I Cverv|ew of Iuven||e kheumato|d Arthr|t|s

A Lt|o|ogy
Cllnlcally and paLhologlcally !8A ls an lnflammaLory dlsease wlLh an unknown
cause 1here are Lwo peak ages of onseL beLween 2 and 3 years of age and beLween
9 and 12 years of age ln many lnsLances Lhe dlsease remalns undlagnosed for years
!8A ls noL a slngle dlsease buL a heLerogeneous group of dlseases 1hree ma[or
Lypes can be ldenLlfled

r auc|art|cu|ar d|sease affecLs only a few [olnLs fewer Lhan 3 1he large [olnLs
such as Lhe shoulder elbow hlp and knee are mosL llkely Lo be affecLed 1hls Lype
of !8A ls mosL common ln chlldren younger Lhan 8 years Chlldren who develop Lhls
dlsease have a 2030 chance of developlng lnflammaLory eye problems and need
frequenL eye examlnaLlons Chlldren who develop Lhls dlsease when older Lhan 8
years have a hlgherLhannormal rlsk of developlng an adulL form of arLhrlLls AbouL
30 of all chlldren wlLh !8A have Lhls Lype
r o|yart|cu|ar d|sease affecLs 3 [olnLs or more someLlmes many more 1he small
[olnLs such as Lhose ln Lhe hands and feeL are mosL llkely Lo be affecLed 1hls Lype
can begln aL any age ln some cases Lhe dlsease ls ldenLlcal Lo adulLLype 8A 1hls
Lype accounLs for abouL 30 of cases of !8A
r System|c d|sease affecLs many sysLems of Lhe body Chlldren may have hlgh
fevers skln rashes and problems caused by lnflammaLlon of Lhe lnLernal organs
such as Lhe hearL spleen llver and oLher parLs of Lhe dlgesLlve LracL lL usually buL
noL always beglns ln early chlldhood Medlcal professlonals someLlmes call Lhls
SLlll's dlsease 1hls Lype accounLs for abouL 20 of cases of !8A

8 athophys|o|ogy
1he rheumaLlc process ls characLerlzed by a chronlc lnflammaLlon of Lhe
synovlum wlLh [olnL effuslon and evenLual eroslon desLrucLlon and flbrosls of Lhe
arLlcular carLllage Adheslons beLween [olnL surfaces and ankylosls of [olnLs occur lf
Lhe process perslsLs long enough
WheLher a slngle [olnL or mulLlple [olnLs are lnvolved Lhe general
manlfesLaLlons resulL from edema [olnL effuslon and synovlal Lhlckenlng 1he
llmlLed moLlon early ln Lhe dlsease ls Lhe resulL of muscle spasm and [olnL
lnflammaLlon laLer lL ls caused by Lhe ankylosls or sofL Llssue conLracLure lnfecLlons
ln[urles or operaLlons ofLen preclplLaLe a flareup of Lhe arLhrlLls Lherefore lL ls
necessary Lo recognlze and LreaL lnfecLlons prompLly
CrowLh may be reLarded durlng perlods of acLlve dlsease usually wlLh growLh
spurLs durlng remlsslons ln severe longsLandlng cases growLh ls slgnlflcanLly
reLarded CorLlcosLerold Lherapy can be a conLrlbuLlng facLor

C red|spos|ng r|sk factors

1 nered|ty 1here ls a geneLlc llnk Lo Lhe developmenL of Lhe dlsease 1esLs
have revealed LhaL up Lo 90 of all sufferers have a speclflc gene known
as PLA827 gene Lhough noL everyone wlLh Lhls gene develops Lhe
dlsease
2 Gender lemales are affecLed somewhaL frequenL Lhan males
3 kace generally more common ln Caucaslan chlldren Lhan Afrlcan
Amerlcan and AslanAmerlcan chlldren and ln any oLher race
D rec|p|tat|ng r|sk factors

1 V|ra| or bacter|a| Infect|on (part|cu|ar|y streptococca|) lL ls belleved LhaL
cerLaln lnfecLlons play a role ln Lhe developmenL of Lhe dlsease
2 1rauma relaLlonshlp Lo !8A remalns unclear
3 Lmot|ona| Stress relaLlonshlp Lo !8A remalns unclear
4 Lnv|ronmenta| factor lL ls belleved Lo sbe an auLolmmune dlsease LhaL
can be Lrlgger by envlronmenLal facLors lf Lhe geneLlc precursor ls
presenL


II Nurs|ng rocess

A Assessment

1 n|story 1ak|ng ] hys|ca| Assessment
noLe hlsLory of lrrlLablllLy or fusslness whlch may be Lhe flrsL slgn of
Lhls dlsease ln Lhe lnfanL or very young chlld noLe complalnLs of paln Lhough
chlldren do noL always communlcaLe Lhls uocumenL hlsLory of wlLhdrawal
from play or dlfflculLy geLLlng Lhe chlld ouL of bed ln Lhe mornlng ([olnL
sLlffness afLer lnacLlvlLy) lnqulre abouL hlsLory of fever (above 393 C for 2
wks or more ln sysLemlc dlsease)
Measure LemperaLure (fever ls presenL wlLh sysLemlc dlsease) lnspecL
skln for evanescenL pale red nonprurlLlc macular rash whlch may be
presenL aL dlagnosls of sysLemlc dlsease Cbserve Lhe galL noLlng llmplng of
guardlng of a [olnL or exLremlLy uocumenL growLh whlch may be delayed
lnspecL and palpaLe each [olnL for edema redness warmLh and Lenderness
noLe poslLlonlng of [olnLs (usually flexed ln poslLlon of comforL) Mlld Lo
moderaLe anemla and an elevaLed eryLhrocyLe sedlmenLaLlon raLe are
common ?oung chlldren wlLh Lhe pauclarLlcular form may demonsLraLe a
poslLlve anLlnuclear anLlbody and adolescenL wlLh polyarLlcular dlsease may
have a poslLlve rheumaLold facLor

2 C||n|ca| Man|festat|on
Invo|ved [o|nts
O SLlffness
O Swelllng
O 1enderness
O 9alnful Lo Louch or relaLlvely palnless
O Warm Lo Louch (seldom red)
O Loss of moLlon
O CharacLerlsLlc of mornlng sLlffness or
gelllng" on arlslng ln Lhe mornlng or
afLer lnacLlvlLy
Non Io|nt |nvo|vement
O ye lnflammaLlon
malalse poor appeLlLe
O LymphadenopaLhy
organomegaly poor
growLh
O nlarged spleen llver
myalgla anemla


3 D|agnost|c Lxams and tests

a LaboraLory LesLs
11 Lrythrocyte sed|mentat|on rate (LSk) S8 ls a nonspeclflc" marker lL does noL polnL
speclflcally Lo !8A buL lndlcaLes acLlve lnflammaLlon ln Lhe body lL ls almosL always
elevaLed ln chlldren wlLh sysLemlc !8A lL usually ls elevaLed ln chlldren wlLh polyarLlcular
dlsease buL ls ofLen normal ln Lhose wlLh pauclarLlcular dlsease
12 Comp|ete b|ood ce|| count (C8C) 1hls LesL measures Lhe amounLs of each Lype of blood
cell ln a sample of blood lL also lndlcaLes Lhe level of hemoglobln Lhe proLeln ln blood
LhaL carrles oxygen around Lhe body A low level of hemoglobln called anemla ls
common ln chlldren wlLh !8A 1hls LesL hlghllghLs abnormallLles ln Lhe numbers of varlous
klnds of whlLe blood cells (parL of Lhe lmmune sysLem) or of plaLeleLs (whlch help blood
cloL) lL can be used Lo dlsLlngulsh !8A from oLher condlLlons LhaL mlghL have slmllar
sympLoms 1he whlLe blood cell counL and plaLeleL counL are usually normal ln people
wlLh !8A
13 Ant|nuc|ear ant|body (ANA) AnLlnuclear anLlbody ls [usL one of Lhe anLlbodles LhaL Lhe
body may produce ln cerLaln auLolmmune dlseases (called auLoanLlbodles) As many as
23 of chlldren wlLh !8A have a poslLlve AnA resulL A poslLlve AnA resulL ls mosL
common ln chlldren wlLh pauclarLlcular dlsease lL ls uncommon ln chlldren wlLh sysLemlc
!8A lL ls llnked Lo an lncreased rlsk of eye lnvolvemenL (uvelLls) AnA ls also more llkely Lo
be poslLlve ln condlLlons relaLed Lo !8A (such as SL or scleroderma) Lhan ln !8A lL ls
ofLen used Lo rule ouL Lhese condlLlons ln a person wlLh arLhrlLls sympLoms very hlgh
levels of AnA may lncrease Lhe rlsk LhaL Lhe dlsease wlll progress Lo adulLLype SL
14 kheumato|d factor (kI) 8heumaLold facLor ls acLually a group of auLoanLlbodles LhaL
occur ln some people wlLh 8A !8A and relaLed condlLlons lL ls mosL ofLen poslLlve ln
chlldren wlLh polyarLlcular !8A and ls rarely poslLlve ln chlldren wlLh sysLemlc !8A lL ls
mosL ofLen used Lo help deLermlne whlch Lype of !8A a chlld has AdolescenLs are more
llkely Lo have a poslLlve 8l resulL Lhan younger chlldren ln facL many conslder a poslLlve
8l resulL a slgn of !8A progresslng Lo adulLLype 8A

b lmaglng sLudles
11 krays glves lnformaLlon abouL wheLher or noL damage has occurred ln Lhe [olnL
12 8one scan may be necessary lf Lhe resulLs of Lhe workup do noL supporL Lhe dlagnosls of
!8A A bone scan can deLecL lnflammaLlon ln Lhe bone and oLher abnormallLles LhaL do
noL show up well on xray
13 MkI ls slmllar Lo xray buL ls much more deLalled and glves a beLLer 3dlmenslonal vlew
of Lhe [olnL lL ls especlally useful lf Lhere has been a fall or accldenL LhaL mlghL have
ln[ured [olnLs lL usually ls noL ordered unless Lhe resulLs of Lhe workup do noL polnL
clearly Lo a dlagnosls of !8A
14 C1 scan also ls slmllar Lo xray buL provldes much greaLer deLall lL may be ordered when
Lhe resulLs of Lhe workup do noL supporL Lhe dlagnosls of !8A C1 scan ls parLlcularly good
aL rullng ouL Lumors and oLher bony abnormallLles LhaL could cause arLhrlLlsllke
sympLoms
13 Dua|energy xray absorpt|ometry (DLkA) scan uOA scannlng ls used Lo measure bone
denslLy and can ldenLlfy osLeopenla or osLeoporosls (loss of bone Llssue) ln chlldren wlLh
polyarLlcular !8A
c oLher LesLs
11 Arthrocentes|s 1hls ls someLlmes called [olnL asplraLlon" lL means Lhe removal of a
sample of synovlal fluld (fluld from a [olnL cavlLy) for LesLlng lL ls usually done Lo rule ouL
lnfecLlons ln Lhe [olnLs
12 Synov|a| b|opsy An orLhopedlc surgeon uses a probe Lo remove a small amounL of Lhe
synovlal Llssue from a [olnL 1he Llssue ls examlned under a mlcroscope for clues as Lo
whaL ls causlng synovlal damage 1hls may be helpful Lo exclude oLher condlLlons LhaL can
cause sympLoms slmllar Lo Lhose of !8A

4 Med|ca| and Surg|ca| treatments
a Io|nt rep|acement(ofLen of Lhe hlps ln paLlenLs wlLh polyarLlcular !8A) usually ls delayed
unLll bone growLh has compleLed
b Stero|d |n[ect|ons to the bone Some chlldren wlLh perslsLlng pauclarLlcular !8A desplLe
medlcal LreaLmenL may beneflL from sLerold ln[ecLlons lnLo a [olnL 1hls may be done by a
rheumaLologlsL an orLhopedlc surgeon or ln some cases a chlld's prlmary care provlder
c Synovectomy ln very severe cases Lo prevenL [olnL damage WlLh lmprovemenLs ln medlcal
LreaLmenL Lhls procedure ls now rarely necessary


8 Nurs|ng Care p|an

a Nurs|ng Dx A|tered Comfort a|n r]t |nf|ammatory process and [o|nt |nf|ammat|on
and musc|e weakness

Lxpected Cutcome 1he chlld wlll experlence rellef from Lhe paln as evldenced by lncreased
sleep decreased resLlessness and lrrlLablllLy and lncreased use of age approprlaLe acLlvlLles

Intervent|on
1 Assess chlld's verbal and nonverbal responses Lo paln Assess for lncreased
resLlessness wlLhdrawal decreased aLLenLlon span lncreased crylng and decreased
sleep

AdmlnlsLer nSAlus as ordered MonlLor slde effecLs and LherapeuLlc blood levels noLe
chlld's response Lo medlcaLlon

3 8eposlLlon affecLed [olnLs ln neuLral poslLlon SupporL [olnLs wlLh spllnLs plllows or
oLher devlces Apply heaL or cold lnsLlLuLe lsomeLrlc exerclses

4 ncourage parenLs Lo sLay wlLh Lhe chlld AsslsL ln dlverslonal acLlvlLles

3 lnsLlLuLe comforL measures used aL home

Lva|uat|on 1he chlld experlences rellef of paln as evldenced by resLlng more comforLably
lncreased levels of selfcare and age approprlaLe developmenLal acLlvlLles

b Nurs|ng Dx Impa|red hys|ca| mob|||ty r]t |nf|ammat|on of the [o|nt and assoc|ated
musc|e weakness

Lxpected Cutcome 1he chlld wlll accepL Lhe acLlvlLy resLrlcLlon as evldenced by a
decreased ln paln lncrease compllance wlLh exerclse program and lncreased [olnL moblllLy
and muscle sLrengLh

Intervent|on
1 AsslsL ln Lhe developmenL of exerclse program lncorporaLe developmenLal norms lnLo
Lhe program CoordlnaLe referrals dally rouLlnes and famlly acLlvlLles

2 Assess muscle sLrengLh and [olnL moblllLy every shlfL and prn

3 MalnLaln correcL body allgnmenL

4 9erform 8CM and sLreLchlng exerclses as approprlaLe ConsulL wlLh Lhe physlclan
regardlng Lhe need for occupaLlonal Lherapy spllnLs and/or fooL boards

3 Apply elasLlc sLocklngs

6 9lan age approprlaLe play acLlvlLles LhaL requlre Lhe use of unaffecLed exLremlLles

Cffer small frequenL feedlngs of food hlgh ln proLeln and calclum

MalnLaln age approprlaLe hydraLlon levels Cffer flulds LhaL wlll acldlfy urlne (e g
cranberry [ulce)

9 MalnLaln urlne ouLpuL aL 12ml/kg/hr Check urlne aL leasL once a shlfL of proLeln blood
and speclflc gravlLy

10MonlLor bowel sounds 9rovlde lncrease roughage ln Lhe dleL and offer favourlLe foods

11Assess resplraLory sLaLus aL leasL once a shlfL ncourage coughlng and deep breaLhlng
lncenLlve splromeLer may be approprlaLe

Lva|uat|on 1he chlld has experlenced no problems r/L lmmoblllLy as evldenced by
O MalnLalnlng muscle and [olnL lnLegrlLy
O xperlenclng no cardlac or resplraLory problems
O MalnLalnlng age approprlaLe welghL and helghL
O Adherlng Lo dally exerclse program

c Nurs|ng Dx 8ody |mage d|sturbance and a|tered ro|e performance r]t act|v|ty
|nto|erance

Lxpected Cutcomes 1he chlld wlll malnLaln opLlmal developmenLal level as evldenced by age
approprlaLe behavlours lncrease soclal lnLeracLlons wlLh frlends and peers and decreased
school problems

Intervent|on
1 Assess chlld's percepLlon regardlng chronlc lllness Ask chlld Lo draw a plcLure of
percepLlon of body

2 AsslsL chlld ln ldenLlfylng sLrengLhs and areas of accompllshmenLs ldenLlfy creaLlve
hobbles or acLlvlLles chlld may ln LhaL wlll enhance sense of worLh

3 ncourage selfcare acLlvlLles ulscuss wlLh parenLs Lhe lmporLance of lncreaslng chlld's
sense of lndependence

4 use age approprlaLe LherapeuLlc play maLerlals or supporL groups Lo asslsL Lhe chlld ln
ldenLlfylng areas of concern r/L Lo esLeem and body lmage

3 lnvolve school or relaLed personnel regardlng speclal needs AsslsL wlLh school reenLry
and focus on ways chlld may parLlclpaLe ln age approprlaLe acLlvlLles

Lva|uat|on 1he chlld demonsLraLes age approprlaLe behavlours a evldenced by reenLerlng
school wlLhouL problems and parLlclpaLlng peerrelaLed acLlvlLles

d Nurs|ng Dx k|sk for |n[ury r]t [o|nt |nf|ammat|on and synov|t|s

Lxpected Cutcome
1he chlld wlll remaln free from ln[ury as evldenced by absence of [olnL lnflammaLlon age
approprlaLe range of moLlon and muscle sLrengLh wlLh no resldual deformlLy

Intervent|on
1 Assess affecLed [olnLs and muscles aL leasL one shlfL noLe changes ln paln swelllng
Lenderness or 8CM

2 uurlng perlods of lnflammaLlon use spllnLs heaL/cold and poslLlonlng wlLh supporL Lo
proLecL Lhe affecLed [olnL and reduce Lhe occurrence of deformlLles

3 AdmlnlsLer nSAlus as ordered Assess chlld's response Lo medlcaLlon monlLor slde
effecLs and blood levels noLlfy Lhe physlclan of any unLoward problems

4 Assess compllcaLlons relaLed Lo lnflammaLlon and llmlLed moblllLy such as conLracLures
and muscle wasLlng

3 Chlcken pox (varlcella) and lnfluenza vacclnes should be admlnlsLered lf chlld ls
recelvlng asplrln be alerL for manlfesLaLlons of vlral lllness lf vlral lllness ls suspecLed
asplrln should be sLopped and anoLher nSAlu prescrlbed

6 lf chlld recelves lmmunosuppressanL drugs assess perlodlcally for manlfesLaLlons of
lnfecLlon keep chlld away from large crowds durlng peak flu season

Assess for vlsual compllcaLlon for lrldocycllLls SLress lmporLance of keeplng scheduled
appolnLmenLs wlLh ophLhalmologlsL

Lva|uat|on 1he chlld wlll remaln free from ln[ury as evldenced by approprlaLe [olnL moblllLy
muscle sLrengLh and no resldual compllcaLlon


e Nurs|ng Dx knowledge deflclL r/L care and LreaLmenL of !uvenlle 8heumaLold ArLhrlLls

Lxpected Cutcomes 1he parenLs wlll provlde safe home care as evldenced by accuraLe
knowledge of [uvenlle arLhrlLls wlll be comforLable wlLh Lhe exerclse programs and wlll
verballze awareness of problem LhaL requlre approprlaLe asslsLance

Intervent|ons
1 Assess parenL's level of undersLandlng regardlng Lhe dlsease LreaLmenL and pasL
experlences wlLh a chronlc lllness

2 AsslsL ln plannlng a reallsLlc and lnLegraLed schedule of acLlvlLy resL personal care drug
admlnlsLraLlon physlcal Lherapy and sLress managemenL

3 9rovlde parenLs and chlld wlLh verbal as well as wrlLLen dlscharge lnsLrucLlon use reLurn
demonsLraLlons Lo ensure parenLal undersLandlng of procedures of exerclses

4 CoordlnaLe medlcal appolnLmenLs referrals and physlcal Lherapy wlLh Lhe chlld's and
parenL's rouLlnes and schedules

3 8evlew medlcaLlons Lo be glven by Lhe parenLs ulscuss slde effecLs lmporLance of
never mlsslng a dose and emergency slLuaLlons LhaL requlre a physlclan

6 use age approprlaLe Leachlng sLraLegles Allow cholces when plannlng care provlde
Llme for chlldren Lo dlscuss LreaLmenL reglmen 8e alerL for lndlcaLlons of anxleLy or
faLlgue

Lva|uat|on 1he parenLs provlde safe and LherapeuLlc home care as evldenced by Lhe
followlng
O Chlld experlences no unLoward effecLs from LreaLmenL
O xerclse program become a rouLlne parL of chlld's day
O 9arenLs demonsLraLe lncrease knowledge of !A