MUSCULOSKELETAL SYSTEM

NURSING PROCESS OF RHEUMATOID ARTHRITIS

LECTURER:

Ns.Leni Merdawati,M.Kep

NAME

ROZI ARDI TAMALA 1511314002

NURSING FACULTY
ANDALAS UNIVERSITY
PADANG
2016/2017
 CHAPTER I

INTRODUCTION

1.1.BACKGROUND
Disease of rheumatoid arthritis (RA) is one of the autoimmune disease in the form of
inflammatory arthritis in adult patients (Singh et al., 2015). Pain in people with RA Synovial
joints, on the part of the tendon sheaths, and exchanges will experience a thickening due to
an inflammation followed by erosion and destruction of bone of the bone around the joint
(Syamsuhidajat, 2010) to be able to cause the disability (Yazici & Simsek, 2010). However,
most of the ongoing chronic rheumatic diseases, namely, recovery and relapse repeatedly
causing damage to the joints permanently in people with RA (Muchid, 2006).

According to the Arthritis Foundation (2015), as much as 22% or more than 50 million
adults in the United States aged 18 years or more was diagnosed with arthritis. From these
data, about 3% or 1.5 million adults experience the RA (Arthritis Foundation, 2015). RA
occurs in 0.5-1% of the adult population in developed countries (Choy, 2012). The
prevalence of RA in Indonesia according to the results of research conducted by Nainggolan
(2010), the number of sufferers of RA in Indonesia year 2009 was 31.3% to 23.6%.

1.2. Purpose

1.2.1. Definition of Rheumatoid Arthritis

1.2.2. Risk Factors Rheumatoid Arthritis
1.2.3. Pathophysiology of Rheumatoid Arthritis
1.2.4. Signs and Symptoms of Rheumatoid Arthritis
1.2.5. Diagnostic test of Rheumatoid Arthritis
1.2.6. Treatment of Rheumatoid Arthritis
1.2.7. Nursing Process
 CHAPTER II

RHEUMATOID ARTHRITIS

2.1. Definition of Rheumatoid Arthritis

The word arthritis means inflammation of the joint (artho meaning joint and itis
meaning inflammation). Inflammation is a medical term describing pain, stiffness, redness
and swelling. Arthritis is a disease that can involve any of the joints in the body, often
occurring in the hip, knee, spine or other weight bearing joints, but can also affect the
fingers and other non-weight-bearing joints. Symptoms of arthritis include joint pain,
swelling, stiffness and fatigue. Untreated inflammation can eventually lead to joint damage,
destruction and disability. Some forms of arthritis can also affect the bodys internal organs.

Rheumatoid athritis (RA) is one of the common conective tissue diseases and the most
destructive to the joints. It is a chronic,progressive,systemic inflammatory autoimmune
diseases process that affects primarily the synovial joints. Systemic means this disease affect
the body system, affecting many joints and other tissues. RA affect over 2 million people,
and European Americans have the disease more often than other groups.

In RA , autoantibodies ( rheumatoid factors [RFs]) are formed that attack healthy tissue,
especially syynovium causing inflammation. RFs consist mainly of immunoglobulins M and
G , and they bind with antigens forming immune complexe. Phatocytes attemp to engulf
these complexes and , as a results, release powerful enzymes, such as cytokines. The B and
T-lymphocytes of the immune system are also stimulates and increase the imflammatory
respone.

Rheumatoid arthritis is a systemic diseases, area of the body beside the synovial joint can
be affected. Inflammatory responses similar to those occuring in synovial tissue may be seen
in any organ or body system in which connective tissue prevalent. If blood vessel
involvement occurs, the organ suplied by that vessel can be affected. The result is
malfunction and eventual failure of the organ or system. Theses pathologic changes may
occurs late in the disease process and cause life theartening problems.
2.2. Risk Factors

The exact causes of RA are unknown, but research has shown that several factors may
contribute to its development:

1. Family history
Some people who develop RA have genetic risk factors. However, having genetic risk
factors for RA does not necessarily mean you will develop the disease.
2. Gender
RA affects women two to three times more often than men.
3. Hormones
There seems to be an increased risk of RA related to hormonal changes. For instance, RA
symptoms often improve during pregnancy, however, these women may experience a
flare up after delivery. RA is less common among women who breastfeed. Also, some
studies have even found that women whove used oral contraceptives had a modest
decrease in the risk of RA.
4. Age
Anyone can get RA at any age, but the risk does increase with age (commonly
developing between ages 40 and 60).

2.3. Pathophysiology

Environmentgene interactions described in the text promote loss of tolerance to self-

proteins that contain a citrulline residue, which is generated by post-translational
modification. This anticitrulline response can be detected in T-cell and B-cell compartments
and is probably initiated in secondary lymphoid tissues or bone marrow. Thereafter,
localization of the inflammatory response occurs in the joint by virtue of poorly understood
mechanisms that probably involve microvascular, neurologic, biomechanical, or other tissue-
specific path ways. Synovitis is initiated and perpetuated by positive feedback loops and in
turn promotes systemic disorders that make up the syndrome of rheumatoid arthritis. ACPA
denotes anticitrullinated protein antibody, and RF rheumatoid factor.
2.4. Signs and Symptom

Rheumatoid athritis affects different people in different ways. Symptoms may slowly
develop over several years, or the disease may progress quickly. Symptoms may be mild or
very severe. You may go through phases called flares or flare-ups when symptoms are
severe. At other times, it may seem as if the disease and its symptoms have gone away. This
is called remission.Joint pain and swelling may happen slowly and may occur over weeks
or months. The small joints in the wrists and hands are often inflamed first. Over time, other
joints may be painful and swollen due to Rheumatoid athritis.

Common sign and symptoms of rheumatoid athritis include:

Joint pain and swelling
Stiffness
Fatigue, depression and irritability
Anemia
Flu- like symtoms, such as feeling generally ill, feeling hot and sweating.
Less common symtoms include:
Weight loss
Inflammation in the eye
Rheumatoid nudules
 Inflamation of other body parts, for example, the lungs and blood vessels and the
membrane around the heart, but this is rare.

2.5. Diagnostic test

Getting a firm RA diagnosis is not always easy. In its early stages, RA may resemble
other forms of inflammatory arthritis. No single test can confirm RA. An experienced
arthritis specialist (rheumatologist) will consider many factors, such as the following

1. Medical history
Your doctor will ask about your personal and family medical history; recent and current
symptoms (pain, tenderness, stiffness, difficulty moving) when they started, if they come and
go, how severe they are and if anything makes them better or worse. The number and pattern
of joints involved can also indicate RA; the disease tends to affect the same joint on both
sides of the body. However, it is possible for the disease to develop in a single joint. RA
involves large and small joints, but typically starts in small joints, such as those in the hands
and feet.

2. Physical exam
Your doctor will examine each joint, looking for tenderness, swelling, warmth and
painful or limited movement. An overall physical exam may reveal other signs, such as
rheumatoid nodules or a low-grade fever.

3. Blood tests
Blood will be drawn for two types of tests. One measures inflammation levels. The other
looks for biomarkers such as antibodies (blood proteins) linked with RA.

4. Imaging tests
An X-ray, ultrasound or magnetic resonance imaging (MRI) scan may be done to look for
joint damage, such as erosions, a loss of bone within the joint and narrowing of joint space.
Their absence doesnt rule out RA, however. It may mean that RA is in an early stage and
hasnt yet damaged the joints. Early images can be compared to ones taken later to help
monitor how well treatment is work

2.6. Treatmens

The general approach to treating RA is to reduce inflammation and prevent long-term

damage to the joints. Pain management is also important. The cornerstone of medication
 therapy for RA is diseasemodifying anti-rheumatic drugs (DMARDs) and a newer class of
medications called biologics

1. Corticosteroids

Cortisol is a hormone produced naturally by the bodys adrenal glands that has many
functions in our bodies. One of cortisols important actions is its antiinflammatory function.
Cortisol can be considered the brake for the immune system, preventing it from
overreacting to infections, injuries and trauma. However, steroids have many potential long
term side effects. Therefore, they are often used as an interim measure to help control
inflammation while waiting for the slower-acting DMARDs to take effect or in the case of
someone experiencing a flare of inflammatory arthritis. Ideally, steroids should be used at
the lowest dosage that provides benefit for the shortest period of time.

2. Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

DMARDs are a class of medications used to treat many different types of inflammatory
arthritis, such as RA, and work well for most people. The earlier a DMARD is started the
more effective it can be to suppress inflammation and prevent joint damage. It is important
to slow or even stop the progression of joint damage, but keep in mind that DMARDs
cannot fix joint damage that has already occurred.

3. Biologics

Biologics are drugs made from living cells (human, animal, bacteria, etc.). They are a
class of medications specially designed to treat inflammatory types of arthritis, such as RA.
Biologic medications work by modifying the bodys inflammatory response. Like
DMARDs, biologics can reduce pain, joint inflammation and damage to bones and cartilage.

2.7. Nursing Process

A. Assessment

1. Identity

Including name, gender, age, address, religion, marital status, education, occupation,
register number, hospital admission date.

2. Main complain
3. History of the disease now
Data collection is done since complaints arise. In rheumatoid arthritis clients, the early
stages are usually characterized by generalized disorders such as malaise, weight loss,
 fatigue, slight heat, and anemia. Local symptoms that occur in the form of swelling,
tenderness, and motion disorders in the metacarpophalangeal joint.
4. Past medical history
Is there a history of previous joint or bone disorders?
Has the patient undergone surgery such as joint replacement?
5. Family health history Assess whether there is a family of previous generations who have
the same complaint with clients.
6. Physical examination After anamnesis, physical examination is very useful to support
data history.
7. Diagnostic test Physicians rely on diagnostic tests to help them provide quality care to
people with RA. Diagnostic tests can take the form of blood analyses, joint fluid
analyses, urine analyses, and x-rays.

B. Nursing management

NANDA NOC NIC

ACUTE PAIN Outcomes to assess and Analagesic administration
Related factor measure actual Determine pain
Biological injury occurrence of the location,characteristic, quality, and
agent diagnosa: severuty before medicating patient
Chemical injury Pain control: Check medical order
agent Recognize pain Check history for allergy
Physical injury agent onset describe Determine analgesic selesction
CHRONIC PAIN causal factors Pain management
Related factor Uses diary to Performs comprehensive assessment
Age > 50 years monitor over time of pain include location,
Chronic Uses preventive characteristic,frequenct,quality,inten
musculoskeletal measure sity, or severity of pain and
condition Pain level: precipitating factor
Fatigue Report pain Observe for non verbal cues of
Famale gender Length of the discomforts, especially in those
Genetic disorder episode unable to communicate effectively
Post trauma related Rubbing affected
condition area
Moaning and crying
Facial expressions
of pain
IMPAIRED Activity intolerance Activity therapy
PHYSICAL walking phase determine patien ability to
MOBILITY walking distance parcipante
Related factor: stair climbing determine patient commitment to
 Activity intolerance tolerance increasing frequncy and activity
Alteration in bone upper and lower assist patient to focus in abilities
structure integrity strength rather than of deficit
Anxiety Endurance Exercise promotion
Decrease in muscle performance of exercise promotion: strength ,
control , mass, and usual routine training, streching, balance, and join
strength physical activity mobility
Musculoskeltal muscle endurance explored barries to exercise
impaired encourage individual to begin or
pain continue exercise
 CHAPTER III

CONCLUSION

3.1.CONCLUSION
Rheumatoid athritis (RA) is one of the common conective tissue diseases and the most
destructive to the joints. It is a chronic,progressive,systemic inflammatory autoimmune
diseases process that affects primarily the synovial joints. . Inflammatory responses similar
to those occuring in synovial tissue may be seen in any organ or body system in which
connective tissue prevalent. If blood vessel involvement occurs, the organ suplied by that
vessel can be affected. The result is malfunction and eventual failure of the organ or system.
Theses pathologic changes may occurs late in the disease process and cause life theartening
problems.
 REFERENCE
Donna D. Ignatavicius, M. Linda Workman.2009. Medical-Srgical Nursing: 6th Edition

The Community Athritis Society.Rheumatoid Athritis-Causes, Symptoms and Treatments

Iain B. Mcinnes, F.R.C.P., Ph.D., And Georg Schett, M.D. 2011.The Pathogenesis Of
Rheumatoid Arthritis. United Kingdom

Athritis Foundation. Understanding Symptoms,Diagnosis and Treatments

Gloria M. Bulechek, Howard K.Butcher, Dkk. 2013. Nursing Interventions Classification (Nic)
:6 Edition . Elseiver : United States Of America

Sue Moorhead, Marion Johnson, Dkk. 2013. Nursing Outcomes Classification (Noc) 5 Edition.
Elseiver : United States Of America