Rheumatoid arthritis (RA) is a chronic, progressive, systemic disease that is characterized by recurrent inflammation of connective tissue, primarily diarthrodial joints (hinged joints that contain a cavity within the capsule that separates the bony elements to allow freedom of movement) and their related structures. RA affects approximately 2% of all adults.
The disease generally begins with inflammation of the synovial membrane, which becomes thickened and edematous. The thickened synovium, or pannus, erodes the articular cartilage and underlying bone, thus causing joint destruction. The small peripheral joints of the hand and wrist and the joints of the knees, ankles, elbows, and shoulders are usually affected symmetrically. The cervical spine may also be affected. Extra-articular involvement of the disease includes inflammation of the tendon sheaths; the bursae; and the connective tissue of the heart, lungs, pleurae, and arteries.
If the disease is left untreated, the inflammatory process of RA moves through four stages. In the first stage, synovitis is caused by congestion and edema of the synovial membrane and joint capsule. In the second stage, the formation of pannus, thickened layers of granulation tissue that cover and invade cartilage begins, and this leads to eventual destruction of the joint capsule and bone. In the third stage, fibrous ankylosis is noted in the inflammatory process; this is the fibrous invasion of the pannus and scar formation that occludes joint space. In the fourth and final stage, the fibrous tissue calcifies, causing ankylosis and total immobility.
Complications caused by RA include temporomandibular joint disease, which impairs the patient’s chewing and causes headaches. Infection, osteoporosis, myositis, cardiopulmonary lesions, lymphadenopathy, and peripheral neuritis may also occur.
Although the specific cause of RA is unknown, there is speculation about multiple causation, which includes infection, autoimmunity, and genetic factors and also environmental and hormonal factors. The strongest evidence of an autoimmune cause is supported by the findings of rheumatoid factor (RF) in the serum of more than 80% of affected individuals. Studies in immunology have identified the appearance of a relationship between RA and the HLA system, which is made up of a series of linked genes on the sixth chromosome, indicating a genetic causative factor.
Nursing care plan assessment and physical examination
Determine if the patient has experienced fatigue, malaise, low-grade fever, weight loss, anemia, or anorexia, which are all common early symptoms of RA. Ask about stiffness: Does it occur before or after physical activity, and does the patient need to “limber up” after inactivity, such as sleeping? Ask if the patient has experienced paresthesia (tingling) of the hands and feet or joint pain with swelling and warmth in the joint. Determine whether the patient is taking medication for pain, and if so, ask about the dosage and frequency.
Observe the patient initially for pallor and signs of fatigue and immobility. Assess all joints carefully, looking for deformities, contractures, immobility, and inability to perform the activities of daily living. Inspect the patient’s fingers for edema or congestion in the joints. Inspect the elbows for rheumatoid nodules, which are subcutaneous, rounded, nontender masses. Note skin lesions or leg ulcers caused by vasculitis. Check for a positive Babinski’s sign, which is caused by spinal cord compression if the vertebrae are involved. If the patient is able to participate, assess the metacarpophalangeal joints by having the patient dorsiflex, extend, and flex the fingers. Assess the patient’s ability to perform radial and ulnar deviation. Also ask the patient to straighten the fingers, then abduct and adduct them. Test the muscle strength of the patient’s hand by having the patient squeeze your hands simultaneously. Ask the patient to make a fist and resist your attempt to pry it open.
To assess the patient’s elbow and shoulder range of motion, ask the patient to flex and extend the arms and to abduct and adduct each extended arm. Test the trapezius muscles by placing your hands on the patient’s shoulders and asking the patient to shrug the shoulders as you press down on them. Look for subcutaneous nodules around the elbows. Observe the range of motion of the hips, knees, and ankles by asking the patient to walk about and to sit down in a chair. If the patient is in pain, you can defer the examination, relying instead on observations of the patient as you observe him or her in the setting.
Initially, assess the patient’s understanding of what the disease means and what she or he believes life holds in the future. Identify the patient’s support system and how available support persons are. If the patient has had RA for some time, assess the patient’s current level of functioning. Determine if the disease affected relationships, work, or leisure activities.
Nursing care plan primary nursing diagnosis: Pain (chronic) related to joint swelling and deformity.
Nursing care plan intervention and treatment plan
The goals of treatment are to relieve pain, inhibit the inflammatory response, preserve joint function, and prevent deformity. Initial medical treatment consists of pharmacologic measures. An appropriate ongoing exercise program is prescribed by the physical therapist; this includes teaching proper body mechanics. Therapy may also include the use of moist heat, but ice may be prescribed in some cases. Splints are provided for painful joints. The physical therapist teaches the patient to use a walker and cane if indicated.
Some patients may undergo surgery to restore joint function. One type of procedure, a synovectomy, involves removal of the inflamed synovium early in the disease process. Patients who are in relatively good physical and mental condition may be candidates for joint reconstructive surgery (arthroplasty). The effectiveness of hip and joint replacement is considered quite good, although replacement surgery associated with other joints is less efficacious. Osteotomy involves cutting the bone to realign the joint and to shift the pressure points to a less denuded area of the joint; this shift relieves pain. Tendon transfers may prevent deformities or relieve contractures.
Teach the patient assistive techniques to manage joint pain, such as meditation, biofeedback, and distraction. Advise the patient to take warm to hot showers or baths in the morning or evening to help relieve the pain. During acute stages of the disease, encourage the patient to avoid exercising the inflamed joints; help the patient understand the need to rest; however, patients do need to maintain mobility and movement of joints that are not involved. Provide necessary assistance with the activities of daily living, and prevent flexion contractures by having the patient lie prone with the feet hanging between the mattress and the footboard several times a day. Keep the patient warm, and provide meticulous skin care.
During subacute and chronic stage of RA, the patient needs to return to as much independence as possible. When mobility improves, encourage the patient to assume more responsibility for self-care. Promote adequate rest, especially after activity, and plan rest periods during the day. Assist the patient with nutrition to prevent anorexia, which contributes to anemia, thus causing further weakness and activity intolerance. Determine whether the patient has a firm mattress and straight-back chairs with arm rests at home to support proper positioning. Show the patient how to avoid flexion contractures of the large muscle groups while sleeping and sitting.
Teach the patient to avoid putting pillows under the legs while sitting and sleeping and to avoid sitting in soft, low chairs. When the acute inflammatory stage subsides and the patient is ready for discharge from the hospital, teach him or her to take medications as prescribed, stressing the need to maintain therapeutic blood levels of the drug. Suggest that the patient use dressing aids such as a long-handled shoehorn, elastic shoelaces, a zipper pull, and a buttonhook. Recommend the use of hand-held shower nozzles, grab bars, and hand rails. As RA progresses and deformity become pronounced, patients may suffer with body image disturbances and inability to engage in sexual activity. Assist the patient and partner to cope with these problems.
Nursing care plan discharge and home health care guidelines
Ensure that the patient understands the appropriate methods for pain relief and the need to notify a home care agency or physician if the regimen is ineffective. Be sure the patient understands any pain medication prescribed, including dosage, route, action, and side effects. Ensure that the patient understands the rest-activity cycle, use of assistive devices, exercise routine, and proper body mechanics. Determine whether or not a home care agency needs to evaluate the home for safety equipment such as rails and grab bars and whether ongoing supervision is required. The Arthritis Foundation, which publishes information about arthritis, is engaged in a national education program about living with the condition. Help the patient get in touch with this organization.