, GIT ulceration and pneumonitis.
- Penicillamine (Cuprimine)-cause BM suppression and autoimmune d/o.
- Infliximab (Reamicade)-can cause infusion reaction (fever, chills, pruritus, urticaria, chest pain); hepatotoxic.
- Sulfasalazine (Azulfidine)-cause GIT and dermatologic reactions; BM suppression; hepatotoxic.
EARLY RA medication:
- Salicylates or NSAIDs
- COX-2 enzyme blockers
- biologic response modifiers
- tumor necrosis factor-alpha (TFN-a)
MODERATE, EROSIVE RA medications:
- Occupational or PT
PERSISTENT, EROSIVE RA medications:
Reconstructive surgery and corticosteroids
ADVANCED, UNREMITTING RA medications:
immunosuppresive agents (methotrexate, azathioprine, cyclophosphamide, and leflunomide).
N/I for pts with RA:
RELIEVING PAIN AND DISCOMFORT
-cold or heat application, massage, position changes, rest, foam, mattress, supportive pillow, splints, relaxation techniques, diversional activities.
-sleep routine (warm baths and relaxation techniques to promote sleep); energy conservation techniques (pacing, delegating, setting priorities); provide REST;
-ROM on affected joints; assistive ambulatory devices
- MONITOR AND MANAGE CX-monitor for medication cx: GIT bleeding/ irritation, BM suppression, kidney/ liver toxicity, infection, mouth sores, and changes in vision. Other s/sx: bruising, breathing problems, dizziness, jaundice, dark urine, black/bloody stool, diarrhea, N&V and headaches.
- *monitor closely for systemic and local infections--> high dose of corticosteroids.