Care of the Patient with Arthritis

Arthritis is a chronic disease that causes painful swelling and inflammation in the joints, which limits movement. A joint is a site where two or more bones are attached and move against each other. At the site where the bones meet to form the joint, cartilage and a synovial membrane with fluid between the bones lubricate the joint movement. Below is a picture of an inflamed knee and a normal knee.

Osteoarthritis (OA) is a degenerative joint disease. Degenerative means the condition is declining or getting worse over time. It is the most common form of arthritis and is the leading cause of disability and pain in adults. OA slowly destroys the joint cartridge and synovial tissue that supports the body's weight. It is usually associated with older adults because of joint defects, overuse, injury, infection, or inflammatory diseases. However, OA can also occur in younger individuals due to trauma. When the cartilage attempts to repair itself, bone spurs form. This change causes joint pain, stiffness, and problems with mobility. Mobility means the ability to move around. A lack of mobility causes disability because the person cannot move their joints like normal. The movement may cause pain, or the joint may not move as much as it used to.

Symptoms of osteoarthritis vary depending on which joints are affected and the severity of the disease. Severity means how bad the problem is. However, most symptoms are pain and stiffness, usually first thing in the morning. The affected joint may become swollen after activity, and symptoms tend to get worse over time. The patient may also experience a limited range of motion due to swelling and pain. The patient may say they hear a clicking or cracking when the joint bends. Because of the pain and limited mobility, the patient may become sedentary. Sedentary means the person does not move around much and usually sits or lies around. This lifestyle can lead to additional medical problems like obesity, diabetes, or heart disease. A patient with Osteoarthritis has a 30% higher risk of falling and a 20% higher risk of fracture than a person without osteoarthritis (Arthritis Foundation, n.d.).

Care aims to improve and strengthen the muscles. It may also include a balance of rest and exercise, using heat and cold to relieve pain, adjustments in activities of daily living, weight loss, and using a cane or walker. Medications can be given to reduce pain and inflammation.

Rheumatoid arthritis (RA) is an autoimmune disease. The body's immune system normally protects against foreign objects like bacteria and viruses. However, in rheumatoid arthritis, the immune system gets confused and attacks the body’s joints instead (Arthritis Foundation, 2021). In the joint, or synovial area, RA forms inflammation, which thickens, resulting in pain at the joint. If the disease is allowed to continue, it will cause damage to the cartilage as well as the bone itself. Joints can become unstable and painful, as well as deformed.

Unlike Osteoarthritis, rheumatoid arthritis can affect the entire body. Patients with Rheumatoid arthritis may complain of fatigue, muscle aches, or a low-grade fever. In advanced stages, the patient may also have lumps under the skin called rheumatoid nodules, which can be tender to the touch. Rheumatoid arthritis cannot be reversed. However, it can be controlled with medication and some types of activity.

It is estimated that over 1.5 million people in the United States have rheumatoid arthritis, most of whom are women. Rheumatoid arthritis usually starts between 30 and 60 (Arthritis Foundation, 2021), but it starts later in life in men. There seems to be a genetic component, although RA's cause is unknown.

Rheumatoid arthritis has a gradual onset. In the early stages, the patient may notice redness or swelling at the joint or experience tenderness and pain. However, this continues to worsen over time and includes morning stiffness, fatigue, loss of appetite, and even a low-grade fever (Arthritis Foundation, 2021). Rheumatoid arthritis tends to affect more than one joint, including small and large joints of the knee or wrist, and typically affects joints on the same side of the body. Symptoms can come and go. The patient may also experience a flare of high inflammation that can last for days or months. The longer the inflammation continues, the more problems will be seen throughout the body. Some of these may include sensitivity to light, impaired vision, eye pain, dry mouth, gum irritation, lumps under the skin or bony areas, shortness of breath due to inflammation in the lungs, damage to nerve cells, skin, and other organs can be impacted due to inflammation in the blood vessels, and anemia (Arthritis Foundation, 2021). Studies also suggest a higher incidence of cardiovascular problems in individuals with Rheumatoid arthritis.

The goal of care is to prevent or reduce pain, stiffness, and swelling and maximize activity. Cares include rest, therapeutic exercises, and medication. Because this is a chronic disease, there is a need for consistent treatment that must be integrated into the person's daily activities. Hot and cold therapies may help to relieve some of the pain. The use of supportive shoes and other assistive devices may be used along with education positioning and body mechanics.

Chances are, you will have several patients with arthritis. This chronic disease forces them to change how they manage their daily lives. There are several things that you can do to help the patients. Remember that some days will be better than others for them. One day, they may be able to do several activities independently; other days, they may need a lot of help. When the patient has flare-ups that include inflammation, it will be important to check to make sure shoes or slippers fit correctly. It is also important to remind your patient to change positions frequently. This includes their neck, hands, arms, hips, and feet. Encouraging them to stretch often can help decrease the stiffness they feel in their joints. Remind the patient to use their strongest joints first and encourage them to sit in chairs with arms so they can push up when rising. Ensure the patient maintains a good balance between rest and activity. The patient may have splints or other devices to help them. Make sure you know how to use the splints and devices properly. Talk to your patient about proper posture since it can prevent additional joint damage. Encourage them to use assistive devices whenever possible.

The patient may have or be at high risk for muscle loss and contractures due to a lack of movement. Be sure to follow any range-of-motion exercise care plans. Do not over-extend a joint. With arthritis, the ability to bend a joint may be much less than normal. Follow the instructions carefully for each planned exercise. If you are unsure about any exercise or how it is performed, ask the nurse before proceeding. Be slow and gentle. Do not make the joint move past any resistance you feel or pain the patient shows. Support each joint by placing one hand above and the other below the joint. Encourage the patients to assist if they can. Be sure to observe if the patient is in pain or becomes uncomfortable. If you need to transfer the patient, use transfer assistive devices to make the move easier for you and the patient.

There are several areas to consider when working with a patient with arthritis. Not only does physical pain need to be addressed, but psychological issues, family issues, and societal issues may also need to be treated. The patient may feel fearful, anxious, or depressed at losing their independence and the ability to care for themselves. They may want information on self-care. The decrease in activity may lead to losing a job and financial stability. Changes in family roles and relationships may also concern the patient. Each area will need to be addressed, and care will be applied to help the patient cope both physically and emotionally. Emotional Support helps the patient to stay positive.

Here are some other ways that can be used to relieve pain and help the patient with daily activities. These treatments are delegated by nurses and detailed in the care plan (Sorrentino & Remmert, 2021). Medication may be used to help control pain and inflammation. Helping the patient with weight control through diet and passive exercise can lessen the strain on the joint and prevent further injury. Be sure to follow the care plan about diet and exercise.

Non-pharmacological pain control may include heat and cold packs, distraction techniques, or relaxation programs—for example, music or guided imagery. Heat increases blood flow and circulation to fight infection and take away fluids from swollen areas. Cold reduces blood flow, which slows down swelling and can the numbness reduce pain. Chemical ice and heat packs are activated by squishing the pack, creating a chemical reaction. There are also assorted hot and cold packs that are manually filled with ice or hot water. Protect the skin from direct contact with heat or cold packs. Padding must be used. There are also devices for soaking in hot or cold water (Sorrentino & Remmert, 2021). Make sure you know how to use the products.

Exercise increases flexibility, decreases pain, and helps improve blood flow. It can also help if weight control is problematic and can benefit mental well-being. For patients with arthritis, over-exercising can increase stress and pain. The swelling and pain may not be noticed for hours (Sorrentino & Remmert, 2021). Exercise will be determined in advance and noted on the care plan.

The patient with arthritis is at a greater risk for falls. Helping them with their activities of daily living may include using toilet seat risers, chairs with higher seats and arm sets, and using assistance devices to move positions or to walk(Sorrentino & Remmert, 2021). All of these actions help prevent falls.

Rest is important for the patient with arthritis, especially after exercising or increasing movement. Make sure the patient uses good body mechanics and posture, as well as canes or walkers for support. There should be a good balance between activity and rest.

Helping the family cope may also include changing family roles and responsibilities. Encouraging and praising patients when they do things independently can help them maintain a positive outlook (Sorrentino & Remmert, 2021).

Encourage patients to brush their teeth at least twice daily. An electric toothbrush may be helpful if the patient fatigues easily while holding a brush, and an oral rinse may also help with dry mouth. Devices to make the toothbrush handle larger and more accessible to hold are also available if the hands are affected by arthritis.

When dressing, it may be helpful to get shoes with Velcro straps instead of ties or use a long-handled shoehorn to put on shoes. If zippers are difficult to grab, use a ribbon tied to the zipper for the patient to grab instead. A long grabber can also help pick up items from the floor or lower areas. Chairs or stools in the kitchen and bathroom can help with fatigue as well (Sorrentino & Remmert, 2021).

Observation is critical in finding out if there are any changes in the patient’s condition. Non-verbal signs such as grimacing or crying when moving can signal a problem. Any new signs or symptoms of pain should be reported. If a new area or joint appears swollen or affected, report it. Asking questions about pain needs to include pain level, how long the pain has been there, and what the patient did to try to relieve the pain. This should all be reported to the nurse. Another aspect to observe is how well the patient is completing daily activities. Can they dress, wash, open a door, or make a meal? If there are problems or changes in these areas, they should also be reported.

In Rheumatoid arthritis, be sure to observe for any signs of new medical issues such as trouble breathing, elevated heart rate, or blood pressure. Care needs to be tailored to the patient’s needs. Not all patients need the same assistance or support. Remember that the patient will want as much independence as possible. Suggest devices or cares that you think will be helpful to the health care team for review.

Scenario/situation/patient description

• Mr. H is an 83-year-old Caucasian male with osteoarthritis of his left knee. It is stiffer in the morning and takes him a while to get moving. He describes the knee as grinding when he walks. He went to his family for dinner today. When he returns to the nursing home, you notice he is limping more than normal. He is complaining of increased pain and just wants to go to bed.

Intervention/strategies

• You reported the increased exercise that day and increased pain to the nurse. After an assessment, the nurse gave an anti-inflammatory and pain medication and changed the care plan to cold compresses for 15 minutes per hour for four hours. Mr. H overexerted that knee and will probably be on reduced activity for a few days to rest it.

Discussion of outcomes

• The anti-inflammatory medication and cold compresses will help prevent swelling and reduce pain. So Mr. H will be up and around faster.

Strengths and weakness

• Had the CNA not reported the problem, Mr. H's overexertion of that knee would probably not have been noticed until the next day. This would have caused more swelling and pain for longer.
• Mr. H needs to be educated about how to handle situations when he may get over-exercise of that knee. He needs to know how to preserve his knee by reducing over-exercising.

Arthritis is a disabling condition. Osteoarthritis occurs gradually over time. Rheumatoid arthritis is an autoimmune condition that can flare up and have a quick beginning. The CNA can help patients with arthritis with daily activities. In caring for patients with arthritis, the staff has to observe and report changes to the nurse.

• Arthritis Foundation. (2021). Rheumatoid arthritis: Causes, symptoms, diagnosis, and treatment and more. Arthritis Foundation. Visit Source.
• Arthritis Foundation. (n.d.). Osteoarthritis. Arthritis Foundation. Visit Source.
• Sorrentino, S., & Remmert, L. (2021). Mosby’s Textbook for Nursing Assistants (10th ed.). Elsevier