Medical Management PDF

11/21/23, 3:14 PM Realizeit for Student Medical Management The goal of treatment at all phases of the RA disease process is to decrease joint pain and swelling, achieve clinical remission, decrease the likelihood of joint deformity, and minimize disability. Initial treatment delays have been impli...

11/21/23, 3:14 PM Realizeit for Student Medical Management The goal of treatment at all phases of the RA disease process is to decrease joint pain and swelling, achieve clinical remission, decrease the likelihood of joint deformity, and minimize disability. Initial treatment delays have been implicated in greater long-term joint deformity. Aggressive and early treatment regimens are warranted. The use of a targeted pharmacologic treatment strategy is recommended to decrease RA disease activity (Singh et al., 2016). A more in-depth look at medications used in the treatment of rheumatoid arthritis will be provided at the end of this learning module. Early Rheumatoid Arthritis Once the diagnosis of RA is made, treatment should begin with either a nonbiologic or biologic DMARD. The goal of using DMARD therapy is preventing inflammation and joint damage. Recommended treatment guidelines include beginning with the nonbiologic DMARDs (methotrexate is the preferred agent but leflunomide, sulfasalazine, or hydroxychloroquine are also used) biologics, or tofacitinibic within 3 months of disease onset. Care should be used with each of these medications by performing routine blood testing for liver and kidney function, along with monitoring the CBC for anemia. Dosage may need to be modified for patients with renal impairment (Comerford & Durkin, 2020). Another treatment approach for RA is the use of biologic DMARDs. These agents have been specifically engineered to target the most prominent proinflammatory mediators in RA—TNF-α, B cells, T cells, IL-1, and IL-6 (see Table 34-2). Biologic DMARDs are the first targeted therapy for RA. Clinical evidence suggests that biologic DMARDs work more quickly and show a greater delay in radiologic disease progression when compared to nonbiologic DMARDs. The biologic DMARDs are more expensive and have fewer years of usage with the RA population. Therefore, they tend to be reserved for patients with persistent moderate to severe RA who have not responded adequately to synthetic DMARDs (Singh et al., 2016). After initiating treatment with a DMARD, patients generally report a beneficial effect within 6 weeks and tolerate the medication relatively well. However, some patients may take longer to see improvement. Corticosteroids are recommended as a “bridge” in the early treatment but are not recommended for long-term therapy due to side effects (Singh et al., 2016). A newer class of drugs, the Janus Kinase (JAK) inhibitors, bind to the active JAK enzyme sites, inhibiting autophosphorylation and thus inhibiting cytokine production and decreasing the immune response (Mogul et al., 2019). JAK inhibitors are used in combination with methotrexate or other nonbiologic DMARDs. They may also be used as monotherapy (Mogul et al., 2019; Singh et al., 2016). NSAIDs and specifically the cyclo-oxygenase 2 (COX-2) enzyme blockers are used for pain and inflammation relief. NSAIDs, such as ibuprofen and naproxen, are commonly prescribed because of their low cost and analgesic properties. They must be used with caution, however, in long-term chronic diseases because of the possibility of gastric ulcers. Several COX-2 enzyme blockers have been approved for treatment of RA. Cyclo-oxygenase is an enzyme that is involved in the inflammatory process. COX-2 medications block the enzyme involved in inflammation (COX-2) while leaving intact the enzyme involved in protecting the stomach lining (COX-1). As a result, COX-2 enzyme blockers are less likely to cause gastric irritation and ulceration than other NSAIDs; however, they are associated with increased risk of cardiovascular disease and must be used with caution (Comerford & Durkin, 2020). The nurse should be aware that NSAIDs do not prevent erosions or alter disease progression and, consequently, are medications useful only for symptom relief (Singh et al., 2016). Additional analgesia may be prescribed for periods of extreme pain. Opioid analgesic agents are avoided because of the potential for continuing need for pain relief. Nonpharmacologic pain management techniques (e.g., relaxation techniques, heat and cold applications) are taught. Established Rheumatoid Arthritis In patients with established RA, a formal program with occupational and physical therapy is prescribed to educate the patient about principles of pacing activities, work simplification, range of motion, and muscle-strengthening exercises. The patient is encouraged to participate actively in the management program. The medication program is reevaluated periodically, and appropriate changes are made if disease progression is occurring despite pharmacologic treatment. Additional agents may be added to enhance the disease-modifying effect of methotrexate. Combination therapy using one nonbiologic DMARD and one biologic DMARD is common (Singh et al., 2016). For more established RA, reconstructive surgery and corticosteroids are often used. Reconstructive surgery is indicated when pain cannot be relieved by conservative measures and the threat of loss of independence is eminent. Surgical procedures include synovectomy (excision of the synovial membrane), tenorrhaphy (suturing of a tendon), arthrodesis (surgical fusion of the joint), surgical repair, and replacement of the joint. Surgery is not performed during exacerbations. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 1/7 11/21/23, 3:14 PM Realizeit for Student Systemic corticosteroids are used when the patient has unremitting inflammation and pain or needs a “bridging” medication while waiting for the slower DMARDs (e.g., methotrexate) to begin taking effect. Low-dose corticosteroid therapy is prescribed for the shortest time necessary to minimize side effects (Singh et al., 2016). Single large joints that are severely inflamed and fail to respond promptly to the measures outlined previously may be treated by local injection of a corticosteroid. Topical analgesic agents such as capsaicin and methylsalicylate are often prescribed. Topical diclofenac sodium gel may help with joint pain in the hands and knees (Comerford & Durkin, 2020). For most patients with RA, the emotional and possible financial burden of the disease can lead to depressive symptoms and sleep deprivation. The patient may require the short-term use of low-dose antidepressant medications, such as amitriptyline, paroxetine, or sertraline, to reestablish an adequate sleep pattern and manage depressive symptoms. Patients may benefit from referrals for talk therapy or group support. Obesity Considerations The prevalence of obesity is increasing in the general population and in patients with RA. One large study reported that the prevalence of obesity, diagnosed with a body mass index (BMI) of greater than or equal to 30 kg/m2, was approximately 20% at diagnosis and increased each year (Nikiphorou, Norton, Young, et al., 2018). Furthermore, the presence of obesity adversely affected disease progression, function, and quality of life in patients with RA followed for 10 to 25 years (Nikiphorou et al., 2018). Management of obesity in the patient with RA is essential. Certain medications (i.e., oral corticosteroids) used in RA treatment stimulate the appetite and, when combined with decreased activity, may lead to weight gain. In fact, one study reported that approximately half the increase in BMI within the first year of diagnosis with RA could be attributed to steroid use (Nikiphorou et al., 2018). A dietician can counsel the patient about better food choices. Food selection should include the five major groups (grains, vegetables, fruits, dairy, and protein), with emphasis on foods high in vitamins, protein, and iron for tissue building and repair. Patients who are overweight or have obesity need to be counseled about eating a healthy, calorie-restricted diet. Nursing Management Nursing care of the patient with RA follows the basic plan of care presented earlier (see Chart 34-3). The most common issues for the patient with RA include pain, sleep disturbance, fatigue, altered mood, and limited mobility. The patient with newly diagnosed RA needs information about the disease to make daily self-management decisions and cope with having a chronic disease. Consultation with a dietician for assessment and assistance with appropriate food choices may be helpful. Chart 34-3 PLAN OF NURSING CARE Care of the Patient with a Rheumatic Disorder Nursing Diagnosis: Acute and chronic pain associated with inflammation and increased disease activity, tissue damage, fatigue, or lowered toleran Goal: Improvement in comfort level; incorporation of pain management techniques into daily life Nursing Interventions Rationale 1. Provide variety of comfort measures: 1. Pain may respond to nonpharmacologic interventions, such as exercise, E relaxation, and thermal modalities. a. Application of heat or cold 2. Pain of rheumatic disease responds to monotherapy or combination b. Massage, position changes, rest medication regimens. c. Foam mattress, supportive pillow, splints 3. Previous pain experiences and management strategies may be different d. Relaxation techniques, diversional activities 2. Administer anti-inflammatory, analgesic, and slow-acting antirheumatic medications as prescribed. 3. Individualize medication schedule to meet patient’s need for pain management. from those needed for persistent pain. 4. Verbalization promotes coping. 5. The impact of pain on an individual’s life often leads to misconceptions about pain and pain management techniques. The individual’s description of pain is a more reliable indicator than https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 2/7 11/21/23, 3:14 PM Realizeit for Student 4. Encourage verbalization of feelings about pain and chronicity objective measurements such as change in vital signs, body movement, of disease. and facial expression. 5. Assess for subjective changes in pain. Nursing Diagnosis: Fatigue associated with increased disease activity, pain, inadequate sleep/rest, deconditioning, inadequate nutrition, emotiona symptoms Goal: Incorporates as part of daily activities strategies necessary to modify fatigue Nursing Interventions Rationale 1. Provide education about fatigue. 1. The patient’s understanding of fatigue will affect their actions. a. Describe relationship of disease activity to fatigue. E a. The amount of fatigue is directly related to the activity of the disease. b. Describe comfort measures while providing them. b. Relief of discomfort can relieve fatigue. c. Develop and encourage a sleep routine (warm bath and relaxation techniques that promote sleep). c. Effective bedtime routine promotes restorative sleep. d. Explain importance of rest for relieving systematic, d. Different kinds of rest are needed to relieve fatigue and are based articular, and emotional stress. on patient’s need and response. e. Explain how to use energy conservation techniques e. A variety of measures can be used to conserve energy. (pacing, delegating, setting priorities). f. Awareness of the various causes of fatigue provides the basis for f. Identify physical and emotional factors that can cause measures to modify the fatigue. fatigue. 2. Alternating rest and activity conserves energy while allowing most 2. Facilitate development of appropriate activity/rest schedule. productivity. 3. Encourage adherence to the treatment program. 3. Overall control of disease activity can decrease the amount of fatigue. 4. Refer to and encourage a conditioning program. 4. Deconditioning resulting from lack of mobility, understanding, and disease activity contributes to fatigue. 5. Encourage adequate nutrition, including source of iron from food and supplements. 5. A nutritious diet can help counteract fatigue. Nursing Diagnosis: Impaired mobility associated with decreased range of motion, muscle weakness, pain on movement, limited endurance, lack o Goal: Attains and maintains optimal functional mobility 1. Encourage verbalization regarding limitations in mobility. 1. Mobility is not necessarily related to deformity. Pain, stiffness, and fatigue may temporarily limit mobility. The degree of mobility is not 2. Assess need for occupational or physical therapy synonymous with the degree of independence. Decreased mobility may consultation. influence a person’s self-concept and lead to social isolation. a. Emphasize range of motion of affected joints. b. Promote the use of assistive ambulatory devices. c. Explain the use of safe footwear. d. Use individual appropriate positioning/posture. 3. Assist to identify environmental barriers. 4. Encourage independence in mobility and assist as needed. 2. Therapeutic exercises, proper footwear, and assistive equipment may improve mobility. Correct posture and positioning are necessary for maintaining optimal mobility. 3. Furniture and architectural adaptations may enhance mobility. 4. Changes in mobility may lead to a decrease in personal safety. 5. The degree of mobility may be slow to improve or may not improve with intervention. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 3/7 11/21/23, 3:14 PM Realizeit for Student a. Allow ample time for activity. b. Provide rest period after activity. c. Reinforce principles of pacing and work simplification. 5. Initiate referral to community health agency. Nursing Diagnosis: Able to perform self care associated with contractures, fatigue, or loss of motion Goal: Performs self-care activities independently or with the use of resources Nursing Interventions Rationale E 1. Assist patient to identify self-care deficits and factors that interfere with ability to perform self-care activities. 2. Develop a plan based on the patient’s perceptions and priorities on how to establish and achieve goals to meet selfcare needs, incorporating energy conservation, and work 1. The ability to perform self-care activities is influenced by the disease simplification concepts. activity and the accompanying pain, stiffness, fatigue, muscle weakness, loss of motion, and depression. a. Provide appropriate assistive devices. 2. Assistive devices may enhance self-care abilities. Effective planning for b. Reinforce correct and safe use of assistive devices. changes must include the patient, who must accept and adopt the plan. c. Allow patient to control timing of self-care activities. 3. Individuals differ in ability and willingness to perform self-care activities. Changes in ability to care for self may lead to a decrease in personal d. Explore with the patient different ways to perform safety. difficult tasks or ways to enlist the help of someone else. 3. Consult with community health care agencies when individuals have attained a maximum level of self-care yet still have some deficits, especially regarding safety. Nursing Diagnosis: Disturbed body image associated with physical and psychological changes and dependency imposed by chronic illness Goal: Adapts to physical and psychological changes imposed by the rheumatic disease Nursing Interventions Rationale E 1. Identify areas of life affected by disease. Answer questions and dispel possible myths. 1. The effects of disease may be more or less manageable once identified a. Assist to identify past coping mechanisms. and explored reasonably. b. Assist to identify effective coping mechanisms. 2. By taking action and involving others appropriately, patient develops or draws on coping skills and community support. 2. Develop plan for managing symptoms and enlisting support of family and friends to promote daily function. Nursing Diagnosis: Difficulty coping associated with actual or perceived lifestyle or role changes Goal: Use of effective coping behaviors for dealing with actual or perceived limitations and role changes Nursing Interventions Rationale https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… E 4/7 11/21/23, 3:14 PM Realizeit for Student 1. Identify areas of life affected by disease. Answer questions and dispel possible myths. 1. The effects of disease may be more or less manageable once identified a. Assist to identify past coping mechanisms. and explored reasonably. b. Assist to identify effective coping mechanisms. 2. By taking action and involving others appropriately, patient develops or draws on coping skills and community support. 2. Develop plan for managing symptoms and enlisting support of family and friends to promote daily function. Collaborative Problems: Complications secondary to effects of medications Goal: Absence or resolution of complications Nursing Interventions 1. Perform periodic clinical assessment and laboratory evaluation. 2. Provide education about correct self-administration, potential side effects, and importance of monitoring. 3. Counsel regarding methods to reduce side effects and manage symptoms. 4. Administer medications in modified doses as prescribed if complications occur. Rationale E 1. Skillful assessment helps detect early symptoms of side effects of medications. 2. The patient needs accurate information about medications and potential side effects to avoid or manage them. 3. Appropriate identification and early intervention may minimize complications. 4. Modifications may help minimize side effects or other complications. Monitoring and Managing Potential Complications Patients commonly have comorbid conditions such as cardiovascular disease that can lead to complications. It has been estimated that the primary cause of death for up to 40% of patients diagnosed with RA is cardiovascular disease. The cause of cardiovascular disease in these patients is thought to be due to elevated lipid values, chronic inflammation, dysfunction of the endothelium, and/or abnormal homocysteine levels (Norris, 2019). Medications used for treating RA may cause serious and adverse effects. The primary provider bases the prescribed medication regimen on clinical findings and past medical history, and then, with the help of the nurse, monitors for side effects using periodic clinical assessments and laboratory testing. The nurse, who can be available for consultation between visits with the primary provider, works to help the patient recognize and deal with these side effects (see Table 34-2). Medication may need to be stopped or the dose reduced. If the patient experiences an increase in symptoms while the complication is being resolved or a new medication is being initiated, the nurse’s counseling regarding symptom management may relieve potential anxiety and distress. Promoting Home, Community-Based, and Transitional Care Educating Patients About Self-Care Patient education is an essential aspect in nursing care of the patient with RA to enable the patient to maintain as much independence as possible, to take medications accurately and safely, and to use adaptive devices correctly (Oh et al., 2018). Patient education focuses on self-management related to the disorder, the therapeutic regimen prescribed to treat it, and the potential side effects of medications. Patients undergoing surgery need education as well. The nurse works with the patient and family on strategies to maintain independence, function, and safety in the home (see Chart 34-4). The patient and family are encouraged to verbalize their concerns and ask questions. Because RA commonly affects young women, major concerns may be related to the effects of the disease on childbearing potential, caring for family, or work responsibilities. The patient with a https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 5/7 11/21/23, 3:14 PM Realizeit for Student chronic illness may seek a “cure” or have questions about alternative therapies. Research indicates that acupuncture is safe and may be beneficial for patients with RA (Chou & Chu, 2018). There is not enough evidence of the effectiveness of other complementary, alternative, and integrative health therapies, and more rigorous research is needed (Chou & Chu, 2018; Katz-Talmor, Katz, Porta-Katz, et al., 2018). The nurse educates patients using topical analgesic agents to apply sparingly, avoid areas of open skin, and avoid contact with eyes and mucous membranes. Patients should also wash their hands carefully after application and assess for local skin irritation. Pain, fatigue, and depressive symptoms can interfere with the patient’s ability to learn and should be addressed before the education is initiated. Various educational strategies may then be used, depending on the patient’s previous knowledge base, interest level, degree of comfort, social or cultural influences, and readiness to learn. The nurse educates the patient about basic disease management and necessary adaptations in lifestyle. Some types of aerobic exercise and strength training should be discussed (Kapale et al., 2017). Because suppression of inflammation and autoimmune responses require the use of anti-inflammatory, disease-modifying antirheumatic, and immunosuppressive agents, the patient is taught about prescribed medications, including type, dosage, rationale, potential 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 significant others. The nurse then reinforces disease management skills during each patient contact. Barriers are assessed, and measures are taken to promote adherence to medications and the treatment program. Continuing and Transitional Care Depending on the severity of the disease and the patient’s resources and supports, referral for home care may be warranted. For example, the patient who is an older adult or frail, has RA that limits function significantly, and lives alone may need referral for home care. The impact of RA on everyday life is not always evident when the patient is seen in the hospital or in an ambulatory care setting. The increased frequency with which nurses see patients in the home provides opportunities for recognizing problems and implementing interventions aimed at improving the quality of life of patients with RA. During home visits, the nurse has the opportunity to assess the home environment and its adequacy for patient safety and management of the disorder. Adherence to the treatment program can be more easily monitored in the home setting, where physical and social barriers to adherence are more readily identified. For example, a patient who also has diabetes and requires insulin may be unable to fill the syringe accurately or unable to administer the insulin because of impaired joint mobility. Appropriate adaptive equipment needed for increased independence is often identified more readily when the nurse sees how the patient functions in the home. Any barriers to adherence are identified, and appropriate referrals are made. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 6/7 11/21/23, 3:14 PM Realizeit for Student For patients at risk for impaired skin integrity, the home health nurse can closely monitor skin status and also educate, provide, or supervise the patient and family in preventive skin care measures. 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 RA. Referrals to physical and occupational therapists may be made as problems are identified and limitations increase. A home health nurse may visit the home to make sure that the patient can function as independently as possible despite mobility problems and can safely manage treatments, including pharmacotherapy. The patient and family should be informed about support services such as Meals on Wheels and local Arthritis Foundation chapters. Because many of the medications used to suppress inflammation are injectable, the nurse may administer the medication to the patient or educate about self-injection. These frequent contacts allow the nurse to reinforce other disease management techniques. The nurse also assesses the patient’s physical and psychological status, adequacy of symptom management, and adherence to the management plan. Patients should know which type of rheumatic disease they have, not just that they have “arthritis” or “arthritis of the knee.” The importance of attending follow-up appointments is emphasized to the patient and family, and they should be reminded about the importance of participating in other health promotion activities and health screening. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IX01cMmy1tXd%2bA0lN30h55hoLMwB%2fCluMLMNMH… 7/7