NCLEX Review Guide: Rheumatoid Arthritis

Disease Process

• Rheumatoid Arthritis (RA) is a chronic, systemic autoimmune inflammatory disease that primarily affects synovial joints in a symmetrical pattern.
• The immune system attacks the synovial membrane, causing inflammation, joint destruction, and eventual deformity and disability.
• Peak onset occurs between ages 30-50, with women affected 3 times more frequently than men.

Clinical Manifestations

• Morning stiffness lasting >1 hour that improves with activity (key distinguishing feature from osteoarthritis).
• Symmetrical joint involvement affecting hands, wrists, knees, and feet with swan neck and boutonniere deformities.
• Systemic symptoms include fatigue, low-grade fever, weight loss, and subcutaneous nodules.

Laboratory Tests

• Rheumatoid Factor (RF) positive in 70-80% of patients, but can be present in healthy individuals.
• Anti-CCP antibodies are more specific for RA and indicate more aggressive disease progression.
• Elevated ESR and CRP indicate active inflammation and disease activity.
• Complete blood count may show anemia of chronic disease and thrombocytosis.

Disease-Modifying Antirheumatic Drugs (DMARDs)

• Methotrexate is the first-line DMARD that requires folic acid supplementation and regular liver function monitoring.
• Biological DMARDs like TNF inhibitors (infliximab, adalimumab) require screening for tuberculosis and hepatitis B before initiation.
• Patients on DMARDs need regular CBC and liver function monitoring due to potential bone marrow suppression and hepatotoxicity.

Supportive Medications

• NSAIDs provide symptomatic relief but do not prevent joint destruction and carry GI and cardiovascular risks.
• Corticosteroids offer rapid anti-inflammatory effects but should be used short-term due to significant side effects.

Nursing Interventions

1. Assess pain level using 0-10 scale and document joint deformities and range of motion.
2. Encourage gentle exercise and physical therapy to maintain joint mobility and prevent contractures.
3. Apply heat during flares to reduce stiffness and cold therapy to reduce acute inflammation.
4. Monitor for medication side effects and ensure compliance with laboratory monitoring schedules.

Patient Education Priorities

• Teach importance of medication adherence even when feeling well, as DMARDs prevent joint destruction.
• Educate about infection prevention due to immunosuppressive effects of medications.
• Emphasize the importance of regular follow-up appointments and laboratory monitoring.
• Discuss joint protection techniques and energy conservation strategies for daily activities.

Serious Complications

• Atlantoaxial subluxation can cause cervical spine instability and requires immediate medical attention if neck pain occurs.
• Rheumatoid nodules in the lungs can cause pulmonary complications including pleural effusion and pulmonary fibrosis.
• Felty syndrome (RA + splenomegaly + neutropenia) increases infection risk significantly.

Quick Check

• ☐ Can you identify the key differences between RA and osteoarthritis?
• ☐ Do you know the priority nursing actions for a patient starting methotrexate?
• ☐ Can you explain why morning stiffness duration is significant?

Frequently Missed Concepts

• Don't confuse RA morning stiffness (>1 hour) with osteoarthritis stiffness (<30 minutes).
• Remember that heat therapy helps with stiffness while cold therapy reduces acute inflammation.
• DMARDs take weeks to months to show effect, unlike NSAIDs which work immediately.

Self-Assessment

• ☐ I can differentiate RA from other types of arthritis
• ☐ I understand the importance of early DMARD therapy
• ☐ I know the key patient education priorities
• ☐ I can identify serious complications requiring immediate intervention