Rheumatoid arthritis is one of several types of arthritis that have been identified as affecting the musculoskeletal system. While the other two types of arthritis are known to affect primarily weight-bearing joints, this type of arthritis is characterized by a chronic systemic inflammation that affects not only the joints but also other cartilage tissues. It can be linked to environmental, genetic, or both factors.
The destruction of connective tissues and synovial fluid within the joints and a decrease in the amounts of synovial fluid between them are frequently present in patients with rheumatoid arthritis. As a result, the joints become weaker, more prone to dislocation, and develop permanent deformities. The disease can also go into remissions and exacerbations, particularly during extreme emotional stress and fatigue. Among patients, common symptoms include, but are not limited to:
- Joint tenderness, stiffness and inflammation (not all cases)
- Joint pain, especially in the mornings
- Soft and spongy feeling in the joints (occur late into the disease)
- Low-grade fever, weakness and fatigue
- Anorexia and weight loss
- Joint deformities, muscle atrophy and decreased range of motion of affected joints
- Elevated rheumatoid factor and ESR levels (especially during exacerbations)
- Late sign: Swan Neck deformity, Boutonniere deformity
Assessment of common nursing diagnoses for the patient includes, but are not limited to the actual and potential health/nursing problems presented below:
- Pain: may be acute or chronic (depending on assessment findings)
- Deficient Self Care
- Impaired Physical Mobility
- Body Image Disturbance/Risk for Body Image Disturbance
- Knowledge Deficit
- Risk for Fracture
- Risk for impaired self-care
Based on the nursing diagnoses above, it is essential that the nurse performs a thorough assessment of the patient, including the presenting signs and symptoms and corroborates these with laboratory data to develop an accurate nursing diagnosis to guide in formulating appropriate care plans. It is also worth to remember that in planning for the care of patients, prevention of complications and maintenance of the optimum level of functioning is a must for patients.
Rheumatoid Arthritis [Actual Diagnoses] Nursing Care Plan
Below are some of the most common nursing care plans for patients with rheumatoid arthritis.
Pain (Acute or Chronic)
Acute pain related physical trauma to the joint and surrounding tissues secondary to rheumatoid arthritis evidenced by (include assessment findings related to pain such as, but not limited to:
- Verbalization of pain (include range on a scale of 1-10, 1 meaning no pain and 10 indicating excruciating pain)
- Increased vital signs (blood pressure, heart rate, pulses, respirations)
- Guarding motion on the affected part
- Joint tenderness/swelling
After nursing interventions, the patient is expected to:
- Report a reduction in pain perception
- Report that the pain has completely dissipated
- Verbalize knowledge of non-pharmacologic interventions to relieve pain
|Assess patient’s report of pain, noting the characteristics of pain. Include the PQRST of pain (P=precipitating factor; Q=quality of verbal description, R= radiation or spread to other parts of the body, S= severity and T=time).
|Several indicators of pain perception needs to be carefully assessed to help the nurse better understand pain and plan for effective management.
|Observe the patient’s mood and demeanor during the assessment, noting for both verbal and non-verbal cues to pain.
|Non-verbal cues to pain include guarding movement, facial grimace, dilation of pupils, increased respirations and others. This helps the nurse place the pain perception of the patient into context.
|Position the patient comfortably, ensuring that proper body alignment is maintained.
|Some patients in pain may assume positions that can worsen the injury and cause increased pain. Ensuring that the patient maintains anatomical alignment prevents contractures from developing, which may further increase pain perception and limit the mobility of the affected joint.
|Provide a firm mattress, or a bed board and a soft pillow.
|Mattresses that are too soft may place unnecessary strain on the affected joints, increasing pain perception.
|During periods of exacerbation or increased pain sensation, ensure that affected joints are free from friction by elevating bed linens.
|Linens that are pushing and pulling across the patient’s skin increase pain perception, especially when they are swollen.
|Stress the importance of ensuring that the joints are placed in a neutral position and positions of flexion are prevented. Use necessary equipment when needed.
|Prolonged flexion of the joints may result in the formation of contractures and reduce overall joint mobility. If needed, also include the proper use of splints trochanter rolls, braces, and sandbags in the instruction.
|Take advantage of the use of heat and cold therapy applied to affected joints.
|Heat may help relieve muscle spasms and joint stiffness, increasing the mobility of the patient. Cold, on the other hand, may help reduce inflammation and swelling.
|Provide patient non-pharmacologic pain management techniques such as backrubs, cool cloths to the forehead, and allowing the patient to assume a position of comfort.
|These measures help the patient relax and reduce overall pain perception.
|Provide diversionary activities to help manage pain, such as guided imagery, use of music, meditation.
|Allows the patient to focus his attention other than the pain. These activities may also help enhance his mood and response to other measures.
|Administer pain medication as ordered.
|Medications help block pain perception by the patient, thereby reducing, if not eliminating, its presence.
Body Image Disturbance
Disturbed body image related to the presence of contractures and physical deformities of the joint secondary to rheumatoid arthritis as evidenced by:
- Visible change in the anatomical appearance of the affected part
- Negative perception of the patient on how he looks
- Inability to move the affected part normally
- Refusal to look, touch or talk about the affected joint
- Isolation and feelings of helplessness
After nursing interventions, the patient is expected to:
- Verbalize acceptance of the affected joint
- Show increased confidence in using modifications to movements involving the affected part
- Cooperate in planning for his long-term care and rehabilitation
- Express willingness to focus on more positive aspects of his body
|Allow the patient to verbalize his concerns about his condition and the changes it has brought to him.
|This helps the nurse to explore underlying thoughts and feelings about the identified nursing problem and provides an opportunity to correct any misconceptions.
|Assess how the patient views himself prior to his diagnosis/change in his appearance and right after the change happens.
|Knowing exactly how the patient views himself and how he relates it to how others see him can help the nurse determine if there is a need to assess further family dynamics and other aspects of the patient’s lifestyle.
|Determine how the patient’s significant others view him and his new physical limitations.
|Verbal and non-verbal cues from SO and/or family may also affect how the patient views himself. This also provides data on whether there is a need for counseling for the patient and his SO in dealing with these changes.
|Involve the patient in planning his care and determining his physical activities.
|This measure helps encourage the patient to cooperate in his care and increases his independence and self-worth. This also makes the patient feel that he is in control of aspects of his care.
|Encourage the patient to perform self-care tasks independently.
|Independence in the performance of self-care activity may help the patient realize that the change in his body image does not necessarily mean uselessness and being unable to do activities he used to do on his own.
|Provide patients with tasks that are easy to accomplish before moving on to more complex ones.
|This increases the patient’s confidence, allowing him to feel good about himself and helps promote an optimal level of functioning.
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