NURSING PROCESS:THE PATIENT WITHA RHEUMATIC DISEASE
The depth and focus of the nursing assessment depend on several factors: the health care setting (clinic or office, home, extended care facility, or hospital), the role of the nurse (home care nurse; nurse practitioner; hospital, clinic, or office nurse), and the needs of the patient. The nurse is often the first of the health care team members to come in contact with the patient. This enables the nurse to assess the patient’s perceptions of the disorder and situ-ation, actions taken to relieve symptoms, plans for treatment, and expectations. The nurse’s assessment may lead to identifying is-sues and concerns that can be addressed by nursing interventions and, through collaboration with other team members, to achieving the expected patient outcomes.
The health history and physical assessment focus on current and past symptoms, such as fatigue, weakness, pain, stiffness, fever, or anorexia, and the effects of these symptoms on the pa-tient’s lifestyle and self-image. Because the rheumatic diseases affect many body systems, the history and physical assessment include a review and examination of all systems, with particular attention given to those areas most commonly affected, includ-ing the musculoskeletal system (see Chart 54-1).
The patient’s psychological and mental status and social sup-port systems are also assessed, as is his or her ability to participate in daily activities, comply with the treatment regimen, and man-age self-care. The information obtained can give insight into the patient’s understanding of the medication regimen and may re-veal misuse of medications, noncompliance, or use of potentially harmful unproven remedies. Additional areas assessed include the patient’s understanding, motivation, knowledge, coping abilities, past experiences, preconceptions, and fears. The effects of the dis-ease on the patient’s self-concept and coping abilities are also as-sessed. The patient’s perception of the condition and its impact influences the decisions, choices, and actions associated with treat-ment recommendations.
Although many nursing diagnoses are appropriate for the patient with a rheumatic disease, a few of the most common include the following:
· Acute and chronic pain related to inflammation and in-creased disease activity, tissue damage, fatigue, or lowered tolerance level
· Fatigue related to increased disease activity, pain, inadequate sleep/rest, deconditioning, inadequate nutrition, emotional stress/depression
· Disturbed sleep pattern related to pain, depression, and medications
· Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack of or improper use of ambulatory devices
· Self-care deficits related to contractures, fatigue, or loss of motion
· Disturbed body image related to physical and psychological changes and dependency imposed by chronic illness
· Ineffective coping related to actual or perceived lifestyle or role changes
Based on assessment data, potential complications may include the following:
Adverse effects of medications
The major goals for the patient may include relief of pain and dis-comfort, relief of fatigue, increased mobility, maintenance of self-care, improved body image, effective coping, and absence of complications.
An understanding of the underlying disease process (ie, degener-ation or inflammation, including degeneration resulting from inflammation or vice versa) guides the nurse’s critical thinking processes. In addition, knowledge about whether the condition is localized or more widely systemic influences the scope of the nursing activity.
Some rheumatic diseases (eg, OA) are more localized alterations in which control of symptoms such as pain or stiffness is possible. Others (eg, gout) have a known cause and specific treatment to control the symptoms. The diseases that usually present the great-est challenge are those with systemic manifestations, such as the dif-fuse connective tissue diseases. The Plan of Nursing Care details the nursing interventions to be considered for each nursing diagnosis.
Medications are used on a short-term basis to relieve acute pain. Because the pain may be persistent, nonopioid analgesics such as acetaminophen are often used. After administering medications, the nurse needs to reassess pain levels at intervals. With persistent pain, assessment findings should be compared with baseline mea-surements and evaluations. Additional measures include explor-ing coping skills and strategies that have worked in the past.
The patient needs to understand the importance of taking medications, such as NSAIDs and disease-modifying agents, ex-actly as prescribed to achieve maximum benefits. These benefits include relief of pain and anti-inflammatory action as the disease is brought under control. Because disease control and pain relief are delayed, the patient may mistakenly believe the medication is ineffective or may think of the medication as merely “pain pills,” taking them only sporadically and failing to achieve control over the disease activity. Alternately, the patient may not understand the need to continue the medication for its anti-inflammatory actions once pain control has been achieved.
A weight reduction program may be recommended to relieve stress on painful joints. Heat applications are also helpful in re-lieving pain, stiffness, and muscle spasm. Superficial heat may be applied in the form of warm tub baths or showers and warm moist compresses. Paraffin baths (dips), which offer concentrated heat, are helpful to patients with wrist and small-joint involve-ment. Maximum benefit is achieved within 20 minutes of appli-cation. More frequent use for shorter lengths of time is most beneficial. Therapeutic exercises can be carried out more com-fortably and effectively after heat has been applied.
In some patients, however, heat may actually increase pain, mus-cle spasm, and synovial fluid volume. If the inflammatory process is acute, cold applications in the form of moist packs or an ice bag may be tried. Both heat and cold are analgesic to nerve pain receptors and can relax muscle spasms. Safe use of heat and cold must be eval-uated and taught, particularly to patients with impaired sensation.
The use of braces, splints, and assistive devices for ambulation, such as canes, crutches, and walkers, eases pain by limiting move-ment or stress from weight bearing on painful joints. Acutely in-flamed joints can be rested by applying splints to limit motion. Splints also support the joint to relieve spasm. Canes and crutches can relieve stress from inflamed and painful weight-bearing joints while promoting safe ambulation. Cervical collars may be used to support the weight of the head and limit cervical motion. A metatarsal bar or special pads may be put into shoes if foot pain or deformity is present.
Other strategies for decreasing pain include muscle relaxation techniques, imagery, self-hypnosis, and distraction.
Fatigue related to rheumatic disease can be both acute (brief and relieved by rest or sleep) and chronic. Chronic fatigue, related to the disease process, is persistent, cumulative, and not eliminated by rest but is influenced by biologic, psychological, social, and personal factors.
Disease-related factors that may influence the amount and severity of fatigue include persistent pain, sleep disturbance, im-paired physical activity, and disease duration. Pain increases fa-tigue by requiring additional physical and emotional energy to deal with it. It may also cause the patient to expend more energy to do tasks in a way that causes less pain. Pain may also interfere with sleep, thereby increasing the fatigue level (Aaronson et al., 1999; Wolfe & Skevington, 2000).
Efforts are aimed at modifying and reducing the fatigue. En-ergy may be regained by using rest periods. The patient’s needs determine the type and amount of rest needed. Naps or night-time sleep can provide systemic rest. Splints can provide articu-lar rest by limiting motion and stress on the joints. Relaxation techniques can provide emotional rest. Inactivity may lead to de-conditioning and fatigue, so measures to build endurance should be instituted. Conditioning exercise, such as walking, swimming, or biking, requires gradual progression of activity and monitor-ing of disease activity.
Psychosocial factors with an effect on fatigue include depres-sion, learned helplessness, and perceived social support (Belza, 2001; Parker et al., 2001). These factors affect the patient’s per-ception and evaluation of the fatigue. Improvement of functional status can improve mood. The patient is taught strategies to con-serve energy, such as planning and grouping activities to mini-mize the number of times the patient needs to climb the stairs each day and sitting down to prepare meals.
Restful sleep is important in helping the patient to cope with pain, minimize physical fatigue, and deal with the changes ne-cessitated by a chronic disease. In patients with acute disease, sleep time is frequently reduced and fragmented by prolonged awakenings. Stiffness, depression, and medications may also compromise the quality of sleep and increase daytime fatigue. A sleep-inducing routine, medication, and comfort measures may help improve the quality of sleep.
Proper body positioning is essential to minimize stress on in-flamed joints and prevent deformities that limit mobility. All joints should be supported in a position of optimal function. When in bed, the patient should lie flat on a firm mattress, with feet positioned against a footboard and with only one pillow under the head because of the risk of dorsal kyphosis. A pillow should not be placed under the knees because this promotes flex-ion contracture. The patient should lie prone several times daily to prevent hip flexion contracture.
Active range-of-motion exercises are encouraged because they prevent joint stiffness. If the patient cannot actively exercise the joints, passive range of motion should be performed.
Measures to reinforce proper body posture and increase mo-bility include walking erect and using chairs with straight backs. When seated, the patient should rest the feet flat on the floor and the shoulders and hips against the back of the chair.
Care must be taken so that splinting for comfort does not re-strict mobility later. The knee is splinted at full extension and the wrist at slight dorsiflexion. Because of the predominant strength of flexor muscles, the joints should not be permitted to “freeze” in positions of flexion. This can be prevented by regularly re-moving the splint and exercising the joint through a range of motion. Splint modification may be needed when changes occur in joint structure.
Additionally, assistive devices may be necessary for mobility. They should be properly fitted and the patient should be in-structed in their correct and safe use. A cane, long enough to allow for only a slight bend of the elbow, should be held in the hand opposite the affected side. Forearm-trough style crutches (platform crutches) may be needed to protect the upper extrem-ities if the disease also involves the hands and wrists. This is es-pecially important for the patient undergoing rehabilitation after lower extremity joint reconstructive surgery. Assistive devices can mean the difference between dependence and independence in mobility; however, they may also alter the patient’s body image, which can become a barrier to compliance with treatment.
Adaptive equipment may increase the patient’s independence. When introducing adaptive equipment, however, the nurse should be sensitive to the patient’s feelings by demonstrating ac-ceptance and positive attitudes about using these devices. The nurse needs to keep in mind that a patient’s deformity does not necessarily equate with the severity of limitations or disability. For example, swollen hands may be more limiting than deformed hands. The nurse in the hospital or in the extended care facility can help preserve the patient’s independence in these settings by making available adaptive equipment for eating, toileting, bathing, and dressing. In the home, the nurse can encourage use of these devices. Again, by relieving pain, stiffness, and fatigue, the nurse may increase the patient’s ability to perform self-care (Luck, 2001).
All aspects of the patient’s life, including perception of self, work role, social life, sexual function, and financial status, may be altered because of the unpredictability and uncertainty of the course of a rheumatic disease. Body image changes may cause so-cial isolation and depression. The nurse and the family need to empathize with the patient’s emotional reactions to the disease. Communication should be encouraged so that the patient and family verbalize feelings, perceptions, and fears related to the dis-ease. The nurse helps the patient and family identify areas in which they have some control over disease symptoms and treat-ment. The nurse also encourages commitment to the treatment program, which is a key to positive outcomes, as well as use of effective coping strategies.
Medications used for treating rheumatic diseases have the potential for serious and adverse effects. Thus, an important aspect of care is avoiding medication-induced complications. The physician bases the prescribed medication regimen on clinical findings and past medical history, then monitors for side effects with periodic clin-ical assessments and laboratory testing. The nurse has a major role in working with the physician and pharmacist to help the patient recognize and deal with side effects from medications. These side effects may include gastrointestinal bleeding or irritation, bone marrow suppression, kidney or liver toxicity, infection, mouth sores, rashes, and changes in vision. Other signs and symptoms include bruising, breathing problems, dizziness, jaundice, dark urine, black or bloody stools, diarrhea, nausea and vomiting, and headaches. Systemic and local infections, which can often be masked by high doses of corticosteroids, need close monitoring (see Table 54-3 for more information about administration considerations).
Patient instruction also includes teaching correct techniques of self-administration of medications, methods of reducing side effects, and measures to ensure regular monitoring. The nurse can be available for consultation between physician visits. If side effects occur, the medication may need to be stopped or the dose reduced. The patient may experience an increase in symp-toms while the complication is being resolved or a new med-ication is being initiated. In such cases, the nurse’s counseling regarding symptom management may relieve potential anxiety and distress.
Patient teaching is an essential aspect of nursing care of the pa-tient with rheumatic disease to enable the patient to maintain as much independence as possible, to take medications accurately and safely, and to use adaptive devices correctly. Patient teaching focuses on the disorder itself, the possible changes related to the disorder, the therapeutic regimen prescribed to treat it, the side effects of medications, strategies to maintain independence and function, and patient safety in the home (Chart 54-2).
The patient and family are encouraged to verbalize their con-cerns and ask questions. Pain, fatigue, and depression can inter-fere with the patient’s ability to learn and should be addressed before initiating teaching. Various educational strategies may then be used, depending on the patient’s previous knowledge base, interest level, degree of comfort, social or cultural influ-ences, and readiness to learn. The nurse instructs the patient about basic disease management and necessary adaptations in lifestyle. Because suppression of inflammation and autoimmune responses requires the use of anti-inflammatory, disease-modifying antirheumatic and immunosuppressive agents, the patient is taught about prescribed medications, including type, dosage, ra-tionale, side effects, self-administration, and required monitoring procedures. If hospitalized, the patient is encouraged to practice new self-management skills with support from caregivers and sig-nificant others. The nurse then reinforces disease management skills during each patient contact. Barriers to compliance are as-sessed and measures are taken to promote adherence to medica-tions and the treatment program.
Depending on the severity of the disorder and the patient’s re-sources and supports, referral for home care may or may not be warranted. However, the patient who is elderly or frail, has a rheumatic disorder that limits function significantly, and lives alone may need a referral for home care.
The impact of rheumatic disease on everyday life is not always evident when the patient is seen in the hospital or an ambulatory care setting. The increased frequency with which nurses see pa-tients in the home provides opportunities for recognizing prob-lems and implementing interventions aimed at improving the quality of life of patients with rheumatic disorders. The patient encountered in the home setting often has a rheumatic disease that is secondary to the primary reason for the visit. In such cases, the problems caused by the rheumatic disease may interfere with the treatment of the primary condition. For example, the patient who is recovering from coronary artery surgery may have been in-structed to exercise but is unable or only partially able to do so because of the rheumatic disease. Conversely, treatment of the primary condition may cause or increase problems related to the rheumatic disease. For example, the cardiac patient who has been instructed to walk long distances every day may find that doing so increases the symptoms of OA in the knees.
During home visits, the nurse has the opportunity to assess the home environment and its adequacy for patient safety and man-agement of the disorder. Compliance with the treatment program can be more easily monitored in the home setting, where physi-cal and social barriers to adherence are more readily identified. For example, the patient with diabetes who requires insulin may be unable to fill the syringe accurately or administer the insulin because of impaired joint mobility. Appropriate adaptive equip-ment needed for increased independence is often identified more readily when the nurse sees how the patient functions in the home. Any barriers to compliance can be identified and appro-priate referrals made.
For patients at risk for impaired skin integrity, the home care nurse can closely monitor skin status and also instruct, provide, or supervise the patient and family in preventive skin care mea-sures. The nurse also assesses the patient’s need for assistance in the home and supervises home health aides, who may meet many of the needs of the patient with a rheumatic disease. Referrals to physical and occupational therapists may be made as problems are identified and limitations increase. A home care nurse can visit the home to make sure the patient can function as indepen-dently as possible despite mobility problems and can safely man-age treatments and pharmacotherapy.
Because many of the medications to suppress inflammation are injectable, the nurse may administer the medication to the pa-tient or teach self-injection procedure. These frequent contacts allow the nurse to reinforce other disease management techniques.
The nurse also assesses the patient’s physical and psychologi-cal status, adequacy of symptom management, and adherence to the management plan. Previous teaching is reinforced with em-phasis on side effects of medications and changes in physical sta-tus indicating disease progression and the need to contact the health care provider for reevaluation; otherwise, patients may wait until their next appointment. The importance of follow-up appointments is emphasized to the patient and family.
Patients with chronic disorders often neglect general health issues if they are focused on their chronic disorder; therefore, the patient and family should be reminded about the impor-tance of participating in other health promotion activities and health screening (eg, immunizations, cholesterol screening, bone density testing, gynecologic examinations, mammography, colonoscopy).
Expected patient outcomes may include:
1) Experiences relief of pain or improved comfort level
a) Identifies factors that cause or increase pain
b) Identifies realistic goals for pain relief
c) Uses pain management strategies safely and effectively
d) Reports decreased pain and increased comfort level
2) Experiences reduction in level of fatigue
a) Identifies factors that contribute to fatigue
b) Verbalizes the relationship of fatigue to disease activity
c) Schedules periodic rest periods and identifies and uses other measures to prevent or modify fatigue
d) Reports decreased level of fatigue
e) Practices energy conservation strategies
3) Improves sleep patterns
a) Reports fewer night-time awakenings
b) Adheres to sleep-inducing routine
c) Reports feeling rested upon awakening
4) Increases or maintains level of mobility
a) Identifies factors that impede mobility
b) Participates in activities and exercises that promote or maintain mobility
c) Uses assistive devices appropriately and safely
d) Demonstrates normal or acceptable body alignment and posture
5) Maintains self-care activities
a) Participates in self-care activities within capabilities
b) Uses adaptive equipment and alternative methods to in-crease participation in self-care activities
c) Maintains self-care at highest possible level
6) Experiences improved body image and coping
a) Verbalizes concerns about the impact of rheumatic dis-ease on appearance and function
b) Sets and achieves meaningful goals
c) States acceptance of self-worth
d) Adapts to body image changes caused by disease
e) Identifies and uses effective coping strategies
7) Experiences absence of complications
a) Takes medications as prescribed
b) States potential side effects of medications and names reportable side effects
c) Verbalizes understanding of rationale for monitoring
d) Complies with recommendations for monitoring
e) Identifies strategies to reduce risks of side effects