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1.

CHAPTER I THE PROBLEM AND ITS SETTING Every person gets old and when this happens, many

problems in the body occur. Getting old is often associated with having problems with the joint like rheumatism and other forms of the said disease that continually hunts not just aged people but even ordinary people with unfortunate fate of having the rheumatic problems. Rheumatoid arthritis (RA) disorder that is may a affect

chronic, systemic inflammatory

many tissues and organs, but principally attacks synovial 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 process the synovium. to The the pathology destruction of the of disease

often

leads

articular

cartilage and ankylosis of the joints. Rheumatoid arthritis can also produce diffuse inflammation and in also tissue.

the lungs, pericardium, pleura, nodular lesions, most common

and sclera, in

subcutaneous

Although the cause of rheumatoid arthritis is

2. unknown, autoimmunity plays a pivotal role in chronicity

and progression, and RA is considered a systemic autoimmune disease. Home Cures are possible for almost every health

disorder existing in the world. The old age people used to have higher living rates and they lived a healthy life as compared to the modern day human being. The sole logic

behind the fact is that they were dependent on the herbal remedies and home cures and not on the chemically treated drugs. Herbal medicines can be grown in your backyard and using them is as simple as growing them. The home cures have least side effects and they do not obstruct the normal growth of body. The herbal medicines contain all the

essential ingredients to treat any disease and that's why they are becoming more and more popular. Apparently, rheumatism is something that can be taken care of from home. The best point concerning a home remedy is that you have many options and, if you think that a particular ingredient does not suit you, you can try an alternative. You should give each remedy at least a week before trying another. This type of natural treatment

3. avoids the conventional medicine that is used in various treatments done today.

General Objectives This study aimed to determine the alternative and most effective home management practices for rheumatism. As a member of the health care provider aims to provide health teaching to manage this chronic illness effectively. Specific Objectives At the end of ten days of intensive care affiliation the student nurse will be able to: Assess the client and the complication of the disease. Teach to accept the findings as an awareness to

promote Healthy lifestyle and Safety living condition. Teach the client how to manage on her own condition especially at home management. Gain and widen knowledge about the entire disease

process formulate appropriate plan of care for the major.

4.

Client Profile Patient: Address: Age: Gender: Nationality: Religion: Leticia Rullan 201 Brgy. Manacnac Palayan City 60 years old Female Filipino Roman Catholic

Educational Attainment: High School Graduate Occupation: Storekeeper

Family History of Illness The patients family has history of hypertension on both side of the family. History of Present Illness The patient was diagnosed with Rheumatoid Arthritis and

Hypertension at Good Samaritan Hospital,4 months ago . Few day prior to consultation at the said hospital she

experienced headache, pain around nape area and stiffness

and joint pain. The doctor submitted her to several test like x-ray, pulse oximeter.

Past and Current Medical Condition Before she was diagnosed with rheumatism she is known to have Hypertension. She was advised to take rest everytime she feels stressed and avoid salty and fatty foods and

strenuous activities. History of Hospitalization and Surgical Operation The patient was hospitalized because of her hypertension and knows she preferred to have monthly check-up to a

private doctor and did not undergo from any surgery. Nutrition and Metabolic Pattern Usual food intake The patient usual fluid intake in the breakfast was 1 cup of rice, egg, and 1 glass of milk. Then in lunch time she preferred pork giniling. In dinner time, she has least food intake cup of rice and pinakbet. Usual Fluid Intake:

The usual fluid intake of my patient was 8-10 glasses of water a day. Food restriction: The doctor advised my patient to avoid salty and fatty foods. Problems with ability to eat: My patient told that she has no problem regarding

ability to eat. Supplementation: My patient vitamin was vitaplus. Elimination Pattern Urination: She urinate 5 times a day with a yellowish color and has no complaint. Bowels: My patient has bowel movement a day with a formed

stool and no complaint about it. Activity and Exercise Pattern Usual daily activities:

The usual daily activities of my patient was walkind around their house, cooking dish. Limitation of Physical activities: The patient doesnt engage in heavy work

Sleep and Rest Pattern She usually sleeps at around 9pm to 5am with a total of 8 hours of sleep. Vital Signs Wt- 58kg Ht- 52 Date 11-14-11 11-15-11 11-17-11 Bp 130/80 mmHg 130/80 mmHg 130/80 mmHg 11-18-11 130/80 mmHg 11-21-11 11-22-11 36C 70 19 T C 36C 36.1C P 75 70 73 R 20 20 21

SUMMARY PRESENTATION OF PATIENT ASESSMENT Body Parts Skull Assessment Findings No tenderness Normal noted palpation, generally with in and Scalp the round upon

prominent frontal occipital

area Lighter in color Normal than complexion; the no

Hair

Face

scars noted Slight dryness, Hair can be black or brown. brittle Nor brittle nor brown No involuntary Normal movement shape is noted, oval

Eyes

and rounded Slight blurred No decrease visual acuity vision, pupil Pupils react to light clear, Decreased

Ear

visual activity No drainage No ringing of ears Skin is same color with complexion

and accommodation Normal

Nose paranasal sinuses

No hearing loss and No discharges, Normal no noted palpation Nasal septum normally straight and not perforated tenderness on

Neck and Throat Chest

Soft, no swollen Normal lymph nodes With expansion Normal and respiration Normal breath sounds No cough Thorax is symmetric

Abdomen

RR-20 soft, tender, Umbilicus

non Normal

is

midline

and

inverted with no signs Upper extremities of

discoloration Swelling pain of symmetrically even in color, warmth and the fingers moisture without swelling No edema

lower Extremities

Swelling pain of Both legs are symmetric in size the joints No swelling or atrophy

CHAPTER II CASE DISCUSSION/PRESENTATION PATHOPHYSIOLOGY

Presentation of antigen to T cells

T- and B-cell proliferation. Angiogenesis in synovial lining

Swelling in small joints, associated with pain, stiffness and fatigue.

Neutophil accumulation in synovial fluid. Cell proliferation. No cartilage invasion

Warm, swollen, effusion, pain, and decreased motion with possible rheumatoid nodules.

Synovitis. Early pannus invasion. Chondrocyte activation. Degradation of cartilage by proteinase.

Increase in severity of physical sign and symptoms.

Figure 1. medical surgical nursing In RA, the autoimmune reaction primarily occurs in the synovial tissue. Phagocytosis produces enzymes within the joint. The enzymes break down collagen causing edema, proliferation of the synovial membrane, and ultimately pannus formation. Pannus destroy cartilage and erodes the bone. The consequence is loss of articular surface and joint motion. Muscle fibers undergo degenerative changes. Tendon and ligament elasticity and contractile power are lost. Pathophysiology of my client Sign and symptoms

Stiffness: The joint does not move as well as it once did. Its range of motion (the extent to which the appendage of the joint, such as the arm, leg, or finger, can move in different directions) may be reduced. Typically, stiffness is most noticeable in the morning and improves later in the day. Inflammation: Redness, tenderness, and warmth are the hallmarks of inflammation. Swelling: The area around the affected joint is swollen and puffy. Risk Factors Age Although rheumatoid arthritis can occur at any age from childhood to old age, onset usually begins between the ages of 30 - 50. Gender Women are more likely to develop RA than men. Family History Some people may inherit genes that make them more susceptible to developing RA, but a family history of RA does not appear to increase an individual's risk. Smoking Heavy long-term smoking is a very strong risk factor for RA, particularly in patients without a family history of the disease. Female gender. After the age of 65, women have a much higher risk of developing osteoporosis Diagnostic Exam

When she was hospitalized last year because of hypertension, she diagnosed also with rheumatoid arthritis she undergo with an x-ray. The result was she has a rheumatoid arthritis. Prevention The first step in helping to prevent or reverse arthritis is proper cellular nutrition. You want to fill your body with good antioxidants, so the free radicals roaming around in your system are neutralized and flushed out of your body before they can do more harm. In the past, good cellular nutrition meant eating the right fruits and veggies every day, but things are more complicated now. Because of the degradation of our food supply, it's harder to get the good antioxidants you need straight from the grocery store. Of course, eating a healthy balanced diet full of fruits and veggies is still a good start, but you need to make sure you're properly supplementing your diet with antioxidants and minerals. Complication Rheumatoid arthritis can affect other parts of the body as well as the joints. Some patients with severe disease may then be at higher risk for complications, such as the following: Peripheral Neuropathy. This condition affects the nerves, most often those in the hands and feet. It can result in tingling, numbness, or burning. Muscle problems. Many patients have weakness of the muscles. Anemia. People with RA may develop anemia, which involves a decrease in the number of red blood cells.

Scleritis and Episcleritis. This is an inflammation of the blood vessels in the eye that can result in corneal damage. Symptoms include redness of the eye and a gritty sensation. Infections. Patients with RA have a higher risk for infections, particularly if they are treated only with immune-suppressing drugs (corticosteroids, anti-tumor necrosis factors, disease modifying drugs). Skin Problems. Skin problems are common, particularly on the fingers and under the nails. Some patients develop severe skin complications that include rash, ulcers, blisters (which may bleed in some cases), lumps under the skin, and other problems. Severe skin disease can reflects a more serious case of RA in general. Kidney. Although rheumatoid arthritis only rarely involves the kidney, many of the drugs used to treat it can damage kidneys. Heart Disease. Patients with RA have increased risk for death from coronary artery disease. Research suggests that he chronic inflammation associated with RA may be a factor.

Nursing Management Physical therapy helps preserve and improve range of motion, increase muscle strength, and reduce pain. Hydrotherapy involves exercising or relaxing in warm water. Being in water reduces the weight on your joints. The warmth relaxes your muscles and helps relieve pain. Relaxation therapy teaches techniques for releasing muscle tension, which helps relieve pain.

Both heat and cold treatments can relieve pain and reduce inflammation. Some people's pain responds better to heat and other's to cold. Heat can be applied by ultrasound, microwaves, warm wax, or moist compresses. Most of these are done in the medical office, although moist compresses can be applied at home. Cold can be applied with ice packs at home.( Medical Surgical Nursing) Medical Management In some cases, reconstructive surgery and/or joint replacement operations provide the best outcome Rheumatoid arthritis was traditionally treated in the past with a stepwise approach starting with nonsteroidal antiinflammatory drugs (NSAIDs) and progressing through more potent drugs such as glucocorticoids, diseasemodifying antirheumatic drugs (DMARDs), and biologic response modifiers. In the because because usually damage. past, DMARDs were avoided early in the disease of their potentially serious side effects and they did not often bring on remission. DMARDs were reserved for people who showed signs of joint

Over time, however, this strategy was recognized as being faulty, because people treated early with DMARDs have better long-term outcomes, with greater preservation of function, less work disability, and a smaller risk of premature death. The goal of drug treatment is to induce remission or at least eliminate evidence of disease activity. DRUG STUDY

NAME Leflunomide (Activan) 10-20


mg once daily

ACTIO N Anal Gesic /anti Pyretic s and muscle relaxa nt Hormo nes and related drugs

INDICAT ION Active RA in adult patients

CONTRAINDIC ATION Severe deficiency of the immune system

SIDE EFFECT Incresase BP; diarrhea, nausea and vomiting, abdominal pain Fluid and elecrtroLyte, muscosk eletal , GIT disturban ces

NSG RESPONS IBILITIES


Watch for impairment of liver function, severe hypoproteine mia

May be taken with or without food


W/draw from long-term therapy gradually.

Methylprednisol one (medrol) 200


mg/day

DOLO-Neurobion

Analge Sic/ antiPyreti c and muscle relaxa nt

Endocri ne, rheumat ic And hema Tologica l disorder s Neuri tis, neuralgia

Systemic fungal infection

Monitor BP, salt, water & K. Pregnancy & lactation.

Acute intermittent porphyria, decompensate d cardiac insufficiency

Rarely allergy caused by vit. B1.

May be taken with or without food (May be taken w/ meals to reduce GI discomfo rt.). Watch for rash & other allergic reaction

NURSING CARE PLAN Rheumatoid Arthritis ASSESSMENT DIAGNOSIS NSG. OBJECTIVES


After 2 weeks of nursing intervention the patient will:

INTERVENTION

RATIONALE

SUBJECTIVE:

Napakasakit ng mga kasukasuhan ko (I'm having severe joint pain) as verbalized by the patient.

Acute pain r/t distension of tissues by accumulation of fluid.

Independent Investig ate reports of pain, noting location and intensit y(scale of 0 10). Note precipit ating factors and nonverba l pain cues. Recommen d/provid e firm mattress or bedboard , small pillow. Elevate linens Helpful in determi ning pain managem ent needs and effecti veness of program

>Report pain is relieved/ controlled

OBJECTIVE:

>Appear relaxed, able to sleep/rest and participate in activities appropriately >Follow prescribed pharmacologica l regimen.

Guarding /protect ive behavior Restless

ness

Soft/sagging mattress, large pillows prevent maintenance of proper body alignment, placing stress on affected joints. Elevation of bed linens reduces pressure on inflamed/painf ul joints. In severe

>Incorporate

facial grimacin g pain scale of 7 out of 10 V/S taken as follows 37.5C

relaxation skills and diversional activities into pain control program

with bed cradle as needed.

disease/acute exacerbation, total bedrest may be necessary (until objective and subjective improvements are noted) to limit pain/injury to joint.

T:

P: 100 R: 20 BP: 120/ 80

ASA exerts an antiinflammatory and mild analgesic effect, decreasing stiffness and increasing mobility. ASA must be taken Collaborative regularly to sustain a therapeutic blood level. Research Apply ice or indicates that cold packs ASA has the when indicated lowest toxicity index Assist with of commonly physical prescribed therapies,

Suggest patient assume position of comfort while in bed or sitting in chair. Promote bedrest as indicate d.

Cold may relieve pain and swelling during acute episodes. Provides sustained heat to reduce pain and improve ROM of affected joints

e.g., paraffin glove, whirlpool baths.

NSAIDs. Characterist ics of antiinflammatory and immune modifier effects coupled with ability to block metalloprotein ases

Administer medications as indicated Salicylates, e.g., aspirin (ASA) (Acuprin, Ecotrin, ZORprin);

ASSESSMEN T

DIAGNOSI S

PLANNING

INTERVENTION

RATIONAL E

EVALUATI ON

SUBJECTIV E: SUMASAKI T RAYUMA KO, HIRAP AKONG LUMAKAD IMPAIRED PHYSICAL MOBILITY RELATED TO PAIN ON BOTH EXTREMIT IES, AS EVIDENCE D BY DISCOMFO RT AND RESTLESS NESS TO PROMOTE COMFORT AND PREVENT OTHER COMPLICAT ION.

>SUPPORT AREAS

OBJECTIVE : >PAIN ON BOTH EXTREMITI ES PAIN SCALE OF 3/5 >DISCOMFO RT >RESTLESS NESS >UNABLE TO WALK >SWELLING ON BOTH EXTREMITI ES

>ASSIST WITH TREATMENT OF UNDERLYING CONDITION CAUSING PAIN LIKE ADMINISTER MEDICATION PRIOR TO ACTIVITY AS NEEDED FOR PAIN RELIEF

>TO PERMIT MAXIMAL EFFORT IN ACTIVITY

AFTER RENDERIN G OF NURSING CARE PROMOTIO N OF MOVEMENT AND PREVENTI ON OF OTHER COMPLICA TION ATTAINED

>ENCOURAGE PARTICIPATION IN SELF CARE, DIVERTIONAL ACTIVITY READING NEWSPAPER SOCIALIZA TION

GOAL WAS MET.

>ENHANCE SELF CONCEPT IN SENSE OF INDEPEND ENT.

>ENCOURAGE ADEQUATE INTAKE OF FLUIDS/

NUTRITIOUS FOOD

COLLABORATIVE:

REFERRAL TO A PHYSICAL THERAPIST.

>PROMOTE S WELL BEING IN MAXIMIZE S ENERGY PRODUCTI ON.

ASSESSMENT

DIAGNOS IS

PLANNING

INTERVENTI ON

RATIONALE

EVALUATION

SUBJECTIVE NANGHIHINA AKO AS VERBALIZED BY THE PATIENT. OBJECTIVE: DECREASED FUNCTIONAL ACTIVITY RESTLESSNE SS FACIAL EXPRESSION : YAWNING, SADNESS INTERRUPTED SLEEP

FATIGUE RELATED TO INCREAS ED DISEASE ACTIVIT Y

AFTER 5 DAYS OF NURSING INTERVEN TION THE PATIENT WILL: VERBA LIZED/ DEMONSTRAT ES INCREASED ABILITY TO MOVE PURPOSE FULLY

INDEPENDEN T PROVIDE PERIODS OF UNINTERRUPTED REST THROUGHOUT DAY (30 MIN 3-4 TIMES A DAY) ALTERNATIN G ACTIVITY WITH REST CLIENT OFTEN HAVE LIMITED ENERGY RESERVE.

CLIENT OFTEN USES ENERGY THAN OTHER TO COMPLETE SAME TASKS.

AFTER RENDERING OF NURSING CARE PROMOTION OF MOVEMENT AND PREVENTION OF OTHER COMPLICATI ON ATTAINED

GOAL WAS MET.

V/S BP- 130/80 MMHG

INTERRUPTED SLEEP:

WARM ENCOURAGE WATER WARM RELAXES SHOWER OR MUSCLE , BOTH

T- 36.3C PR -75 RR-19

IMMEDIATELY BEFORE BEDTIME

FACILITATI NG TOTAL BODY ENCOURAGE RELAXATION GENTLE TO ROM MAXIMIZE EXERCISE EFFECTS OF AFTER HEAT BATH COLLABORA -TIVE: ADMINISTER NIGHTIME ANALGESIC / LONGACTING ANTIINFLAMA TORY DRUGS AS PRESCRIBED

REDUCES MODERATE INFLAMMATION

Foreign Literature In Philippines as well as in many other countries there is a general overview of the health of the

population based on a national survey. Therefore it is the time to look at the population risk groups. Rheumatism is

the

most

frequent in the aged

illness United

diagnosed more over

in

population. 12% of

For the with

example, population rheumatoid

Kingdom and

than are the

65

years In

affected age

arthritis.

Finland,

adjusted

incidence of rheumatoid arthritis in the adult population was 31.7/100,000. Projecting to the year 2020, an estimated 18.2% of Americans will be affected by arthritic disorders, equivalent to 60 million people. The spread of these

illnesses will increase in the coming years for several reasons. First, the trends in demographic changes indicate that the proportion growing. of older people ageing in is population accompanied is by

constantly

Secondly,

chronic diseases, including musculoskeletal disorders. According to Dr. Edward R. Laskowski of the Mayo

Clinic, the application of heat or ice may be useful in the healing swollen, process. red and In general, you should Acute use ice for is

painful

joints.

inflammation

often damaging to our own tissues; in cases of rheumatism, the inflammation is actually doing more damage than the original problem. Therefore, ice is recommended in order to inhibit inflammation; this occurs via reduced blood flow and decreased swelling.

However,

if

the

condition

has

been

present

for

significant period of time, blood flow should be stimulated in order to promote an active healing process. Chronic

inflammation may lead to the deposition of scar tissue, which acts to inhibit your body's natural repair processes. By applying heat, your blood vessels are forced to dilate and allow more blood to enter the area.

(http://www.livestrong.com/article/330159-exercises-for-rheumatism/,
mayoclinic.com , www.google.com)

Overall, the body's immune response has one primary function: to protect the body from an object that the body does not recognize as a normal object. The immune response can be either normal or abnormal. Inflammation is also one of the body's first responses to infections as the body tries to rush immune cells and cytotoxic chemicals to the infected tissue to defend against the infections or foreign particles. Arthritis tends to develop inflammation in the joints and their surrounding tissues. Rheumatoid arthritis is an autoimmune disease where the body perceives tissue in the joints as being a foreign object and fights the tissue through an immune response. Tests for rheumatoid arthritis are rather simple and readily available. Rheumatoid arthritis has many options available for treatment such as medications and minor surgeries. Future advancements are continually being tested in clinical settings to help in improving treatment for rheumatoid arthritis patients. (Lethbridge Research Journal. 2007. Volume 2 Number 1.)

There are many alternative methods a person can do to treat their rheumatism. Especially if they have rheumatism in their knees. Put on a good liniment like icy hot or Ben Gay before you go to sleep. When you awake, your knees will not be stiff. Do not walk or stand when you are in pain. Sit down and take a rest for a while. Do not push yourself. Know your limitations. Get the right kind of exercise. Exercises like bike riding,

swimming, walking and floor exercises are all good for the joints. Make sure you get your doctor's permission before starting any exercise program. Three time a week for 30 minutes at a time is plenty of time for a exercise regime. Do you or someone that you love suffer from rheumatoid arthritis? If so, the pain and discomfort that is commonly

associated with rheumatoid arthritis may be too much to handle. When it is, there are many rheumatism sufferers

who turn to over-the-counter medications to seek relief. Yes, these over-the-counter medications will work in most cases, but did you also know that there are natural and safe ways to manage and treat rheumatism? There are and a

few of these natural remedies are highlighted below. The natural types consumption remedy come for of raw juices is an effective Two and

rheumatoid rated

arthritis. and

specific are green

that

highly

recommended

juices, as well as potato juice. been used to treat the pain

In fact, potato juice has and discomfort commonly For

associated with rheumatoid arthritis for years on end. potato juice, cut a potato into thin slices. so, leave the skin intact.

When doing

Place the potato slices in a

glass of cold water and leave sitting for a few hours, overnight is best. Then drink.

The consumption of Omega 3 Fatty Acids are another natural way to treat many of the symptoms of arthritis. Omega 3 Fatty Acids are found in most fish. not like eating Those who do 3

fish are encouraged to examine Omega

Fatty Acid supplements, which are available for sale at most drug stores and health stores. This natural remedy

can provide relief from all forms of arthritis; however, those with rheumatoid arthritis see and feel the best

results. Warm olive oil massaged over the area is another easy and natural way to relieve the What pain is and nice discomfort about this

associated

with

arthritis.

approach is that most individuals already have olive oil in their homes. When using warm olive oil, be sure to let

cool a little, as olive oil that is too hot can result in painful skin burns. In addition to plain olive oil, sage,

rosemary, or garlic can be diluted with olive oil, with

about ten more parts of olive oil.

When applied to the

impacted area, relief should be felt immediately. Baths are another natural way to treat the pain and discomfort often associated with arthritis. When using

baths to seek relief, warm baths are advised.

In fact,

cold bathes can result in increased pain, which is not the goal. In addition to a traditional warm bath, many of

those suffering from arthritis recommend adding about three or four tablespoons of Epson salt to the bathwater. Those

diagnosed with arthritis should remain in a warm bath for at least thirty minutes. Small amounts of exercise is another natural way to relieve the pain and discomfort commonly associated with arthritis. arthritis concerned. The only problem is that those suffering from must proceed with caution where exercise is

Moving around, whether it be through walking or

squeezing a stress ball, can help, but it also important not to over do it. Those who overexert themselves are

likely to experience even more pain and discomfort. As you can see, there are a number of natural remedies and home remedies that can be used to seek relief from arthritis. If you are not suffering from arthritis, but if

you know someone who is, you may want to pass these easy and natural remedies onto that person. Unfortunately, many

individuals are unaware of natural remedies and their many benefits.(http://www.knrn.org/natural-remedies-for-arthritis.html,


www.google.com)

Local Literature

Holistic tropical center

Healing of

in

the

Philippines AM

Located

on

the a to

island using

Cebu,

Philippines, and

Wellness

is

holistic

healing

natural

therapy

overcome disease and achieve total health and well-being. We also teach our students the keys to life-long health through diet. Rather than use the word patient, we prefer to call the people who come here students because they are here not only to be cured but also to experience how to remain healthy and disease-free for the rest of their lives. Our naturopathy treatments courses run between 12 days and 4 weeks or more, and include detoxification, herbal colon cleansing, mud/water/sun therapies, water cleansing, fasting, alternative medicines, and exercise. These are the practice of yoga, meditation and vegetarian

complemented by music, art, classes, outings and games. We do not offer out-patient short-term care.

The Wellness Center Situated in a quiet neighborhood of Pagsabungan, Mandaue, Cebu, the Ananda Marga Wellness Center is the countrys center. first It affordable a stay-in holistic

alternative

healing

practices

approach to health through various natural therapies, the practice of yoga, meditation and vegetarian diet. We do not only assist our students in their healing, but we also

teach them the path to life-long health. EMPOWERS PEOPLE - to overcome problems caused by excess fat, stress and disease - to cure themselves through a system of natural therapy without depending on medicines to become physically fit, mentally relaxed and fully

conscious to learn new healthy systems of eating, exercise,

drinking water and harmonious thought We offer a complete systematic, in-patient natural therapy program. Daily activities are not only therapeutic but also entertaining and educative.

OUR MAIN THERAPIES

- a nutritious, delicious DIET of alkaline food (fruits, vegetables and other light vegetarian food), freeing the digestive system from its normal burdens so the body can naturally heal itself - our unique SUPER HERBAL DETOX, which is superior to any leading absorbs colon toxins cleansing from the herbal products. It not but only also

digestive

system,

ultimately from the entire body. It is vital for getting a new start in your life. - an exercise program with a wide range: a) gentle YOGA POSTURES walking for and the mild glands and nerves b) SLOW EXERCISE games c) VIGOROUS EXERCISE of of

brisk

walking & running, treadmill, swimming (at a nearby pool), aerobic dance and active games - various individually prescribed treatments include MUD PACK applying hygienic mud to specific areas of need, or in some cases to the whole body both absorbing toxins and attracting healing blood STEAMBATH to sweat out toxins, while keeping the face in fresh air (not like sauna, which compels one to breathe in toxic air) HOT FOOTBATH also to sweat out toxins, with a

particular effect on lower body and lung problems

COLEMA (in between COLonic machine and EnEMA) internally cleansing the intestines SPINAL BATH to cool the spine only, our best physical treatment for releasing stress WARM CIDER VINEGAR BATH done only just before sleeping for those who have difficulty to sleep, enabling nerves to thoroughly relax HYDRO BUBBLE BATH with 300 jets of warm or hot water, directed at specific areas of the needy body, together with aromatic oils SYSTEMATIC SUNBATH alternating in and out of the sun, with water or oil massage according to need, for fixed

number of minutes and during a fixed interval HIPBATH attracting healing blood to the lower internal organs including the digestive organs and the female organs HOT WATER BAGS AND ICE PACKS depending on whether one needs heat for relaxation or cold for healing - WATER-DRINKING SYSTEM, 3 to 4 litres or more daily, to cleanse toxins - MENTAL EXERCISE & MEDITATION (including deep relaxation and visualization) to convert stress into calm positivism

- a graduated program of specialized ELIMINATION DIETS & FASTING on juices, broths, fruits and/or vegetables for

several days.(http://manilasector.org/?p=92, www.google.com) Autoreactivity plays a major role in the pathogenesis of RA. The rheumatoid factor has been and still is for now more than 50 years the only autoreactivity that is clinically applied in the diagnosis of RA. This well reflects the current way of thinking that a single antigen or a single cause drives an individual into disease. Although by now many other autoantigens and autoreactivities have been described, their discovery was always on the search for the one and only autoreactivity that causes RA. This includes also immune reactivities directed against xenogenic antigens. But, none of the known RA-associated autoreactivities is present in all RA patients and none of them occurs exclusively in RA. Thus, the observed sensitivities and specificities are well below 100%. Therefore, RA has often been postulated to consist of various immunological subentities with similar clinical symptoms. Nevertheless, none of the autoreactivities correlates with a distinct clinical feature or course of disease. It is about time to say goodbye to the idea that a single antigen or

immunoreactvity causes and maintains rheumatoid arthritis. In this paper we present RA as the clinical outcome of an immune system that has shifted from a healthy to an autoimmune steady state. This is accomplished by many different reactivities and autoreactivities that occur either in parallel or one after the other. The entirety of the known RA-associated reactivities and (auto)antigens is presented in detail. The major RArelevant autoantigens comprise BiP, citrulline, the Saantigen, hnRNP A2, p205, IgG, calpastatin, calreticulin, collagen and the shared HLA-DR epitope. The accumulation of factor--involving autoreactivities, cytokines, environmental and genetic factors--that challenge the normal regulatory mechanisms of the immune system lead to a regulatory catastrophe. (Z Rheumatol. 2007 Feb;60(1):1-1)

Foreign Studies Recent studies using tumor necrosis factor-alpha inhibitors, both alone and in combination with other medications, have shown that patients demonstrate

significant improvement based on American College of Rheumatology criteria (Felson et al.,2006) Respondents to a population pain survey who had

reported having musculoskeletal pain in the survey and who had consulted 12 and about months their as pain as in primary care to in the

previous research

well to an

consenting

further was

agreeing

interview.

Information

gathered about their pain and the use of all treatments for pain, including CAM, in the previous year. Background Surveys have suggested medicines that (CAM) use is of high complementary and and

alternative

increasing

worldwide. Longitudinal studies in the UK between 1993 and 1999, 1995 and 2001 and between 1998 and 2006 and in the USA between 1990 and 1997 have confirmed the trend. CAM is most commonly used for chronic pain and in particular

musculoskeletal pain and is often used in combination with conventional therapies. GPs are the conventional medical

practitioners most frequently consulted for chronic pain in the UK. A number of surveys use. have of been these conducted were in the UK to

explore surveys,

CAM

Some

general with

population definitive

surveys

among

patients

rheumatologic

diagnoses

attending

hospital

clinics,

or

surveys

of

healthcare

professionals

exploring

their

patients' use of CAM and access to it. In primary care in the UK, surveys targeted healthcare

professionals rather than patients. We are not aware of surveys conducted in the UK that have directly explored CAM use among primary care patients who suffer from chronic musculoskeletal pain. Evidence suggests that users do not necessarily access CAM through primary care and also they are often reluctant to inform their doctors of their use of these treatments. Figures on access to CAM through primary care and on health have professionals' provision actual of CAM CAM, use

therefore,

might

under-represented

among primary care patients. We are not aware of previous surveys of primary care patients that have enquired about the perceived helpfulness of treatments for from the patients' perspectives. seeking This is

important

understanding

healthcare

behaviour

among chronic pain sufferers, for informing effective pain management in primary care and because of potential safety issues related to CAM use. We focus wanted to address these pain issues with who particular are using

on

musculoskeletal

sufferers

primary care in the UK. We have therefore investigated the pattern of CAM use in a sample of chronic musculoskeletal

pain patients who were consulting primary care in the UK. Our hypothesis was that this group of patients would have a higher prevalence of CAM use than general population

samples or pain sufferers generally. This was based on the idea that this than group the will have selectively more severe have

problems

general

population

because

they

sought health care and because chronic musculoskeletal pain is often unresponsive to conventional primary care

treatment http://www.google.com An alternative treatment approach for RA has emerged in the area of biologic therapies. Biologic response

modifiers are a group of agents that consist of molecules produced by cells of the immune system or by cells that participate in the inflammatory reaction. (Koopman,2006)

Local Study In initiating a community oriented programme for the control of rheumatic disease (COPCORD), 1685 people of all ages from a rural area in the Philippines were questioned by primary health care workers (PHW) for limb and spinal rheumatic pain and disability. The total complaint rate was 15.3% for men and 18.5% for women. For those 15 years and

older present

the at

age the and

adjusted time 22.6%

rheumatic of survey

pain were UK

rates 28.4%

for for

pain the The

Philippines

for

Lawrence's

population.

most common rheumatic pain sites in this community were knee, lumbar spine, neck and the trapezius muscle. The

disability rate was 4.5% for those 15 years and older. One quarter of those with pain had received medical attention and the remainder, herbal treatment, massage, various faith and/or self-treatment methods. (http://www.springerlink.com/content/gg813l16x4690623/, www.google.com) The Study of Active Controlled Monotherapy Used for Rheumatoid Arthritis, An IL-6 Inhibitor (SAMURAI) study demonstrated that, compared with DMARDs, tocilizumab monotherapy significantly inhibited progression of structural damage in Japanese RA patients.[21] In addition, preliminary results reported from the Tocilizumab Safety and the Prevention of Structural Joint Damage (LITHE) study showed that, compared with MTX alone, tocilizumab plus MTX treatment resulted in significantly less progression of joint destruction.[22] In the present study, X-ray images at baseline and at Week 52 of tocilizumab treatment were available for 149 of 232 patients, allowing us to evaluate the radiographic effect of tocilizumab. As stated above, the duration of disease in patients enrolled in this study

was 12.4 years, and estimated yearly progression was significantly high, with 20.8 (1.3) at baseline. Considering the results of the impact on radiographic and clinical response to infliximab therapy concomitant with methotrexate in patients with rheumatoid arthritis by trough serum level in a dose escalating (RISING) study, in which we reported a disease duration of ~8 years and mean estimated yearly progression of 8.1 (9.1) the present

study included patients with remarkably severe clinical features with long disease duration and progressive joint destruction. Irrespective of these severe conditions, the 95% inhibitory effect of tocilizumab indicates how powerful its inhibition of joint destruction is. Surprisingly, we found that tocilizumab inhibits the radiographic damage, not only in patients treated without TNF inhibitors, but also in those treated with TNF inhibitors. Although further research is needed, our findings suggest that the pathological condition of RA is dependent on TNF. The good results obtained with tocilizumab are consistent with those of both domestic and foreign studies. ( http://www.medscape.com/viewarticle/750779_4)

CHAPTER III METHODS AND PROCEDURE FOR DATA GATHERING DATA GATHERING TECHNIQUE The Data Gathering Technique used is Interview, Survey Home Visits and Questionnaires. To answer the research problems the student nurse used a non-experimental design, questionnaires, survey study.

Questionnaire aim research for

to gather information for purposes of surveys, analysis or even to

market

corroborate other research findings.

They are one of the It is to be

cheapest and most feasible ways of gathering data. important to remember that for any questionnaire

really effective it has to be designed well. Interview is used to collect form facts, are structured interviews more in than their oral

simplest

sometimes

little

questionnaires. The student nurse interview the client by asking the questions in the questionnaire prepared by the Clinical Instructor, it is done to obtain a higher response rate with respondents, especially children, who might not be literate or capable of correctly completing a complex

questionnaire. The student nurse also brought instruments for assessment of the clients present condition.

ADMINISTRATION OF INSTRUMENT The student nurses of Nueva Ecija University of Science and Technology together with their Clinical Instructors first asked for the permission of the Barangay Captain before conducting their case study. We also gathered that Barangay Manacnac have a total population of 1652 and total house hold of 457. the student After gaining the Barangay Captains approval nurse first visited one of the respondents

house which became her client. She gather information by means of an interview, certain questions were asked about the clients profile and her past and present medical

status. Basic instruments such as thermometer, BP cuff and sphygmomanometer was used to assess the clients vital

signs. Weighing scale was also used to get the clients weight, the information acquired serves as the primary

information about the client for the case study.

LOCALE OF THE STUDY History of Manacnac

Ang kabisera ng lalawigan ng Nueva Ecija ay ang lungsod ng Palayan. Dito matatagpuan ang Barangay Manacnac. Ayon sa kasaysayan, na sakop ang Manacnac ay dating sitio ng

Maligaya

ng Laur, Nueva Ecija na may kaunting

populasyon, taong 1953 si Ginoong Anong Simanero ang naging kapitan sa lugar na ito. Kung iyong makikita ang Barangay na ito, para kang nasa isang bundok na malayo sa kabayanan. Ang lugar na ito ay may gulod na ang makikita ay puro mga damo at talahib maliban lamang sa piggery na pag-aari ng mga Wycoco. Tanong 1965 ng mapagpasyahan ng kongreso ng Pilipinas na ang Palayan City ang magiging bagong kapital ng Nueva Ecija. December 5, 1965 ang inaguration ng City Government sa Palayan napagpasyahan ito ni ex-official Mayor Eduardo L. Joson.Sina Mayor Elpidio O. Cucio at kanyang Vice Mayor na si Felipe Bautista ay nahalal bilang unang subsequent local official. Taong 1966 nang naging Kapitan si G. Romulo V.

Sandoval sa Barangay Manacnac noong ang barangay na ito ay sakop parin ng Laur. Nang panahong iyon may isang dayuhan na nanggaling sa Novaliches Q.C. ang nag interas na bumili ng lupa sa nasabing barangay at dito na rin siya nanirahan. Siya ay si Ginoong Pedro Valenzuela. Nag-donate ng

kalahating hektaryang lupa para sa eskwelahan ng Cabanatuan City at Atate, pumapasol ang mga batang nag-aaral noon dito. Taong 1972 nang dahil sa ordinansang pinasa bg

Sanggunian, Ang barangay Manacnac ay naging isang barangay sa Palayan City at nang panahong iyon ay kapitan parin si Ginoong Sandoval. Taong 1976 tumaas muli ang populasyon ng barangay mula sa bilang na 662 ay naging 852 at may bilang na 128 ang bubong ng bahay, may pamilyang 131 nang sumapit ang EDSA Revolution taong 1986 itinalaga ni Kgg. Presidente Aquino si Don Pacifico M. Fajardo na OIC ng Palayan City at Vice si Flor Agustib na kasalukuyang kapitan parin si Romulo V. Sandoval.

LOCATION MAP

Sampling Design Purposive sampling starts with a purpose in mind and the sample is thus selected to include people of interest and exclude those who do not suit the purpose. This method is popular with newspapers and magazines which want to make a particular point. This is also true for marketing researchers who are seeking support for their product. They typically start with people in the street, first approaching only 'likely suspects' and then starting with questions that reject people who do not suit. Purposive sampling is non-probability and hence can be subject to bias and error.
http://changingminds.org/explanations/research/sampling/purposive_samplin g.htm)

CHAPTER IV CONCLUSION AND RECOMMENDATION CONCLUSIONS In the light of above findings of the study, the

following conclusions were arrived at: 1. That the most common problems encountered in physical aspect of the respondents is pain, followed by fatigue, eating disorder, weight loss, anemia. 2. The most common problem encountered in emotional aspect is feeling helplessness followed by loneliness, anxiety and fear. 3. The most common problem encountered in social aspect is delaying on immediate job or meeting followed by

withdrawing from social activities, and decreased number of friends. 4. The most common problem encountered in economical is shortage of money followed by delayed pension, change of employment, early retirement. 5. The most common is home wearing management pajamas when it comes is to the

physical

aspect

because

that

simplest way to prevent too much exposure to cold climate.

Followed by sleeping 8 hours a day, taking steam bathing, massage the affected area, wearing stocky net/socks,

applying hot compress on the affected area, and applying cold packs on affected area. 6. All remedies they choose, the most effective remedies is efficascent oil followed by pau linament oil, white flower and Betet were used as home remedies. 8. Pain reliever medications were prescribed because of

effectiveness of drug followed by taking over the counter medicine, and taking extra supplement. 9. Maintaining proper body position is the simplest way to prevent further deterioration of the cartilages thats why it prevents too much pain. Followed by avoiding heavy

works, elevating their legs, attending aerobics exercise at least twice a week, always engage in brisk walking every morning. 10. Home management for eating disorder the most convenient is eating fruits and vegetables because they can acquired it immediately and affordable to their backyards. Followed by eating green leafy vegetables like malungay, talbos ng kamote, eating food rich in omega 3 fatty acids and fish oil such as canned tuna etc., avoiding eating food rich in

uric

acid

such

as

mongo,

sitaw,

gizzards,

nuts,

and

drinking at least one glass of milk a day. 11. The home management in social aspect is watching

television because they divert their attention to forget the pain. Followed by playing with their grandson, reading books and newspaper, and going to mall with their

relatives, going to amusement park, and playing chess with their friends.

RECOMMENDATIONS The researchers of the study hereby recommend that: 1. Relatives must provide knowledge to the elderly with regards to home remedies and proper practices because old aged are easily forget their activities. Practices vary

according to the individual but tasked could be done with encouragement. 2. Patient should able to manage their activity daily

living to lessen the factor that can cause Rheumatism to occur. They should also practice to limit eating rich in uric acid such as monggo, sitaw, gizzards etc., because the crystals of uric acid are deposited in the joints that

causing pain.

3.

Patient

should

have

awareness

about

Rheumatism

by

discussing this home management and affective practices as the primary prevention for further deteriorations of body functions, the disease process of Rheumatism

BIBLIOGRAPHY Bautista Joy,THEORETICAL FOUNDATION OF NURSING. A Beginner Journey Into Professional Nursing. first edition 2008 Brunner & Suddarths Textbook of Medical-Surgical Nursing. eleventh edition 2008 Cacanindin,Nursing research : study notes and guide. 2010. by C&E Publishing, inc. 839 EDSA South Triangle, Quezon city Concise Oxford English Dictionary eleventh edition Seeley, Stephens, & Tate Essentials Physiology sixth edition 2007. Of Anatomy And

www.google.com;rheumatismworldhealthorganization
http://www.disabled-world.com/health/autoimmunediseases /rheumatoid-arthritis/ra-diagnosis.php article 5 Galanes feb 2006/

www.google.com; http://www.livestrong.com/article/330159exercises-for-rheumatism/ mayoclinic.com article 1 Puzas January 2006 www.google.com; http:// www.knrn.org/natural-remedies-forarthritis.html/2005 article7 Gulanik www.google.com ; http://manilasector.org/?p=92,/2007 aricle3 klopp

ww. Google.com www.google.com; http://www.springerlink.com/content/gg813l16x4690623/, dec 2009

ACKNOWLEDGEMENT As a student nurse wish to acknowledge and express their deep appreciation and gratitude for the kind

assistance given by numerous people who helped them in the preparation of this case study. First and foremost, I want to offer sincerest

gratitude to my clinical instructor, Mrs. Girlie Tayao, RN, who was supported and guided me throughout my case study, for the humble sharing of her knowledge and experiences, for the motivation and overwhelming encouragement, and for her patience and understanding in checking my case.

To my staffing, Mr. Christian Gabuya for her wholehearted assistance and suggestions. To the Dean of College of Nursing, Mrs. Eppie DC.

Bugarin, RM, RN, Ph.D for her valuable contribution to this study. To the personnel of Barangay Manacnac Palayan City for providing necessary information to my research in

conducting this study. Lastly and most importantly, the God almighty who has given His great mercy and blessings for the years of study of the researchers and who has given them a great privilege to be His children. Angelica P. Bravo

DEDICATION

After sufferings,

all

the and

challenges, sleepless

trials, nights, I

hardships, made this

efforts

humble piece of work a successful one. So, with love and respect, I dedicate this priceless output to the following persons: To my clinical instructor Mrs. Girlie Tayao RN who lend her helping hands to guide me in the success of this study; To my loving parents who always extend their best love and care that serve as their inspiration in my studies; To support; Above all, to the Lord Jesus Christ who is the divine source of their strength, knowledge and abilities for my staffing who always give their everlasting

without Him, this work would have been in vain. To all of them, I am humbly dedicate this piece of work. Angelica P. Bravo TABLE OF CONTENS

Pag es Title i Acknowledgement ii Dedication iii Table of Contents .vi I. THE PROBLEM AND ITS SETTING Introduction 1 General Objectives 4 Specific Objectives 4 Clients Profile Foreign Studies 21 Local Studies 24