Chapter 54Assessment and Management of Patients With Rheumatic Disorders :Chapter 54Assessment and Management of Patients With Rheumatic Disorders


Arthritis :Arthritis Refers to the inflammation of a joint, while rheumatic disease involves the bones and the muscles as well Affects women twice as much as men Most common types are osteoarthritis, rheumatoid arthritis, and gout 2


Rheumatic Diseases :Rheumatic Diseases Also called arthritis, rheumatic diseases include more than 100 different disorders They primarily affect the joints, but also muscles, bone, ligament, tendons, and cartilage Classification Monoarticular or polyarticular Inflammatory or noninflammatory


Clinical Manifestations :Clinical Manifestations Pain Joint swelling Limited movement Stiffness Weakness Fatigue


Systemic Effects of RA—Extraarticular Features :Systemic Effects of RA—Extraarticular Features


Typical Deformities of Rheumatoid Arthritis :Typical Deformities of Rheumatoid Arthritis


Patient Assessment and Diagnostic Findings :Patient Assessment and Diagnostic Findings Health history: include onset of and evolution of symptoms, family history, past health history, and contributing factors Functional assessment Arthrocentesis X-rays, bone scans, CT scans, and MRIs Tissue biopsy Blood studies: see Table 54-1 See Chart 54-1


Nursing Process—Planning the Care of the Patient With a Rheumatic Disease :Nursing Process—Planning the Care of the Patient With a Rheumatic Disease Major goals may include: Relief of pain and discomfort Relief of fatigue Promotion of restorative sleep Increased mobility Maintenance of self-care Improved body image Effective coping Absence of complications


Drug Therapy-RA :Drug Therapy-RA Various NSAIDs and salicylates to treat arthritis pain and inflammation Aspirin is often used in high dosages of 4 to 6 g/day (10 to 18 tablets) NSAIDs have antiinflammatory, analgesic, and antipyretic properties NSAIDS Do not alter natural history of RA Full effectiveness may take 2 to 3 weeks Some relief may be noted within days May be used when patient cannot tolerate high doses of aspirin DMARDs (Disease-Modifying Antirheumatic Drugs) Choice of drug is based on disease activity, level of function Can lessen the permanent effects of RA


Drug Therapy-RA :Drug Therapy-RA Immunosuppressives Methotrexate is “gold standard” for RA treatement Corticosteriods Aid in symptom control (for flare-ups) but should not be used as a mainstay of treatment because of risk of avascular necrosis and osteoporosis Immunodulators Regulates and normalizes immune system Topical Analgesics


Nursing Interventions RA-Diet :Nursing Interventions RA-Diet No special diet for RA Balanced nutrition is important Symptoms accompanying RA may Cause patient to have a loss of appetite Interfere with patient’s ability to shop for and prepare food Occupational therapist can help make food preparation easier by Modifying home environment Identifying useful assistive devices


Nursing Interventions RA-Rest :Nursing Interventions RA-Rest Alternate scheduled rest periods with activity throughout day Helps relieve pain and fatigue Amount of rest varies Total bed rest Rarely necessary Should be avoided to prevent stiffness and immobility Even a patient with mild disease may require daytime rest in addition to 8 to 10 hours of sleep at night Nurse should help patient Identify ways to modify daily activities to avoid overexertion Pace activities and set priorities on basis of realistic goals


Nursing Interventions RA- Mobility :Nursing Interventions RA- Mobility Lightweight splints may be prescribed to rest an inflamed joint and prevent deformity Should be removed regularly to perform skin care and ROM exercises Should be reapplied as prescribed Occupational therapist may help identify additional self-help devices to assist in activities of daily living Morning care and procedures should be planned around morning stiffness To relieve joint stiffness and increase comfort Sitting or standing in a warm shower Sitting a tub with warm towels around shoulders Simply soaking hands in a basin of warm water


Nursing Interventions RA-Mobility (cont.) :Nursing Interventions RA-Mobility (cont.) Good body alignment while resting can be maintained through use of a firm mattress or bed board Encourage positions of extension Avoid flexion positions Splints and casts can help maintain proper alignment and promote res Lying prone for half an hour twice daily is recommended Pillows should never be placed under knees Increases risk of joint contracture A small, flat pillow may be used under head and shoulders


Nursing Interventions RA- Joint Protection :Nursing Interventions RA- Joint Protection Important to protect joints from stress Nurse can help identify ways to modify tasks to put less stress on joints during routine activities Energy conservation requires careful planning Pacing: Work should be done in short periods with scheduled breaks Time-saving joint protective devices should be used whenever possible Tasks can also be delegated to other family members Assistive devices that help with simple tasks can increase patient independence


Nursing Interventions RA- Heat and Cold Therapy :Nursing Interventions RA- Heat and Cold Therapy Help relieve pain, stiffness, and muscle spasm Ice Especially beneficial during periods of disease exacerbation Application should not exceed 10 to 15 minutes at one time Superficial heat sources Can relieve stiffness to allow participation in therapeutic exercises Moist heat Relief of chronic stiffness Application should not exceed 20 minutes Alert patient to not use a heat-producing cream with another external heat device


Nursing Interventions RA- Exercise :Nursing Interventions RA- Exercise Individualized exercise is an integral part of the treatment plan Usually developed by a physical therapist Nurse should reinforce program participation and ensure that exercises are being done correctly Inadequate joint movement can result in progressive joint immobility and muscle weakness Overaggressive exercise can result in increased pain, inflammation, and joint damage Gentle ROM exercises are usually done daily to keep joints functional


Nursing Interventions RA- Psychologic Support :Nursing Interventions RA- Psychologic Support Self-management and adherence to treatment program can only be done if patient has a thorough understanding of RA Nature and course of disease Goals of therapy Patient’s value system and perception of disease must be considered Patient is constantly challenged by problems of Limited function and fatigue Loss of self-esteem Altered body image Fear of disability or deformity Evaluation of family support system is important Nurse can help patient recognize fear and concerns