Question

A 50-year-old woman with rheumatoid arthritis (RA) presented to her nurse practitioner for a follow-up visit at the rheumatology clinic. After being diagnosed with moderate RA 18 months earlier, the patient was started on methotrexate, a standard disease-modifying antirheumatic drug (DMARD). After more than a year of successful disease management, the patient experienced several flare-ups with swelling and pain in her hand joints, which began a few months prior to her recent clinic visit. After conducting tests that indicated high levels of inflammatory markers, the patient's rheumatologist prescribed a TNFα-inhibitor in combination with methotrexate.

In her visit with the rheumatology clinic's Registered Nurse, the patient expressed concerns about side-effects to the new therapy and overall management of her disease. BP – 118/65, P – 75, RR – 18, SPo2 – 98%, afebrile

Make a Nursing care plan with 1 diagnose and 3 goal and per goal have 9 inerventions and rationale.

Answer 1

Rheumatoid Arthritis

Nursing Diagnosis: ACUTE PAIN RELATED TO INFLAMMATORY PROCESS AS EVIDENCED BY REPORTING PAIN IN HAND JOINTS.

Goals:

• Patient reports relief / control of pain
• Patient appears relaxed, able to sleep/rest & participates in activities appropriately
• Patient incorporates relaxation skills and diversional activities into the pain control program

Nursing Interventions	Rationale
Assess the pain score and the characteristics of pain ( location, type, intensity, precipitating factors)	favourable in determining pain management needs and effectiveness of the program
Provide a firm mattress or bedboard , small pillow. Elevate linens with bed cradle as needed	soft and sagging mattresses, large pillows prevent maintenance of proper body alugnmeal, placing on stress on affected joints. Elevation of bed linens reduces pressure on inflammed or painful joints
Encourage patient to assume a position of comfort while in bed or sitting in a chair. Promote bed rest as indicated	in severe disease or acute exacerbation, total bestest may be necessary to limit pain or injury to joint
Place and monitor use of pullopi, sandbags, trochanter rolls, splints, braces	rests painful joints and maintains a neutral position
Encourage frequent changes of position	prevents general fatigue and joint stiffness
Monitor the duration, note the intensity of morning stiffness	duration more accurately reflects the severity of the condition
Encourage patient to take a warm bath or shower upon arising or at bedtime. Apply warm, moist compresses to affected joints several times a day.monitor water temperature of compress, baths and so on.	Heat promotes muscle relaxation and mobility, decreases pain and relieves morning stiffness. Sensitivity to heat may be diminished and dermal injury may occur.
Provide gentle massage	promotes relaxation and reduces muscle tension
Encourage the use of stress management techniques such as progressive relaxation, biofeedback, visualisation, guided imagery and controlled breathing. Provide therapeutic touch.	Promotes relaxation, provides a sense of control and may enhance coping abilities.
Involve in diversional activities appropriate for the individual situation	refocuses attention, provides stimulation, and enhances self esteem and feelings of general well being
Medicare as per order before planned activities and exercises	promotes relaxation, reduces muscle tension and spasms, facilitating particupparti in therapy
Administer medications as indicated and as per order such as Salicylates, Nonsalisylates, Glucocorticoids, DMARD, COX-2 inhibitors, antacids	Salicylates exerts an anti-inflammatory and mild analgesic effect, decreasing stiffness and increasing mobility. Nonsalisylates controls mild to moderate pain and inflammation by inhibition of prostaglandin synthesis. Glucocorticoids modify immune response and supress inflammation. DMARD vary in action, but all reduce pain and swelling and lessening arthritic symptoms.COX-2 inhibitors interfere with the prostaglandin production. Antacids are given with NSAIDs to minimize gastric irritation and discomfort.
Apply ice or cold packs when indicated	cold may relieve pain and swelling during acute episodes
Assist with physical therapis such as paraffin glove, whirlpool baths	provides sustained heat to reduce pain and improve ROM of affected joints.
Instruct in use and monitor the effect of Transcutaneous Electrical Nerve Stimulator unit if used.	Constant low level electrical stimulus blocks the transmission of pain sensations.