Nursing Care Plans

Nursing Diagnosis #1

Diagnosis	Deficient Knowledge
Related factors	·       New diagnosis ·       Unfamiliarity with treatment regimen ·       Lack of interest/denial
Defining Characteristics (signs/symptoms)	·       Asking lots of questions ·       Asking no questions ·       Verbalized misconceptions ·       Inaccurate follow through
Expected Outcome	Patient verbalizes understanding of RA and treatment
Assessment	Assess patients understanding of RA
Intervention	Ask what they understand of the disease. Discuss topics such as disease process, treatment options, chronicity, inflammation, remission, exacerbation, and control versus cure.

Nursing Diagnosis #2

Diagnosis	Joint Pain
Related factors	·       Inflammation associated with increased disease activity. ·       Degenerative changes secondary to longstanding inflammation.
Defining Characteristics (signs/symptoms)	·       Patient reports pain ·       Guarding or motion toward affected joints ·       Facial mask of pain ·       Moaning or other sounds associated with pain
Expected Outcome	Patient reports mild to moderate pain rather than severe Patient implements pain management plan that includes both pharmacological and non-pharmacological strategies
Assessment	·       Assess signs or symptoms of joint inflammation such as redness, warmth, swelling, and decreased motion. ·       Evaluate location and description of pain. ·       Assess interference with lifestyle.
Intervention	Discuss pharmacological strategies including anti-inflammatory medications, DMARD’s. Encourage patient to monitor position and to always maintain anatomically correct alignment of the body Encourage patient  to use knee pillow to prop knees, small pillow under head, and wear prescribed splints. Encourage use of hot or cold packs. Encourage use of ambulation aids when pain is related to ambulation.

Diagnosis	Joint Stiffness
Related factors	Inflammation associated with increased disease activity Degenerative changes secondary to longstanding inflammation
Defining Characteristics (signs/symptoms)	Complaints of joint stiffness Guarding Refusal to participate in usual self-care activities Decreased functional ability
Expected Outcome	Patient verbalizes decrease in stiffness Patient is able to participate in self-care activities
Assessment	Assess patients description of stiffness, including location, timing, and length of time stiffness persists How it affects activities How they alleviate stiffness How does stiffness interfere with lifestyle?
Intervention	Encourage patient to take 15 minutes warm shower or bath in the morning Provide sufficient time between tasks, and don’t schedule a lot of events when you are most stiff Encourage the patient to take anti-inflammatory medications in the morning, and to not take them on an empty stomach. Avoid prolonged periods of inactivity

Diagnosis #4

Diagnosis	Impaired Physical Mobility
Related factors	Pain, Stiffness, fatigue, psychosocial factors, altered joint function, and muscle weakness
Defining Characteristics (signs/symptoms)	Patient’s description of difficulty with purposeful movement Decreased ability to transfer and ambulate Reluctance to attempt movement Decreased muscle strength Decrease range of motion
Expected Outcome	Patient performs physical activity independently within liits of RA Patient demonstrates use of adaptive techniques that promote ambulation and transfer
Assessment	Assess patients description of what type of movement aggravates or alleviates the condition and to what degree they interfere with their lifestyle Observe patients ability to ambulate and to move all joints functionally Assess ability to perform ADL’s Assess need for assistive or adaptive devices
Intervention	Reinforce the need for adequate time to perform activities Reinforce proper use of ambulation devices as taught by a physical therapist Encourage patient o wear footwear when ambulating Reinforce exercise taught by the physical therapist Instruct patient to avoid excessive exercise during an inflammatory exacerbation

Nursing Diagnosis #5

Diagnosis	Chronic Pain
Related factors	Chronic physical or psychosocial disability
Defining Characteristics (signs/symptoms)	Pain over long periods of time Weight changes Irritability Fatigue Depression Reduced interaction with people Altered ability to continue previous activities
Expected Outcome	Patient reports pain less than 4 on a 0-10 scale Patient uses pharmacologic and non-pharmacologic pain interventions Patient engages in desired activities without an increase in pain level
Assessment	Assess pain characteristics Assess for signs/symptoms associated with pain Assess patients perception of the effectiveness of methods used for pain relief in the past Assess patients expectations about pain relief
Intervention	Encourage patient to keep a pain diary Acknowledge and convey acceptance of the patient pain experience Provide patient and family with information about chronic pain and options available for pain management Assist in making decisions about selecting a particular management strategy Refer to physical therapy

Gulanick, M. & Myers, J. L. (2011). Nursing Care Plans, 7^th Edition. Elsevier Mosby, St. Louis, MO.

Nursing Care for Rheumatoid Arthritis

 Nursing foals for working with those with Rheumatoid Arthritis are to achieve satisfactory pain management, have minimal loss of function in affected joints, support therapy goals, emotional and functional support, and help maintain independence and ability to care for self for as long as possible. 

Rheumatoid arthritis isn’t preventable, but when it is diagnosed a early treatment can prevent functional loss and joint damage. Nurses can be involved in community awareness to support early detection and advocate for patients utilizing resources from places like The Arthritis Foundation. 

 http://www.arthritis.org/about-arthritis/understanding-arthritis/early-arthritis-treatment.php

Here is a congressional briefing about advocating for rheumatoid arthritis including stories from patients and providers:

Nurses and patients can learn a lot from the Arthritis Foundation, following are a number of topics regarding healthy living:

Eating Health: http://www.arthritis.org/living-with-arthritis/arthritis-diet/

Best Foods for RA: http://www.arthritis.org/living-with-arthritis/arthritis-diet/best-foods-for-arthritis/

Workout Videos: http://www.arthritis.org/living-with-arthritis/exercise/videos/

There are dozens of videos, for example here is an example of a thai chi video:

https://www.youtube.com/watch?t=21&v=98K97FysAGY

Using supplements: http://www.arthritis.org/living-with-arthritis/treatments/natural/supplements-herbs/guide/

Pain Management including fighting fatigue: http://www.arthritis.org/living-with-arthritis/pain-management/

How to pass through life stages with arthritis, such as pregnancy, aging, and caregiving: http://www.arthritis.org/living-with-arthritis/life-stages/

When nurses work with someone who is first diagnosed, the goals include reducing inflammation, managing pain, maintaining joint function, and prevention of joint deformity. We will address about rest, activity, medications (both taking them and figuring out how to get them), and occupational and physical therapy. Another important topic is over the counter medications along with prescribed medications, non-drug management, and how to respond to flare-ups.

Managing RA at home includes figuring out how to schedule rest and work, and to simplify some tasks in order to protect your joints. Fatigue can affect daily life, so scheduled rest periods are important, such as taking a rest before you become totally exhausted, using a stool while preparing food and good positioning. RA can create constant challenges by limiting function, altered body image, pain and fear of disability. Strong family support systems and community resources can be helpful, and self-help groups are helpful to some. Chronic pain can lead to depression, investing in your interests and seeking out professional help if you think necessary can help.

Treating Rheumatoid arthritis

The goal of treatment of RA is the control of synovitis (joint inflammation) and prevention of joint injury. Depending on the severity of the disease, therapy with medications will be initiated along with other therapies. We will start with talking about medications.

Medication therapy is directed at achieving remission or low disease activity by control of inflammation and use of disease-modifying antirheumatic drugs (DMARD). The best outcomes come when there is early recognition and diagnosis. A rheumatologist can provide expert care in the management of these medications. Following are the principles that guide treatment.

• Early use of disease-modifying antirheumatic drugs (DMARDs) for all patients diagnosed with RA.  Used alone or in combinations, with methotrexate being a first line drug. Methotrexate suppresses synovitis and prevents articular bone erosions. DMARD therapy is initiated early in the disease.
• Methotrexate is contraindicated in:
• Women who are contemplating becoming pregnant
• Women who are pregnant
•  Patients with liver disease or excessive alcohol intake
• Patients with severe renal impairment
• Methotrexate requires monitoring of bone marrow, liver and lung toxicity
• Alternatives to methotrexate include TNF inhibitors, nonbiological traditional DMARDs, or other alternatives. For more information visit
• Additional information http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/basics/treatment/con-20014868
•  Importance of tight control with target of remission or low disease activity
• Use of antiinflammatory agents, including nonsteroidal antiinflammatory drugs (NSAIDs) and glucocorticoids, only as adjuncts to therapy, never alone. They are used for temporary control of inflammation, but do not provide long-term control of the disease.
•  Disease activity and response to therapy should be monitored regularly
• Those with moderate to sever RA will require ongoing therapy. A minority who reach a sustained clinical remission of greater than 1 year can reduce DAMRD doses while monitoring closely, although this is controversial.

Additional treatment of RA include

1. Nutritional therapy: there is no special diet, balanced nutrition is important. Fatigue, pain, depression, limited endurance and mobility deficits can accompany RA. Maintaining balanced nutrition can assist in combating these. Additionally, if taking corticosteroids, unwanted weight gain can occur. 
2. Therapeutic exercise: this is an integral part of the treatment plan, and an individualized one is best done by a physical therapist or other professional. Exercise can prevent progressive joint immobility and muscle weakness. Over-exercise can also cause pain, inflammation or other damage, so it is important to be careful. 
3. Rest and joint protection: gentle range of motion exercises can be done regularly to keep joings functional. Water can provide a two-way resistance that asks more of muscles and less of joints. 
4. Heat and cold applications: Can relieve stiffness, pain and muscle spasm. During disease exacerbation, ice is especially helpful. Heat sources that are superficial such as heating pads, moist hot packs, and warm baths or showers can relieve stiffness and allow more participation in therapeutic activity. 
5. Complementary and alternative therapies
1. herbal products
2. movement therapies

References:

Schur, P. F., & Cohen, S. (2015). Initial treatment of moderately to severely active rheumatoid arthritis in adults. Up to Date. Retrieved form http://www-uptodate-com.offcampus.lib.washington.edu/contents/initial-treatment-of-moderately-to-severely-active-rheumatoid-arthritis-in-adults?source=search_result&search=rheumatoid+arthritis+treatment&selectedTitle=1~150

Lewis, Heitkemper. Medical-Surgical Nursing, 8th Edition.