6 Rheumatoid Arthritis Nursing Care Plans

Acute Pain

Patients with rheumatoid arthritis may experience acute pain due to injury, which can be caused by several factors. Injury can result in tissue distension due to fluid accumulation, leading to pressure and pain. The inflammatory process in rheumatoid arthritis can also worsen pain and cause further joint damage. Joint destruction caused by injury can further limit mobility and exacerbate pain.

Nursing Diagnosis

• Acute Pain

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

Desired Outcomes

• The client will report relief/control of pain.
• The client will appear relaxed, able to sleep/rest and participate in activities appropriately.
• The client will follow the prescribed pharmacological regimen.
• The client will incorporate relaxation skills and diversional activities into the pain control program.

Nursing Assessment and Rationales

1. 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.

2. Monitor the duration, not the intensity, of morning stiffness.
Duration more accurately reflects the disease’s severity.

Nursing Interventions and Rationales

1. Recommend or provide a firm mattress or bedboard, and a small pillow. Elevate linens with bed cradle as needed.
Soft and sagging mattresses and large pillows prevent the maintenance of proper body alignment, placing stress on affected joints. Elevation of bed linens reduces pressure on inflamed or painful joints.

2. 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 the joint.

3. Place and monitor the use of pillows, sandbags, trochanter rolls, splints, and braces.
Rests painful joints and maintains a neutral position. Note: The use of splints can decrease pain and may reduce damage to joints; however, prolonged inactivity can result in loss of joint mobility and function.

4. Encourage frequent changes of position. Assist the patient to move in bed, supporting affected joints above and below, and avoiding jerky movements.
Prevents general fatigue and joint stiffness. Stabilizes joints, decreasing joint movement and associated pain.

5. Recommend that the 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.

6. Provide gentle massage.
Promotes relaxation and reduces muscle tension.

7. 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.

8. Involve in diversional activities appropriate for the individual situation.
Refocuses attention, provides stimulation, and enhances self-esteem and feelings of general well-being.

9. Medicate before planned activities and exercises as indicated.
Promotes relaxation, and reduces muscle tension and spasms, facilitating participation in therapy.

10. Administer medications as indicated:

• 10.1. Salicylates: aspirin (ASA) (Acuprin, Ecotrin, ZORprin)
  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.

• 10.2. Nonsalicylates (NSAIDs): ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), sulindac (Clinoril), piroxicam (Feldene), fenoprofen (Nalfon), diclofenac (Voltaren), ketoprofen (Orudis), ketorolac (Toradol), nabumetone (Relafen)
  These drugs control mild to moderate pain and inflammation by inhibiting prostaglandin synthesis.

• 10.3. Glucocorticoids: prednisone (Deltasone), methylprednisolone (Depo-Medrol), dexamethasone (Decadron)
  These drugs modify the immune response and suppress inflammation.

• 10.4. Disease-modifying antirheumatic drugs (DMARD): methotrexate (Rheumatrex), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), gold compounds, auranofin (Ridaura), azathioprine (Imuran), leflunomide (Arava)
  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 the progression of RA and damage to joints.

• 10.5. COX-2 inhibitors: celecoxib (Celebrex), rofecoxib (Vioxx)
  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.

• 10.6. Biologicals: etanercept (Enbrel), infliximab (Remicade)
  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.

• 10.7. Tetracyclines: minocycline (Minocin)
  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.

• 10.8. d-Penicillamine (Cuprimine)
  May control the systemic effects of RA synovitis and scleroderma if other therapies have not been successful. A high rate of side effects (thrombocytopenia, leukopenia, aplastic anemia) necessitates close monitoring. Note: Drugs should be given between meals because drug absorption is impaired by food, as well as antacids and iron products.

• 10.9. Antacids: misoprostol (Cytotec), omeprazole (Prilosec)
  Given with NSAID agents to minimize gastric irritation and discomfort, reducing the risk of GI bleed.

• 10.10. Codeine-containing medications
  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.

11. Assist with physical therapies such as paraffin gloves, and whirlpool baths.
Provides sustained heat to reduce pain and improve ROM of affected joints.

12. Apply ice or cold packs when indicated.
Cold may relieve pain and swelling during acute episodes.

13. Instruct in use and monitor the effect of the transcutaneous electrical nerve stimulator (TENS) unit if used.
Constant low-level electrical stimulus blocks the transmission of pain sensations.