Advanced Concept of Nursing- IIUNIT- VII

Advance Nursing Management Of MusculoskeletalDiseases

(Rheumatoid Arthritis)

In The Name of God

(A PROJECT OF NEW LIFE HEALTH CARE SOCIETY, KARACHI)

UNIT- VIIAdvance Nursing Management Of Musculoskeletal

Diseases(Rheumatoid Arthritis)

Shahzad BashirRN, BScN, DCHN,MScN (Std.DUHS)

InstructorNew Life College of NursingUpdated on June 13, 2016

Objectives• At the end of the unit, students will be able to:1. Utilize Functional health pattern to identify patients problems

related to neurovascular disorders including:– Osteoarthritis and RHEUMATOID ARTHRITIS– Osteomylitis– Osteoporosis

2. Integrate pathophysiology and pharmacology concepts of disease.3. Apply nursing process with support on Evidence-Based Nursing

(EBN) to provide to the clients with neurovascular disorders.4. Discuss the holistic approach for nursing management of the

patient with neurovascular diseases.5. Develop a teaching plan for a client experiencing disorders of the

neurovascular disorders.

• At the end of the unit, students will be able to:1. Utilize Functional health pattern to identify patients problems

related to neurovascular disorders including:– Osteoarthritis and RHEUMATOID ARTHRITIS– Osteomylitis– Osteoporosis

2. Integrate pathophysiology and pharmacology concepts of disease.3. Apply nursing process with support on Evidence-Based Nursing

(EBN) to provide to the clients with neurovascular disorders.4. Discuss the holistic approach for nursing management of the

patient with neurovascular diseases.5. Develop a teaching plan for a client experiencing disorders of the

neurovascular disorders.

8/22/2016 2Shahzad Bashir NLCON

Rheumatoid Arthritis• Chronic, systemic, progressive inflammatory

disease of the synovial tissue, bilateral,involving numerous joints.

• Synovitis -warm, red, swollen joints resultingfrom accumulation of fluid and inflammatorycells.

• Classified as autoimmune process• Exacerbations and remissions• Can cause severe deformities that restrict

function.

• Chronic, systemic, progressive inflammatorydisease of the synovial tissue, bilateral,involving numerous joints.

• Synovitis -warm, red, swollen joints resultingfrom accumulation of fluid and inflammatorycells.

• Classified as autoimmune process• Exacerbations and remissions• Can cause severe deformities that restrict

function.

Conti…• RA- chronic, progressive, systemic disease of

unknown etiology.

• The clinical manifestations are primarilyinflammation of synovial tissue in the joints.

• The inflammatory response may affect anyarea of the body in which connective tissue ispresent (blood vessels, heart, skin, etc).

• RA- chronic, progressive, systemic disease ofunknown etiology.

• The clinical manifestations are primarilyinflammation of synovial tissue in the joints.

• The inflammatory response may affect anyarea of the body in which connective tissue ispresent (blood vessels, heart, skin, etc).

RA- Risk Factors

• Female gender 2:1 and 4:1(Khanna, Arnold, Pencharz, et al., 2006)

• Age 20-50 years• Genetic predisposition• Epstein Barr virus• Stress

• Female gender 2:1 and 4:1(Khanna, Arnold, Pencharz, et al., 2006)

• Age 20-50 years• Genetic predisposition• Epstein Barr virus• Stress

Rheumatoid Arthritis- Dx• Rheumatoid Factor antibody- High titers

correlate with severe disease, 80% pts.• Antinuclear Antibody (ANA) Titer- positive

titer is associated with RA.• C- reactive protein- 90% pts.• ESR: Elevated, moderate to severe elevation• Arthocentesis- synovial fluid aspirated by

needle

• Rheumatoid Factor antibody- High titerscorrelate with severe disease, 80% pts.

• Antinuclear Antibody (ANA) Titer- positivetiter is associated with RA.

• C- reactive protein- 90% pts.• ESR: Elevated, moderate to severe elevation• Arthocentesis- synovial fluid aspirated by

needle

RA – Signs and Symptoms• Joints- bilateral and symmetric stiffness, tenderness,

swelling and temp. changes in joint.• Pain at rest and with movement• Pulses- check peripheral pulses, use doppler if necessary,

check capillary refill.• Edema- observe, report and record amt. and location of

edema.• ROM, muscle strength, mobility, atrophy• Anorexia, weight loss• Fever- generally low grade

• Joints- bilateral and symmetric stiffness, tenderness,swelling and temp. changes in joint.

• Pain at rest and with movement• Pulses- check peripheral pulses, use doppler if necessary,

check capillary refill.• Edema- observe, report and record amt. and location of

edema.• ROM, muscle strength, mobility, atrophy• Anorexia, weight loss• Fever- generally low grade

RA- Sign and Symptoms

1. Fatigue- unusual fatigue, generalized weakness2. Morning stiffness lasting longer than 1 an hour after

rising, subsides with activity.3. Red, warm, swollen, painful joints4. Systemic S&S5. Pain- at rest and with movement

1. Fatigue- unusual fatigue, generalized weakness2. Morning stiffness lasting longer than 1 an hour after

rising, subsides with activity.3. Red, warm, swollen, painful joints4. Systemic S&S5. Pain- at rest and with movement

Presentation of antigento T cells

T- and B-cell proliferation.Angiogenesis in synovial

lining.

Swelling in small joints,associated with pain,stiffness, and fatigue.

Neutrophil accumulationin synovial fluid. Cell

proliferation. No cartilageinvasion.

Warm,swollen,effusions,pain,and

decreased motion with possiblerheumatoid nodules.

Pathophysiology of rheumatoidarthritis.

Neutrophil accumulationin synovial fluid. Cell

proliferation. No cartilageinvasion.

Warm,swollen,effusions,pain,and

decreased motion with possiblerheumatoid nodules.

Synovitis. Early pannusinvasion. Chondrocyteactivation. Degradation

of cartilage byproteinase.

Increase in severityof physical signsand symptoms.

Subchondral boneerosion. Pannus invasionof cartilage. Chindrocyte

proliferation. Laxity ofligaments.

Joint instability,contractures,decreased

ROM, systemiccomplications.

Initiation of rheumatoid arthritis

Production of rheumatoid factorsImmunoglobulin G

Prostaglandin release

Deposition of immune complex

Inflammation of synovium

Edema Release oflysosomal enzymes

Release of oxygenfree radicals

Release ofarachidonic acid and

prostaglandin

Release ofantibodies

Legend:- pathophysiology- manifestation- manifestation

Edema Release oflysosomal enzymes

Release of oxygenfree radicals

Release ofarachidonic acid and

prostaglandin

Release ofantibodies

Release ofcomplement

Synovialhypoxia

Destruction of Synovium

Pain

Leukocyteattracted

Macrophagesattracted

Rheumatoidnodules

Loss of jointspace

Joint fusion

Muscle spasm

Joint swelling

Rheumatoid Arthritis- Tx• Rest, during day- decrease wt. bearing stress.• ROM- maintain joint function, exercise –water.• Medication- analgesic and anti-inflammatory (NSAIDS),

steroids, Gold therapy, topical meds. Immunosuppressivedrugs- Imuran, Cytoxan, methotrexate. Monitor for toxiceffects

• Biological response modifiers (BRM):Inhibit action oftumor necrosis factor (Humira, Enbrel, Remicade)

• Ultrasound, diathermy, hot and cold applications• Surgical- Synovectomy, Arthroplasty, Total hip

replacement.

• Rest, during day- decrease wt. bearing stress.• ROM- maintain joint function, exercise –water.• Medication- analgesic and anti-inflammatory (NSAIDS),

steroids, Gold therapy, topical meds. Immunosuppressivedrugs- Imuran, Cytoxan, methotrexate. Monitor for toxiceffects

• Biological response modifiers (BRM):Inhibit action oftumor necrosis factor (Humira, Enbrel, Remicade)

• Ultrasound, diathermy, hot and cold applications• Surgical- Synovectomy, Arthroplasty, Total hip

replacement.

Nursing Diagnosis1. Mobility, impaired physical/Walking,

impairedMay be related to:– Skeletal deformity– Pain, discomfort– Intolerance to activity; decreased muscle strength

2. Body Image disturbed/Role Performance,ineffective May be related to:– Changes in ability to perform usual tasks– Increased energy expenditure; impaired mobility

1. Mobility, impaired physical/Walking,impairedMay be related to:– Skeletal deformity– Pain, discomfort– Intolerance to activity; decreased muscle strength

2. Body Image disturbed/Role Performance,ineffective May be related to:– Changes in ability to perform usual tasks– Increased energy expenditure; impaired mobility

Conti….3. Pain, acute/chronic

– May be related to:– Injuring agents: distension of tissues by

accumulation of fluid/inflammatory process,destruction of joint

4. Self-Care deficit– May be related to:– Musculoskeletal impairment; decreased

strength/endurance, pain on movement– Depression

3. Pain, acute/chronic– May be related to:– Injuring agents: distension of tissues by

accumulation of fluid/inflammatory process,destruction of joint

4. Self-Care deficit– May be related to:– Musculoskeletal impairment; decreased

strength/endurance, pain on movement– Depression

Nursing Interventions• Assist with/encourage physical activity• Provide a safe environment• Utilize progressive muscle relaxation• Refer to support groups• Emotional support

– Administer prescribed medications, which may include nonsteroidal anti-inflammatory drugs, aspirin, slow acting antirheumatic medication andcorticosteroid.

– Provide pain relief. Provide comfort measures, including massage and positionchanges. Apply hot or cold therapy to affected joints according to the client’sneeds.

– Promote self care.– Promote adequate rest and sleep to prevent fatigue; provide comfort measures,

including a foam mattress and supportive pillows; and discuss energyconservation techniques.

– Promote client and family coping.

• Assist with/encourage physical activity• Provide a safe environment• Utilize progressive muscle relaxation• Refer to support groups• Emotional support

– Administer prescribed medications, which may include nonsteroidal anti-inflammatory drugs, aspirin, slow acting antirheumatic medication andcorticosteroid.

– Provide pain relief. Provide comfort measures, including massage and positionchanges. Apply hot or cold therapy to affected joints according to the client’sneeds.

– Promote self care.– Promote adequate rest and sleep to prevent fatigue; provide comfort measures,

including a foam mattress and supportive pillows; and discuss energyconservation techniques.

– Promote client and family coping.

Conti…– Encourage proper body alignment to prevent contractures.– Collaborate with the physical therapist to design and

provide the client with a physical therapy program, whichbegins after the acute phase resolves. Encourage a muscleactivity program for self- care. Water exercises areexcellent because water promotes buoyancy, which easesjoint movements.

– Recommend a weight reduction program, if appropriate.– Collaborate with the occupational therapist and promote the

use of braces, splints, and assistive mobility devices, ifappropriate.

– Discuss relaxation techniques, such as imagery, self-hypnosis, biofeedback, diversionary activities, anddistraction for pain management.

– Discuss maintaining optimal nutritional status.– Provide a referral to the Arthritis Foundation.

– Encourage proper body alignment to prevent contractures.– Collaborate with the physical therapist to design and

provide the client with a physical therapy program, whichbegins after the acute phase resolves. Encourage a muscleactivity program for self- care. Water exercises areexcellent because water promotes buoyancy, which easesjoint movements.

– Recommend a weight reduction program, if appropriate.– Collaborate with the occupational therapist and promote the

use of braces, splints, and assistive mobility devices, ifappropriate.

– Discuss relaxation techniques, such as imagery, self-hypnosis, biofeedback, diversionary activities, anddistraction for pain management.

– Discuss maintaining optimal nutritional status.– Provide a referral to the Arthritis Foundation.

Complications

• Sjogrens’s syndrome (degeneration of the salivary andlachrymal glands, causing dryness of the mouth and eyes.)

• Joint deformity• Vasculitis• Cervical subluxation (misalignment in cervical

vertebrae)

• Sjogrens’s syndrome (degeneration of the salivary andlachrymal glands, causing dryness of the mouth and eyes.)

• Joint deformity• Vasculitis• Cervical subluxation (misalignment in cervical

vertebrae)

Effects of rheumatoid arthritis onparticular joints

Boutonniere deformity.

Subluxation in the metacarpophalangeal joints, with ulnar deviation, in a patient with rheumatoid arthritis of the hands.

References• Porter, P. A & Perry, A. G. (2003). Basic

Nursing: Essentials for practice (5th ed.) St.Louis: Mosby.

• Erb, G. K., (2000). Fundamentals of Nursing:Concept, process and practice (5th ed.).Addison: Wesley.

• Bruner, L.S., & Suddarth, D.S. (2001). Textbook of Medical-Surgical Nursing (9th Ed.).Philadelphia: Lippincott.

• Porter, P. A & Perry, A. G. (2003). BasicNursing: Essentials for practice (5th ed.) St.Louis: Mosby.

• Erb, G. K., (2000). Fundamentals of Nursing:Concept, process and practice (5th ed.).Addison: Wesley.

• Bruner, L.S., & Suddarth, D.S. (2001). Textbook of Medical-Surgical Nursing (9th Ed.).Philadelphia: Lippincott.

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THANKSTHANKS THANKS

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