Capitol University

College of Nursing

RHEUMATOID ARTHRITIS

In partial fulfillment of the requirements

Of RLE 7 1st semester, SY 2010-2011

PRESENTED BY:
Katrene Lequigan

PRESENTED TO:
Rick Wilson Bunao, RN
CLINCAL INSTRUCTOR

AUGUST 2010
 Table of Contents

Introduction……………………………………………………………………………..

Client’s Profile………………………………………………………………………….

Socio-demographic data……………………………………………………..

Vital Signs……………………………………………………………………..

Physical Assessment………………………………………………………...

Anatomy and Physiology…………………………………………………………….

Pathophysiology………………………………………………………………………

Laboratory Tests and Results……………………………………………………...

Nursing Care Plans………………………………………………………………….

Drug Studies…………………………………………………………………………

Discharge Planning…………………………………………………………………

Learning Experiences………………………………………………………………

References.......................................................................................................
 Introduction

Having heard such a very common case wherein even up to the present
times experts have not yet discovered the causes of the disease condition, I am
really curious and pursue to study the case.

Rheumatoid arthritis, of the knee, is one type of arthritis. It is a chronic,

systemic, an autoimmune disease, inflammatory disorder that may affect many
tissues and organs, but principally attacks synovial joints. It is an autoimmune
disease because certain immune cells malfunction and attack a person's own
body. Inflammation is normally a response by the body's immune system to
"assaults" such as infections, wounds, and foreign objects. The inflammation is
misdirected to attack the joints. The process produces an inflammatory response
of the synovium (synovitis) secondary to hyperplasia of synovial cells, excess
synovial fluid, and the development of pannus in the synovium. The pathology of
the disease process often leads to the destruction of articular cartilage and
ankylosis of the joints. Autoimmune diseases are illnesses that occur when the
body's tissues are mistakenly attacked by their own immune system. The
immune system contains a complex organization of cells and antibodies
designed normally to "seek and destroy" invaders of the body, particularly
infections. Patients with autoimmune diseases have antibodies in their blood that
target their own body tissues, where they can be associated with inflammation.
(http://en.wikipedia.org/wiki/Rheumatoid_arthritis)

Rheumatoid arthritis typically manifests with signs of inflammation, with

the affected joints being swollen, warm, painful and stiff, particularly early in the
morning on waking or following prolonged inactivity. Increased stiffness early in
the morning is often a prominent feature of the disease and may last for more
than an hour, signs of inflammation and early morning stiffness are absent, and
movements induce pain caused by the wear-and-tear. When the disease is
active, symptoms can include fatigue, loss of energy, lack of appetite, low-grade
fever, flu like symptoms.
(http://www.medicinenet.com/rheumatoid_arthritis/article.htm)

About 1% of the world's population is afflicted by rheumatoid arthritis.

Onset is most frequent between the ages of 40 and 50, but no age is immune.
The prevalence rate of rheumatoid arthritis is approximately 1% of the population
(range 0.3-2.1%). Although rheumatoid arthritis (RA) can occur at any age, the
incidence increases with advancing age. The peak incidence of RA occurs in
individuals aged 40-60 years. Although rheumatoid arthritis can develop at any
age, you’re most likely to develop the condition between the ages of 25 and 45.
Some studies have suggested that there is a connection between drinking coffee
and developing rheumatoid arthritis. More work needs to done to confirm this
association. Another point of interest is that smoking has been identified as a
risk factor for developing rheumatoid arthritis. (http://www.medscape.com)

……………………………………………………………………...
This case study has come to realization with the primordial aim of

understanding the disease condition in order to formulate plans of effective

nursing interventions that would help bring back the patient to the normal health

status in a gradual stage. Nursing care has been rendered to patient for one-duty

shift. Hence, evaluation of the effectivity and efficiency of such nursing

interventions was not well established.

•
 Client’s Profile

Socio-demographic Data

Patient X is a 38-year-old, male, a Filipino citizen, from Salay, Misamis

Oriental. He is religiously affiliated to Roman Catholic, chrisyian group. He is
married to with 2 children. His primary language is Cebuano and is a high school
graduate. He is as an animal slaughter at Sr. Pedro. He is working and standing
for 12 hours. He drinks coffee 2 cups per day. He tried to use marijuana by
smoking during her 20’s for about 5 leaves per day. He also has inherited asthma
from both sides of his parents who had a history of the disease.

Five days prior to admission, patient X experienced joint pain on the left
knee, inflamed and swollen. He complained fever and manifest fatigue and lack
of appetite. He started to consult a doctor on July 19, 2010 and admitted at
NMMC Medical Ward on July 20, 2010.

Patient X’s age is 38 years old. His mobility status is limited due to his joint
pain at left knee. She requires special nutritional needs for his condition – low fat
especially low saturated fats and low in sodium. She also needs to eat
vegetables and fruits.

Vital Signs

Temperature: 36.5 degrees Celcius Respiratory Rate: 21 cpm

Pulse Rate: 72 bpm Blood Pressure: 110/800 mmHg

Physical Assessment

This portion of the case study will present the deviation from the abnormal
findings of the physical assessment presented in a cephalo-caudal approach.
These data are then considered in the making of the nursing care plan.

Head

Aspect of Consideration Findings

Hair Dry Hair

Scalp Dandruff

Nose
Aspect of Consideration Findings

Mucosa Pale

Discharge Serous

Mouth

Aspect of Consideration Findings

Lips Pallor and dry

Mucosa Pallor

Teeth Missing teeth

Skin

Aspect of Consideration Findings

 Texture  Rough

 Moisture  Dry

Abdomen

Aspect of Consideration Findings

Bowel sounds  Hypoactive

Elimination Pattern

Aspect of Consideration Findings

Usual bowel Pattern  3-5 times a week, with

brown colored stool

Bowel sounds  Hypoactive

Others: LBM  July 19, 2010

Activities of Daily Living /Mobility Status

0- Total independence 3- Assist with device and person

1- Assist with device 4- Total dependence

 2- Assist with person

Feeding: 2 Meal Preparation: 4 Bed Mobility: 2

Bathing: 2 Cleaning: 4 Chair /toilet transfer: 2

Dressing; 2 Laundry: 4 Ambulation: 2

Grooming: 2 Toileting: 4 ROM: 2

Extremities

Aspect of Consideration Findings

Range Of Motion Decreased ROM at left knee

Joint Pain

Joint swelling at left knee

Gait smooth

Cognitive – Perceptual Pattern

Aspect of Consideration Findings

Emotional State Worried to his family, anxious

Pain

Aspect of Consideration Findings

Pain scale 3/10 (occasional pain)

Anatomy and Physiology

Joints

These are point of attachment or contact between two bones
Variously classified according to its movement and flexibility
 Fibrous joints- with fibrous tissue with little or no movement
 Cartilaginous joints- with cartilage
 Synovial joints- with capsule; freely; movable joints
Bursae
 Small synovial fluid sacs located at friction points around joints, between
tendons, ligaments and bones. Act as cushions, decrease stress on adjacent
structure.

The knee, also known as the genual joint, is situated at the interface of the
human body's two longest bones, the tibia and the femur. The joint, essential in
nearly every activity of daily living as well as in many athletic endeavours, is the
most vulnerable to severe injury of any in the body. No orthopedic injury causes
the active person more grief; only CNS (brain and spine) injuries are more
devastating overall. Prior to delving into the different injury types, it is worthwhile
to review how the knee works and why it is so uniquely prone to catastrophic
injuries. This document is intended to serve to provide a concise yet reasonably
comprehensive overview of knee function, in order to enable users of the Knee
Library to more fully comprehend complex knee problems as well as to obtain
greater benefit from the advanced-level resources proffered on this site.

Ligament: strong band of connective tissue that connects one bone to another.
Ligaments are very much alive: they contain blood vessels and are innervated.
Their strength derives from their parallel-aligned collagen fibres. In simplest
terms, ligaments handle tensile forces.

Tendon: strong band of connective tissue that connects a muscle group to a

bone. A tendon's structure is similar to that of a ligament. (Like ligaments,
tendons handle tensile forces only.)
Cartilage: in the context of orthopedics, this is generally a bearing surface. This
is what the menisci (discussed subsequently) and articular cartilages are
comprised of. Cartilage handles compression and shear forces.

Retinaculum: connective tissue, which in orthopedics helps keep a certain

structure in place. (One example of retinacular tissue is that which helps keep the
patella from moving side-to-side.)

Proximal: closest to the person's torso

Distal: furthest from the person's torso

Anterior: towards the front of the body (or simply the frontmost portion of the
structure under discussion). Example: anterior cruciate ligament

Posterior: towards the rear of the body (or simply the rearmost portion of the
structure under discussion). Example: posterior cruciate ligament

Medial: closest to the centreline of the body. Example: medial collateral ligament
(discussed below; also see diagrams)

Lateral: furthest from the centreline of the body. Example: lateral collateral
ligament (discussed below; also see diagrams)

Sagittal: acting from front-to-back or back-to-front (i.e. same as anterior-

posterior or posterior-anterior). Memory aid: think of the mythical archer
Sagittarius: the plane of his bow is a sagittal plane. (A sagittal plane is any plane
parallel to the plane of Sagittarius's bow.)
Coronal (same as Frontal): if you lie on a bed on your back, then this is any
plane running through your body that is parallel to the bed surface.

Transverse: This is any plane that cuts your body is the shortest way possible. If
you stand in a pool in waist-deep water, the surface of the water is bisecting your
body in a transverse plane.

Valgus: bent inwards, or inwards-directed forcing. Knockkneedness=genu

valgum. (To remember this, think of the upper-case letter L superimposed on a
picture of a knock-kneed person: the person's legs are widest at the feet, just like
the letter L.)

Varus: bent outwards, or outwards-directed forcing. Bowleggedness=genu

varum. (To remember this, think of the lower-case letter r being superimposed on
a picture of a bow-legged person: the person's legs are widest at the
knees...exactly where that superimposed letter r is widest.)

Bony anatomical aspects:

Femur: the thighbone. This happens to be the largest bone in the body, and it
runs from the hip to the knee. At the knee, we can feel the condyles of the femur
(medial and lateral condyles, i.e. the two large bony knobs that define the distal
end of this bone). At the hip, we can feel the greater trochanter. Otherwise, the
femur is completely encased by thick musculature.

Tibia: the shinbone. The proximal end of this bone forms the lower portion of the
knee (also known as the tibial plateau). The front of the tibia is known as the tibial
crest (discussed below), and it can easily be felt as a long bony ridge running
down the front of the lower leg.

Fibula: the lower leg harbours two bones; parallel to the tibia is the fibula. The
fibula is located on the outside (i.e. lateral) side of the lower leg, and is somewhat
shorter than the tibia. Having two bones in the lower leg enables the foot to the
swivelled side-to-side in the transverse plane. (This is similar to the forearm,
which harbours the radius and ulna; these can cross each other, thereby
enabling the person to turn his/her palm upwards.)

Tibial Tubercle: (also known as tibial tuberosity). This is the bony knob just
below the patella (described subsequently). It serves as the attachment point for
the patellar tendon.
Tibial Crest: This is the bony ridge that runs down the front of the lower leg, from
the patella almost to the ankle. It can easy be felt (palpated) with one's fingers.
(Incidentally, this is the only anatomical landmark that is well-suited to being
grasp by the shell of a knee brace. But most knee-brace manufacturers avoid
designing their braces to interface with the tibial crest because of the added cost
due to increased manufacturing complexity.)

Patella: This little sesamoid (sesame-seed-shaped) bone is also known as the

kneecap, and it is best thought of as part of the knee's extensor mechanism. Its
function is simply to serve as a pulley for the quadriceps muscles (described
later) to act more efficiently. The patella slides in a groove in the femur (between
the femur's two condyles); this groove is known as the patellofemoral groove, or
simply the trochlea (or the femoral sulcus). If the quadriceps muscle group pulls
to one side (something which can have many causes; examples include the
person being knock-kneed, or simply some sort of muscle-strength imbalance),
tracking problems can arise. The patella can become dislocated (i.e. come out of
its groove), a very painful condition. Damage to articular cartilage on the
underside of the patella can cause chronic pain (patellofemoral pain syndrome,
chondromalacia). (Note: Tracking of the patella is closely related to the Q-angle,
i.e. the quadriceps-pull angle. While the Q-angle is affected by whether or not the
person is knock-kneed, note that Q-angle measurements reflect far more than
just the valgus-varus angle at the knee. The Q-angle also reflects problems such
as an outwards-twisted tibia, a laterally positioned tibial tuberosity, or an overly
tight lateral retinaculum. [The Q-angle is the angle formed by a line drawn from
the ASIS to the central patella and a second line drawn from the central patella to
the tibial tubercle. The ASIS is the Anterior Superior Iliac Spine, a landmark point
on the pelvis. If you stand with arms akimbo, the fingers on your left hand are
covering the left ASIS; likewise for the right.]).
 Pathophysiology

Precipitating Factor (figure A)

Etiologic Factors Actual Rationale

Developing of Patient X 5 days prior to admission,

inflammation and experience a joint patient experienced joint pain at
swelling of joint pain and swelling the left knee and swelling.
of left knee

Predisposing Factor (figureB)

Etiologic Factors Actual Rationale

Age: Most likely to Patient X most Rheumatoid arthritis occur at

develop the condition likely to develop any age.
between the ages of 25 and more prone
and 45. on having
rheumatoid
arthritis, his age is
38 years old.

Gender: Recent studies Patient X’s gender Man is also prone to rheumatoid
found out that in any is male arthritis
gender, rheumatoid
arthritis would occur

Lifestyle: Some studies Patient X drink Foreign studies suggested that

have suggested that coffee 2cups per smoking and drinking coffee are
there is a connection day also a risk factors for rheumatoid
between drinking coffee arthritis.
and developing
rheumatoid arthritis.

Another point of interest Patient X has

is that smoking has been been smoking of
identified as a risk factor marijuana during
for developing 20’s.
rheumatoid arthritis.
 Predisposing Precipitating
Factors: (Please Factors: (Please
refer to Fig B) Initiation of rheumatoid refer to Fig A)
arthritis

Immunoglobuli Production of rheumatoid

n factors

Prostaglandin
release

Deposition of immune
complex

Inflammation of
synovium

Release of
edema Release of
Release of arachidonic Release of
oxygen
lysosomal acid antibodies
free
enzymes and
radicals
prostaglandin
Synovi
al Release of
hypoxi Pai
complem
a n
ent
Destruction of
synovium
Leukocy
te
attracte
Joint d
Joint
swelling
Loss of joint
space

Macrophag
es
attracted

Rheumatoid
nodules

Muscl
e
 Macrophag
es
attracted

Rheumatoid
nodules

Muscl
e

Laboratory Test and Results

Hematologic Report:July 20, 2010

Results Normal

WBC 12.8 10 ٨3/uL 5.0-10.0

Monocyte 11 % 4.5-10.5

WBC------- An elevated number of white blood cells is called leukocytosis. This

can result from bacterial infections, inflammation, leukemia, trauma, intense
exercise, or stress.
Monocyte---- Levels of monocytes in the blood tend to rise when someone has
an infection, because more of these cells are needed to fight it. Monocytes can
also increase in response to stress and other factors.

Microscopic Examination/Sedimentation:July 20, 2010

Results Normal

Pus Cells (WBC) 3-5/hpf 0-5

Pus Cells--------result in infection

Examination Results:July 20, 2010

Results

Erythrocyte Sedimentation Rate------118 mm/hr

Normal

Below 50 yrs. Old-----<15 mm/hr.

A very high ESR usually has an obvious cause, such as a marked increase in
globulins that can be due to a severe infection. The rising ESR can mean an
increase in inflammation.

Discharge Plan

Medication

> Strict compliance to the drug regimen should be emphasized

> Emphasis to take home medication consistently following the right drugs,
dosage, timing & frequency, and route.

Exercise

> It is best to start the exercise program slowly until you get stronger, also find a
suitable exercise program to suit your condition.
> Exercise is important this makes your heart stronger, lowers blood pressure,
and help keep your body healthy.

> Maintaining a regular exercise will help facilitate adequate blood flow for
nourishing different parts of the body.

> Exercise can reduce joint pain and fatigue. It can also increase ROM and
strength.

Treatment

> Have a regular check-up with your physician regarding with your condition for
any continuing treatment and medications.

Health Teachings

> Emphasis on personal hygiene to promote comfort and prevent infection.

> Do regular exercises, eat right food, and take medications to enhance recovery
and healing as indicated by the physician.

> Adequate rest is important.

> Information about his disease condition

> Increase physical activity, once a day move each joint through its full ROM.

Out Patient

> Regular check-up for monitoring of development and if there are presence of
complication.

Diet

> Consult a nutritionist for a proper diet program.

Tips:

> Eat nutritious and healthy food, to avoid constipation. Eat foods such as
oatmeal, whole-grain breads and cereals, fruits and vegetables.

> Drink at least 8-10 glasses of water a day; limit the amount of soda, tea and
coffee.

>Loosing weight not only give you look better, it helps you and your joints feel
better and reduces pain.
Spirituality

>Tell the patient/client to pray for God, for him nothing is impossible. Ask for
inner strength to carry his trials

Learning Experiences

In doing this case study, the essence of patience and hard working were
always there. Everything I have done entails patience, knowledge and skills in
doing research studies about the case. I have learned a lot about proper nursing
interventions, rendering care to my patients, regarding the disease conditions,
manifestations and a lot more. One should also need to analyze all the significant
data to know the relationship of other data.
While in the other hand, my experience in NMMC-Medical Ward was
honestly a big and challenging experienced in my life. It was fortunate to have a
good relationship to my group mates, hospital staffs and to my beloved clinical
instructor as well. What happened in this rotation was a lot of new ideas, new
learning and new applications for my field. In the ward, I also learned a lot of new
procedures and I was totally amazed and proud to myself because I am confident
in doing some procedures in the ward. I admit that I have committed a couple of
mistakes, but what is more important is what I’ve learned from my mistakes.
I would like to thank, our ever grateful, God Almighty, thank you so much
for giving me strength to handle each situation confidently. To my dear CI,
Mr. Rick Wilson Bunao, RN, thank you for being effective in the field. As a clinical
instructor, he emphasized the values of professionalism, respect and patience.
To my PCI that was patience and understanding, thank you Ma’am. To my
beloved parents who have shown support and understanding in all activities. And
to the Hospital Staffs who help and guide us for this rotation.

References

http://www.google.com

http://www.yahoo.com

http://www.scrib.com

http://www.nursingcrib.com

http://www.wikipedia.com

http://www.webmd.com
http://www.emedicinehealth.com

http://www.arthritis.about.com

http://www.medicinenet.com