This report will discuss the health issues regarding a patient with chronic Rheumatoid Arthritis. It will contain a brief biographical detail of the patient, discuss in detail the cause and effect of the disease, outline the biopsychosocial impacts the disease has had on the patient and finally it will analyse therapies that there are available and will discuss the effectiveness of these therapies.
Section 1 – Brief Biographical Detail
Following the guidelines set by the Nursing and Midwifery Council’s code of conduct (NMC 2002) “protect confidential information” the patient under observation will be named Carol.
Carol is a 74 year old, widowed female who suffers with rheumatoid arthritis (RA) and is a retired factory worker. Carol has been retired for approximately 27 years and lives alone in her bungalow. Her onset of Arthritis began shortly after her husband’s death around 4 years ago.
Before her acute onset of Arthritis, Carol, who is an ex-smoker, enjoyed her social life and gardening. Unfortunately Arthritis has affected her hands mainly and is no longer able to do the things she loves. She finds it increasingly difficult to tidy her garden and do simple tasks such as the weekly shopping and ironing. Whilst discussing Carol’s condition she stated “I can’t do anything strenuous, just a little bit of weeding and I can’t carry heavy bags so my Daughter does the shopping for me.” Carol finds that if she does participate in these tasks she requires 24 hours bed rest to recover from the flare up.
This causes Carol to suffer depression and after observing many patients who suffer with Arthritis; this seems to be a very common trend within the disease. Along with depression, Carol feels that her physical health has suffered also. She believes that she is more susceptible to illnesses such as colds and flu and finds she gets these frequently. Carol also considers her age to have a great impact on her mental and physical state. She believes her age is a factor preventing her doing things she used to love such as going to the local labour club in the evening. All of these thoughts and feelings lead to her feelings of depression which contributes to flare ups of her Arthritis becoming more frequent.
Along with RA, Carol also has a past medical history of Inflammatory Osteoarthritis, Inflammatory Arthroplathy, high blood pressure, hyperlipidemia and she is a non-insulin dependent diabetic.
Section 2 – Cause and Effect of Condition
The exact cause of RA is unknown to medical professions and years of research has gone into finding an exact cause, however, as of yet, none have been found. Some scientists believe that the disease is caused by some kind of infection, viral or bacterial, but there is no solid evidence to support this theory. Even though an exact cause cannot be determined, scientists do believe that the disease does carry some hereditary traits and can be passed from family member to family member through generations. This does not, however, mean that if a family member does suffer from arthritis someone of the same gene pool will.
RA is “a disease in which the joints in the body become inflamed.” It is classed as an autoimmune disease as the immune cells in the body attack the effected joint. A normal joint unaffected by Arthritis is covered with cartilage allowing the end of each bone to move alongside each other with little or no friction. A normal joint also has a membrane surrounding it called the Synovium, which produces a thick fluid to act as lubrication. This fluid is known as Synovial Fluid. In a patient with Rheumatoid Arthritis such as Carol, the Synovium becomes swelled and sore. In addition to the membrane becoming sore, it also gets an angry red colour which is caused by the increased blood flow to the area. This happens because the body believes there is an infection in the membrane and begins to attack it causing pain and heat.
Joints swell due to the Synovial membrane increasing its production of fluid which is kept stored in the joint space and surrounding areas of the joint. This can also lead to the pain that the patient feels during an Arthritic flare. Due to swelling in the joints, tendons surrounding the joint are stretched to accommodate it. This causes the nerve endings in the muscle to become irritated not only by the swelling but also by the chemicals in the Synovial Fluid.
RA affects different people in different ways. “Most people with Rheumatoid Arthritis have some damage in a number of joints, and a few – about 1 in 20 (5%) of the those with Rheumatoid Arthritis – have quite severe damage in a lot of joints.” (ARC, 2005)
Arthritis is an extremely destructive disease and can cause many deformities of the joints. Nodules known as Rheumatoid Nodules are also quite common and around 25% of patients diagnosed with Rheumatoid Arthritis will suffer from these nodules. The nodules are usually found on pressure areas such as the elbows and metacarpophalangeal joint. Patients may also, in very rare cases, experience inflammation of the body organs such as; the eyes and mouth, the lining of the heart and the lining of the lungs.
The joints become damaged by the inflammation occurring in them and this is why the treatment patients receive is aimed at reducing the inflammation and discomfort rather than trying to eliminate the disease all together. Rheumatoid Arthritis is combated in several different ways, most purely to reduce swelling in the joints.
A range of anti-inflammatory drugs are used to diminish swelling in the joints. Drugs such as; corticosteroids, DMARD’s and NSAID’s are used commonly to reduce swelling in the joints.
Corticosteroids are also named “steroids” and are the same kind of steroid that are produced by the body naturally and are extremely effective on swollen joints. They can be administered in three different ways. The first way is orally in the form of Prednisolone which is taken in low doses for up to 3 months. The second way is to inject the swollen joint with a steroid known as Depomedrone and is often referred to as a DMI (Depomedrone Injection).
This is only administered by qualified Rheumatologists as it has to be a totally aseptic procedure to reduce introducing infection into the joint space. These injections tend to work well within Rheumatoid patients and can last up to 8 weeks. The third and final way to administer steroids is by intramuscular injection, also known as an IMMP (Intra-Muscular Methylprednisolone). This is usually injected into the upper, outer, quadrant of the buttock and again tends to work well in reducing swelling and therefore combats pain.
DMARD’s are the short term for Disease Modifying Anti-Rheumatic Drugs. They work by suppressing the body’s immune function and stops the attack on the healthy joint membrane. These drugs are usually used when a less powerful drug such as Cyclosporine has been tried and has failed. DMARD’s take a few weeks to start working on the body and so have to be taken for a long time before the patient starts to feel any effect from them. As patients are on these powerful drugs for long periods of time, they require regular blood monitoring and general check up’s.
After discharge from hospital, a patient is required to have a 6 week blood monitoring test and then 3 months after that if everything seems normal and the patient is happy to continue on the drugs. Examples of the most commonly used drugs are; Sulphasalazine, which is taken in low doses initially and then slowly increased according to the Doctors opinions, Methotrexate, which acts to suppress the immune system and is also taken by mouth in weekly doses. Methotrexate can also be taken via weekly injections depending on patient preference. Most patients prefer to take the medication orally. Usually patients take Folic Acid three days after taking Methotrexate.
For example, if a patient took Methotrexate on a Thursday, they would take Folic Acid on a Saturday, Sunday and Monday. NSAID’s are Non-Steroidal Anti-Inflammatory Drugs and work by inhibiting the synthesis of the body’s proteins known as prostaglandins. These proteins are produced by the body when an injury occurs in a cell and contributes to inflammation. By inhibiting the synthesis of the proteins the injured cells will not swell and will therefore, in theory, reduce swelling if a flare up of the disease does take place. Many Rheumatoid patients have to try a range of drugs before they find which the right one for them is. Other drug therapies include Anti-TNF treatments which are usually given by injection or intravenous drips.
In terms of physiotherapy, there are many therapies available for patients suffering from Arthritis. There are many relaxation techniques that a patient can undergo to relieve not only pain but stress. One of the most common relaxation techniques is to relax the whole body by lying in a comfortable position and working from the feet up, tense and then relax the muscles. This is done three times and is said to relax the body and in turn prevent any flare up’s due to stress. Simple breathing is also a technique used to relax the body and the mind which is very important as Arthritis can cause much stress and depression. Physiotherapists see patients in hospital everyday and help them with exercises tailored for their condition and their abilities. The most common exercises are knee lifts which is usually done by sitting on a chair and lifting the leg and also hand exercises which are usually finger based to help the grabbing motion that many Arthritis sufferers encounter.
There are also ice and heat therapies available for patients. The member of staff applying the heat or the ice must undergo training to do so. Heat and ice can burn the skin and lead to blistering and, in worst cases, scarring. To apply ice, the patient must have a barrier between the skin and the ice pack. The barrier used is a damp paper towel which allows the ice to penetrate the skin and also protects it from burning the skin. The ice bag used must be full enough for it to cover the effected area and all air in the bag must be expelled. This again helps the coldness of the ice to penetrate the skin. After the ice is placed on the effected joint, a towel is wrapped round the bag and the barrier to keep it in place. It is vital that the patient is aware that the bag of ice should only be kept on for 15 to 20 minutes. Nurses usually ask the patient to use the patient call system after 20 minutes so the ice can be removed. However, it is also important that the Nurse remembers which patients have ice on an effected joint.
Applying heat is slightly different than applying ice. The heat pads are kept in hot water in a thermos container and are removed with tongs to prevent scolding of the skin. It is important that the correct pad id chosen for the effected joint. A long, thin pad is for the neck and shoulders and generally the smaller more square shaped pads are used for the lower back. To apply heat, there must be three layers between the heat pad and the skin, otherwise burning will take place. The barrier layers are made from a folded towel which is wrapped around the heat pad. It is then up to the patient to tell the nurse where is most comfortable and beneficial for the pains and aches. As with the ice, heat must only be kept on for 15 to 20 minutes.
It is the physiotherapists who decide which patients require heat and which require ice and should only be applied if the physiotherapist gives permission or it is documented in the patient file. Again, it is important to remember that only staff members trained in heat and ice therapy are able to apply it.
Section 3 – Biopsychosocial Impacts
As a result of the condition that Carol has she now finds it hard to complete tasks that a normal healthy person would easily complete. For example, shopping has become a very difficult task to complete as Carol suffers from Rheumatoid Nodules on her fingers and has quite advanced RA in the hands too. Due to this she tires easily and requires assistance with shopping and menial tasks such as gardening and cooking her meals throughout the day.
Carol finds herself feeling very lonely throughout the days with not having her Husband around anymore and her Daughters work full time. This contributes to her feelings of depression. Carol is finding it difficult to come to terms with the fact that she can’t do her usual jobs around the house and can’t go to the social events she used to love such as going to the local labour club for a game of bingo and a few drinks.
When Carol experiences a Rheumatic flare, cold and flu like symptoms become present and this is when she realises that she has pushed herself too much and requires 24 hours bed rest to recover from the flare.
In terms of her RA and how it has affected her body, she feels that the condition has got slowly worse and she also feels that she is not able to cope as well with her age.