A debilitating disease marked by swelling, tenderness, and synovial joint destruction, rheumatoid arthritis (RA) can lead to severe functional disability and poor quality of life, imposing substantial burdens on patients and their caregivers. (See Who gets RA?)
What’s more, the disease is linked to systemic comorbidities, such as cancer, infections, and cardiovascular and mental health conditions. These comorbidities increase mortality and shorten life expectancy. And while more aggressive treatments have decreased the incidence of extra-articular RA manifestations, the disease also can affect the eyes, lungs, kidneys, skin, hematopoietic system, blood vessels, nervous system, and salivary glands. Evidence suggests that both genetics and environmental factors play a role in RA development.
Once focused in acute-care settings, care of patients with RA has moved into home and ambulatory settings. However, patients in these venues don’t always have access to a nurse practitioner (NP) or rheumatology RN who can provide specialty care. This article highlights the importance of early diagnosis, discusses current therapeutic recommendations for managing pain and achieving remission, and describes RNs’ role in caring for these patients in the community.
Early diagnosis (within 6 months of RA symptom onset) coupled with aggressive treatment reduces the risk of joint damage and disability, helps maintain joint integrity, and enhances productivity and quality of life. However, with no diagnostic gold standard available, early diagnosis can be challenging.
Before development of the antibodies against citrullinated peptides (ACPA) test, rheumatoid factor (RF) was the only laboratory test available to diagnose RA. The ACPA test promotes early, accurate diagnosis, with a specificity of 90% to 97%. On the other hand, the RF test is relatively sensitive (70% to 75%) but rather nonspecific (as low as 50%) because other rheumatic and nonrheumatic conditions (such as Sjögren’s syndrome and hepatitis C infection) may trigger positive RF tests. Abnormal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) results can help assess treatment response, but these inflammatory markers aren’t useful in diagnosing early-onset RA.
Many clinical features of RA—joint deformities, rheumatoid nodules, and joint erosion on X-ray—don’t appear in early disease stages. However, pain and swelling in fingers and toes have high sensitivity for RA (94.6%) early in the disease, but specificity of only 15.3%.
Given the difficulty of accurate early diagnosis, clinicians commonly rely on a combination of a history consistent with inflammatory arthropathy (for example, morning stiffness lasting an hour or longer) and physical findings of joint swelling in classic RA patterns (symmetrical involvement of small joints). RA diagnosis may be made even without a positive RF/ACPA test.
Early aggressive treatment
Before 1980, the pyramid approach to RA treatment started with aspirin or other nonsteroidal anti-inflammatory drugs. Disease-modifying anti-rheumatic drugs (DMARDs), such as methotrexate, were reserved for patients with severe disease or those who didn’t respond to conservative treatment. Reluctance to prescribe DMARDs stemmed from lack of knowledge about early aggressive treatment to minimize permanent joint damage, unfamiliarity with optimal dosing, and few effective drugs with high benefit-to-risk ratios. As a result, many patients became disabled 10 to 20 years after diagnosis due to severe joint deformities and extra-articular manifestations.
Current RA treatment recommendations focus on early aggressive therapy. For example, clinicians should initiate DMARDs (preferably methotrexate) immediately after diagnosis, with the goal of achieving remission or low disease activity. Patients who don’t respond to traditional DMARD monotherapy may be candidates for combination therapy, such as multiple traditional DMARDs or concomitant biologic agents, such as tumor necrosis factor inhibitors (TNFis); examples of TNFis include etanercept, infliximab, and adalimumab. The current treatment model has dramatically reduced severe joint deformities and extra-articular manifestations.
Patients receiving these agents require close monitoring for adverse effects. For example, methotrexate is associated with hepatotoxicity and bone marrow suppression, so patients taking this drug should undergo complete blood counts and liver enzyme tests every 2 to 3 months. And because of the immunomodulating actions of biologics that increase the risk of certain infections, patients taking TNFis and other biologic agents should be tested for latent tuberculosis and receive pneumococcal, zoster, and influenza vaccinations before beginning treatment. (See Recommended drug therapies for RA.)
Patients with extensive joint damage need ongoing treatment and close monitoring, along with instructions to adhere to prescribed drug therapy. These actions are best coordinated through a multidisciplinary approach. Depending on the individual patient’s needs, the team may include a rheumatologist, rheumatology NP, RN, pharmacist, physical therapist, occupational therapist, podiatrist, physician assistant, and social worker. To help ensure optimal physical and psychosocial functioning and quality of life, the team provides education and support based on the patient’s goals.
Some multidisciplinary models include specialized arthritis programs, ongoing management, triage, rural consultant support, and telemedicine. Given the lack of reimbursement for hospitalization, most multidisciplinary programs are conducted in outpatient and community settings as day-patient programs. In the United States and across Europe, nurses have become an integral part of the multidisciplinary team, engaging in tasks traditionally performed only by rheumatologists. (See NPs’ impact on RA care.)
Providing care in the community
With limited availability of rheumatology NPs and rheumatology RNs in home health care, some long-term care facilities, hospices, schools, and faith-based organizations employ RNs to manage and coordinate the plan of care established by the rheumatologist or NP.
So RNs must be knowledgeable about RA pathophysiology, treatment, and management. We’ll use the nursing process steps of assessment, diagnosis, planning, implementation, and evaluation as a guide for managing patients and, as applicable, their caregivers.
Conduct an initial assessment
During your initial assessment of the patient and caregiver, establish goals and expected outcomes for successful disease management. Many patients with RA experience anxiety, anger, frustration, and depression. When you recognize these emotions, encourage the patient to discuss them with the rheumatologist or NP.
Key nursing actions at this stage are to establish a therapeutic relationship with the patient and caregiver, assess their understanding of RA and its management, and evaluate their physical, emotional, and psychological well-being.
Identify appropriate nursing diagnoses
RA signs and symptoms vary with disease severity. Note joint swelling and pain, morning stiffness, and deformities. Pain and deformities may limit the patient’s ability to perform activities of daily living (ADLs), which may lead to frustration, low self-esteem, and poor quality of life. Evaluate family dynamics as well as ethnic and cultural influences on the patient’s perception of RA and self-care abilities.
Use the information you’ve gathered to identify appropriate nursing diagnoses. Common ones for patients with RA are pain and discomfort, activity intolerance and impaired mobility, self-care deficits, fall risk, ineffective coping, altered body image or role performance, ineffective health maintenance, nonadherence to the therapeutic regimen, and caregiver role strain.
Collaborate in care planning
Work with the patient and caregiver to set measurable short- and long-term goals to achieve expected outcomes based on the nursing diagnoses. Evaluate their readiness to learn and motivation to participate in care. As you do this, be sure to:
• reinforce the multidisciplinary team approach to care
• discuss psychological factors related to RA, such as depression, anxiety, and stress
• explain drugs used to treat RA
• discuss nonpharmacologic approaches, such as joint protection, heat and cold therapy, range-of-motion exercises, and complementary and alternative therapies, as prescribed by the provider.
To enhance your effectiveness, ask open-ended questions, be sensitive to cultural preferences and family communication styles, and avoid arguing with the patient or caregiver.
Implement the plan
After devising a plan of care, implement evidence-based strategies based on established priorities, and provide patient education. Explain to the patient and caregiver that RA is a progressive chronic systemic disease that eventually may affect ADLs. Discuss the importance of adhering to prescribed drug therapy and nonpharmacologic treatment to control pain. Because of the remitting and relapsing nature of RA, review signs and symptoms of flares with the patient and caregiver.
Use the following strategies to enhance your effectiveness:
• Identify the preferred teaching method for and learning styles of the patient and caregiver.
• Educate them about the prescribed drug regimen to control pain and achieve remission.
• Reinforce the importance of medication adherence. Discuss adverse reactions, drug interactions, and use of herbal and complementary remedies with prescribed medications.
• Monitor medication efficacy and the patient’s tolerance.
• Promote participation in selfcare, including safety issues such as hot and cold therapy and coping with the stress or depression that may accompany RA.
• Review and obtain appropriate adaptive devices to help the patient perform ADLs.
• Provide consumer health material on RA and information about local support groups. (See Online resources for patients with RA.)
• Teach the patient and caregiver how to recognize and manage acute flares and systemic complications of RA.
• Urge them to keep follow-up appointments.
To determine if the expected outcomes and goals of care are being met, regularly evaluate how the plan of care is progressing.
• Monitor medication therapy, including efficacy, side effects, and signs and symptoms of RA flares (for example, changes in morning stiffness, fatigue, painful or swollen joints).
• Inform other multidisciplinary team members of the effectiveness of medications, nonpharmacologic measures, and disease progress.
• Collaborate with other multidisciplinary team members to help the patient or caregiver achieve unmet goals.
• Work with the patient and caregiver to refine goals as needed.
Your role in enhancing patient outcomes
Nurses in the community help patients with RA achieve the ultimate goal of remission or low disease activity. Based on the patient’s individual needs, encourage and assist him or her to establish health behaviors and activities that promote rest and exercise, reduce stress, and encourage independence.
Adeline Chu is an assistant professor of nursing in the School of Health Sciences at Seattle Pacific University and a clinical assistant professor in the Department of Biobehavioral Nursing and Health Informatics at the University of Washington in Seattle. Bernard Ng is chief of the Rheumatology Section at VA Puget Sound Healthcare System in Seattle and an associate professor of medicine in the Division of Rheumatology at the University of Washington in Seattle.
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