Developing a comprehensive nursing care plan for rheumatoid arthritis patients requires a thorough understanding of the nursing diagnosis for this condition. Learn about common nursing diagnoses for rheumatoid arthritis and how they can be used to improve patient outcomes. Discover assessment, planning, and intervention strategies for rheumatoid arthritis nursing care plans.
Table of contents
- What is Rheumatoid Arthritis?
- Nursing Care Plans & Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- See also
What is Rheumatoid Arthritis?
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 is characterized by the destruction and proliferation of synovial membranes 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 & Management
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.
Nursing Problem Priorities
The following are the nursing priorities for patients with rheumatoid arthritis (RA):
- Manage pain and discomfort through appropriate pain management interventions and strategies.
- Promote joint mobility and prevent deformities through range-of-motion exercises, joint protection techniques, and assistive devices.
- Provide education on self-care strategies, including medication adherence, joint protection, and energy conservation techniques.
- Address potential complications such as inflammation, joint erosion, and systemic involvement through close monitoring and collaboration with the healthcare team.
- Support emotional well-being and provide counseling to address the impact of chronic pain and functional limitations.
- Facilitate referrals and coordinate care with other healthcare providers, such as rheumatologists and occupational therapists, for specialized treatment and interventions.
Assess for the following subjective and objective data:
- Reports joint pain, stiffness, and tenderness
- Reports of morning stiffness lasting more than 30 minutes
- History of family members with RA or other autoimmune diseases
- Visible joint swelling, redness, or warmth
- Limited range of motion in affected joints
- Presence of deformities or nodules, such as rheumatoid nodules
- Joint tenderness or pain upon palpation
- X-ray or imaging findings showing joint erosion or changes in the affected joints
- Laboratory findings of positive rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP) antibodies
- Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels
Assess for factors related to the cause of rheumatoid arthritis (RA):
- Injuring agents: distension of tissues by the accumulation of fluid/inflammatory process, destruction of joint
- Skeletal deformity
- Pain, discomfort
- Intolerance to activity; decreased muscle strength
- Visible joint deformities
- Changes in ability to perform usual tasks
- Increased energy expenditure; impaired mobility
- Long-term degenerative disease process
- Inadequate support systems
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with rheumatoid arthritis based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- 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.
- The client will maintain a position of function with the absence/limitation of contractures.
- The client will maintain or increase the strength and function of the affected and/or compensatory body part.
- The client will demonstrate techniques/behaviors that enable the resumption/continuation of activities.
- The client will verbalize increased confidence in the ability to deal with illness, changes in lifestyle, and possible limitations.
- The client will formulate realistic goals/plans for the future.
- The client will perform self-care activities at a level consistent with individual capabilities.
- The client will demonstrate techniques/lifestyle changes to meet self-care needs.
- The client will identify personal/community resources that can provide needed assistance.
- The client will maintain a safe, growth-promoting environment.
- The client will Demonstrate appropriate, effective use of resources.
- The client will verbalize understanding of the condition/prognosis, and potential complications.
- The client will verbalize understanding of therapeutic needs.
- The client will develop a plan for self-care, including lifestyle modifications consistent with mobility and/or activity restrictions.
Nursing Interventions and Actions
Therapeutic interventions and nursing actions for patients with rheumatoid arthritis (RA) may include:
1. Managing Pain Relief
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.N
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.
Monitor the duration, not the intensity, of morning stiffness.
Duration more accurately reflects the disease’s severity.
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.
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.
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.
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.
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.
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 the 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, and reduces muscle tension and spasms, facilitating participation in therapy.
Administer medications as indicated.
See Pharmacologic Management
Assist with physical therapies such as paraffin gloves, and 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 the transcutaneous electrical nerve stimulator (TENS) unit if used.
Constant low-level electrical stimulus blocks the transmission of pain sensations.
2. Enhancing Physical Mobility
Impaired physical mobility is a common problem among rheumatoid arthritis patients caused by several factors. Inflammation and joint damage can result in pain, limiting movement. Disuse or atrophy can cause decreased muscle strength, further hindering mobility. Skeletal deformities, such as joint deformities or spinal curvature, can restrict movement and lead to additional mobility issues.
Assess and continuously monitor the degree of joint inflammation and pain.
The level of activity and exercise depends on the progression and resolution of the inflammatory process.
Maintain bedrest or chair rest when indicated. Schedule activities providing frequent rest periods and uninterrupted nighttime sleep.
Systemic rest is mandatory during acute exacerbations and important throughout all phases of the disease to reduce fatigue, and improve strength.
Assist with active and passive ROM and resistive exercises and isometrics when able.
Maintains and improves joint function, muscle strength, and general stamina. Note: Inadequate exercise leads to joint stiffening, whereas excessive activity can damage joints.
Encourage the patient to maintain an upright and erect posture when sitting, standing, and walking.
Maximizes joint function, and maintains mobility.
Urge the patient to perform activities of daily living (ADLs), such as practicing good hygiene, dressing, and feeding himself.
ADLs that can be done should be encouraged to maximize function.
Discuss and provide safety needs such as raised chairs and toilet seats, use of handrails in the tub, shower, and toilet, proper use of mobility aids, and wheelchair safety.
Helps prevent accidental injuries and falls.
Reposition frequently using adequate personnel. Demonstrate and assist with transfer techniques and use of mobility aids such as a walker, cane, and trapeze.
Relieves pressure on tissues and promotes circulation. Facilitates self-care and patient independence. Proper transfer techniques prevent shearing abrasions of the skin.
Position with pillows, sandbags, and trochanter roll. Provide joint support with splints, and braces.
Promotes joint stability (reducing risk of injury) and maintains proper joint position and body alignment, minimizing contractures.
Suggest using a small or thin pillow under the neck.
Prevents flexion of the neck.
Provide foam or alternating pressure mattresses.
Decreases pressure on fragile tissues to reduce risks of immobility and development of decubitus.
3. Enhancing Body Image and Self-Esteem
Patients with rheumatoid arthritis (RA) may experience challenges with body image and self-esteem due to visible joint deformities, functional limitations, and the chronic nature of the condition. These factors can affect the perception of self-image, causing emotional distress, lowered self-esteem, and potential social isolation, highlighting the importance of providing emotional support, counseling, and promoting a holistic approach to care.
Note withdrawn behavior, use of denial, or over-concern with body changes.
May suggest emotional exhaustion or maladaptive coping methods, requiring more in-depth intervention or psychological support.
Encourage verbalization about concerns about the disease process, and future expectations.
Provides an opportunity to identify fears and misconceptions and deal with them directly.
Encourage a balanced diet, but make sure the patient understands that special diets won’t cure RA. Stress the need for weight control.
Obesity adds further stress to joints.
Ascertain how the patient views self in usual lifestyle functioning, including sexual aspects.
Identifying how illness affects the perception of self and interactions with others will determine the need for further intervention and counseling.
Discuss the patient’s perception of how SO perceives limitations.
Verbal and nonverbal cues from SO may have a major impact on how the patient views self.
Acknowledge and accept feelings of grief, hostility, and dependency.
Constant pain is wearing, and feelings of anger and hostility are common. Acceptance provides feedback that feelings are normal.
Set limits on maladaptive behavior. Assist the patient to identify positive behaviors that will aid in coping.
Helps the patient maintain self-control, which enhances self-esteem.
Involve patients in planning care and scheduling activities.
Enhances feelings of competency and self-worth, and encourages independence and participation in therapy.
Assist with grooming needs as necessary.
Maintaining appearance enhances self-image.
Give positive reinforcement for accomplishments.
Allows patient to feel good about self. Reinforces positive behavior. Enhances self-confidence.
Administer medications as indicated (antianxiety and mood-elevating drugs).
May be needed in presence of severe depression until the patient develops more effective coping skills.
Refer to psychiatric counseling like a psychiatric clinical nurse specialist, psychiatrist or psychologist, or social worker.
Patient and SO may require ongoing support to deal with the long-term and debilitating process.
4. Promoting Independent Self-Care
Independent self-care for patients with rheumatoid arthritis (RA) involves empowering the patients to take an active role in managing the condition by adhering to medication schedules, practicing self-help strategies for pain management, utilizing assistive devices to aid in activities of daily living, and seeking support and resources to enhance the overall well-being and independence in self-care.
Ascertain the usual level of functioning (0–4) before the onset or exacerbation of illness and potential changes now anticipated.
May be able to continue usual activities with necessary adaptations to current limitations.
Assess barriers to participation in self-care. Identify and plan for environmental modifications.
Prepares for increased independence, which enhances self-esteem.
Maintain mobility, pain control, and exercise program.
Support physical and emotional independence.
Urge the patient to perform activities of daily living (ADLs), such as practicing good hygiene, dressing, and feeding himself.
ADLs that can be done should be encouraged to maximize function.
Allow the patient sufficient time to complete tasks to the fullest extent of ability. Capitalize on individual strengths.
May need more time to complete tasks by self but provides an opportunity for a greater sense of self-confidence and self-worth.
Consult with rehabilitation specialists (occupational therapists).
Helpful in determining assistive devices to meet individual needs (buttonhook, a long-handled shoehorn, reacher, hand-held shower head).
Arrange a home-health evaluation before discharge, with follow-up afterward.
Identifies problems that may be encountered because of the current level of disability. Provides for more successful team efforts with others who are involved in care (occupational therapy team).
Arrange for a consult with other agencies (Meals on Wheels, home care service, nutritionist).
May need additional kinds of assistance to continue in the home setting.
5. Initiating Patient Education and Health Teachings
Patients with rheumatoid arthritis may have deficient knowledge related to several aspects of the disease. This can include a lack of understanding about the causes, symptoms, and treatment options available for managing the condition. Inadequate knowledge about self-care and symptom monitoring may also impact a patient’s ability to effectively manage their disease and maintain their overall health. In addition, Inefficient home maintenance may arise as patients with RA may experience difficulty in performing household tasks, necessitating assistance, modifications, or adaptations to the living conditions to ensure a safe and supportive home environment.
Determine the level of physical functioning using Functional Level Classification 0–4.
Identifies the degree of assistance and support required. For example, the level 0 patient is completely able to perform usual activities of daily living (self-care, vocational, and avocational), whereas the level 4 patient is limited in all these areas and does not participate in the activity.
Evaluate the environment to assess the ability to care for self.
Determines the feasibility of remaining or changing the home layout to meet individual needs.
Determine financial resources to meet the needs of an individual situation. Identify support systems available to the patient, (extended family, friends, and neighbors).
The availability of personal resources and community support will affect the ability to problem-solve and choice of solutions.
Develop a plan for maintaining a clean, healthful environment such as sharing of household repairs and tasks between family members or by contract services.
Ensures that needs will be met on an ongoing basis.
Identify sources for necessary equipment (lifts, elevated toilet seats, wheelchair).
Provides an opportunity to acquire equipment before discharge.
Coordinate home evaluation by the occupational therapist and rehabilitation team.
Useful for identifying adaptive equipment, and ways to modify tasks to maintain independence.
Identify and meet with community resources (visiting nurses, homemaker service, social services, senior citizens’ groups).
Can facilitate transfer or support continuation in a home setting.
Review disease process, prognosis, and future expectations.
Provides a knowledge base from which patients can make informed choices.
Identify adverse drug effects (tinnitus, gastric intolerance, GI bleeding, purpuric rash).
Prolonged, maximal doses of aspirin may result in an overdose. Tinnitus usually indicates high therapeutic blood levels. If tinnitus occurs, the dosage is usually decreased by 1 tablet every 2–3 days until it stops.
Discuss the patient’s role in the management of the disease process through nutrition, medication, and a balanced program of exercise and rest.
The goal of disease control is to suppress inflammation in joints and other tissues to maintain joint function and prevent deformities.
Assist in planning a realistic and integrated schedule of activity, rest, personal care, drug administration, physical therapy, and stress management.
Provides structure and defuses anxiety when managing a complex chronic disease process.
Identify individually appropriate exercise program components (swimming, stationary bike, nonimpact aerobics)
Can increase the patient’s energy level and mental alertness, and minimize functional limitations. The program needs to be customized based on the joints involved and the patient’s general condition to maximize effect and reduce the risk of injury.
Stress the importance of continued pharmacotherapeutic management.
The benefits of drug therapy depend on the correct dosage (aspirin must be taken regularly to sustain therapeutic blood levels of 18–25 mg per dL).
Recommend the use of enteric-coated or buffered aspirin or nonacetylated salicylates such as choline salicylate (Arthropan) or choline magnesium trisalicylate (Trilisate).
Coated or buffered preparations ingested with food minimize gastric irritation, reducing the risk of bleeding and hemorrhage. Note: Non-acetylated products have a longer half-life, requiring less frequent administration in addition to producing less gastric irritation.
Suggest taking medications, such as NSAIDs, with meals, milk products, or antacids, and at bedtime.
Limits gastric irritation. Reduction of pain at HS enhances sleep, and increased blood level decreases early-morning stiffness.
Stress the importance of reading product labels and refraining from OTC drug usage without prior medical approval.
Many products (cold remedies, antidiarrheals) contain hidden salicylates that increase the risk of a drug overdose and harmful side effects.
Review the importance of a balanced diet with foods high in vitamins, protein, and iron.
Promotes general well-being and tissue repair and regeneration.
Encourage the obese patient to lose weight, and supply with weight reduction information as appropriate.
Weight loss reduces stress on joints, especially hips, knees, ankles, and feet.
Provide information and resources for assistive devices (wheeled dolly or wagon for moving items, pick-up sticks, lightweight dishes, and pans, raised toilet seat, safety handlebars).
Reduces the force exerted on joints and enables the individual to participate more comfortably in needed and desired activities.
Discuss energy-saving techniques (sitting instead of standing to prepare meals or shower).
Prevents fatigue; facilitates self-care and independence.
Encourage maintenance of correct body position and posture both at rest and during an activity like keeping joints extended, not flexed, wearing splints for prescribed periods, avoiding remaining in a single position for extended periods, positioning hands near the center of the body during use, and sliding rather than lifting objects when possible.
Good body mechanics must become a part of the patient’s lifestyle to lessen joint stress and pain.
Review the necessity of frequent inspection of the skin and meticulous skin care under splints, casts, and supporting devices. Demonstrate proper padding.
Reduces the risk of skin irritation and breakdown.
Discuss the importance of medical follow-up and laboratory studies, (ESR, salicylate levels, PT).
Drug therapy requires frequent assessment and refinement to ensure optimal effect and to prevent overdose or dangerous side effects (aspirin prolongs PT, increasing the risk of bleeding).
Provide sexual and childbirth counseling as necessary.
Information about different positions and techniques or other options for sexual fulfillment may enhance personal relationships and feelings of self-worth and self-esteem. Note: A large number of patients with RA are in childbearing years and need counseling, support, and medical interventions.
Identify community resources (Arthritis Foundation).
Assistance and support from others promote maximal recovery.
6. Administering Medications and Pharmacologic Support
The medications used for rheumatoid arthritis (RA) typically include disease-modifying antirheumatic drugs (DMARDs) to slow down the progression of the disease and reduce joint inflammation, as well as nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids for pain and inflammation management. Biologic response modifiers (biologics) may also be prescribed for patients with moderate to severe RA who do not respond adequately to other treatments, targeting specific components of the immune system to reduce inflammation and joint damage.
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.
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.
Glucocorticoids: prednisone (Deltasone), methylprednisolone (Depo-Medrol), dexamethasone (Decadron)
These drugs modify the immune response and suppress inflammation
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.
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.
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.
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.
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.
Antacids: misoprostol (Cytotec), omeprazole (Prilosec)
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.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
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