Rheumatoid Arthritis Nursing Care Plan Notes

 

Definition

• Rheumatoid arthritis (RA) is an inflammatory disorder of unknown origin that primarily involves the synovial membrane of the joints. Phagocytosis produces enzymes within the joint.
• The enzymes break down collagen, causing edema, proliferation of the synovial membrane, and ultimately pannus formation.
• Pannus destroys cartilage and erodes the bone.
• The consequence is loss of articular surfaces and joint motion.
• Muscle fibers undergo degenerative changes.
• Tendon and ligament elasticity and contractile power are lost.
• RA affects 1% of the population worldwide, affecting women two to four times more often than men.

Clinical Manifestations

Clinical features are determined by the stage and severity of the disease.

• Joint pain, swelling, warmth, erythema, and lack of function are classic symptoms.
• Palpation of joints reveals spongy or boggy tissue.
• Fluid can usually be aspirated from the inflamed joint.

Characteristic Pattern of Joint Involvement

• Begins with small joints in hands, wrists, and feet.
• Progressively involves knees, shoulders, hips, elbows, ankles, cervical spine, and temporomandibular joints.
• Symptoms are usually acute in onset, bilateral, and symmetric.
• Joints may be hot, swollen, and painful; joint stiffness often occurs in the morning.
• Deformities of the hands and feet can result from misalignment and immobilization.

Extraarticular Features

• Fever, weight loss, fatigue, anemia, sensory changes, and lymph node enlargement
• Raynaud’s phenomenon (cold and stress-induced vasospasm)
• Rheumatoid nodules, nontender and movable; found in subcutaneous tissue over bony prominences
• Arteritis, neuropathy, scleritis, pericarditis, splenomegaly, and Sjögren syndrome (dry eyes and mucous membranes)

Assessment and Diagnostic Methods

• Several factors contribute to an RA diagnosis: rheumatoid nodules, joint inflammation detected on palpation, laboratory findings, extraarticular changes.
• Rheumatoid factor is present in about three fourths of patients.
• RBC count and C4 complement component are decreased; erythrocyte sedimentation rate is elevated.
• Creactive protein and antinuclear antibody test results may be positive.
• Arthrocentesis and x-rays may be performed.

Medical Management

Treatment begins with education, a balance of rest and exercise, and referral to community agencies for support.

• Early RA: medication management involves therapeutic doses of salicylates or NSAIDs; includes new COX2 enzyme blockers, antimalarials, gold, penicillamine, or sulfasalazine; methotrexate; biologic response modifers and tumor necrosis factoralpha (TNF.) inhibitors are helpful; analgesic agents for periods of extreme pain.
• Moderate, erosive RA: formal program of occupational and physical therapy; an immunosuppressant such as cyclosporine may be added.
• Persistent, erosive RA: reconstructive surgery and corticosteroids.
• Advanced unremitting RA: immunosuppressive agents such as methotrexate, cyclophosphamide, azathioprine, and lefunomide (highly toxic, can cause bone marrow suppression, anemia, GI tract disturbances, and rashes). Also promising for refractory RA is a Food and Drug Administration (FDA)–approved apheresis device: a protein A immunoadsorption column (Prosorba) that binds circulating immune system complex (IgG).
• RA patients frequently experience anorexia, weight loss, and anemia, requiring careful dietary history to identify usual eating habits and food preferences. Corticosteroids may stimulate appetite and cause weight gain.
• Lowdose antidepressant medications (amitriptyline) are used to reestablish adequate sleep pattern and manage pain.

Nursing Management

The most common issues for the patient with RA include pain, sleep disturbance, fatigue, altered mood, and limited mobility. The patient with newly diagnosed RA needs information about the disease to make daily selfmanagement decisions and to cope with having a chronic disease.

Relieving Pain and Discomfort

• Provide a variety of comfort measures (eg, application of heat or cold; massage, position changes, rest; foam mattress, supportive pillow, splints; relaxation techniques, diversional activities). It takes time to find the right foam mattress and supportive pillows, but after looking at lots of reviews such as leesa reviews, you will find one perfect for your needs.
• Administer anti-inflammatory, analgesic, and slow-acting antirheumatic medications as prescribed.
• Individualize medication schedule to meet patient’s need for pain management.
• Encourage verbalization of feelings about pain and chronicity of disease.
• Teach pathophysiology of pain and rheumatic disease, and assist patient to recognize that pain often leads to unproven treatment methods.
• Assist in identification of pain that leads to use of unproven methods of treatment.
• Assess for subjective changes in pain.

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Reducing Fatigue

• Provide instruction about fatigue: Describe relationship of disease activity to fatigue; describe comfort measures while providing them; develop and encourage a sleep routine (warm bath and relaxation techniques that promote sleep); explain importance of rest for relieving systematic, articular,
• and emotional stress.
• Explain how to use energy conservation techniques (pacing, delegating, setting priorities).
• Identify physical and emotional factors that can cause fatigue.
• Facilitate development of appropriate activity/rest schedule.
• Encourage adherence to the treatment program.
• Refer to and encourage a conditioning program.
• Encourage adequate nutrition, including source of iron from food and supplements.

Increasing Mobility

• Encourage verbalization regarding limitations in mobility.
• Assess need for occupational or physical therapy consultation: Emphasize range of motion of affected joints; promote use of assistive ambulatory devices; explain use of safe footwear; use individual appropriate positioning/posture.
• Assist to identify environmental barriers.
• Encourage independence in mobility and assist as needed: Allow ample time for activity; provide rest period after activity; reinforce principles of joint protection and work simplification.
• Initiate referral to community health agency.

Facilitating Self Care

• Assist patient to identify sel-fcare deficits and factors that
• interfere with ability to perform self-care activities.
• Develop a plan based on the patient’s perceptions and priorities on how to establish and achieve goals to meet selfcare needs, incorporating joint protection, energy conservation, and work simplification concepts: Provide appropriate assistive devices; reinforce correct and safe use of assistive devices; allow patient to control timing of self-care activities; explore with the patient different ways to perform difficult tasks or ways to enlist the help of someone else.
• Consult with community health care agencies when individuals have attained a maximum level of selfcare yet still have some deficits, especially regarding safety.

Improving Body Image and Coping Skills

• Help patient identify elements of control over disease symptoms and treatment.
• Encourage patient’s verbalization of feelings, perceptions, and fears.
• Identify areas of life affected by disease. Answer questions and dispel possible myths.
• Develop plan for managing symptoms and enlisting support of family and friends to promote daily function.

Monitoring and Managing Potential Complications

• Help patient recognize and deal with side effects from medications.
• Monitor for medication side effects, including GI tract bleeding or irritation, bone marrow suppression, kidney or liver toxicity, increased incidence of infection, mouth sores, rashes, and changes in vision. Other signs and symptoms include bruising, breathing problems, dizziness, jaundice, dark urine, black or bloody stools, diarrhea, nausea and vomiting, and headaches.
• Monitor closely for systemic and local infections, which often can be masked by high doses of corticosteroids.

Teaching Points

• Focus patient teaching on the disease, possible changes related to it, the prescribed therapeutic regimen, side effects of medications, strategies to maintain independence and function, and safety in the home.
• Encourage patient and family to verbalize their concerns and ask questions.
• Address pain, fatigue, and depression before initiating a teaching program, because they can interfere with patient’s ability to learn.
• Instruct patient about basic disease management and necessary adaptations in lifestyle.

Continuing Care

• Refer for home care as warranted (eg, frail patient with significantly limited function).
• Assess the home environment and its adequacy for patient safety and management of the disorder.
• Identify any barriers to compliance, and make appropriate referrals.
• For patients at risk for impaired skin integrity, monitor skin status and also instruct, provide, or supervise the patient and family in preventive skin care measures.
• Assess patient’s need for assistance in the home, and supervise home health aides.
• Make referrals to physical and occupational therapists as problems are identified and limitations increase.
• Alert patient and family to support services such as Meals on Wheels and local Arthritis Foundation chapters.
• Assess the patient’s physical and psychological status, adequacy of symptom management, and adherence to the management plan.
• Emphasize the importance of followup appointments to thepatient and family.

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