Question

Rheumatoid Arthritis

Utilized Rheumatoid Arthritis and develop the nursing process to develop two plans of care: 1 physiological and 1 psychosocial nursing diagnosis Included the following information in each* plan of care: 1. Priority nursing diagnosis 2. 1 short‐term and 1 long‐term goal ‐ 5 nursing interventions with rationale statements 4. 3 ‐ 5 evaluative statements based on interventions 5. A minimum of 3 teaching considerations

Utilized the nursing process to develop two plans of care: 1 physiological and 1 psychosocial nursing diagnosis Included the following information in each* plan of care: 1. Priority nursing diagnosis 2. 1 short‐term and 1 long‐term goal 3. 3 ‐ 5 nursing interventions with rationale statements

3 ‐ 5 evaluative statements based on interventions 5. A minimum of 3 teaching considerations

Answer 1

Rheumatoid arthritis (RA) is a form of arthritis that causes pain, swelling, stiffness, and loss of function in your joints. It is a chronic, systemic inflammatory disease that involves the connective tissues and characterized by destruction and proliferation of synovial membrane resulting in joint destruction, ankylosis, and deformity.

No one knows what causes rheumatoid arthritis. Researchers speculate that a virus may initially trigger the body’s immune response, which then becomes chronically activated and turns on itself (autoimmune response). Immunologic mechanisms appear to play an important role in the initiation and perpetuation of the disease in which spontaneous remissions and unpredictable exacerbations occur. RA is a disorder of the immune system and, as such, is a whole-body disease that can extend beyond the joints, affecting other organ systems, such as the skin and eyes.

Nursing Care Plans

The most common issues that should be addressed in the nursing care plan for the patient with rheumatoid arthritis (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 self-management decisions and to cope with having a chronic disease.

Here are six (6) nursing care plans (NCP) and nursing diagnosis for rheumatoid arthritis:

1. Acute Pain
2. Impaired Physical Mobility
3. Disturbed Body Image
4. Self-Care Deficit
5. Risk for Impaired Home Maintenance
6. Deficient Knowledge
7. Other Possible Nursing Care Plans

Nursing Management

Nursing care of the patient with RA should follow a basic plan of care.

Nursing Assessment

The assessment of a patient with RA can contribute to its diagnosis.

• History and physical exam. The history and physical examination address manifestations such as bilateral and symmetric stiffness, tenderness, swelling, and temperature changes in the joints.
• Extra-articular changes. The patient is also assessed for extra-articular changes and these include weight loss, sensory changes, lymph node enlargement, and fatigue.

Nursing Diagnosis

Bases on the assessment data, the major nursing diagnoses appropriate for the patient are:

• Acute and chronic pain related to inflammation and increased disease activity, tissue damage, fatigue, or lowered tolerance level.
• Fatigue related to increased disease activity, pain, inadequate sleep/rest, deconditioning, inadequate nutrition, and emotional stress/depression
• Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack or improper use of ambulatory devices.
• Self-care deficit related to contractures, fatigue, or loss of motion.
• Disturbed body image related to physical and psychological changes and dependency imposed by chronic illness.
• Ineffective coping related to actual or perceived lifestyle or role changes.

Nursing Care Planning & Goals

Main Article: 6 Rheumatoid Arthritis Nursing Care Plans

The major goals for a patient with RA are:

• Improvement in comfort level.
• Incorporation of pain management techniques into daily life.
• Incorporation of strategies necessary to modify fatigue as part of the daily activities.
• Attain and maintain optimal functional mobility.
• Adapt to physical and psychological changes imposed by the rheumatic disease.
• Use of effective coping behaviors for dealing with actual or perceived limitations and role changes.

Nursing Interventions

The patient with RA needs information about the disease to make self-management 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).
• 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.

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 self-care 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 self-care 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 ofself-care 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 follow up appointments to the patient and family.

Evaluation

Expected outcomes include:

• Improved comfort level.
• Incorporated pain management techniques into daily life.
• Incorporated strategies necessary to modify fatigue as part of the daily activities.
• Attained and maintained optimal functional mobility.
• Adapted to physical and psychological changes imposed by the rheumatic disease.
• Used effective coping behaviors for dealing with actual or perceived limitations and role changes.

Discharge and Home Care Guidelines

Patient teaching is an essential aspect of discharge and home care.

• Disorder education. The patient and family must be able to explain the nature of the disease and principles of disease management.
• Medications. The patient or caregiver must be able to describe the medication regimen (name of medications, dosage, schedule pf administration, precautions, potential side effects, and desired effects.
• Pain management. The patient must be able to describe and demonstrate use of pain management techniques.
• Independence. The patient must be able to demonstrate ability to perform self-care activities independently or with assistive devices.

Documentation Guidelines

The focus of documentation include:

• Client’s description of response to pain.
• Specifics of pain inventory.
• Expectations of pain management.
• Acceptable level of pain.
• Manifestations of fatigue and other assessment findings.
• Degree of impairment and effect on lifestyle.
• Level of function, ability to participate in specific or desired activities.
• Functional level and specifics of limitations.
• Needed resources and adaptive devices.
• Available and use of community resources.
• Observations, presence of maladaptive behavior, emotional changes, level of independence.
• Prior medication use.
• Plan of care.
• Teaching plan.
• Response to interventions, teachings, and actions performed.
• Attainment or progress towards desired outcomes.
• Modifications to plan of care.
• Long term needs.