Rheumatoid Arthritis NCLEX Review

Rheumatoid arthritis (RA) is an autoimmune condition in which the patient’s immune system attacks healthy cells inside the joints, leading to an inflammatory state. While the exact etiology of RA is unknown, it is thought to be a combination of both genetics and the environment. A study conducted in 2021 found that close to 33% of RA cases could be attributed to modifiable risk factors: obesity, smoking and alcohol consumption.

Rheumatoid Arthritis Pathophysiology

In rheumatoid arthritis, immune cells attack the synovium causing it to become thick and inflamed. This inflammation leads to the classic symptoms of painful, swollen and red joints that are difficult to move. Recall that the synovium surrounds joints and produces the synovial fluid that allow for joint movement.

As the immune system attacks the synovium and immune complexes develop, vascular permeability increases and the inflammation triggers further destruction of both cartilage and bone by cells called fibroblast-like synoviocytes (FLS). These FLS can migrate to other joints, can invade tendons and cartilage, and even stimulate osteoclasts to further destroy bone.

Who is most at risk for RA?

Rheumatoid arthritis risk increases with age and women are three times more likely than men to develop the disease. Additionally, patients with a family history of RA are at higher risk as are those with HLA class II genotypes.

Modifiable risk factors include: 

• Cigarette smoking and exposure to second-hand smoke in childhood
• Periodontal disease
• Obesity (BMI > 30 increases risk by 30%) 
• Alcohol consumption

What are the complications of RA? 

There are many complications of rheumatoid arthritis that go well beyond the damage it causes to the joints.

• The inflammation associated with RA can affect the lungs, heart, blood vessels, skin and eyes, with the cardiovascular system most commonly affected. Chronic inflammation is thought to increase the development of atherosclerosis and RA patients are at higher risk for heart failure, heart disease, coronary artery disease and arrhythmias.
• Lung disease, which may be caused by the medications used to treat RA, can include pleuritis, pleural effusion, pneumonia, pulmonary nodules and interstitial fibrosis.
• Weight gain due to the pain of exercising may lead to diabetes, hypertension, high cholesterol and heart disease.
• Chronic inflammation contributes to insulin resistance, which leads to Type 2 diabetes.
• Rheumatoid arthritis and treatment with corticosteroids can lead to osteoporosis. In fact, patients with RA are 60 – 100% more likely to have an osteoporotic fracture when compared against individuals without the condition.
• Immune dysfunction and immunosuppressant medication both put the patient with RA at higher risk for opportunistic infections.
• Depression is often seen in patients with debilitating physical issues.
• Other complications include lymphoma, periodontal bone loss, and anemia.  
• Lastly, patients with RA are more likely to be unemployed due to the physical limitations of the disease.

Now that you have a better understanding of rheumatoid arthritis, let’s go through how to care for these patients using the Straight A Nursing LATTE method. 

L: How does the patient LOOK?

The classic symptoms of RA are swollen, warm and painful joints that are usually more stiff in the morning or after periods of inactivity. The patient may report that the symptoms started in smaller joints such as the hands and then progressed to knees, ankles, wrists, shoulders or hips. Usually the symptoms will appear in both joints bilaterally (for example, both knees or both wrists).

The patient with RA will have “flares” where symptoms are worse for a period of time. In advanced cases, the joints will appear deformed and are especially noticeable in the hands. 

Other signs/symptoms include: 

• Musculoskeletal – Reduced grip strength, nodules under the skin, swollen joints that feel “boggy” on palpation, muscle weakness (due to glucocorticoid use or synovitis in the knee)
• Integumentary – Skin ulcers on the lower limbs, dry mouth, and gum inflammation
• Blood vessels – Venous stasis, vasculitis, and arterial insufficiency (which can all contribute to the development of skin ulcers)
• Respiratory – Shortness of breath secondary to lung inflammation
• Optic – Dry and red eyes
• Other – Low grade fever, depression, anemia
• Fatigue – Fatigue secondary to pain, difficulty sleeping, anemia, emotional stress and physical decline

A: How do you ASSESS the patient?

Your priority assessment for a patient with RA is to assess the patient’s joints for swelling, deformity, tenderness, morning stiffness, and range of motion. 

Other key assessments include: 

• Perform a thorough pain assessment using the PQRST format: What provokes the pain or makes it better? Describe the quality of the pain. Does the pain radiate? What is the severity of the pain? Does the pain get worse or better over time, and how long has the pain lasted?
• Assess the patient’s level of fatigue and ask about sleep habits.
• Ask the patient about their ability to perform ADLs, engage in physical activity, and perform their work duties.  
• Weigh the patient to assess for weight loss which can be due to RA or medications.
• Assess the patient’s gait as part of a fall-risk evaluation.
• Evaluate any other body system that is exhibiting symptoms such as the skin, lungs and eyes.

T: What TESTS are utilized for rheumatoid arthritis? 

There are no specific tests for RA. Diagnosis is challenging and relies on a combination of lab tests, the patient’s symptoms and history, and ruling out other potential causes such as lupus, fibromyalgia and Sjogren’s Syndrome). 

Specific tests include:

• Rheumatoid factor (RF) – This antibody is present in 80% of patients with RA. However, since it may be present with other conditions, it’s not definitive for diagnosis.
• Antinuclear antibody (ANA) – A positive ANA is suggestive of RA. On its own it is not definitive for diagnosis since other conditions can cause an elevated level.
• Erythrocyte sedimentation rate (ESR) – Elevated in inflammatory states, including RA.
• C-reactive protein (CRP) – Elevated in inflammatory states, including RA.
• Anti-citrullinated peptide antibodies (ACPA) – The test is positive in most people with RA, even long before symptoms develop. It is considered to be more sensitive for RA than the rheumatoid factor antibody test. 
• CBC – Patients with RA will often have elevated WBCs during a flare, anemia and possibly also thrombocytosis.
• Liver and kidney function tests – These tests are conducted to rule out other causes for the patient’s symptoms. In addition, if the patient is being treated with RA medications, doses may need to be adjusted based off renal and hepatic function.
• Imaging studies (X-ray, ultrasound, MRI, etc.) – Imaging studies are utilized to assess joints for the changes associated with RA. Many times patients will have osteopenia, joint space narrowing, and erosion of bone and cartilage. Additionally, an MRI can show thickening of the synovium.
• Synovial fluid examination – The synovial fluid may be evaluated to rule out other causes such as infectious arthritis or gout. In RA, the synovial fluid usually shows the presence of leukocytes. 

The American College of Rheumatology has developed a diagnostic criteria that scores the patient in the following areas after ruling out other potential causes: number of joints involved, rheumatoid factor antibody test, ESR or CRP (tests for inflammation), symptoms lasting at least six weeks.

T: What TREATMENTS are provided for rheumatoid arthritis?

While there is no cure for rheumatoid arthritis, there are several treatments available that can help control synovitis, prevent joint injury, reduce long-term complications and even achieve remission. When treatment is started early, there’s a better chance the patient will respond well to therapy due to the fast moving nature of the disease. Treatments for RA are broad and include medications, rest, exercise, and nutrition. 

Medication – Treatment for RA typically includes the use of a DMARD with an NSAID or corticosteroid. 

• Nonsteroidal anti-inflammatory drugs (NSAIDS) – NSAIDs reduce inflammation while providing analgesia for joint pain. They are typically started early to control symptoms as it takes several weeks for the patient to respond to DMARD therapy. NSAIDs should be taken with food to minimize gastric upset. NSAIDS increase risk for bleeding and the development of peptic ulcers. Ex: Ibuprofen, naproxen, meloxicam.
• Corticosteroids – Corticosteroids are also used along with DMARD therapy and may be used instead of or in coordination with NSAIDs. Patients taking corticosteroids should be monitored for adverse effects including hyperglycemia, hypertension, risk for infection, poor wound healing, and osteoporosis. Corticosteroids are not intended for long-term use and should be tapered off as soon as feasible (never stopped abruptly). Ex: Prednisone and methylprednisolone
• Disease-modifying antirheumatic drug (DMARD) – DMARDs are immunosuppressive and immunomodulatory medications that interfere with pathways in the inflammatory cascade. Studies show that RA is most susceptible to these medications early in the disease and that response rates tend to decrease over time, which is why it is recommended that DMARD therapy be started early. Note that patients taking DMARDs will be at higher risk for infection, due to their immunosuppressive effects. DMARDs can be divided into three main categories – nonbiologic (traditional DMARDs), biologic and targeted synthetic. 

Nonbiologic DMARDs most commonly used are methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide.

• Methotrexate – The first medication typically used is methotrexate, which has faster onset and lower toxicity than other DMARDs. Methotrexate is given weekly PO or SubQ and increased as tolerated. It is contraindicated in pregnancy and breastfeeding and comes with a long list of common side effects such as nephropathy, anorexia, nausea, vomiting, diarrhea, anemia, leukopenia and thrombocytopenia. 
• Hydroxychloroquine (Plaquenil) – Hydroxychloroquine is an antimalarial agent that has anti-inflammatory properties. Patients will receive routine eye exams due to the risk of vision loss and should be monitored for cardiomyopathy and QT prolongation during the initiation of therapy and periodically throughout.
• Sulfasalazine (Azulfidine) – Sulfasalazine is typically utilized in patients who did not respond to or who cannot tolerate NSAIDs. This medication can cause crystals to form in the urine, so instruct the patient to drink plenty of water.
• Leflunomide (Arava) – Leflunomide decreases pain and inflammation to slow progression of the disease and improve physical functioning. Common adverse effects are headache, dizziness, diarrhea, nausea, alopecia, and rash.

Biologic DMARDs are produced by recombinant DNA technology and are typically used when conventional DMARDs fail, or may be used in combination with methotrexate. Some biologic medications target tumor necrosis factor (TNF) while others target different molecules. Common side effects from these medications include GI upset, fatigue, and headache though there are many more and vary from one medication to another. Biologic DMARDs are given via infusion and subcutaneous injection and include: Etanercept, infliximab, adalimumab, rituximab, abatacept, rituximab, tocilizumab, certolizumab and golimumab (notice most of these end in “mab”).

Targeted synthetic DMARDs target different pathways than the biologics and are indicated in moderate to severe disease for patients who are not responding to conventional DMARDs. Like other DMARDs, these medications put the patient at high risk for infection including tuberculosis. These medications are given PO and include tofacitinib, baricitinib, upadacitinib, and filgotinib (notice they all end in “nib”).

Because of the many adverse effects of DMARDs, patients should have baseline blood tests done prior to starting therapy to assess for anemia, renal functional, and hepatic function. They should also have an eye exam conducted (if starting on hydroxychloroquine) and be screened for tuberculosis as well as hepatitis B and C. In addition, they should receive all recommended vaccinations.

• Pain Medications – During RA “flares” the patient will likely need something to help with pain. Common pain medications include acetaminophen, tramadol, and capsaicin (a topical solution). Opioids such as oxycodone or hydrocodone may be used in severe cases.
• Supplements – Supplements may be utilized to help with inflammation and stiffness. Because herbal supplements can interact with many medications, always advise patients to discuss them with their physician before taking. Common supplements include curcumin (turmeric), green tea, ginger, and Omega-3 fatty acids (fish oil).

Rest and exercise – Exercise is important for maintaining a healthy weight, maintaining muscle mass and reducing joint pain. Low impact activities are encouraged such as swimming, walking and bicycling. It’s also important that patients balance exercise with rest to reduce fatigue and joint inflammation.

PT/OT – Physical therapy and occupational therapy may be utilized as needed to promote functional independence.

Key nursing interventions – Much of your nursing care for a patient with rheumatoid arthritis will focus on addressing pain and inflammation. Interventions include:

• Provide hot or cold packs for pain relief. Heat tends to help with stiffness and cold helps with inflammation. 
• Encourage the patient to eat small frequent meals high in vitamins, protein and iron. This helps prevent weight loss and provides adequate nutrition.
• Assist with self-care and ADLs as needed, while also promoting independence.
• Encourage ROM exercises of affected joints, and perform PROM if the patient is unable to participate actively.
• Cluster nursing care, giving the patient opportunities to rest.

E: How do you EDUCATE the patient/family?

In addition to teaching the patient how to take their medications and what to watch for, your teaching can also include:

• Teach the patient how to use heat and cold to address pain. A hot shower in the morning can help with the morning joint stiffness and pain in the hands can be treated with a heating pad or hot paraffin. Additionally, swelling can be addressed with ice packs. 
• Teach patients to receive appropriate vaccines on schedule to reduce risk of infectious disease, which is increased with immunosuppressive therapy. Some medication therapies will require the patient to avoid live vaccines, so instruct them to always check with their rheumatologist in advance.
• Teach the patient that gentle exercise can help and should be continued even through a “flare.”
• Many medications for RA come with a heightened risk for infection, so teach your patient basic infection prevention measures such as hand hygiene, avoiding being around others who are ill, and wearing a mask when appropriate in public.
• Because patients with RA are at higher risk for cardiovascular disease, teach patients strategies to reduce their risk such as smoking cessation, exercise, maintaining a healthy weight, and reducing cholesterol levels.  
• Teach patients that good posture and body alignment can help protect joints.
• If the patient is taking DMARDs or corticosteroids, advise them to wear sunscreen or avoid sun exposure to prevent sunburns and rashes.
• If taking DMARDs, advise the patient to speak to their prescriber before taking PPIs such as pantoprazole (Protonix) as this can increase the risk of the DMARDs’ adverse effects.
• Some DMARDs, such as methotrexate, can cause liver damage. Teach the patient to avoid alcohol and to report any signs of hepatotoxicity such as jaundice, dark urine and pain in the upper right abdomen.
• Teach the patient taking a DMARD that they will get lab tests done routinely to monitor WBCs, RBCs, platelets, renal function and hepatic function.
• Teach patients strategies to protect the small joints such as maintaining a neutral position when possible, carrying heavy items with whole hands and arms (not just fingers), avoid gripping items for extended periods of time (such as steering wheels) and to avoid repetitive movement for long periods such as writing or knitting.  
• And lastly, teach patients to decrease their modifiable risk factors with smoking cessation, maintaining a healthy weight, avoiding alcohol and maintaining good dental hygiene.

Take this topic on the go by tuning in to episode 261 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

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