RHEUMATIC DISEASES / RHEUMATOID ARTHRITIS

A Case Study

Presented to the

Faculty of the College of Allied Health Sciences

PHINMA University of Pangasinan

Dagupan City

In Partial Fulfillment

Of the Requirements for the Degree

Bachelor of Science in Nursing

Submitted by:

Manuel, John Edryl

Caido, Kathleen

Maquinad, Alexis

Molano, Regent

Ramirez, Olga

Ramos, Trixie

Torio, Jesus Jasper

March 2024

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 I. Introduction

In the last decade we have significantly increased our knowledge of the underlying

pathobiology of rheumatoid diseases, introduction of immunotherapy has aid us in realizing that

Rheumatic diseases are not only a medical condition but a condition that causes a person to

suffer a lifelong suffering, something that can bring them into torment every day. It is sad,

actually, because it keeps a person from enjoying activities of daily life. Rheumatic diseases are

among the most prevalent chronic diseases of the musculoskeletal system and connective tissue

and can affect different age groups of the population and negatively interfere with the quality of

life of patients.

Rheumatic Diseases, long tolerated by many as a condition that affects their activities of

their daily living, is now recognized as a major public health problem, one that can have long-

lasting consequences. Those consequences—for those who are affected—include joint pain,

fever, fatigue, limited range of motion, rashes, and organ involvement.

It is a systemic immune condition, encompasses a wide range of disorders that primarily

affect the joints, muscles, and connective tissues, with rheumatoid arthritis (RA) being the most

common.

Rheumatoid arthritis (RA), as one of the most common musculoskeletal disorders in

more than 100 diseases and other health conditions, is a chronic autoimmune disorder that

primarily affects the joints. It occurs when the immune system mistakenly attacks the body’s

own tissues, particularly the synovium—the lining of the membranes that surround the joints.

It is unknown what specifically causes rheumatoid arthritis. Scientists believe that

hormones, the environment, and heredity all play a role.

 II. Patient Profile

Name: Jack

Age: 40

Gender: Male

Medical history: Rheumatoid Arthritis

Chief of complaint: Persistent joint pain, stiffness and swelling in hands and knees

III. Anatomy and Physiology

This section presents a description and anatomical presentation of Rheumatoid Arthritis.

Description

Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes joint inflammation, pain,
and sometimes disability. It affects millions of people worldwide. It is classified as a chronic
disease of the diffuse connective tissues that is characterised by diffuse inflammation and
degradation in the tissues.

The immune system mistakenly targets the synovium, releasing inflammatory chemicals that
break down cartilage and bone.

While the exact cause is unknown, it’s believed to be a combination of genetic predisposition and
environmental triggers. The immune system’s attack involves T-cells, B-cells, macrophages, and
cytokines, all contributing to the inflammatory cascade.

RA can also affect other organs besides joints, leading to skin nodules, eye inflammation, lung
problems, and even heart complications. While there’s no cure, early diagnosis and treatment can
help control the disease and minimize long-term damage.
Anatomy

Synovium

The synovium, in normal joints, is a thin delicate lining that serves several important functions.
The synovium serves as an important source of nutrients for cartilage since cartilage itself is
avascular. In addition, synovial cells synthesize joint lubricants such as hyaluronic acid, as well
as collagens and fibronectin that constitute the structural framework of the synovial interstitium.

1. Synovial lining or intimal layer: Normally, this layer is only 1-3 cells thick. In RA, this
lining is greatly hypertrophied (8-10 cells thick). Primary cell populations in this layer are
fibroblasts and macrophages.
2. Subintimal area of synovium: This is where the synovial blood vessels are located; this
area normally has very few cells. In RA, however, the subintimal area is heavily
infiltrated with inflammatory cells, including T and B lymphocytes, macrophages, mast
cells, and mononuclear cells that differentiate into multinucleated osteoclasts. The intense
cellular infiltrate is accompanied by new blood vessel growth (angiogenesis). In RA, the
hypertrophied synovium (also called pannus) invades and erodes contiguous cartilage and
bone. As such, it can be thought of as a tumor-like tissue, although mitotic figures are rare
and, of course, metastasis does not occur.

Cartilage

Composed primarily of type II collagen and proteoglycans, this is

normally a very resilient tissue that absorbs considerable impact and
stress. In RA, its integrity, resilience and water content are all
impaired. This appears to be due to elaboration of proteolytic
enzymes (collagenase, stromelysin) both by synovial lining cells and
by chondrocytes themselves. Cytokines including IL1 and TNF drive
the generation of reactive oxygen and nitrogen species and while
increasing chondrocyte catabolic pathways and matrix destruction,
also inhibit new cartilage formation. Polymorphonuclear leukocytes
in the synovial fluid may also contribute to this degradative process.

Bone

Composed primarily of type I collagen, bony destruction is a

characteristic of RA. This process is primarily driven by the
activation of osteoclasts. Osteoclasts differentiate under the
influence of cytokines especially the interaction of RANK with its
ligand. The expression of these are driven by cytokines including
TNF and IL1, as well as other cytokines including IL-17. There may
also be a contribution to bony destruction from mediators derived
from activated synovial cells.

Synovial Cavity

The synovial cavity is normally only a “potential” space with 1-2ml

of highly viscous (due to hyaluronic acid) fluid with few cells. In RA,
large collections of fluid (“effusions”) occur which are, in effect,
filtrates of plasma (and, therefore, exudative – i.e., high protein
content). The synovial fluid is highly inflammatory. However, unlike
the rheumatoid synovial tissue in which the infiltrating cells are
lymphocytes and macrophages but not neutrophils, in synovial fluid
the predominant cell is the neutrophil.

IV. Pathophysiology
Stage 1: Early RA

In the autoimmune process of RA, the body mistakenly attacks its own joint tissue. In early RA,
the patient may not have many symptoms except for some stiffness in the early hours of the
morning, primarily small joints — hands, the foot, sometimes the knees (Bhatt, 2018).

Stage 2: Antibodies Develop and Swelling Worsens

In many cases, RA progresses to the second stage without being diagnosed. In the second stage
the body makes the antibodies and the joints start swelling up. It can affect other organ systems
and cause inflammation there: the lungs, the eyes, a skin rash, and it can even affect the heart.
Lumps on the elbows called rheumatoid nodules may also develop (Bhatt, 2018).

Stage 3: Symptoms Are Visible

In this latter, more severe stage, blood tests and imaging are less relevant for diagnosis because
you can actually see the effects of the disease. The joints start becoming bent and deformed, the
fingers become crooked, these misshapen joints can press on the nerves and can cause nerve pain
as well.. In the older days we used to see more deformed joints when we did not have much
treatment, but now we are seeing less and less (Bhatt, 2018)

Stage 4: Joints Become Fused

If not treated, the disease will progress to the last stage, in which “there’s no joint remaining at
all and the joint is essentially fused (Bhatt, 2018)

V. NCP

(PALAGAY NALANG AKO NUNG TATLONG NCP DITO THE :3 )

VI. DRUG STUDY

 (TAS YUNG TATLONG DS DIN HEHE)

VII. PATIENT EDUCATION

Educating patients about rheumatoid arthritis (RA) involves helping them understand the
disease, its management, and how to improve their quality of life. By covering these topics,
you can help patients with RA better understand their condition, manage their symptoms, and
improve their quality of life.

Here are some examples of patient education topics:

1. Understanding RA and Its Effects:

-Education: Explain that RA is an autoimmune disorder where the immune system attacks
the joints, causing inflammation, pain, and potential joint damage. It often affects multiple
joints symmetrically.

-Rationale: Knowledge about RA helps patients understand their symptoms and the
importance of managing the condition to prevent joint damage and improve function.

2. Medication Management:

-Education: Provide information on the different types of medications used in RA,

including disease-modifying antirheumatic drugs (DMARDs), biologics, and nonsteroidal
anti-inflammatory drugs (NSAIDs). Explain how to take these medications, potential side
effects, and the importance of adherence.

-Rationale: Understanding medications helps patients manage their disease effectively and
reduces the risk of complications. Adherence is crucial for controlling symptoms and
preventing disease progression.

3. Exercise and Physical Therapy:

 -Education: Discuss the benefits of regular exercise, including improving joint function,
reducing stiffness, and enhancing overall physical fitness. Suggest low-impact activities like
swimming or walking and the importance of working with a physical therapist to develop a
personalized exercise plan.

-Rationale: Exercise helps maintain joint function and reduces stiffness, while physical
therapy can address specific joint issues and improve strength and flexibility.

4. Diet and Nutrition:

-Education: Recommend a balanced diet rich in fruits, vegetables, lean proteins, and whole
grains. Discuss the potential benefits of anti-inflammatory foods and the importance of
maintaining a healthy weight to reduce stress on the joints.

-Rationale: Proper nutrition supports overall health and can help manage inflammation and
weight, which can reduce joint stress and improve symptoms.

5. Joint Protection Techniques:

-Education: Teach strategies for protecting joints, such as using assistive devices (e.g., grab
bars, specialized kitchen tools), avoiding excessive strain on joints, and using proper body
mechanics during daily activities.

-Rationale: Joint protection techniques help reduce pain and prevent further joint damage,
making daily activities easier and more manageable.

6. Stress Management and Coping Strategies:

-Education: Discuss the impact of stress on RA symptoms and suggest techniques for stress
management, such as mindfulness, relaxation exercises, or counseling.

-Rationale: Managing stress can help improve overall well-being and potentially reduce the
severity of RA symptoms.
7. Monitoring and Reporting Symptoms:

-Education: Advise patients to monitor their symptoms and report any changes or
worsening to their healthcare provider. Explain the importance of regular check-ups and lab
tests to assess disease activity and adjust treatment as needed.

-Rationale: Regular monitoring and communication with healthcare providers ensure timely
adjustments to treatment, which can help better manage the disease and prevent
complications.
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