Nursing Care Plan (NCP) for Rheumatoid Arthritis (RA)
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Outline
Lesson Objectives for Rheumatoid Arthritis (RA)
- Define Rheumatoid Arthritis:
- Understand the definition and characteristics of Rheumatoid Arthritis (RA) as a chronic autoimmune inflammatory disorder affecting the joints.
- Recognize Clinical Manifestations:
- Identify the clinical manifestations of RA, including joint pain, swelling, stiffness, and systemic symptoms such as fatigue and malaise.
- Understand Pathophysiology:
- Comprehend the underlying pathophysiology of RA involving autoimmune responses, synovial inflammation, and joint destruction.
- Explore Diagnostic Methods:
- Familiarize oneself with diagnostic methods for RA, including laboratory tests (e.g., rheumatoid factor, anti-cyclic citrullinated peptide antibodies) and imaging studies (e.g., X-rays, MRI).
- Learn Multidisciplinary Management:
- Understand the multidisciplinary approach to RA management, incorporating pharmacological interventions, physical therapy, and patient education.
Pathophysiology of Rheumatoid Arthritis (RA)
- Autoimmune Response:
- RA involves an autoimmune response where the immune system mistakenly attacks the synovium, the lining of the membranes that surround the joints.
- Autoantibodies, such as rheumatoid factor and anti-cyclic citrullinated peptide antibodies, contribute to immune system activation.
- Synovial Inflammation:
- The autoimmune response triggers inflammation of the synovial membrane, leading to synovitis.
- Inflamed synovium releases cytokines, including tumor necrosis factor (TNF) and interleukins, perpetuating inflammation and joint damage.
- Pannus Formation:
- Chronic inflammation results in the formation of a thickened synovial tissue called pannus.
- Pannus invades and erodes cartilage and bone within the joint, causing joint deformities and destruction.
- Joint Erosion and Destruction:
- Pannus formation, combined with the release of enzymes and other destructive substances, leads to erosions of cartilage and bone.
- Joint destruction occurs over time, impacting joint function and causing deformities.
- Systemic Manifestations:
- RA is not limited to joints; it can have systemic effects, impacting organs such as the heart, lungs, and blood vessels.
- Systemic inflammation contributes to fatigue, malaise, and an increased risk of cardiovascular complications.
Etiology of Rheumatoid Arthritis (RA)
- Genetic Factors:
- Genetic predisposition plays a role in the development of RA, with specific human leukocyte antigen (HLA) genes associated with increased susceptibility.
- Environmental Triggers:
- Environmental factors, such as infections or exposure to certain toxins, may trigger the autoimmune response in genetically susceptible individuals.
- Hormonal Influence:
- Hormonal factors, particularly in women, are implicated in the development of RA. Hormonal changes, such as those during pregnancy or menopause, can influence disease activity.
- Smoking:
- Smoking is a well-established environmental risk factor for RA. It not only increases the risk of developing RA but also exacerbates disease severity.
- Immunologic Dysregulation:
- Dysregulation of the immune system, leading to the production of autoantibodies and inflammatory cytokines, is a central component of RA etiology.
- Abnormal activation of T lymphocytes and B lymphocytes contributes to the autoimmune response.
Desired Outcome in the Management of Rheumatoid Arthritis (RA)
- Pain Management:
- Alleviate joint pain and discomfort associated with RA to improve the individual’s overall quality of life.
- Utilize pharmacological and non-pharmacological interventions to achieve pain relief.
- Joint Functionality:
- Preserve or improve joint functionality, allowing for increased mobility and independence in daily activities.
- Implement strategies to reduce joint stiffness and limitations.
- Inflammation Control:
- Control and manage inflammation to prevent further joint damage and deformities.
- Utilize disease-modifying anti-rheumatic drugs (DMARDs) and biologic agents to suppress inflammation.
- Prevention of Joint Deformities:
- Minimize or prevent the development of joint deformities through early and effective management.
- Implement joint protection techniques and adaptive devices to support joint integrity.
- Enhanced Quality of Life:
- Improve the individual’s overall quality of life by addressing both physical and psychosocial aspects of living with RA.
- Provide education, support, and resources to promote self-management and coping.
Rheumatoid Arthritis (RA) Nursing Care Plan
Subjective Data:
- Fatigue
- Joint stiffness, symmetrical
- Joint pain
Objective Data:
- Warmth of joints
- Joint edema
- Dislocations
- Deformity of joints
- Ulnar deviation of hands
- Fever
- Weight loss
Nursing Assessment for Rheumatoid Arthritis (RA)
- Pain Assessment:
- Conduct a comprehensive pain assessment, including the location, intensity, and characteristics of joint pain.
- Utilize pain scales and encourage the individual to express their pain experience.
- Joint Assessment:
- Assess all affected joints for signs of inflammation, including swelling, warmth, and tenderness.
- Document joint limitations, range of motion, and any deformities.
- Functional Assessment:
- Evaluate the individual’s ability to perform activities of daily living (ADLs) independently.
- Identify areas of difficulty or dependency and collaboratively plan interventions.
- Psychosocial Assessment:
- Assess the individual’s psychosocial well-being, including emotional responses to living with a chronic condition.
- Identify coping mechanisms, support systems, and any signs of depression or anxiety.
- Fatigue Assessment:
- Evaluate the impact of RA-related fatigue on daily functioning and quality of life.
- Assess for factors contributing to fatigue, such as poor sleep or medication side effects.
- Medication Adherence:
- Assess the individual’s adherence to prescribed medications, including DMARDs, biologics, and pain management drugs.
- Identify any barriers to adherence and provide education accordingly.
- Joint Protection Strategies:
- Assess the individual’s knowledge and use of joint protection techniques during daily activities.
- Provide additional education and resources to minimize stress on affected joints.
- Cultural and Lifestyle Considerations:
- Consider cultural factors and individual lifestyle preferences in the assessment process.
- Tailor interventions to align with the individual’s beliefs, practices, and priorities.
Implementation for Rheumatoid Arthritis (RA)
- Pharmacological Management:
- Administer prescribed medications, including disease-modifying anti-rheumatic drugs (DMARDs), nonsteroidal anti-inflammatory drugs (NSAIDs), and biologics, to control inflammation and manage symptoms.
- Monitor for potential side effects and collaborate with the healthcare team to adjust medications as needed.
- Pain Management Strategies:
- Implement pain management strategies, including the use of analgesics, heat or cold therapy, and joint protection techniques.
- Collaborate with physical therapists to develop individualized pain relief strategies.
- Joint Protection and Assistive Devices:
- Educate the individual on joint protection techniques to minimize stress on affected joints during daily activities.
- Provide information on and facilitate the use of assistive devices such as braces, splints, or adaptive tools.
- Physical Activity and Exercise:
- Collaborate with a physical therapist to develop a tailored exercise program that focuses on improving joint flexibility and muscle strength.
- Encourage regular, low-impact exercise to maintain overall health and well-being.
- Patient Education and Self-Management:
- Provide comprehensive education on RA, its progression, and the importance of adherence to the treatment plan.
- Empower the individual with self-management strategies, including lifestyle modifications, stress management, and recognizing early signs of disease exacerbation.
Nursing Interventions and Rationales
- Assess and manage chronic and acute pain
- Pillow supports
- Warm compresses to loosen stiff joints/relax muscles
- Cold compresses to numb pain and reduce swelling
- Administer PRN pain meds
- Administer medications appropriately
- NSAIDs are given to reduce inflammation and ease pain
- Steroids (prednisone) is often given to reduce inflammation and slow joint damage
- DMARDs (methotrexate, hydroxychloroquine) are disease-modifying antirheumatic drugs that are given to slow the progression of RA and save the joints and tissues from permanent damage
- Biologic agents (rituximab, adalimumab) are biologic response modifiers and work by targeting parts of the immune system that trigger inflammation.
- Promote self-care
- Cluster care, promote rest
- Promote positive self-image
- Encourage activity / exercise
- Nutrition and lifestyle education
- Healthy diet
- Avoid alcohol
- Quit smoking
Evaluation of Nursing Care Plan (NCP) for Rheumatoid Arthritis (RA)
- Pain Relief:
- Evaluate the effectiveness of pain management interventions in providing relief and improving the individual’s ability to cope with pain.
- Assess changes in pain intensity, duration, and frequency.
- Joint Functionality:
- Monitor improvements in joint functionality, including increased range of motion and decreased joint stiffness.
- Assess the individual’s ability to perform ADLs independently.
- Inflammation Control:
- Assess the success of anti-inflammatory medications and DMARDs in controlling systemic and joint-specific inflammation.
- Monitor laboratory markers, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).
- Prevention of Joint Deformities:
- Evaluate the success of interventions in preventing or minimizing the development of joint deformities.
- Assess joint stability and alignment.
- Enhanced Quality of Life:
- Assess improvements in the overall quality of life, considering physical, emotional, and social well-being.
- Evaluate the individual’s ability to engage in meaningful activities and maintain a positive outlook.
References
- https://www.webmd.com/rheumatoid-arthritis/guide/coping-with-pain
- https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/diagnosis-treatment/drc-20353653
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Transcript
Hey guys, let’s take a look at the care plan for rheumatoid arthritis, also known as RA. In this lesson, we’ll briefly take a look at the pathophysiology and etiology of RA. We’re also going to look at additional things like subjective and objective data included in the care plan, as well as nursing interventions and rationales.
RA is an auto-immune disease where the immune system mistakenly targets and attacks the joint linings causing uncontrolled inflammation of the synovium. Bilateral joints are affected, primarily the wrists, the hands, and also the knees. RA is characterized by bone erosion and joint deformity, so as the disease progresses, other joints may be affected symmetrically. Chronic inflammation and degenerative changes are the hallmark aspects of RA. Doctors are unsure of what triggers RA, but it appears to be partially genetic. The genetic predisposition makes the patient more susceptible to environmental factors like viruses and bacteria that may trigger the initial inflammation. Once the inflammation begins, the synovial fluid thickens and the tendons and ligaments stretch, resulting in the joint losing its shape and alignment. While there is no cure for RA, the goal is to manage the symptoms and slow the disease progression. Medication, physical and occupational therapy and possible surgery may be necessary.
Let’s take a look at some of the subjective and objective data that your patient with rheumatoid arthritis may present with. Now remember, subjective data are going to be things that are based on your patient’s opinions or feelings. They might express fatigue, symmetrical joint stiffness and joint pain.
Objective data includes warmth of the joints, joint edema, dislocations, deformity of joints, including deviation of the hands, fever and weight loss.
Nursing interventions are a super important part of a care plan, so let’s take a look at those. The primary complaints of patients with RA is intense pain and stiffness of those joints. To manage this pain, use pillow supports, warm compresses to loosen stiff joints and relax the muscles, cold compresses to numb the pain and reduce the swelling, and finally, PRN pain meds.
In addition to pain meds, other medications are necessary to treat RA. NSAIDS are given to reduce inflammation and ease pain. Steroids like prednisone are given to reduce inflammation and slow joint damage. Disease-modifying antirheumatic drugs like methotrexate are given to slow the progression of RA and save the joints and tissues from permanent DNA damage. Finally, biologic agents like rituximab are biologic response modifiers that work by targeting parts of the immune system that trigger inflammation.
Promoting self care in patients with RA is critical because as the disease progresses, it may be difficult for patients to perform ADL’s such as feeding themselves or combing their hair. Provide tools such as eating utensils or toothbrushes with larger grips to encourage the patient to remain independent. Also, fatigue is a very common symptom of RA, so it’s important to cluster care and promote rest. For your patients who have RA, help to promote a positive self image, as patients with joint deformities may experience a negative body image. Although these patients do fatigue easily, encourage exercise to help loosen those joints, so encourage activity as tolerated. Nutrition and lifestyle education is critical with RA patients. When patients are in pain, they sometimes want to turn to comfort foods, which is definitely understandable, but instead help them to make healthy food choices, avoid alcohol, avoid smoking and encourage hydration. Patients may also want to consult with a nutritionist regarding an anti-inflammatory diet.
Okay, guys, here is a look at the completed care plan for rheumatoid arthritis. We love you guys. Now, go out and be your best self today and as always, happy nursing!
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