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.
Section 4 – Analysis of Therapies
Carol has received many therapies including several DMARD’s. The table below shows the DMARD’s that Carol has received and the effects that they had on her:
None of these DMARD’s worked for Carol and so another option was in need of exploration. It was then decided after a Multi-Disciplinary Team meeting that Carol should be started on the Anti-TNF drugs mentioned earlier in the report.
The Anti-TNF drug chosen for Carol was Adalimumab. Carol was educated on Adalimumab and was given all the relevant information to take the drug safely. She became well aware of the side effects of the drug as an information pack was given to her to read at her leisure. Common side effects include; headaches, rashes, nausea and upset stomach. More serious side effects include; minor urinary tract infections, sinuses and respiratory tract infections. Every patient that is commenced on a drug of this kind is made aware of all of these side effects. It is very important that if a patient gets any of these symptoms, for them to contact a member of the nursing staff for appropriate monitoring of the symptoms. Regular blood monitoring is carried out as with most of the rheumatoid drugs used with many patients. The blood tests for this drug in particular, checks for the level of red blood cells and platelets as the drug can reduce production of the two.
Other therapies that Carol received included physiotherapy and occupational therapy. Physiotherapy for Carol was intense to help her regain as much independence as possible on her date of discharge. Therapy began the day after admission and was documented very carefully. A diary of physiotherapy which Carol received is documented below:
Physio: Pt. admitted 10/4/07
11/4/07 – pt lying to sitting independently. Ice R knee in lying position. (20mins). Heat to neck in supported position. (20mins). Knees (static quads), neck (flexion/extension/retraction) x3 reps, x3 daily.
Pt tolerated ice and heat well.
11/4/07 – DMI R knee – R knee injected using aseptic technique as per protocol with 2mls x 1% lidocane and 80mg depomedrone. Advised to have 48hrs bed rest, using ice analgesia.
12/4/07 – pt reports improvements to neck and knees since DMI.
- Remeasured pts walking stick (requires longer one).
Pt tolerated physio well with minimal problems. Reduced knee swelling but a slightly increased temp. Full range of neck movement – now pain free.
13/4/07 – pt reported feeling “a bit out of sorts” but mobilises well with new stick. Swelling continues to improve. New stick height improves posture.
17/4/07 – feeling better after the weekend. Mobilises in room, no aids used. Sat out in chair reading – poor posture. Discussion re: neck posture and correct use of adjustable table.
Neck extension x3 demonstrated by patient. No problems.
Quads regime x3 each leg – fatigue of R knee
No swelling evident in R knee
Mobile with one Fischer stick in L hand
Pt progressed well – R knee settled
Pt discharged from physiotherapy.
Ongoing assessments were arranged with Carol on discharge. Regular blood monitoring was required 8 weeks after discharge and then again 3 months after. Appointments for blood monitoring were made with the nurse specialists and Carol was given Rheumatology help numbers in-case she required extra help and advice after discharge.
Carol was given health promotion advice before her discharge regarding her diabetes. During her stay in hospital her blood sugar levels were high, ranging between 10-24 mmols. Carol regularly checks her BM’s herself at home and claimed it is usually between 4 and 5 mmols. However, she did admit that she struggles to read the screen on her blood sugar monitoring kit. Nursing staff advised her to get a member of her family to bring the testing kit in so that she could be educated how to monitor herself correctly and how to control her sugar levels correctly. The day before her discharge, Carols BM was checked again and was still very high. To help Carol when she returned home, a specialist diabetes nurse was contacted to come and visit her and help her monitor her bloods in the right way and she was referred onto the diabetes clinic.
Carol stated whilst in hospital that she did not require social services at home to help her with cooking meals and dressing as she felt she was quite capable to do this herself.
On discharge, Carol’s take home medication was packed away for her and was talked through. This is the same with every patient on the ward. On the day of discharge a check list is read and marked off and the patient asked if they know what drugs they are taking and what they are for. If the patient doesn’t know what the drug is for, the member of staff checking the list will explain to the patient what the drug is used for. This is very useful to the patient as many of the patients require a number of medications, not just rheumatic medications, and many of the drugs used in the rheumatology department are new to the patient.
In conclusion, Carol did find the therapies she received in hospital benefited her condition and mental state also as she regained some form of independence. Ongoing care was made available for Carol as she left hospital and she was made aware that she wasn’t ever alone in coping with her illness and shouldn’t just put up with pain, she must talk to her GP and be re-referred to the department. Carol was educated on the balance between exercise and rest and was told to not push herself too much to reduce the risk of flares.
There is no cure for rheumatoid arthritis, only precautions to reduce the risk of getting it and reduce the symptoms when a patient suffers with it. Preventative techniques such as good posture and healthy diet are the most effective ways of combating the disease and these are the most effective ways for patients to be pain free and independent.