Care of the Patient with Arthritis – CPD: Practice Effectively
The purpose of this activity is to educate the CNA in the most common types of arthritis, signs and symptoms of the disease and how to manage their patients who are effected.
After completing this course, the learner will be able to:
- Describe arthritis and the prevalence
- Discuss the most common types of arthritis: osteoarthritis and rheumatoid
- Recognize the signs and symptoms of Osteoarthritis and Rheumatoid Arthritis
- Describe management of the arthritic patient
- Recognize what should be reported to the nurse
Mrs. D is a 62-year-old, African-American female. She is a retired executive who has always been active and physically fit. Recently, she had not been feeling well and complained of a mild fever and extreme fatigue. She is at the office today because she thinks she may have the flu. Upon your first observations, you find that Mrs. D does indeed have a fever. She tells you that she has had a fever for about a week now, but the fatigue has been getting worse over the last month. You also notice that she has a slight limp. You ask about it, and Mrs. D tells you that she started a new workout and she must have strained her knee. She rates the pain at a 7 out of 10. Since Mrs. D is wearing shorts, you can see that the right knee is swollen and red. You also notice that her left knee is swollen although not red. Mrs. D tells you that the left knee is sore but not as much as the right knee. When you ask if any other joints hurt, Mrs. D states “Yes, my right hand and fingers are stiff as well.” Concerned, you ask Mrs. D if she would like the Dr. to look to at her knee and hand as well. She agrees.
Mr. H is also at the office today. He is a 52-year-old, Caucasian male who works as a high school teacher. He states that his left knee has been hurting more and more over the last several months. He describes the knee as a “grinding” with the pain. It is stiffer in the morning and takes him awhile to get moving. As you are talking to Mr. H, he tells you that about six years ago he fell off a ladder. He thinks he landed on his left side. Although, he states he did not break any bones, he does recall that his left leg hurt for several weeks after the fall. When asked, Mr. H tells you that he has been using hot and cold packs on the knee which seems to help. He also states that he has been taking over-the-counter Ibuprofen, which has helped a little. He is concerned that the pain and the grinding feeling are getting worse.
Arthritis is a chronic disease that causes significant disabilities. Management of arthritis centers on teaching the patient how to live with the condition while continuing to have quality in daily life activities. The healthcare team provides education, encouragement, management skills, and support to cope with this disease.
What is Arthritis
Arthritis is an umbrella term that describes over 100 types of conditions. It is the leading cause of disability in America and it impacts individuals of all ages, sexes, and races. Over 52 million adults and 300,000 children have some type of arthritis (Arthritis, 2016). Arthritis is mostly seen in women and often occurs as people get older.
The term arthritis is used to describe inflammation of the joints and is a hallmark sign. There are several types of arthritis; this article will focus on Osteoarthritis and Rheumatoid arthritis.
The human body has 206 bones (Grossman & Porth, 2014). The site where two or more bones attached is called a joint or articulation site. There are several types of joints that are classified by their mobility. At the site where the bones met to form the joint, there is cartilage and a synovial membrane with synovial fluid that acts to protect the area (Osteoarthritis, 2015). Arthritis can occur due to several conditions including general wear and tear on joints, infection, broken bones, or autoimmune disease. Symptoms of joint inflammation include pain, swelling, and lack of mobility. There is no cure for arthritis. Therefore, healthcare providers and caregivers focus on how to help the patient manage the disease and maintain quality of life.
Osteoarthritis (OA) is a degenerative joint disease. It is the most common form of arthritis and is the leading cause of disability and pain in adults. OA slowly causes destruction of the weight-bearing joint cartridge and synovial tissue (Grossman & Porth, 2014). It is usually associated with older adults because of joint defects, overuse, injury, infection, or inflammatory diseases. However, OA can also occur in younger individuals due to trauma (Osteoarthritis Causes, 2011). Joint changes include a loss of cartilage and synovial tissue resulting in inflammation. When the cartilage attempts to repair itself osteophytes, or spurs, are created. This change causes joint pain and stiffness and problems with mobility.
Symptoms of osteoarthritis can vary depending on which joints are affected and the severity of the disease (Osteoarthritis Causes, 2011). However, most symptoms are pain and stiffness, usually first thing in the morning. The affected joint may become swollen after activity and symptoms tend to get worse over time. The patient may also experience limited range of motion due to the swelling and pain. However, the joint mobility and pain may improve with movement. The patient may state that they hear a clicking or cracking when the joint bends as well (Grossman & Porth, 2014). Because of the pain and limited mobility, the patient may become sedentary. This lifestyle can lead to additional medical problems such as diabetes or heart disease. Furthermore, the patient with Osteoarthritis has a 30% higher risk of falling and has a 20% higher risk of fracture than a person without osteoarthritis (Osteoarthritis Causes, 2011). There is no cure for osteoarthritis. Interventions are aimed at improving and strengthening opposing muscle groups (Grossman & Porth, 2014). Interventions may also include a balance of rest and exercise, use of heat and cold to relieve pain, adjustments in daily living activities, weight reduction, and the use of a cane or walker if needed (Grossman & Porth, 2014). Medications can be given; however, side effects need to be assessed.
Rheumatoid arthritis (RA) is a systematic autoimmune disease. The immune system of the body normally protects against foreign objects such as bacteria and viruses. However, in rheumatoid arthritis, the immune system gets confused and attacks the body’s own joints instead (What is Rheumatoid Arthritis, 2015). In the joint, or synovial area, RA forms inflammation which thickens, resulting in pain at the joint. If the disease is allowed to continue it will cause damage to the cartilage as well as the bone itself (What is Rheumatoid Arthritis, 2015). Joints can become unstable and painful, as well as deformed. This disease, unlike Osteoarthritis, can affect the entire body. The patient with Rheumatoid arthritis may complain of fatigue, muscle aches, or have a low-grade fever. In advanced stages, the patient may also have lumps under the skin called rheumatoid nodules which can be tender to the touch (Grossman & Porth, 2014). Rheumatoid arthritis cannot be reversed. However, it can be controlled with medication and some forms of activity (Grossman & Porth, 2014).
It is estimated that over 1.5 million people in the United States have rheumatoid arthritis (What is Rheumatoid Arthritis, 2015). The majority of those are women. Rheumatoid arthritis is usually seen between ages of 30 and 60 (What is Rheumatoid Arthritis, 2015). However in men, it is seen to start later in life. There also seems to be a genetic component, although there is no known cause of RA (Grossmam & Porth, 2014).
Rheumatoid arthritis has a gradual onset. In the early stages, the patient may notice redness or swelling at the joint or experience tenderness and pain (Grossman & Porth, 2014). However, this continues to worsen over time and includes morning stiffness, fatigue, loss of appetite, and even a low-grade fever (What is Rheumatoid Arthritis, 2015). Rheumatoid arthritis tends to affect more than one joint including small and large joints of the knee or wrist and typically affects joints on the same side of the body. Symptoms can come and go. The patient may experience a flare that can last for days or months as well. The longer the inflammation continues, additional problems will be seen throughout the body. Some of these may include sensitivity to light, impaired vision, eye pain, dry mouth, gum irritation, lumps under the skin or bony areas, shortness of breath due to inflammation in the lungs, damage nerve cells, skin and other organs can be impacted due to inflammation in the blood vessels, and anemia (What is Rheumatoid Arthritis, 2015). Studies also suggest a higher incidence of cardiovascular problems in individuals with Rheumatoid arthritis (Palmer & Miedany, 2013).
The goal of interventions is to prevent or reduce pain, stiffness, swelling, and maximize activity. Interventions include rest, therapeutic exercises, and medication. Because this is a chronic disease there is a need for continuous adherence to treatment that must be integrated into the person’s daily activities (Grossman & Porth, 2014). Hot and cold treatments may help to relieve some of the pain. The use of supportive shoes and other assistive devices may be used along with education positioning and body mechanics (Grossman & Porth, 2014).
Care of The Patient with Arthritis
Chances are, you will have several patients with arthritis. This chronic disease forces them to change how they manage their daily lives. There are several things that you can do to help the patient. Remember that some days will be better than others for them. One day they may be able to do several activities on their own and other days they may need a lot of help. When the patient has flare ups that include inflammation, it will be important to check to make sure shoes or slippers fit correctly. It is also important to remind your patient to change positions frequently. This includes their neck, hands, arms, hips, and feet. Encouraging them to stretch often can help decrease the stiffness they feel in their joints (Vera, 2016). Remind the patient to use their strongest joints first and encourage them to sit in chairs with arms so they can push up when rising. Make sure the client maintains a good balance between rest and activity (Vera, 2016). The patient may have splints or other devices to help them out (Vera, 2016). Make sure you know how to use those properly. Talk to your client about proper posturing as this can prevent additional joint damage. Encourage them to use assistive devices whenever possible.
The patient may have, or be at a high risk, for contractures. Be sure to follow any range-of-motion exercise care plans. Follow the instructions carefully for each planned exercise. If you are unsure about any exercise or how it is performed, ask the nurse before proceeding. Be slow and gentle. Do not make the joint move past any resistance you feel or pain the patient exhibits (Hegner & Acello,2015). Support each joint by placing one hand above and the other below the joint (Hegner & Acello, 2015). However, encourage the patient to assist if they can. Be sure to observe if the patient is in pain or becomes uncomfortable. If you need to transfer the patient, use transferring assistive devices to make the move easier on you and the patient (Hegner & Acello, 2015).
There are several areas to consider when working with a patient who suffers from arthritis. Not only does physical pain need to be addressed, but psychological issues, family issues and societal issues may also need to be treated. The patient may feel fearful, anxious or depressed at loosing their independence and the ability to care for themselves. They may want information on self-management (Ryan, Lillie, Thwaites, & Adams, 2013). The decrease in activity may lead to loosing a job and financial stability. Changes in family roles and relationships may also be a concern for the patient. Each area will need to be addressed and interventions applied to help the patient cope both physically and emotionally (Ryan, Lillie, Thwaites, & Adams, 2013).
Here are some other interventions that can be used to relieve pain and help the patient with daily activities (Sorrentino & Remmert, 2013):
- Heat and Cold. Heat increases blood flow which reduces swelling. Cold can help with pain after the joint has been used.
- Exercise. Exercise increased flexibility, decrease pain, and help improve blood flow. It can also help if weight control is a problem and can be beneficial to mental well-being.
- Rest. Making sure the client rests is also important especially after exercising or increased movement. Make sure the client uses good body mechanics and posture as well as using canes or walkers for support.
- Weight Control. Helping the client with weight control through diet and passive exercise can lessen the strain on the joint and prevent further injury. Be sure to talk with the nurse about diet and exercise.
- Falls. The client with arthritis is at a greater risk for falls. Helping them with their activities of daily living as needed may include the use of toilet seat risers, chairs with higher seats and arm sets, and the use of assistance devices to move positions or to walk will help to prevent falls.
- Emotional Support. Helping the patient to stay positive is also important. Helping the family to cope as well may consist of changing family roles and responsibilities. Encouraging and praising when the client do things on their own can help them maintain a positive outlook.
- Non-Pharmacological pain control-. This may include distraction techniques or relaxation programs. For example, music or guided imagery (Ryan, Lillie, Thwaites, & Adams, 2013).
- Medication. Medications may also be used to help control pain and inflammation. Be sure to ask the nurse what side effects to look for if the client is taking medications.
If the patient is having dental or mouth issues, suggest that they brush twice daily. An electric toothbrush may be helpful if the patient fatigues easily while holding a brush. Using an oral rinse to help with dry mouth as well (National Rheumatoid Arthritis Society, 2016). There are also devices to put on the tooth brush to make the handle larger and easier to hold if the hands are affected by either type of arthritis.
When dressing it may be helpful to purchase shoes with Velcro straps instead of ties or use a long handled shoe horn to put on shoes. If zippers are difficult to grab, use a ribbon tied to the zipper for the patient to grab instead. Use of a long grabber can also help to pick up items from the floor or lower areas. Chairs or stools in the kitchen and/or bathroom can help with fatigue as well (National Rheumatoid Arthritis Society, 2016).
What Should Be Reported to the Nurse
Observation and assessment are key in finding out if there are any changes in the patient’s condition. Non-verbal signs such as grimacing or crying when moving can signal a problem. Any new sign or symptoms of pain should be reported. Likewise, if a new area or joint appears swollen or affected, it should be addressed. Asking question about the new flare up can consist of duration, pain level, and what the patient did to try to relieve the pain. This should all be reported to the nurse. Other aspects to observe is how well the patient is completing daily activities. Can they dress themselves, wash themselves, open a door or make a meal? If there are problems or changes in these areas, it should also be reported.
In Rheumatoid arthritis, be sure to observe for any signs of new medical issues such as trouble breathing, elevate heart rate or blood pressure. Ask the patient about their level of fatigue, if they have had a fever lately, gum irritation, eye pain or new lumps under the skin. Any new symptoms or concerns need to be reported.
Making sure the patient understands any new medications, treatments or directions is also important. If there is a concern that the patient does not understand, a discussion with the nurse should take place to strategize a plan to make sure the patient understands.
Most important is to tailor the interventions to the patient’s needs. Not all patients need the same assistants or support. Remember that the patient will want as much independence as possible. Suggest devices or interventions that you think will be helpful to the health care team for review.
Case One: Mrs. D
Mrs. D has symptoms of Rheumatoid arthritis. She has a fever, soreness, fatigue and symmetrical pain in the knee joints. The Dr. most likely ordered blood work to see if she has a Rheumatoid factor level. This test can help determine if Rheumatoid arthritis is the problem along with a full evaluation of her symptoms. Once diagnosed, Mrs. D will need education on how to care for herself and what support is available to help her with this disease.
Case Two. Mr. H
Mr. H has Osteoarthritis. He described grinding of the knee and pain only in one joint. He also has a history of a trauma. The Dr. may have ordered additional tests such as a radiograph view the knee joint. Once diagnosed, you will need to educate Mr. H on the disorder as well as how to control the pain.