Case Study of Rheumatoid Arthritis Final

 

INTRODUCTION Rheumatoid arthritis (RA) is a chronic, systemic  systemic  inflammatory disorder that disorder  that may affect

many man y tis tissu sues es and and orga organs, ns, but but princ princip ipall ally y attac attacks ks flexib flexible le (synovial) synovial) joi joint nts. s. The The proc process ess involves an inflammatory response of the capsule around the joints (synovium ( synovium)) secondary to swelling (hyperplasia (hyperplasia)) of synovial cells, excess synovial fluid, and the development of fibrous tissue (pannus (pannus)) in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis (fusion) of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, membrane around the heart (pericardium (pericardium), ), the membranes of the lung (pleura ( pleura), ), and white of the eye (sclera ( sclera), ), and also nodular lesions, lesions, most common in subcutaneous tissue. tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, progression, and RA is considered considered a systemic autoimmune disease disease..  About 1% of the world's population population is afflicted afflicted by rheumatoid rheumatoid arthritis, arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. In addition, individuals with the HLA-DR1 or  HLA-DR4  HLA-DR4  serotypes have an increased risk for developing the disorder. It can be a disabling and painful  painful  condition, which can lead to substantial loss of functioning and mobility if not adequately treated. It is a clinical diagnosis made on the basis of symptoms, physical exam, radiographs (X-rays) X-rays) and labs, although the American American College of Rheumatology Rheumatology (ACR) and the European League Lea gue again against st Rheu Rheumat matism ism (E (EUL ULAR) AR) publi publish sh class classifi ificat cation ion criter criteria ia for the the purpo purpose se of  research.. Diagnosis and long-term management are typically performed by a rheumatologist, research rheumatologist , an expert in joint, muscle and bone diseases.

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Various treatments are available. Non-pharmacological Non-pharmacological treatment includes physical  physical  therapy,, orthoses, occupational therapy and nutritional therapy but these do not stop the therapy progression progress ion of joint destruction. Analgesi destruction. Analgesia a (painkillers) and anti-inflammatory drugs, including steroids,, are used to suppress the symptoms, while disease-modifying steroids disease-modifying antirheumatic antirheumatic drugs  drugs  (DMARDs) are required to inhibit or halt the underlying immune process and prevent longterm damage. In recent times, the newer group of  biologics has increased treatment options. Clinical trials have shown that consumption of fish oil reduces the number of swollen joints for  people with rheumatoid arthritis provides a beneficial beneficial anti-inflammatory effect, effect, and provides a protective effect for occlusive cardiovascular disease, for which people with RA are at risk. The name is based on the term "rheumatic "rheumatic fever "",, an illness which includes joint pain and is derived deri ved from the Greek word word

ῥεύμα-rheu εύμα-rheuma ma

(nom.),

ῥεύματοςεύματος-rheumatos rheumatos

(gen.) ("flow, ("flow,

curren cur rent" t"). ). The The suffix suffix -oid -oid ("res ("resemb emblin ling" g")) gives gives the trans translat lation ion as joint joint infla inflamma mmatio tion n that that resembles rheumatic fever. fever. The first recognized description of rheumatoid rheumatoid arthritis was made in 1800 by Dr.  Augustin Jacob Landré-Beauvais Landré-Beauvais (1772–1840) of Paris. While rheumatoid arthritis primarily affects  joints,  joints, problems involving other  organs of the body are known to occur. Extra-articular ("outside the joints") manifestations other than anemia (which is very common) are clinically evident in about 15–25% of individuals individuals with rheumatoid arthritis. It can be diff diffic icul ultt to dete determ rmin ine e whet whethe herr dise diseas ase e mani manife fest stat atio ions ns are are dire direct ctly ly caus caused ed by the the rheumatoid process itself, or from side effects of the medications commonly used to treat it – for example, lung fibrosis from methotrexate or osteoporosis or osteoporosis from corticosteroids. The incidence of RA is in the region of 3 cases per 10,000 populations per annum. Onset is uncommon under the age of 15 and from then on the incidence rises with age until the age of 80. The prevalence rate is 1%, with women affected three to five times as often as men. It is up to three times more common in smokers than non-smokers, particularly in men, 2

 

heavy smokers, and those who are rheumatoid factor positive. A study in 2010 found that those who drank modest amounts of alcohol regularly were four times less likely to get rheumatoid arthritis than those who never drank. Some Native American groups have higher  prevalence prevalenc e rates (5–6%) and people from the Caribbean region have lower prevalence rates. FirstFir st-de degre gree e relati relative ve’s ’s preva prevalen lence ce rate rate is 2–3% 2–3% and disea disease se genetic concordance concordance in monozygotic twins is approximately 15–20%. It is st stron rongly gly associ associat ated ed wi with th the the inher inherite ited d tissu tissue e type type (MHC) (MHC) antige antigen n HLA-DR HLA-DR4 4 (most (most specifically DR0401 and 0404)—hence family history is an important risk factor. The risk of first developing the disease (the disease incidence) incidence) appears to be greatest for women between 40 and 50 years of age, and for men somewhat later. RA is a chronic disease, and although rarely, a spontaneous remission may occur, the natural course is almost alm ost invari invariabl ably y one one of persi persist stent ent sympt symptoms oms,, waxi waxing ng and and wanin waning g in inten intensit sity y, and and a progressive deterioration of joint structures leading to deformations and disability.

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OBJECTIVES At the end of the first semester for the school year 2012-2013, in partial fulfillment for the prelim pre lim re requ quire iremen ments ts of Nursi Nursing ng Care Care Manag Manageme ement nt 106, 106, I would would be able able to acquir acquire e a comprehensive knowledge on the concept of management of clients with Musculoskeletal Disorders particularly on the Rheumatoid Arthritis. We aim to complete this case study to help us discern a deeper understanding on all the factors contributing to the joint pain and other clinical manifestations of a patient with rheumatoid arthritis. Thus, we may be able to enhance our dexterity skills in the field of  Nursi Nur sing, ng, and and ex exerc ercise ise our ratio rational nal/v /ver erbal bal abilit abilities ies and and apply apply right right attitu attitude de durin during g the completion of the study.

Scope and Limitations The scope of this case study is focused basically on the illness of the Patient whom we have chosen as the subject of interest because of his underlying condition conditions s may contribute contribute to our limited knowledge on the concept of Musculoskeletal Disorder Management.

It is expected that our skills capabilities as Nursing Student are limited only through:  Assessment,  Assessme nt, Study of Pathophysiology Pathophysiology,, Drug Study, Study, Discharge Discharge Planning, Planning, Diet Analysis and Nursing Care Management of patient from time of Admission to Discharged and follow-up home visits.

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DEMOGRAPHIC DEMOGRA PHIC DAT DATA

NAME: Mr. A

ROOM: Alley C

 ADDRESS:  ADDRES S: Brgy. Brgy. Bal-ason Bal-ason Gingoog Gingoog City

HOSPITAL HOSPITAL #: #: 283330

 AGE: 49 y/o

ADMISSION ADMISSIO N #: 3796 3796

HEIGHT:: 5’7” HEIGHT

ATTENDING PHYSICIAN: Dr. Cezar 

WEIGHT:: 50 kg WEIGHT

DATE DA TE OF ADMISSION: 07/25/12

GENDER: Male

TIME OF ADMISSION: 12:35

STATUS: Single NATIONALITY: NA TIONALITY: Filipino Filip ino RELIGION: Iglesia ni Cristo BIRTHDATE: January 12, 1966 BIRTHPLACE: Bal-ason Gingoog City DIAGNOSES: Rheumatoid Arthritis and Urinary tract infection (UTI) CHIEF COMPLAINT: Swelling and Pain at the lower extremities

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DEVELOPMENTAL THEORIES ERIK ERICKSON’S PSYCOSOCIAL THEORY He organized life into eight stages that extend from birth to death (many developmental theories only cover childhood). Then, since adulthood covers a span of many years, Erikson divided the stages of adulthood adulthood into the experiences of young adults, middle aged adults and older adults. While the actual ages may vary considerably from one stage to another, the ages seem to be appropriate for the majority of people.

Middle Adulthood: 35 to 55 or 65 Ego Development Outcome: Generativity vs. Self absorption or Stagnation

Erikson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect expect to "be in char charge, ge,"" the role we've we've longe longerr envied envied.. The The signif significa icant nt task task is to perpetuate perpetua te culture and transmit values of the culture through the family (taming the kids) and work wo rking ing to es estab tablis lish h a stable stable enviro environme nment. nt. St Stren rengt gth h comes comes throug through h care care of others others and and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness. OBSERVATION:

The patient belongs to this stage according to his age, his 49 years old so as I’ve inte interv rvie iewe wed d him him duri during ng my duty duty at MOPH MOPH he’s he’s stil stilll sing single le and and neve neverr talk talk abou aboutt any any relationships, and there was a time that we asked him why he’s just smiling and shrugging his shoulder.. Maybe my shoulder m y patient is in stagnation stage because there is no sense of responsibility responsibility to the family because he doesn’t have family the wife and children.

SIGMUND FREUD’S PSYCHOSEXUAL THEORY 6

 

 According  Accordin g to Sigmund Freud, Freud, personality is mostly established by the age of five. Early experiences play a large role in personality development and continue to influence behavior  later in life. Freud's theory of psychosexual development is one of the best known, but also one of the most controversial. Freud believed that personality develops through a series of  childhood stages during which the pleasure-seeking energies of the id become focused on certain erogenous areas. This psychosexual energy, or  libido, libido, was described as the driving force behind behavior. Genital Stage Age Range: Puberty to Death Erogenous Zone: Maturing Sexual Interests

During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. This stage begins during puberty but last throughout the rest of a person's life. Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas.

OBSERVATION:

The patient belongs to Genital stage because according to Freud the genital stage is in puberty up to death, so my patient maybe has a strong sexual interest to the opposite sex of  course it is obvious because men has a strong libido than female.

ROBERT HAVIGHURST’S THEORY  From examining the changes in your own life span you can see that critical tasks arise 7

 

at certain times in our lives. Mastery of these tasks is satisfying and encourages us to on to new challen challenges. ges. Difficu Difficulty lty with them slows slows progres progress s toward toward future future accompl accomplishm ishments ents and goals. As a mechanism for understanding the changes that occur during the life span. Robert Havigh Hav ighur urst( st(19 1952, 52, 1972, 1972, 1982) 1982) has has ident identifi ified ed critic critical al devel developm opmen enta tall tasks tasks that that occu occur  r  throughout througho ut the life span. Although Although our interpretations interpretations of these tasks naturally change over the years years and and wi with th new resear research ch findi finding ngs. s. Havigh Havighurs urst's t's develo developme pmenta ntall tasks tasks offer offer lasti lasting ng testimony to the belief that we continue to develop throughout our lives.

Developmental Tasks of Early Adulthood (Ages 40–60)

 Assisting teenage children to become responsible and happy adults. Achieving Achieving adult social and civic responsibility. Reaching and maintaining satisfactory performance in one’s occupational career. Developing adult leisure time activities. Relating oneself to one’s spouse as a person. To accept and adjust to the physiological changes of middle age. Adjusting to aging parents.

OBSERVATION:

The patient belongs to this stage according his age but the characteristics are not yet achieve because he don’t have wife and children but he is responsible to himself and can adjust and accept the changes occurs in his age and also he can maintain satisfactory performance in the particular career.

JEAN PIAGET’S COGNITIVE THEORY  He proposed that children's thinking does not develop entirely smoothly: instead, there are 8

 

certain points at which it "takes off" and moves into completely new areas and capabilities. He saw these transitions as taking place at about 18 months, 7 years and 11 or 12 years. This has been taken to mean that before these ages children are not capable (no matter how br brig ight ht)) of unde unders rsta tand ndin ing g thin things gs in cert certai ain n way ways, and and has has been been used used as the the basi basis s for  for  scheduling the school curriculum.

Formal operational (11 years and up)

Can think think logically logically about about abstract abstract proposit propositions ions and test hypothe hypotheses ses systema systematica tically lly.. Becomes concerned with the hypothetical, the future, and ideological problems. OBSERVATION:

The patient belongs to this stage, as what the meaning states above he can properly think logically regarding in an abstract and concrete thinking or propositions. Also have an idea of  what are problems occur now a days and also in the future.

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NURSING ASSESSMENT PHYSICAL ASSESSMENT

Assessment

Body

Build,

Height

Normal Findings

and Normal in proportion and has Height: 5’7”

Weight

no deformities.

Posture and Gait

Good posture and body gait

Body and Breath odor

No un unwanted bo body or or br breath

Signs of Distress

Actual Findings

Weight: 50 kg

Cannot st stand on on his own an and needs assistance because he cannot balance during ambulation.

Has a body odor because he

odor 

neverr took neve took a bath bath sinc since e he was admitted.

No distress noted

Patient

always

complains

pain pa in in his his kn knee ees s and and feet feet..  And feels feels uncomfortable. uncomfortable. Signs of Health or Illness

Healthy appearance

The pa p atient now su s uffers pa p ain and

altered

level

of  

functioning.  Attitude

Cooperative Cooperative

Patient cooperates cooperates when we aske asked d ques questi tion on to him. him. But But when

he

wants

to

do

something he wants do it by his own or with the help of her  sister and he doesn’t like me to help him.

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 Affect/Mood  Affect /Mood

Appropriate Appropriate to situation situation

Patient cooperates cooperates and active during

our

physical

assessment. assessme nt. And answer only question when he likes it. Quantity,

Quality

Organization of Speech

and Un Under dersta standa ndable ble,, pace,

modera moderate te

exhibits

Normal. Nothing alters in his thought speech or the he talk.

association Relevan Rele vance ce and Organiza Organization tion Lo Log gical ical of Thoughts

sequ sequen enc ce,

make makes s The patient answer is relevant

sense, has sense of reality

to the que questi stions that hat ar are e being asked.

Uniformity of skin color

Uniformity except in in a arreas ex ex- Pale skin color. posed to the sun

Edema

No edema

Edema noted in knees and feet.

Skin Lesions

 Abrasions ns in the hands and No fr freckles, No No bi birthmarks,  Abrasio no abrasions or lesions

Skin Moisture

legs.

Moisture in skin folds and the Moist in axilla and skin folds axillae

during hot temperature.

Skin Temperature

Uniform, within normal range

Slightly warm to touch.

Skin Turgor

Skin springs back to previous Patient state when pinched

skin

when

is

pinched it doesn’t return to its original state.

Scalp

Evenly distributed

Presence of dandruff.

Hair Thickness

Thick hair

Evenly distributed

Hair Texture

Silky, resilient hair

Normal

 Amount of Body Hair Hair

Variable

Normal 11

it

 

Nail Plate Shape

Convex curvature

Normal

Texture

Smooth

Normal

Nail Bed Color

Highly vascular, pi pink, pr prompt Ca Capi pilla llary ry refil refilll is delay delayed, ed, it return of pink color 

returns in 5 seconds.

Skull and Face Hea ead d

Rounde nded, smoot mooth h

symm symmet etrrica ical, Normal head shape. skull

cont ontour our,

no

nodule Eyes and Vision Eyebrows

Hair

evenly

distributed, Normal

symmetrical, skin intact Eyelid

Skin intact, no discharges, no Intact skin. discolorations, symmetrical

Eyelashes

Equally

distributed,

slightly Normal

curved outward Conjunctiva

Transparent,

sometimes normal

appear white, shiny, smooth, pink or red

Lacrimal Gland

No edema or tearing

Cornea

Transparent,

shiny

No edema noted. and Normal

smooth, smoo th, blinks blinks when when cornea cornea is touched Pupils

Black color, equal size

Color bl black an and ha has eq equal size.

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Near Vision

Able to read newsprint

Patient able to read without the use of glasses can’t read in far distance.

Ears and Hearing  Auricles

Color is uniform, symmetric, Normal mobi mo bile le,, firm firm,, pinn pinna a

reco recoil ils s

when folded Nose and Sinuses Nares

Symmetric and straight, no Normal disc disch har arge ges s,

no

swe swelli lling, ng,

uniform color, not tender  Lining of nose

Nasal septum in midline

Normal

Mouth Lips Buccal Mucosa

Uniform

pink,

soft, Dry lips and pale.

symmetrical Teeth and Gums

Complete

teeth,

smooth, Com Complet plete e teeth, teeth, slightly slightly pink

white tiny tooth enamel, pink gums. gums, moist, retractions Tongu ongue e

Cent Centra rally lly

firm,

loca locate ted, d,

pink pink

no in Normal

color, freely movable Pala Pa late tes, s, Uvul Uvula, a, Tonsi onsils ls

Ligh Lightt

pink pink,,

disc disch har arge ges s,

smoo smooth th,, pr pres ese ent

no Normal, present gag reflex. gag

reflex Shape and Symmetry

Symmetrical

Normal

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Spinal Deformities

Spine vertically aligned

Inspect Neck Muscles

Symmetrical

with

Normal head Normal

centered Observe Head Movement

Coordinated,

smooth, Normal

movement with no discomfort, equal strength Muscle

Size

is is

sy s ymmetrical,

n no o Normal

contracture, normally firm Movement

Smooth

coordinated Limited body movement

movements, equal strength Joints

No swelling, tenderness

Swelling extremities.

GORDONS ASSESSMENT

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in

the

lower  

 

Function

Nutrition

Before Hospitalization

During Hospitalization

•Eats only 2 meals a day because he forget for gets s to eat eat durin during g night due of tiredness.

•Wanted to drink soft drin drinks ks and and want wants s to eat “tahong” and sardines sard ines.. He doesn’t doesn’t like like to eat eat the the food foods s are being •He loves to drink that by the carbonated drinks and prepared any salty foods. hospital.

Interpretation

• Attendin Attending g physici physician an orde ordere red d low low purin urine e diet, die t, becau because se rich rich in purine will worsen the client’s condition.

• Low purine diet and full diet is being advised by the doctor.

Elimination

•Able to urinate & defeca def ecate te normal normally ly twice twice everyday by himself and even without any assistance.

•His sist •His sister er assi assist sted ed him when he wants to defec de fecate ate but but he only only urinates at the bedside in the bedpan.

•His condition does affect his elimi elimina natition on patt patter ern n due to pain in the lower  extremities.

•Defecate usually in the afternoon after his work. Sleeping

•He has a regular sleep •Abnormal sleeping • Di Dist stur urbe bed d patter tern and wake up pattern due to pain of the pattern. early in the morning due lower extremities. to his work.

slee sleep p

•patient cannot •patient cannot sleep sleep •Normal sleep is 8-9 hrs. cont contin inuo uous usly ly duri during ng per day night.

CognitiveCognitiv e- Perceptual Perceptual • Pattern

understand

comprehend well

and •abl •able e to unde unders rsta tand nd • He is coop cooper erat ativ ive e and well can comprehend during and responsive. interaction. 15

 

ANATOMY ANA TOMY AND PHYSIOL PHYSIOLOGY OGY

Diarthodial joints are lined at their margins by a synovial membrane (synovium) with

•

synovial cells lining this space. The lining cells synthesize protein as well as being phagocytic.

•

Synovial fluid is transparent, viscous fluid. Its function is to lubricate the joint space

•

and transport nutrients to the articular cartilage. Mech Me chan anic ical al,, chem chemic ical al,, im immu muno nolo logi gic, c, or bact bacter erio iolo logi gic c dama damage ge may may alte alterr the the

•

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perm pe rmea eabi bili lity ty of the the memb membra rane ne and and ca capi pill llar arie ies s to prod produc uce e va vary ryin ing g degr degree ees s of  inflammatory response. Inflamma Infl ammatory tory joint joint fluids fluids contain contain lytic lytic enzymes enzymes that produce produce depoly depolymeriz merizatio ation n of 

•

hyaluronic acid, which greatly impairs the lubricating ability of the fluid  Analysis of synovial synovial fluid plays plays a major major role in the diagnosis diagnosis of joint joint disease. disease.

•

 A variety of disorders produces changes in the number and types of cells and

•

chemical composition of the fluid. (e.g. gout – uric acid crystals) Synovial fluid for RA is sterile, cloudy, and has an increased neutrophil count.

•

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