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الموضوع: Rheumatoid Arthritis

  1. #1
    تاريخ التسجيل
    Feb 2006
    الدولة
    قلب امي
    المشاركات
    877

    افتراضي Rheumatoid Arthritis

    السلام عليكم ورحمة الله وبركاته

    اعضاء طبيب دوت كوم


    اهلا وسهلا بكم بمنتدى كلية التمريض التي يسرها تقديم كل ماهو جديد ومفيد


    لاعضائها الكرام


    تقدم اليكم عن مرض RHEUMATOID ARTHRITIS


    بالتفصيل مع الخطة التمريضية المتبعة


    تمنياتنا ان ينال على رضاكم


    ودمتم بالف صحة وعافية







    اعداد وتنفيذ مركز التديب و التعليم

  2. #2
    تاريخ التسجيل
    Feb 2006
    الدولة
    قلب امي
    المشاركات
    877

    افتراضي

    RHEUMATOID ARTHRITIS
    RA is a chronic inflammatory disease that affects joints and other organ systems. RA affects 0.5% to 1% of the population worldwide.
    Pathophysiology and Etiology

    • Immunologic processes result in inflammation of synovium, producing antigens and inflammatory by-products that lead to destruction of articular cartilage, edema, and production of a granular tissue called pannus


    • Granulation tissue forms adhesions that lead to decreased joint mobility.
    • Similar adhesions can occur in supporting structures, such as ligaments and tendons, and cause contractures and ruptures that further affect joint structure and mobility.
    • The etiology is unknown but is probably a combined effect of environmental, epidemiologic, infectious, and genetic factors.
    • An infectious agent has not been identified, but many infectious processes can produce a polyarthritis similar to RA.
    • Women are affected more frequently than men.


    Clinical Manifestations

    • Arthritis
      • Bilateral, symmetric arthritis affects any diarthrodial joint, but most commonly involves the hands, wrists, knees, and feet



    • Skin manifestations
      • Rheumatoid nodules : elbows, occiput, sacrum.
      • Vasculitic changes : brown, splinterlike lesions in fingers or nail folds.

    • Cardiac manifestations
      • Acute pericarditis.
      • Conduction defects.
      • Valvular insufficiency.
      • Coronary arteritis.
      • Cardiac tamponade : rare.

    • Pulmonary manifestations
      • Asymptomatic pulmonary disease.
      • Pleural effusion, pleurisy.
      • Interstitial fibrosis.
      • Laryngeal obstruction caused by involvement of the cricoarytenoid joint rare.

    • Neurologic manifestations
      • Mononeuritis multiplex : wrist drop, foot drop.
      • Carpal tunnel syndrome.
      • Compression of spinal nerve roots.
      • Distal sensory neuropathy

    • Other manifestations
      • Fever.
      • Fatigue.
      • Weight loss.
      • Episcleritis



    Diagnostic Evaluation

    • Complete blood count (CBC) : normochromic, normocytic anemia of chronic disease; may also have iron deficiency anemia (hypochromic, microcytic).
    • RF : positive in 70% to 80% of patients with RA.
    • ESR and C-reactive protein : elevated due to active inflammation.
    • Synovial fluid analysis
    • X-rays : changes develop within 2 years.
      • Hands/wrists : marginal erosions of the proximal interphalangeal (PIP), metacarpophalangeal, and carpal joints; generalized osteopenia.
      • Cervical spine : erosions that produce atlantoaxial subluxation.

    • Magnetic resonance imaging (MRI) : to detect spinal cord compression that results from C1 to C2 subluxation and compression of surrounding vascular structures.
    • Bone scan : increased uptake in the joints involved in RA.
    • Synovial biopsy.
      • Inflammatory cells associated with RA.
      • Excludes other causes of polyarthritis by noting the lack of other pathologic findings.



    Management

    • NSAIDs to relieve pain and inflammation.
    • DMARDs to reduce disease activity.
      • Monotherapy or combination of older agent, such as methotrexate or hydroxychloroquine, with newer agent, such as tumor necrosis factor (TNF) inhibitor or biologic agent.
      • Combination of TNF inhibitor and methotrexate has shown greater benefit in improving signs and symptoms, prevent radiologic deterioration of the joint, and improve physical function in comparison with monotherapy.
      • Goal is to have long-term impact on the joint.

    • Corticosteroids to reduce inflammatory process.
    • Local comfort measures:
      • Application of heat and cold.
      • Use of splints.
      • Use of transcutaneous electrical nerve stimulation (TENS) unit.
      • Iontophoresis delivery of medication through the skin using direct electrical current.

    • Nonpharmacologic modalities:
      • Behavior modification.
      • Relaxation techniques.

    • Surgery:
      • Synovectomy.
      • Arthrodesis joint fusion.
      • Total joint replacement.



    Complications

    • Loss of joint function because of bony adhesions and damage of supporting structures 7% of patients become disabled within 5 years of onset; 32% cannot work after 10 years.
    • Anemia of chronic disease.
    • Felty's syndrome : neutropenia, splenomegaly, and deformity; occurs in 1% of patients


    Nursing Assessment

    • Perform joint examination if indicated, including which joints affected; ROM of each joint; presence of heat, redness, swelling, and possible joint effusion.
    • Note presence of deformities:
      • Swan neck : PIP joints hyperextend.
      • Boutonniere : PIP joints flex.
      • Ulnar deviation : fingers point toward ulna.

    • Assess pain using a pain measurement scale such as the visual analog scale (10 cm straight line scored 0 to 100; patient makes a mark indicating intensity of pain).
    • Assess functional status using the American College of Rheumatology : revised criteria for classification for global functional status.
      • Class I : Completely able to perform usual activities of daily living (ADLs).
      • Class II : able to perform usual self-care and vocational activities, but limited in avocational activities.
      • Class III : able to perform usual self-care activities, but limited in vocational and avocational activities.
      • Class IV : limited ability to perform usual self-care, vocational, and avocational activities.

    • Assess for adherence to treatment plan, any complementary methods used, and any adverse reactions to medications.


    Nursing Diagnoses

    • Chronic Pain related to disease process
    • Impaired Physical Mobility related to pain and limited joint motion
    • Dressing or Grooming Self-Care Deficit related to limitations secondary to disease process
    • Ineffective Coping related to pain, physical limitations, and chronicity of RA


  3. #3
    تاريخ التسجيل
    Feb 2006
    الدولة
    قلب امي
    المشاركات
    877

    افتراضي

    Nursing Interventions
    Controlling Pain

    • Apply local heat or cold to affected joints for 15 to 20 minutes, three to four times per day. Avoid temperatures likely to cause skin or tissue damage by checking temperature of warm soaks or by covering cold packs with a towel.
    • Administer or teach self-administration of pharmacologic agents.
      • Advise patient when to expect pain relief, based on mechanism of action of the drug.

    • Encourage use of adjunctive pain control measures.
      • Progressive muscle relaxation.
      • TENS.
      • Biofeedback.
      • Meditation.
      • Acupuncture or similar therapies.



    Optimizing Mobility

    • Encourage warm bath or shower in the morning to decrease morning stiffness.
    • Encourage measures to protect affected joints.
      • Perform gentle ROM exercises.
      • Use splints.
      • Assist with ADLs if necessary.

    • Encourage exercise consistent with degree of disease activity.
    • Refer to physical therapy and occupational therapy.


    Promoting Self-care

    • Provide pain relief before self-care activities.
    • Provide privacy and an environment conducive to performance of daily activities.
    • Schedule adequate rest periods.
    • Discuss importance of promoting the patient's self-care at an appropriate level with patient and family.
    • Help patient attain appropriate assistive devices, such as raised toilet seats, special eating utensils, and zipper pulls. Contact occupational therapist, social worker, or Arthritis Foundation for information.


    Strengthening Coping Skills

    • Be aware of potential job, child-care, home maintenance, and social and family functioning problems that may result from RA.
    • Encourage patient to vocalize problems and feelings.
    • Assist with problem-solving approach to explore options and to gain control of problem areas.
    • Reinforce effective coping mechanisms.
    • Refer to social worker or mental health counselor as needed.


    Patient Education and Health Maintenance

    • Instruct patient and family in the nature of disease.
      • Chronic nature of RA with characteristic exacerbations and remissions with time.
      • Disease can have systemic affects that result in constitutional symptoms and involvement of other organ systems.
      • Severity of RA is variable, but most patients are not confined to bed or wheelchair.
      • RA has no cure; avoid miracle cures.

    • Educate about pharmacologic agents.
      • Medication must be taken consistently to achieve maximum benefit.
      • Most medications used in the treatment of RA require periodic laboratory testing to monitor for potential adverse effects.
      • Advise patient of possible adverse effects of medications and need to report adverse effects to health care provider.
      • Advise patients to discuss the use of any complementary or alternative therapies with their health care provider.
      • Reinforce to patient the need for lifelong treatment.

    • During periods of remission, encourage patient to exercise regularly, choosing an activity that is inexpensive, convenient, enjoyable, and not dependent on the weather. Suggest dancing, mall walking, use of stationary bicycle in the home, or contacting the local YMCA about special programs for arthritis.
    • Evaluation: Expected Outcomes



    • Reports reduction in pain
    • Wears wrist splints correctly and performs range-of-motion exercises twice per day
    • Maintains independent toiletry, bathing, and feeding
    • Verbalizes concerns about cleaning and cooking; meets with occupational therapist



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