Rheumatoid arthritis (RA): Nursing process (ADPIE)

Clara Reed is a 44-year-old female client who presents to the rheumatology clinic after being referred by her primary care physician. For the past several weeks, she has been having pain, stiffness and swelling in both hands along with stiffness in her body that is worse in the morning. She has also been feeling fatigued and her appetite has decreased.

Alright, so rheumatoid arthritis is a chronic, autoimmune, inflammatory disorder that mostly affects the joints, but can also involve other organ systems like the skin and lungs. This condition is typically triggered by an interaction between genetic and environmental factors. Rheumatoid arthritis tends to run in families and it’s been associated with the HLA-DR4 gene.  Other risk factors include being female, middle aged, and obese.  Finally environmental factors like infections, smoking, and   exposure to asbestos and silica are also linked to the disease.

A person with the HLA–DR4 gene, might develop rheumatoid arthritis after getting exposed to something in the environment like cigarette smoke or a specific pathogen. These environmental factors can cause modification of the proteins in our body and turn them into antigens that trigger the immune system to produce specific autoantibodies against them. 

The first antibody  is called rheumatoid factor, or RF, and targets modified IgG antibodies; whereas the second antibody is called anti-cyclic citrullinated peptide antibody or anti-CCP, and targets citrullinated proteins, like citrullinated collagen II. 

Next, these antibodies and immune cells enter the circulation and reach joints. Here, immune cells release inflammatory cytokines that induce inflammation and stimulate synovial cells to proliferate. Increased number of synovial and immune cells in the joint creates a pannus, which is a thick synovial membrane with granulation tissue. 

Over time, the cytokines released in the pannus start to damage the articular cartilage, leaving the underlying bone exposed. As a result, bones start to directly rub against one another, eventually causing bone erosion. Meanwhile, the antibodies that enter the joint space bind to their targets and form immune complexes that accumulate in the synovial fluid, activating the complement system and inducing further destruction of the joint.