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.
- Acute Pain
- Impaired Physical Mobility
- Disturbed Body Image
- Self-Care Deficit
- Risk for Impaired Home Maintenance
- Deficient Knowledge
Risk factors may include
- Injuring agents: distension of tissues by the accumulation of fluid/inflammatory process, destruction of joint
Possibly evidenced by
- Reports of pain/discomfort, fatigue
- Self-narrowed focus
- Distraction behaviors/autonomic responses
- Guarding/protective behavior
- Client will report relieved/controlled of pain.
- Client will appear relaxed, able to sleep/rest and participate in activities appropriately.
- Client will follow the prescribed pharmacological regimen.
- Client will incorporate relaxation skills and diversional activities into the pain control program.
|Consider reports of pain, noting location and intensity (scale of 0–10). Note precipitating factors and nonverbal pain cues.||Favorable in determining pain management needs and effectiveness of the program.|
|Recommend or provide a firm mattress or bedboard, small pillow. Elevate linens with bed cradle as needed.||Soft and sagging mattress, large pillows prevent maintenance of proper body alignment, placing stress on affected joints. Elevation of bed linens reduces pressure on inflamed or painful joints.|
|Suggest patient assume a position of comfort while in bed or sitting in a chair. Promote bedrest as indicated.||In severe disease or acute exacerbation, total bedrest may be necessary (until objective and subjective improvements are noted) to limit pain or injury to joint.|
|Place and monitor use of pillows, sandbags, trochanter rolls, splints, braces.||Rests painful joints and maintains a neutral position. Note: Use of splints can decrease pain and may reduce damage to joint; however, prolonged inactivity can result in loss of joint mobility and function.|
|Encourage frequent changes of position. Assist the patient to move in bed, supporting affected joints above and below, avoiding jerky movements.||Prevents general fatigue and joint stiffness. Stabilizes joint, decreasing joint movement and associated pain.|
|Monitor the duration, not the intensity, of morning stiffness.||Duration more accurately reflects the disease’s severity.|
|Recommend that patient take a warm bath or shower upon arising or at bedtime. Apply warm, moist compresses to affected joints several times a day. Monitor water temperature of compress, baths, and so on.||Heat promotes muscle relaxation and mobility, decreases pain, and relieves morning stiffness. Sensitivity to heat may be diminished and dermal injury may occur.|
|Provide gentle massage.||Promotes relaxation and reduces muscle tension.|
|Encourage the use of stress management techniques such as progressive relaxation, biofeedback, visualization, guided imagery, self-hypnosis, and controlled breathing. Provide Therapeutic Touch.||Promotes relaxation, provides a sense of control and may enhance coping abilities.|
|Involve in diversional activities appropriate for individual situation.||Refocuses attention, provides stimulation and enhances self-esteem and feelings of general well-being.|
|Medicate before planned activities and exercises as indicated.||Promotes relaxation, reduces muscle tension and spasms, facilitating participation in therapy.|
|Administer medications as indicated:|
||ASA exerts an anti-inflammatory and mild analgesic effect, decreasing stiffness and increasing mobility. ASA must be taken regularly to sustain a therapeutic blood level. Research indicates that ASA has the lowest toxicity index of commonly prescribed NSAIDs.|
||These drugs control mild to moderate pain and inflammation by inhibition of prostaglandin synthesis.|
|These drugs modify immune response and suppress inflammation.|
|These drugs vary in action, but all reduce pain and swelling, lessening arthritic symptoms rather than eliminating them. Arava (FDA approved in 1998) is the first oral drug shown to slow progression of RA and damage to joints.|
||A new class of medication, COX-2 inhibitors interfere with prostaglandin production, similarly to NSAIDs, but are less likely to harm the stomach lining or kidneys. May be used in combination with other medications.|
||These injectable drugs are the first genetically engineered medications for arthritis. These anti-TNF compounds block inflammation and rapidly decrease pain and joint swelling. Enbrel is self-injected twice a week and may be used in combination with methotrexate. Remicade is administered IV at 1- to 3-month intervals. Note: Because of concerns about immune function suppression, Enbrel is recommended only for patients who are unable to tolerate methotrexate or failed to respond to at least two other DMARDs.|
||Characteristics of anti-inflammatory and immune modifier effects coupled with the ability to block metalloproteinases (associated with joint destruction) have resulted in dramatic benefits in research studies.|
||May control the systemic effects of RA synovitis and scleroderma if other therapies have not been successful. High rate of side effects (thrombocytopenia, leukopenia, aplastic anemia) necessitates close monitoring. Note: Drug should be given between meals because drug absorption is impaired by food, as well as antacids and iron products.|
||Given with NSAID agents to minimize gastric irritation and discomfort, reducing the risk of GI bleed.|
||Although narcotics are generally contraindicated because of the chronic nature of the condition, short-term use of these products may be required during periods of acute exacerbation to control severe pain.|
|Assist with physical therapies such as paraffin glove, whirlpool baths.||Provides sustained heat to reduce pain and improve ROM of affected joints.|
|Apply ice or cold packs when indicated.||Cold may relieve pain and swelling during acute episodes.|
|Instruct in use and monitor the effect of transcutaneous electrical nerve stimulator (TENS) unit if used.||Constant low-level electrical stimulus blocks the transmission of pain sensations.|
Other Possible Nursing Care Plans
Other nursing diagnoses you can use as care plans.
- Fatigue—increased energy requirements to perform ADLs, states of discomfort.
- Pain, chronic—accumulation of fluid/inflammation, destruction of joint.
- Mobility, impaired physical—skeletal deformity, pain/discomfort, decreased muscle strength, intolerance to activity.
- Self-Care deficit/Home Maintenance, impaired—musculoskeletal impairment, decreased strength/endurance, pain on movement, inadequate support systems, insufficient finances, unfamiliarity with neighborhood resources.
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Musculoskeletal Care Plans
Care plans related to the musculoskeletal system:
- Amputation | 4 Care Plans
- Congenital Hip Dysplasia | 4 Care Plans
- Fracture | 8 Care Plans
- Juvenile Rheumatoid Arthritis | 4 Care Plans
- Laminectomy (Disc Surgery) | 8 Care Plans
- Osteoarthritis | 4 Care Plans
- Osteoporosis | 4 Care Plans
- Rheumatoid Arthritis | 6 Care Plans
- Scoliosis | 4 Care Plans
- Total Joint (Knee, Hip) Replacement | 5 Care Plans