Capitol University

College of Nursing
RHEUMATOID ARTHRITIS
In partial fulfillment of the reuirements
Of R!E " #
st
semester$ S% &'#'(&'##
)RESENTED *%+
,atrene !euigan
)RESENTED TO+
Ri-. /ilson *unao$ RN
C!INCA! INSTRUCTOR
AU0UST &'#'
Table of Contents
Introduction..
Clients Profile.
Socio-demographic data..
Vital Signs..
Physical Assessment...
Anatomy and Physiology.
Pathophysiology
aboratory Tests and !esults...
"ursing Care Plans.
#rug Studies
#ischarge Planning
earning $%periences
!eferences.......................................................................................................
Intro1u-tion
&a'ing heard such a 'ery common case (herein e'en up to the present
times e%perts ha'e not yet disco'ered the causes of the disease condition) I am
really curious and pursue to study the case.
!heumatoid arthritis) of the *nee) is one type of arthritis. It is a chronic)
systemic) an autoimmune disease) inflammatory disorder that may affect many
tissues and organs) but principally attac*s syno'ial +oints. It is an autoimmune
disease because certain immune cells malfunction and attac* a person,s o(n
body. Inflammation is normally a response by the body,s immune system to
-assaults- such as infections) (ounds) and foreign ob+ects. The inflammation is
misdirected to attac* the +oints. The process produces an inflammatory response
of the syno'ium .syno'itis/ secondary to hyperplasia of syno'ial cells) e%cess
syno'ial fluid) and the de'elopment of pannus in the syno'ium. The pathology of
the disease process often leads to the destruction of articular cartilage and
an*ylosis of the +oints. Autoimmune diseases are illnesses that occur (hen the
body,s tissues are mista*enly attac*ed by their o(n immune system. The
immune system contains a comple% organi0ation of cells and antibodies
designed normally to -see* and destroy- in'aders of the body) particularly
infections. Patients (ith autoimmune diseases ha'e antibodies in their blood that
target their o(n body tissues) (here they can be associated (ith inflammation.
.http122en.(i*ipedia.org2(i*i2!heumatoid3arthritis/
!heumatoid arthritis typically manifests (ith signs of inflammation) (ith
the affected +oints being s(ollen) (arm) painful and stiff) particularly early in the
morning on (a*ing or follo(ing prolonged inacti'ity. 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
mo'ements induce pain caused by the (ear-and-tear. 4hen the disease is
acti'e) symptoms can include fatigue) loss of energy) lac* of appetite) lo(-grade
fe'er) flu li*e symptoms.
.http122(((.medicinenet.com2rheumatoid3arthritis2article.htm/
About 56 of the (orld,s population is afflicted by rheumatoid arthritis.
7nset is most fre8uent bet(een the ages of 9: and ;:) but no age is immune.
The pre'alence rate of rheumatoid arthritis is appro%imately 56 of the population
.range :.<-=.56/. Although rheumatoid arthritis .!A/ can occur at any age) the
incidence increases (ith ad'ancing age. The pea* incidence of !A occurs in
indi'iduals aged 9:->: years. Although rheumatoid arthritis can de'elop at any
age) youre most li*ely to de'elop the condition bet(een the ages of =; and 9;.
Some studies ha'e suggested that there is a connection bet(een drin*ing coffee
and de'eloping rheumatoid arthritis. ?ore (or* needs to done to confirm this
association. Another point of interest is that smo*ing has been identified as a
ris* factor for de'eloping rheumatoid arthritis. (http://www.medscape.com)
22222222222222222222222222333
This case study has come to reali0ation (ith the primordial aim of
understanding the disease condition in order to formulate plans of effecti'e
nursing inter'entions that (ould help bring bac* the patient to the normal health
status in a gradual stage. "ursing care has been rendered to patient for one-duty
shift. &ence) e'aluation of the effecti'ity and efficiency of such nursing
inter'entions (as not (ell established.

Client4s )rofile
So-io(1emographi- Data
Patient @ is a <A-year-old) male) a Bilipino citi0en) from Salay) ?isamis
7riental. &e is religiously affiliated to !oman Catholic) chrisyian group. &e is
married to (ith = children. &is primary language is Cebuano and is a high school
graduate. &e is as an animal slaughter at Sr. Pedro. &e is (or*ing and standing
for 5= hours. &e drin*s coffee = cups per day. &e tried to use mari+uana by
smo*ing during her =:s for about ; lea'es per day. &e also has inherited asthma
from both sides of his parents (ho had a history of the disease.
Bi'e days prior to admission) patient @ e%perienced +oint pain on the left
*nee) inflamed and s(ollen. &e complained fe'er and manifest fatigue and lac*
of appetite. &e started to consult a doctor on Culy 5D) =:5: and admitted at
"??C ?edical 4ard on Culy =:) =:5:.
Patient @s age is <A years old. &is mobility status is limited due to his +oint
pain at left *nee. She re8uires special nutritional needs for his condition E lo( fat
especially lo( saturated fats and lo( in sodium. She also needs to eat
'egetables and fruits.
5ital Signs
Temperature1 <>.; degrees Celcius !espiratory !ate1 =5 cpm
Pulse !ate1 F= bpm Glood Pressure1 55:2A:: mm&g
)hysi-al Assessment
This portion of the case study (ill present the de'iation from the abnormal
findings of the physical assessment presented in a cephalo-caudal approach.
These data are then considered in the ma*ing of the nursing care plan.
&ead
Aspe-t of Consi1eration 6in1ings
&air
Scalp
#ry &air
#andruff
"ose
Aspe-t of Consi1eration 6in1ings
?ucosa Pale
#ischarge Serous
?outh
Aspe-t of Consi1eration 6in1ings
ips Pallor and dry
?ucosa Pallor
Teeth ?issing teeth
S*in
Aspe-t of Consi1eration 6in1ings
Te%ture !ough
?oisture #ry
Abdomen
Aspe-t of Consi1eration 6in1ings
Go(el sounds &ypoacti'e
$limination Pattern
Aspe-t of Consi1eration 6in1ings
Hsual bo(el Pattern <-; times a (ee*) (ith bro(n
colored stool
Go(el sounds &ypoacti'e
7thers1 G? Culy 5D) =:5:
Acti'ities of #aily i'ing 2?obility Status
:- Total independence <- Assist (ith de'ice and person
5- Assist (ith de'ice 9- Total dependence
=- Assist (ith person
Beeding1 = ?eal Preparation1 9 Ged ?obility1 =
Gathing1 = Cleaning1 9 Chair 2toilet transfer1 =
#ressingI = aundry1 9 Ambulation1 =
Jrooming1 = Toileting1 9 !7?1 =
$%tremities
Aspe-t of Consi1eration 6in1ings
!ange 7f ?otion #ecreased !7? at left *nee
Coint Pain
Coint s(elling at left *nee
Jait smooth
Cogniti'e E Perceptual Pattern
Aspe-t of Consi1eration
$motional State
6in1ings
4orried to his family) an%ious
Pain
Aspe-t of Consi1eration
Pain scale
6in1ings
<25: .occasional pain/
Anatomy an1 )hysiology
7oints

These are point of attachment or contact bet(een t(o bones

Variously classified according to its mo'ement and fle%ibility
6i8rous 9oints- (ith fibrous tissue (ith little or no mo'ement
Cartilaginous 9oints- (ith cartilage
Synovial 9oints- (ith capsuleI freelyI mo'able +oints
*ursae
Small syno'ial fluid sacs located at friction points around +oints) bet(een
tendons) ligaments and bones. Act as cushions) decrease stress on ad+acent
structure.
The *nee) also *no(n as the genual +oint) is situated at the interface of the
human body,s t(o longest bones) the tibia and the femur. The +oint) essential in
nearly e'ery acti'ity of daily li'ing as (ell as in many athletic endea'ours) is the
most 'ulnerable to se'ere in+ury of any in the body. "o orthopedic in+ury causes
the acti'e person more griefI only C"S .brain and spine/ in+uries are more
de'astating o'erall. Prior to del'ing into the different in+ury types) it is (orth(hile
to re'ie( ho( the *nee (or*s and (hy it is so uni8uely prone to catastrophic
in+uries. This document is intended to ser'e to pro'ide a concise yet reasonably
comprehensi'e o'er'ie( of *nee function) in order to enable users of the Knee
ibrary to more fully comprehend comple% *nee problems as (ell as to obtain
greater benefit from the ad'anced-le'el resources proffered on this site.
Ligament: strong band of connecti'e tissue that connects one bone to another.
igaments are 'ery much ali'e1 they contain blood 'essels and are inner'ated.
Their strength deri'es from their parallel-aligned collagen fibres. In simplest
terms) ligaments handle tensile forces.
Tendon: strong band of connecti'e tissue that connects a muscle group to a
bone. A tendon,s structure is similar to that of a ligament. .i*e ligaments)
tendons handle tensile forces only./
Cartilage: in the conte%t of orthopedics) this is generally a bearing surface. This
is (hat the menisci .discussed subse8uently/ and articular cartilages are
comprised of. Cartilage handles compression and shear forces.
Retinaculum: connecti'e tissue) (hich in orthopedics helps *eep a certain
structure in place. .7ne e%ample of retinacular tissue is that (hich helps *eep the
patella from mo'ing side-to-side./
Proximal: closest to the person,s torso
Distal: furthest from the person,s torso
Anterior: to(ards the front of the body .or simply the frontmost portion of the
structure under discussion/. $%ample1 anterior cruciate ligament
Posterior: to(ards the rear of the body .or simply the rearmost portion of the
structure under discussion/. $%ample1 posterior cruciate ligament
Medial: closest to the centreline of the body. $%ample1 medial collateral ligament
.discussed belo(I also see diagrams/
Lateral: furthest from the centreline of the body. $%ample1 lateral collateral
ligament .discussed belo(I also see diagrams/
Sagittal: acting from front-to-bac* or bac*-to-front .i.e. same as anterior-
posterior or posterior-anterior/. ?emory aid1 thin* of the mythical archer
Sagittarius1 the plane of his bo( is a sagittal plane. .A sagittal plane is any plane
parallel to the plane of Sagittarius,s bo(./
Coronal (same as Frontal): if you lie on a bed on your bac*) 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 (ay possible. If
you stand in a pool in (aist-deep (ater) the surface of the (ater is bisecting your
body in a trans'erse plane.
Valgus: bent in(ards) or in(ards-directed forcing. Knoc**neednessLgenu
'algum. .To remember this) thin* of the upper-case letter superimposed on a
picture of a *noc*-*need person1 the person,s legs are (idest at the feet) +ust li*e
the letter ./
Varus: bent out(ards) or out(ards-directed forcing. Go(leggednessLgenu
'arum. .To remember this) thin* of the lo(er-case letter r being superimposed on
a picture of a bo(-legged person1 the person,s legs are (idest at the
*nees...e%actly (here that superimposed letter r is (idest./
*ony anatomi-al aspe-ts+
Femur: the thighbone. This happens to be the largest bone in the body) and it
runs from the hip to the *nee. At the *nee) (e can feel the condyles of the femur
.medial and lateral condyles) i.e. the t(o large bony *nobs that define the distal
end of this bone/. At the hip) (e can feel the greater trochanter. 7ther(ise) the
femur is completely encased by thic* musculature.
Tiia: the shinbone. The pro%imal end of this bone forms the lo(er portion of the
*nee .also *no(n as the tibial plateau/. The front of the tibia is *no(n as the tibial
crest .discussed belo(/) and it can easily be felt as a long bony ridge running
do(n the front of the lo(er leg.
Fiula: the lo(er leg harbours t(o bonesI parallel to the tibia is the fibula. The
fibula is located on the outside .i.e. lateral/ side of the lo(er leg) and is some(hat
shorter than the tibia. &a'ing t(o bones in the lo(er leg enables the foot to the
s(i'elled side-to-side in the trans'erse plane. .This is similar to the forearm)
(hich harbours the radius and ulnaI these can cross each other) thereby
enabling the person to turn his2her palm up(ards./
Tiial Tuercle: .also *no(n as tibial tuberosity/. This is the bony *nob +ust
belo( the patella .described subse8uently/. It ser'es as the attachment point for
the patellar tendon.
Tiial Crest: This is the bony ridge that runs do(n the front of the lo(er leg) from
the patella almost to the an*le. It can easy be felt .palpated/ (ith one,s fingers.
.Incidentally) this is the only anatomical landmar* that is (ell-suited to being
grasp by the shell of a *nee brace. Gut most *nee-brace manufacturers a'oid
designing their braces to interface (ith the tibial crest because of the added cost
due to increased manufacturing comple%ity./
Patella: This little sesamoid .sesame-seed-shaped/ bone is also *no(n as the
*neecap) and it is best thought of as part of the *nee,s e%tensor mechanism. Its
function is simply to ser'e as a pulley for the 8uadriceps muscles .described
later/ to act more efficiently. The patella slides in a groo'e in the femur .bet(een
the femur,s t(o condyles/I this groo'e is *no(n as the patellofemoral groo'e) or
simply the trochlea .or the femoral sulcus/. If the 8uadriceps muscle group pulls
to one side .something (hich can ha'e many causesI e%amples include the
person being *noc*-*need) or simply some sort of muscle-strength imbalance/)
trac*ing problems can arise. The patella can become dislocated .i.e. come out of
its groo'e/) a 'ery painful condition. #amage to articular cartilage on the
underside of the patella can cause chronic pain .patellofemoral pain syndrome)
chondromalacia/. ."ote1 Trac*ing of the patella is closely related to the M-angle)
i.e. the 8uadriceps-pull angle. 4hile the M-angle is affected by (hether or not the
person is *noc*-*need) note that M-angle measurements reflect far more than
+ust the 'algus-'arus angle at the *nee. The M-angle also reflects problems such
as an out(ards-t(isted tibia) a laterally positioned tibial tuberosity) or an o'erly
tight lateral retinaculum. NThe M-angle is the angle formed by a line dra(n from
the ASIS to the central patella and a second line dra(n from the central patella to
the tibial tubercle. The ASIS is the Anterior Superior Iliac Spine) a landmar* point
on the pel'is. If you stand (ith arms a*imbo) the fingers on your left hand are
co'ering the left ASISI li*e(ise for the right.O/.
)athophysiology
Precipitating Bactor .figure A/
$tiologic Bactors Actual !ationale
#e'eloping of
inflammation and
s(elling of +oint
Patient @
e%perience a +oint
pain and s(elling
of left *nee
; days prior to admission)
patient e%perienced +oint pain at
the left *nee and s(elling.
Predisposing Bactor .figureG/
$tiologic Bactors Actual !ationale
Age1 ?ost li*ely to
de'elop the condition
bet(een the ages of =;
and 9;.
Patient @ most
li*ely to de'elop
and more prone
on ha'ing
rheumatoid
arthritis) his age is
<A years old.
!heumatoid arthritis occur at
any age.
Jender1 !ecent studies
found out that in any
gender) rheumatoid
arthritis (ould occur
Patient @s gender
is male
?an is also prone to rheumatoid
arthritis
ifestyle1 Some studies
ha'e suggested that
there is a connection
bet(een drin*ing coffee
and de'eloping
rheumatoid arthritis.
Another point of interest
is that smo*ing has been
identified as a ris* factor
for de'eloping
rheumatoid arthritis.
Patient @ drin*
coffee =cups per
day
Patient @ has
been smo*ing of
mari+uana during
=:s.
Boreign studies suggested that
smo*ing and drin*ing coffee are
also a ris* factors for rheumatoid
arthritis.
Initiation of rheumatoid
arthritis
Immunoglobuli
n
Deposition of immune
complex
Destruction of
synovium
Release of
complem
ent
eu!ocy
te
attracte
d
"rostaglandin
release
In#ammation of
synovium
"redisposing
$actors: ("lease
refer to $ig %)
Release of
lysosomal
en&ymes
"roduction of rheumatoid
factors
"recipitating
$actors: ("lease
refer to $ig ')
edema
Release of
antibodies
Release of
oxygen
free
radicals
(ynovi
al
hypoxi
a
Release of
arachidonic
acid
and
prostaglandin
"ai
n
)oint
)oint
swelling
oss of *oint
space
!a8oratory Test an1 Results
Hematologi- Report+7uly &'$ &'#'
Results Normal
4GC 5=.A 5: P<2u ;.:-5:.:
?onocyte 55 6 9.;-5:.;
WBC------- An ele'ated number of (hite blood cells is called leu*ocytosis. This
can result from bacterial infections) inflammation) leu*emia) trauma) intense
e%ercise) or stress.
+acrophag
es
attracted
Rheumatoid
nodules
+uscl
e
Monocyte---- e'els of monocytes in the blood tend to rise (hen someone has
an infection) because more of these cells are needed to fight it. ?onocytes can
also increase in response to stress and other factors.
Mi-ros-opi- E:amination;Se1imentation+7uly &'$ &'#'
Results Normal
Pus Cells .4GC/ <-;2hpf :-;
Pus Cells--------result in infection
E:amination Results+7uly &'$ &'#'
Results
$rythrocyte Sedimentation !ate------55A mm2hr
Normal
Gelo( ;: yrs. 7ld-----Q5; mm2hr.
A 'ery high $S! usually has an ob'ious cause) such as a mar*ed increase in
globulins that can be due to a se'ere infection. The rising $S! can mean an
increase in inflammation.
Dis-harge )lan
Me1i-ation
R Strict compliance to the drug regimen should be emphasi0ed
R $mphasis to ta*e home medication consistently follo(ing the right drugs)
dosage) timing S fre8uency) and route.
E:er-ise
R It is best to start the e%ercise program slo(ly until you get stronger) also find a
suitable e%ercise program to suit your condition.
R $%ercise is important this ma*es your heart stronger) lo(ers blood pressure)
and help *eep your body healthy.
R ?aintaining a regular e%ercise (ill help facilitate ade8uate blood flo( for
nourishing different parts of the body.
R $%ercise can reduce +oint pain and fatigue. It can also increase !7? and
strength.
Treatment
R &a'e a regular chec*-up (ith your physician regarding (ith your condition for
any continuing treatment and medications.
Health Tea-hings
R $mphasis on personal hygiene to promote comfort and pre'ent infection.
R #o regular e%ercises) eat right food) and ta*e medications to enhance reco'ery
and healing as indicated by the physician.
R Ade8uate rest is important.
R Information about his disease condition
R Increase physical acti'ity) once a day mo'e each +oint through its full !7?.
Out )atient
R !egular chec*-up for monitoring of de'elopment and if there are presence of
complication.
Diet
R Consult a nutritionist for a proper diet program.
Tips1
R $at nutritious and healthy food) to a'oid constipation. $at foods such as
oatmeal) (hole-grain breads and cereals) fruits and 'egetables.
R #rin* at least A-5: glasses of (ater a dayI limit the amount of soda) tea and
coffee.
Roosing (eight not only gi'e you loo* better) it helps you and your +oints feel
better and reduces pain.
Spirituality
RTell the patient2client to pray for Jod) for him nothing is impossible. As* for inner
strength to carry his trials
!earning E:perien-es
In doing this case study) the essence of patience and hard (or*ing (ere
al(ays there. $'erything I ha'e done entails patience) *no(ledge and s*ills in
doing research studies about the case. I ha'e learned a lot about proper nursing
inter'entions) rendering care to my patients) regarding the disease conditions)
manifestations and a lot more. 7ne should also need to analy0e all the significant
data to *no( the relationship of other data.
4hile in the other hand) my e%perience in "??C-?edical 4ard (as
honestly a big and challenging e%perienced in my life. It (as fortunate to ha'e a
good relationship to my group mates) hospital staffs and to my belo'ed clinical
instructor as (ell. 4hat happened in this rotation (as a lot of ne( ideas) ne(
learning and ne( applications for my field. In the (ard) I also learned a lot of ne(
procedures and I (as totally ama0ed and proud to myself because I am confident
in doing some procedures in the (ard. I admit that I ha'e committed a couple of
mista*es) but (hat is more important is (hat I'e learned from my mista*es.
I (ould li*e to than*) our e'er grateful) Jod Almighty) than* you so much
for gi'ing me strength to handle each situation confidently. To my dear CI)
?r. !ic* 4ilson Gunao) !") than* you for being effecti'e in the field. As a clinical
instructor) he emphasi0ed the 'alues of professionalism) respect and patience.
To my PCI that (as patience and understanding) than* you ?aam. To my
belo'ed parents (ho ha'e sho(n support and understanding in all acti'ities. And
to the &ospital Staffs (ho help and guide us for this rotation.
Referen-es
http122(((.google.com
http122(((.yahoo.com
http122(((.scrib.com
http122(((.nursingcrib.com
http122(((.(i*ipedia.com
http122(((.(ebmd.com
http122(((.emedicinehealth.com
http122(((.arthritis.about.com
http122(((.medicinenet.com