3. Rheumatoid arthritis: chronic, systemic, collagen, inflammatory disease; etiology unknown; may be autoimmune, viral, or genetic; affects primarily women age 20 - 40 yr; present in 2-3% of total population; follows a course of exacerbations and remissions.
   1. Pathophysiology: synovitis with edema —> proliferation of various blood material (formation of pannus) —> destruction and fibrosis of cartilage (fibrous ankylosis); calcification of fibrous tissue (osseous ankylosis).
   2. Assessment:
      1. Subjective data:
         1. Joints: pain; morning stiffness; swelling.
         2. Easily fatigues; malaise.
         3. Anorexia; weight loss.
      2. Objective data:
         1. Subcutaneous nodules over bony prominences.
         2. Bilateral symmetrical involvement of joints: crepitation, creaking, grating.
         3. Deformities: contractures, muscle atrophy.
         4. Lab data: blood: decreased - hemoglobin/hematocrit; RBCs; increased - WBCs (12,000-15,000), sedimentation rate (>20 mm/hr), rheumatoid factor.
   3. Analysis/nursing diagnosis:
      1. Pain related to joint destruction.
      2. Impaired physical mobility related to joint contractures.
      3. Risk for injury related to the inflammatory process.
      4. Body image disturbance related to joint deformity.
      5. Self-care deficit related to musculoskeletal impairment.
      6. Risk for activity intolerance related to fatigue and stiffness.
      7. Altered nutrition, less than body requirements, related to anorexia and weight loss.
      8. Self-esteem disturbance related to chronic illness.
   4. Nursing care plan/implementation:
      1. Goal: prevent or correct deformities.
         1. Activity:
            1. Bed rest during exacerbations.
            2. Daily ROM - active and passive exercises even in acute phase 5-10 min periods; avoid fatigue and persistent pain.
            3. Heat or pain medication before exercise.
         2. Medications: aspirin (high dosages); nonsteroidals; steroids; antacids given for possible GI upset with ASA, steroids; diseasemodifying antirheumatics (methotrexate, hydroxychloroquine, sulfasalazine).
         3. Fluids: at least 1500 mL liquid daily to avoid renal calculi; milk for GI upset.
      2. Goal: health teaching.
         1. Side effects of medications: tarry stools (GI bleeding); tinnitus (ASA).
         2. Psychosocial aspects: possible need for early retirement; financial hardship; loss of libido; unsatisfactory sexual relations.
         3. Prepare for joint repair or replacement if indicated.
   5. Evaluation/outcome criteria:
      1. Remains as active as possible; limited loss of mobility; performs self-care activities.
      2. No side effects from drug therapy (e.g., GI bleeding).
      3. Copes with necessary lifestyle changes; complies with treatment regimen.