Nursing Guide to Rheumatoid Arthritis: Nursing Diagnosis, Interventions, & Care Plans

Definition 

Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes the immune system to attack the joints, leading to pain, swelling, and stiffness. Unlike osteoarthritis, RA affects both sides of the body and can also impact organs such as the heart, lungs, skin, and blood vessels (Mayo Clinic, 2023; Cleveland Clinic, 2024).

Rheumatoid Arthritis Etiology and Epidemiology

The exact cause is unknown, but RA likely develops from a combination of genetic, hormonal, and environmental factors. Some individuals have genes that increase their risk, and triggers such as infections, stress, or smoking can also activate the disease (Arthritis Foundation, 2021; Cleveland Clinic, 2024).

Unlike the wearing and tearing damage from osteoarthritis, rheumatoid arthritis affects the synovial joint linings (Mayo Clinic, 2021). The inflammatory nature of rheumatoid arthritis brings about synovitis, or inflammation of the synovium, the connective tissue lining inside the joint capsule. Rheumatoid arthritis presents as one of three types:

• Symmetric
• Relapsing
• Destructive

Common characteristics of rheumatoid arthritis comprise:

• Higher prevalence in females by two to three times
• Typical appearance between the ages of 30 and 60
• Most common form of inflammatory arthritis
• Typically involves:
  • Three or more fingers
  • Wrist
  • Other joints
• Destructive arthritis leading to musculoskeletal disability
• Potential extraarticular complications appearing in primarily seropositive individuals include:
  • Rheumatoid nodules
  • Dermal vasculitis
  • Sjogren syndrome
  • Felty syndrome
  • Interstitial lung disease
  • Pericarditis
  • Neuritis
  • Amyloidosis
  • Hypothyroidism

Causes are unknown but believed to be potentially from a combination of genetic and environmental factors:

• Smoking and other bronchial stressors
• Infectious disease such as:
  • Epstein bar
  • Cytomegalovirus
  • Proteus species
  • Escherichia coli
• Familial history
• Gene susceptibility
• Obesity
• Periodontitis
• Coffee consumption
• Silica exposure

The exposure of a genetically predisposed individual to certain environmental stressors is thought to create an autoimmune response leading to the rheumatoid condition.

Rheumatoid arthritis reportedly affects an estimated 1.5 million adults in the U.S. (DynaMed, n.d.). Incidence rate annually is 41 cases per 100,000 men and 36 per 100,000 women.

Risk factors for rheumatoid arthritis originate from:

• Familial history
• Genetics
• Environmental impacts

Diagnostic Criteria

Early diagnosis is crucial to prevent joint damage and long-term disability. Diagnosis relies on a combination of blood tests, imaging studies, and clinical evaluation (Arthritis Foundation, 2021; Cleveland Clinic, 2024).

Blood Tests 

• Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies are often present.
• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) help assess inflammation.

Imaging Tests 

• X-rays, ultrasound, and MRI detect joint damage in the early stages.

Common Signs and Symptoms 

• Joint pain, swelling, and tenderness, usually in the hands, wrists, and feet
• Morning stiffness lasting longer than 30 minutes
• Fatigue, fever, and unintended weight loss, especially in the early stages
• Redness and warmth in affected joints
• Eye dryness and pain
• Lung symptoms, including shortness of breath and scarring
• Rheumatoid nodules on the skin
• Blood vessel inflammation in severe cases

Red Flags 

• Sudden, severe joint pain and swelling
• Difficulty moving joints or loss of function
• Shortness of breath or chest pain, which may indicate lung or heart complications
• Numbness or weakness that could suggest nerve damage

Potential Complications 

Without proper management, RA can lead to serious long-term complications such as:

• Osteoporosis
• Heart disease
• Lung disease
• Rheumatoid nodules
• Increased infection risk
• Carpal tunnel syndrome

ICD-10 Code for Rheumatoid Arthritis: M05 & M06 

• M05 – Refers to rheumatoid arthritis with rheumatoid factor  
• M06 – Refers to other rheumatoid arthritis  

Treatments 

Pharmacological 

Disease-modifying antirheumatic drugs (DMARDs), biologics, and Janus kinase (JAK) inhibitors are the primary treatments for slowing RA progression and reducing inflammation (Cleveland Clinic, 2024; Arthritis Foundation, 2021; Mayo Clinic, 2023):

• DMARDs are the first-line treatment that prevents joint damage.
• Biologic DMARDs, including TNF inhibitors, IL-6 inhibitors, B-cell therapy, and T-cell therapy, target specific immune pathways to reduce inflammation.
• JAK inhibitors block inflammatory signals inside cells, offering an alternative to biologics.
• NSAIDs relieve pain and swelling but do not slow disease progression.
• Corticosteroids provide quick relief from inflammation but are for short-term use due to side effects.

Non-Pharmacological 

• Physical therapy helps maintain joint function and reduce stiffness.
• Anti-inflammatory nutrition, including foods rich in omega-3 fatty acids such as salmon, flaxseed, and walnuts, may help reduce symptoms.
• Smoking cessation is essential, as smoking worsens RA and decreases medication effectiveness.

Surgical 

• Joint replacement surgery, such as knee or hip replacements, may be necessary in severe cases of joint damage.
• Synovectomy removes the inflamed joint lining and can relieve pain and improve function (Arthritis Foundation, 2021).

Nursing Management 

Assessment and Interventions 

Pain and Mobility Management

• Assess pain levels and joint stiffness regularly.
• Encourage gentle exercises such as walking, stretching, and aquatic therapy to maintain movement.
• Use heat therapy to relieve stiffness and cold packs to reduce swelling.
• Educate individuals on assistive devices, including ergonomic tools such as jar openers, buttonhooks, and arthritis-friendly utensils that reduce joint strain.
• Monitor for worsening joint deformities and refer to physical therapy when needed.

Inflammation and Medication Management

• Monitor for side effects of RA medications, especially increased infection risk with biologics and JAK inhibitors.
• Educate on DMARD consistency to prevent flare-ups and slow disease progression.
• Assess for corticosteroid side effects, such as weight gain, osteoporosis, and high blood sugar, and provide strategies to manage them.

Psychosocial and Cultural Considerations

Psychosocial Support

• Chronic pain and fatigue can contribute to anxiety and depression. Providing emotional support and mental health resources is essential.
• Fatigue, joint pain, and mobility challenges can limit daily activities and work productivity. Adjusting routines and finding support groups can help individuals cope with these changes.

Cultural Considerations

• Some individuals may prefer alternative treatments, such as herbal supplements or acupuncture. They should be informed about safe complementary therapies and potential interactions with prescribed medications.
• Dietary habits may influence treatment adherence. If recommending anti-inflammatory foods, consider cultural dietary preferences such as vegetarian or religious-based diets.
• Certain cultural beliefs about disability may impact how individuals approach care. Open discussions can help ensure their concerns are addressed.

Home Management of Rheumatoid Arthritis 

Self-Care 

• Tracking symptoms in a journal can help individuals monitor pain levels, medication effects, and flare patterns
• Engaging in low-impact exercises such as yoga and tai chi can improve joint flexibility and strength
• Managing flare-ups includes getting adequate rest, adjusting medications as directed, and using heat or cold therapy for symptom relief

Safety Measures 

• Using adaptive tools such as long-handled reachers, electric can openers, and thick-grip pens can help reduce strain on the hands
• Modifying the home environment by installing grab bars, using non-slip rugs, and choosing supportive chairs can help prevent falls
• Conserving energy by pacing daily activities and taking rest breaks can help reduce fatigue and joint stress

Content Release Date 

4/1/2022

Content Expiration

12/31/2028

Content Contributor

The content for this course was written by Sherry D. Haszto, M.S.N., R.N.
Sherry is a nursing professional with over 21 years of experience. She has earned an Associate Degree in Nursing from Randolph Community College, a Bachelor of Science in Nursing from the University of North Carolina at Greensboro, and a Master of Science in Nursing from Walden University. Her background includes work in oncology and hematology, home healthcare, hospice and palliative care, healthcare education, nursing consultation, performance improvement, and quality assurance. Sherry is committed to supporting patient care and healthcare education, focusing on enhancing patient outcomes and maintaining quality standards in all aspects of her work.

References

• Arthritis Foundation. (2021). Rheumatoid arthritis: Causes, symptoms, treatments, and more. https://www.arthritis.org/diseases/rheumatoid-arthritis
• Cleveland Clinic. (2024). Rheumatoid arthritis. https://my.clevelandclinic.org/health/diseases/4924-rheumatoid-arthritis
• Mayo Clinic. (2023). Rheumatoid arthritis. https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648